Practice Examination Three Part One You will have two hours and 30 minutes to complete Part One.

1. A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer's location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess? A. Return of the gag reflex. B. Bowel sounds. C. Peripheral pulses. D. Intake and output. 2. The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process? A. Assessment. B. Analysis. C. Planning. D. Evaluation. 3. The nurse is administering sublingual nitroglycerin (Nitrostat) to the client. Immediately afterward, the client may experience which of the following symptoms? A. Nervousness or paresthesia. B. Throbbing headache or dizziness. C. Drowsiness or blurred vision. D. Tinnitus or diplopia. 4. A client who is a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The client's cervical examination would reveal which of the following? A. 2 cm dilated; 100% effaced at 0 station. B. 4 to 5 cm dilated; 80% effaced at -1 station. C. 2 cm dilated; 50% effaced at +1 station. D. 3 cm dilated; 50% effaced at 0 station. 5. A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub--a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position? A. Semi-Fowler's. B. Leaning forward while sitting. C. Supine. D. Prone. 6. Which of the following would be most appropriate for the nurse to include in the plan of care for a dying child to meet the child's emotional needs during the last days of life? A. Restrict visitors to the parents to avoid overtaxing the child. B. Answer the child's questions about illness and death honestly. C. Focus on the child's physical needs to attempt to prevent

sadness. D. Encourage the child to play quietly with a roommate to provide pleasure. 7. The skin lesions evident in herpes zoster are similar to those seen in which disease? A. Impetigo. B. Syphilis. C. Varicella. D. Rubella. 8. A client with newly diagnosed type 1 diabetes mellitus is learning about diabetic foot care. Which of the following statements by the client indicates further instruction is needed? A. "I should use lotions. " B. "I should use antiperspirants. " C. "I should use foot soaks. " D. "I should use nail files. " 9. The nurse is teaching a client and his family about dietary practices related to Parkinson's disease. A priority for the nurse to address is risk of A. fluid overload and drooling. B. aspiration and anorexia. C. choking and diarrhea. D. dysphagia and constipation. 10. While inspecting the client's chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. The nurse suspects which of the following problem from this assessment? A. Hemothorax. B. Flail chest. C. Pneumothorax. D. Tension pneumothorax. 11. Which assessment finding would lead the nurse to suspect dehydration in a preterm neonate? A. Bulging fontanels. B. Excessive weight gain. C. Urine specific gravity below 1.012. D. Urine output below 1 mL/hour. 12. The client is taking lithium (Lithobid). Which instruct should the nurse give to the client? A. Drink at least six to eight glasses of water per day and to avoid caffeine. B. Limit the use of salt in his diet. C. Discontinue medicine when feeling better. D. Increase the amount of sodium in his diet. 13. During the first 24 hours after a client is diagnosed with addisonian crisis, which of the following should the nurse perform frequently? A. Weigh the client. B. Test urine for ketones.

C. Assess vital signs. D. Administer oral hydrocortisone. 14. A 68-year-old woman is admitted to the general surgical unit for removal of a breast mass malignancy. In the presurgical assessment of the client, which of the following choices would be most appropriate for the nurse to ask when assessing her selfconcept? A. "Let's talk about what you'd like to do that you haven't done. " B. "List for me your accomplishments and achievements in life. " C. "Tell me how this breast surgery will make you feel about yourself. " D. "What does your husband say when he compliments you?" 15. Promethazine hydrochloride (Phenergan) 35 mg IM is ordered for a client who is experiencing nausea and vomiting after surgery. The ampule's label reads 25 mg/mL. How many mL should the nurse prepare to administer? A. 0.7 mL. B. 1.0 mL. C. 1.4 mL. D. 1.8 mL. 16. Which of the following would the nurse expect to find in a client diagnosed with hyperparathyroidism? A. Hypocalcemia. B. Hypercalcemia. C. Hyperphosphatemia. D. Hypophosphaturia. 17. Which of the following home regimens should the nurse suggest to relieve itching in children with chicken pox? A. Generous amounts of fine baby powder. B. Oatmeal preparation baths. C. Terrycloth towels moistened with hydrogen peroxide. D. Cool compresses moistened with a weak salt solution. 18. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550mL. What should the nurse do? A. Increase the frequency of the catheterizations. B. Insert an indwelling urinary catheter. C. Place the client on fluid restrictions. D. Use a condom catheter instead of an invasive one. 19. The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Set up a strict eating plan for the client. B. Encourage the client to exercise, which will reduce her anxiety. C. Restrict visits with the family until the client begins to eat. D. Provide privacy during meals.

20. A client reports a severe headache shortly after a lumbar puncture for a myelogram. What would be the nurse's best response? A. Increase the client's fluid intake. B. Administer prescribed antihypertensives. C. Offer roll lenses to the client. D. Place cooling packs over the lumbar puncture site. 21. A client diagnosed with gestational diabetes has been admitted for induction of labor at 38 weeks. The client asks the nurse, "My previous labors started on their own. How will this induction of labor be different from my last labor?" Upon which theory would the nurse base her response? A. An induction causes the contractions to be more intense during the first stage of labor. B. The risk of uterine rupture is less because the oxytocin (Pitocin) is controlled with an infusion pump. C. The goal of induction is to produce a contractile pattern similar to that observed in spontaneous labor. D. During an induction, fetal monitoring begins as soon as oxytocin is started, whereas in a spontaneous labor, monitoring begins when signs of distress occur. 22. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching? A. Make inhalation longer than exhalation. B. Exhale through an open mouth. C. Use diaphragmatic breathing. D. Use chest breathing. 23. The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this? A. Interpreting proverbs. B. Spelling words backward. C. Counting by serial sevens. D. Discussing hypothetical ethical situations. 24. Which event may trigger pain in the client with trigeminal neuralgia? A. Walking in the mall. B. Sitting in the sun. C. Eating lunch. D. Sleeping. 25. The nurse should plan to include which of the following interventions in the plan of care for a child admitted to the hospital with a medical diagnosis of febrile seizure? A. Keep the child supine. B. Place the child in respiratory isolation and restrict visitors. C. Keep the room temperature low and bedclothes to a minimum. D. Place a padded tongue blade at the bedside. 26. A 20-year-old woman has just been diagnosed with Crohn's

disease. She has lost 10 lb (4.5kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment? A. Let the client eat as desired during hospitalization. B. Weigh the client daily. C. Ask the client to list what she eats during a typical day. D. Place the client on IO status and draw blood for electrolyte levels. 27. The nurse discusses discharge plan with the parents of a child following a sickle cell crisis. Which of the following would the nurse emphasize the need to seek prompt health care? A. Headaches and nausea. B. Fatigue and lassitude. C. Skin rash and itching. D. Sore throat and fever. 28. During a shock state, the renin-angiotensin-aldosterone system exerts which effect on renal function? A. Decreased urine output, increased reabsorption of sodium and water. B. Decreased urine output, decreased reabsorption of sodium and water. C. Increased urine output, increased reabsorption of sodium and water. D. Increased urine output, decreased reabsorption of sodium and water. 29. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. Which of the following is the first step the nurse should take to help the woman stop smoking? A. Assess the client's readiness to stop. B. Suggest that the client reduce the daily number of cigarettes smoked by one-half. C. Provide the client with the telephone number of a formal smoking-cessation program. D. Help the client develop a plan to stop. 30. Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip? A. Gastric gavage. B. Intravenous fluids. C. Rubber-tipped medicine dropper. D. Bottle with a lamb's nipple. 31. The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia? A. Atropine. B. Dobutamine (Dobutrex). C. Bretylium (Bretylol). D. Lidocaine (Xylocaine).

32. The nurse is caring for a client who has a history of alcohol abuse. Why would the client act as if he didn't have a problem? A. The client has never taken the CAGE questionnaire. B. Denial is a defense mechanism commonly used by alcoholics. C. Thought processes are distorted. D. Alcohol is expensive. 33. A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes" even though he wears corrective glasses. The nurse would suspect that the client is experiencing a deficiency in which of the following vitamins? A. Vitamin A. B. Vitamin B complex. C. Vitamin E. D. Vitamin C. 34. Which condition could a mother have and still be allowed to breast-feed her child? A. Positive for human immunodeficiency virus (HIV). B. Active tuberculosis (TB). C. Cardiac disease. D. Endometritis. 35. As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing? A. Slipped epiphysis. B. Developmental dysplasia of hip. C. Idiopathic scoliosis. D. Physical dexterity. 36. For a client in addisonian crisis, it would be very risky for a nurse to administer A. potassium chloride. B. normal saline solution. C. hydrocortisone. D. fludrocortisone. 37. A neonate receives an Apgar score at 1 and 5 minutes after birth. The 5-minute Apgar score is more predictive for which of the following? A. Residual neurologic damage. B. Residual respiratory depression. C. Congenital heart defects. D. Gestational age of the neonate. 38. During a private conversation, a client with borderline personality disorder asks the nurse to "keep my secret" and then displays multiple self-inflicted, superficial lacerations on the forearms. What is the nurse's best response? A. "This type of behavior requires you to be on suicide precautions. " B. "I'm going to tell your physician. Do you want to tell me why

you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection. " D. "Whenever something important occurs in treatment, the team needs to know about it. I'll have to tell the others, but let's talk about it first. " 39. A client, a gravida 3 para 2 at 35 weeks' gestation, comes in to the antepartum clinic for a check-up. She has been experiencing backaches after standing all day at her job as a grocery clerk. Which of the following exercise would the nurse suggest to relieve backache? A. The pelvic tilt. B. Squatting. C. Stretching. D. Walking. 40. Which outcome would indicate successful treatment of diabetes insipidus? A. Fluid intake of less than 2,500 mL in 24 hours. B. Urine output of more than 200 mL/hour. C. Blood pressure of 90/50 mmHg. D. Pulse rate of 126 beats/minute. 41. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects the client has a belief that he is A. highly important or famous. B. being persecuted. C. connected to events unrelated to himself. D. responsible for the evil in the world. 42. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD) ? A. Ineffective thermoregulation. B. Impaired gas exchange. C. Risk for injury. D. Decreased cardiac output. 43. A 16-year-old girl comes to the school nurse complaining of cramps, backache, and nausea with her periods. The nurse most likely would interpret these symptoms as which of the following? A. Pathologic. B. Physiologic. C. Psychogenic. D. Psychosomatic. 44. The nurse recognizes that spinal shock is likely to persist for the first several weeks after the injury. Which of the following symptoms would be unexpected during the period of spinal shock? A. Tachycardia. B. Rapid respirations. C. Hypertension. D. Dry, warm skin. 45. Which of the following case meets the criteria for ivoluntary commitment?

A. A single parent who leaves her minor children unattended and stays out all night drinking. B. A person who lives alone and isn't able to care for himself and has schizophrenia with delusions of persecution. C. A man who threatens to kill his wife. D. A person with depression who says he's tired of living but doesn't have a suicide plan. 46. The nurse is changing the subclavian dressing over the catheter insertion site. Which one of the following actions would be appropriate for the nurse to incorporate into the dressing change? A. Place the client in high-Fowler's position. B. Check for tubing kinks and leakage. C. Cleanse the area, starting 2 inches from the insertion site and moving inward. D. Remove old ointment from the insertion site with soap and warm water. 47. Before bowel surgery, the infant is to receive oral neomycin for 3 days. The appropriate pediatric dosage of neomycin sulfate is 10. 3 mg/kg q 4 hours. The infant weighs 15 pounds, 6.4 ounces. Which of the following dosages most closely approximates a safe daily dose? A. 50 mg/day. B. 150 mg/day. C. 280 mg/day. D. 430 mg/day. 48. When assessing a client as a candidate for crutch walking, the nurse should take into account that for some elderly people, crutch walking is an impractical goal primarily because which of the following reason? A. Decreased reaction time. B. Decreased visual acuity. C. Decreased motor coordination. D. Decreased level of comprehension. 49. As part of the respiratory assessment, the nurse observes the neonate's nares for patency and mucus. Which of the following is the reason that the nurse employs this assessment? A. Neonates are obligate nose breathers. B. Nasal patency is required for adequate feeding. C. Problems with nasal patency may cause flaring. D. A deviated septum will interfere with breathing. 50. The nurse is caring for a client who exhibits signs of somatization. Which of the following statements is most relevant? A. Clients with somatization are cognitively impaired. B. Anxiety rarely coexists with somatization. C. Somatization exists when medical evidence supports the symptoms. D. Clients with somatization often have lengthy medical records. 51. Theophylline ethylenediamide is administered to a client with COPD. The nurse knows that the medication is for which of the

following purpose? A. To reduce bronchial secretions. B. To relax bronchial smooth muscle. C. To strengthen myocardial contractions. D. To decrease alveolar elasticity. 52. Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? A. Monitoring intake and output. B. Initiating oral feedings. C. Allowing the infant to rest undisturbed. D. Providing age-appropriate diversionary activities. 53. Eight hours after catheterization, the postoperative client with abdominal hysterectomy has not voided. The client tells the nurse, "I don't think I can urinate. " What should the nurse do? A. Call and inform the surgeon of the client's status. B. Administer additional pain medication. C. Increase the client's fluid intake. D. Assess the client's bladder. 54. An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large neonates, to shorten the second stage of labor, or for a malpresentation. When caring for the mother following an assisted birth, the nurse should keep which of the following in mind? A. A vacuum extractor is safer than forceps because it causes less trauma to the neonate and the mother's perineum. B. The neonate will develop a cephalohematoma as a result of the instrumentation. C. The use of instruments during the birth process is a fairly rare occurrence. D. Additional nursing interventions are needed to ensure an uncomplicated postpartum. 55. Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia? A. Change current diet habits. B. Seek prompt antibiotic therapy for viral infections. C. Receive prophylactic antibiotic therapy. D. Obtain annual influenza and pneumococcal vaccines. 56. A mother of a 4-month-old infant asks the nurse when she should wean from breast-feeding and begin using a cup. Which of the following would be the best indication of the infant's readiness to be weaned? A. Taking solid foods well. B. Sleeping through the night. C. Shortening the nursing time. D. Eating on a regular schedule. 57. The plan of care for a client with hypertension taking propranolol hydrochloride would include which of the following?

A. Instructing the client to discontinue the drug if nausea occurs and to monitor blood pressure. B. Instructing the client to notify the physician of irregular or slowed pulse rate. C. Monitoring blood pressure every week and adjusting the medication dose accordingly. D. Measuring partial thromboplastin time weekly to evaluate blood clotting status. 58. After teaching the mother about tests performed to monitor the success of the infant's treatment for congenital hypothyroidism, the nurse would determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of which of the following? A. Blood electrolyte levels. B. Metabolic rate. C. Muscular coordination. D. Bone age. 59. The nurse is preparing the client with heart failure to go home. Which of the following should be most important to include in the discharge education? A. Monitor urine output daily. B. Monitor daily potassium intake. C. Maintain bed rest for at least 1 week. D. Weigh daily. 60. Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which of the following? A. Poor ability to concentrate urine. B. Little skin pigment to prevent sunburn. C. Poorly functioning temperature control center. D. Abnormally high salt loss through perspiration. 61. Which of the following nursing diagnoses would be most appropriate for a client newly diagnosed with non-insulin-dependent diabetes mellitus? A. Risk for infection related to newly diagnosed diabetes. B. Altered nutrition, more than body requirements related to overproduction of insulin. C. Altered health maintenance related to lack of knowledge of proper foot care. D. Pain related to elevated blood glucose levels. 62. The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems? A. Depression is commonly characterized by pain disorders and somatic complaints. B. Combining evaluations will save time and allow for quicker delivery of health care. C. Most insurance plans won't cover evaluation of both as

separate entities. D. The physician doesn't have the training to evaluate for psychosocial considerations. 63. The nurse teaches the client with peptic ulcer disease about how to effectively adjust his response to work-related stress. Which of the following statements by the client indicates that the education is effective? A. "My job is too stressful. I will have to find a different career. " B. "I don't have any control over my stressors at work. My coworkers are difficult to work with. " C. "Well, I guess this ulcer means I won't be able to work toward a promotion. " D. "I will have to improve my ability to cope with stress. " 64. Which of the following would be best to help prepare a preschool-aged child for an injection? A. Having an older child explain that shots do not hurt. B. Helping the child to imagine she is in a different place. C. Giving the child a play syringe and a bandage to give a doll injections. D. Giving the child a pounding board to encourage expressions of anger. 65. A woman who is 10 weeks pregnant complains about her fatigue and frequent urination. What would be the nurse's response? A. Recognize these as normal early pregnancy signs and symptoms. B. Question her further about these signs and symptoms. C. Tell the client that she'll need blood work and urinalysis. D. Tell the client that she may be excessively worried. 66. The nurse would teach the client to implement which of the following nasal care measures after the nasal packing is removed? A. Irrigate the nares with normal saline solution daily. B. Remove old blood from inside the nares with cotton-tipped applicators. C. Avoid cleaning the nares for at least 2 days. D. For comfort lubricate the membranes with a water-soluble lubricant. 67. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate? A. Obtain a detailed account of the adolescent's prenatal and early developmental history. B. Discuss sexual preferences and behaviors with the parents present for legal reasons. C. Discuss the client's smoking with parents present in the room. D. Assess the adolescent in private; gather additional information from the parents. 68. The nurse is caring for a client with bipolar disorder in a manic state. Which of the following nursing interventions should be included in the plan of care?

A. Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. B. Listening attentively with a neutral attitude and avoiding power struggles. C. Offering high-calorie meals and strongly encouraging the client to finish all food. D. Insisting that the client remain active through the day so that he'll sleep at night. 69. Which of the following statements represents a major principle of chronic pain management? A. A physiologic approach is most effective. B. A psychological approach is most effective. C. A pharmacologic approach is most effective. D. A multidisciplinary approach is most effective. 70. Which of following would lead the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? A. An increased sense of rectal pressure. B. An increase in fetal heart rate variability. C. A decrease in intensity of contractions. D. Episodes of nausea and vomiting. 71. A client is recovering from a gastric resection for peptic ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? A. Increases food intake and tolerance gradually. B. Experiences occasional episodes of nausea and vomiting. C. Experiences a rapid weight gain within 1 week. D. Drinks 2000 mL/day of water. 72. The nurse is preparing to care for a client diagnosed with catatonic schizophrenia. In anticipation of this client's arrival, what should the nurse do? A. Notify security. B. Prepare a magnesium sulfate drip. C. Place a specialty mattress overlay on the bed. D. Communicate the client's nothing-by-mouth status to the dietary department. 73. The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next? A. Assess the infusion system, note the client's condition, and notify the physician. B. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved. C. Increase the flow rate to infuse an additional 300 mL over the next hour. D. Maintain the flow rate at the current rate and document any discrepancy in the chart.

74. After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6 lb (2.7 kg) weight gain, ascites, and pedal edema. These findings indicate which of the following? A. They are normal signs of an ovulatory stimulant. B. The client is demonstrating signs of hyperstimulation syndrome. C. The client is having a reaction to the menotropins. D. The client is probably pregnant. 75. A parent reports that his 2-year-old child often fails when running. The nurse interprets this as indicating which of the following as a normal aspect of a toddler's vision? A. Near-sightedness. B. Far-sightedness. C. Binocular vision. D. Strabismus. 76. A client with hepatitis A expresses concern that his friends may also acquire hepatitis. Which of the following is most commonly used for prophylactic treatment of people exposed to hepatitis A? A. Penicillin. B. Sulfadiazine (Microsulfon). C. Immune serum globulin. D. Interferon. 77. A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms? A. The opportunity to verbalize memories of trauma to a sympathetic listener. B. Family support. C. Prescribed medications taken as ordered. D. Alcoholics Anonymous (AA) meetings. 78. The nurse preparing to give a child an intramuscular injection chooses to give the injection into the gluteal muscle. The site is acceptable because which of the following reasons? A. The child has been walking for 1 year. B. The child has small deltoid muscles. C. The child is older than 2 years. D. The child weighs more than 25 pounds. 79. A client with testicular cancer is scheduled for a right orchiectomy. The day before surgery, the client asks the nurse whether losing a testicle will have influence on his manhood. Which of the following facts about orchiectomy should form the basis for the nurse's response? A. Testosterone levels are decreased. B. Sexual drive and libido are unchanged. C. Sperm count increases in the remaining testicle. D. Secondary sexual characteristics change. 80. A client with intrauterine growth retardation is admitted to

the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is LEAST likely to be included in her plan of care? A. Monitoring vital signs, including assessment of fetal wellbeing, every 15 to 30 minutes. B. Allowing the client to ambulate as tolerated. C. Helping the client use breathing exercises to manage her contractions. D. Carefully titrating the oxytocin based on her pattern of labor. 81. The nurse is caring for a client who exhibits magical thinking. Which of the following best describes magical thinking? A. Strong positive and negative feelings that cause conflict. B. Returning to an earlier developmental stage. C. Meaningless repetition of words. D. The belief that thoughts or wishes can control other people or events. 82. The primary reason for withholding food and fluids from a client who will receive general anesthesia is to help prevent A. constipation during the immediate postoperative period. B. vomiting and possible aspiration of vomitus during surgery. C. pressure on the diaphragm with poor lung expansion during surgery. D. gas pains and distention during the immediate postoperative period. 83. Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock? A. Axillary temperature is 99.8F?(37.7). B. Blood pressure is 45/25 mmHg. C. Heart rate during sleep is 205 beats per minute. D. Respiratory rate while awake is 32 breaths per minute. 84. A client who has been admitted to the emergency room is restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances? A. Hypokalemia. B. Hypercalcemia. C. Hypomagnesemia. D. Hypernatremia. 85. What is the nurse's most important role in caring for a client with a mental health disorder? A. To offer advice. B. To know how to solve the client's problems. C. To establish trust and rapport. D. To set limits with the client. 86. The physician decides to artificially rupture the membranes. Following this procedure, the nurse needs to check the fetal heart tones. Why should the nurse do so? A. To determine fetal well-being. B. To prepare for an imminent delivery.

C. To assess for prolapsed cord. D. To assess fetal position. 87. When caring for a client with ulcerative colitis, the nurse should include which of the following nursing interventions in the plan of care? A. Encouraging the use of stool softeners. B. Suggesting sitz baths as needed. C. Arrange for the client to have a private bathroom. D. Wearing a gown to provide direct care. 88. A 2-year-old child is brought to the emergency room with a broken arm. Which of the following findings would lead the nurse to suspect child abuse? A. The child has bruises on the forearms. B. The child's clothes are dirty, torn, and obviously "hand-medowns. " C. The child's father alters the story of the injury each time he tells it. D. The child's mother did not come to the hospital with the child. 89. The client with diverticulitis is treated as an outpatient with drug therapy. Which drug therapy will most probably be employed? A. Antidepressants. B. Laxatives. C. Steroids. D. Broad-spectrum antibiotics. 90. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to have which of the following findings? A. Tension and irritability. B. Slow pulse. C. Hypotension. D. Constipation. 91. A 35-year-old multigravida at 16 weeks gestation tells the nurse that she has had frequent mood swings during this pregnancy. What would be the nurse's best suggestion to the client? A. Seek professional counseling. B. Keep her feelings to herself. C. Try to avoid fatigue and stress. D. Decrease her narcissistic behaviors. 92. Which of the following postoperative complications would the nurse particularly anticipate in a client undergoing a pelvic surgical procedure such as an ileal conduit? A. Bleeding. B. Infection. C. Thrombophlebitis. D. Atelectasis. 93. When preparing to give a child with insulin-dependent diabetes his dose of regular and NPH humulin insulin, which of the following actions would be most appropriate? A. Taking the premixed insulin out of the refrigerator, then

withdrawing the amount into in one syringe. B. Using two syringes, one for each type of insulin, and giving two injections. C. Withdrawing the NPH insulin first, then withdrawing the regular insulin into one syringe. D. Withdrawing the regular insulin first, then withdrawing the NPH insulin into one syringe. 94. Which of the following factors would be most important in selecting the needle length to use for a subcutaneous injection of hydromorphone hydrochloride? A. The diameter of the needle. B. The amount of adipose tissue at the administration site. C. The amount of medication to be administered. D. The viscosity of the solution to be injected. 95. When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following? A. Fetal hypoxia. B. Maternal comfort. C. The contraction pattern. D. The status of a trapped cord. 96. A client in a psychiatric clinic unit tells the nurse, "I don't think I can face going home tomorrow. " The nurse replies, "Do you want to talk more about it?" The nurse is using which of the following techniques? A. Presenting reality. B. Making observations. C. Restating. D. Exploring. 97. The nurse notices that a client's abdominal wound has eviscerated. Which of the following would the nurse do first? A. Notify the client's physician immediately. B. Reinsert the protruding viscera into the abdominal cavity. C. Place the client in reverse Trendelenburg's position. D. Cover the wound with sterile saline-moistened dressings. 98. Which of the following concepts would the nurse incorporate into the plan of care for a 4-year-old child to psychologically prepare the child for cardiac catheterization? A. Anxiety decreases when a preschooler is protected from learning about unpleasant events. B. Preschoolers are unable to understand the procedure. C. Little psychological preparation can be given to preschoolers. D. Preparation is a joint responsibility of the physician, parents, and nurse. 99. Labor is divided into how many stages? A. Two. B. Three.

C. Four. D. Five. 100. The most effective health-promotion measure related to glaucoma that the nurse could teach clients is which of the following? A. Appropriate blood pressure control. B. Prompt treatment of all eye infections. C. Avoidance of extended-wear contact lenses by older people. D. Annual intraocular pressure measurements for people older than 40 years. 101. A client with a history of panic attacks seeks to increase social interaction. Each time the client tries to go to the dayroom, she begins to perspire and becomes short of breath. Which action by the nurse will help ease the client's feelings of panic? A. Have other clients volunteer to accompany the client. B. Tell the client she has to overcome her fear. C. Allow the client to stay in her room. D. Walk with the client and stay with her while she's in the dayroom. 102. A school-aged child is admitted to the hospital with newly diagnosed, insulin-dependent diabetes mellitus. On admission his blood sugar is 180 mg/dL. His urine tests negative for ketones. He receives 10 units of regular humulin insulin subcutaneously half hour after admission. What should the nurse do next? A. Carefully regulate an intravenous solution of normal saline and insulin at 2. 5 hours after admission. B. Encourage the child to drink at least 500 mL of a sugar-free clear liquid 1.5 hours after admission. C. Begin intravenous administration of 5% dextrose in water 1 hour after admission. D. Assess the child 2. 5 hours after admission for shakiness, feelings of anxiety, or decreased level of consciousness. 103. Which of the following is NOT a contributory factor to thermoregulation in the preterm neonate? A. Immature central nervous system (CNS). B. Large skin surface area. C. Lack of subcutaneous (SC) and brown fat. D. Tendency toward capillary fragility. 104. The nurse assesses the client's urinary stoma regularly for edema. Which of the following signs and symptoms might indicate excessive stomal edema? A. Elevated temperature. B. Urine output below 30 mL/hour. C. Urine dribbling from the stoma. D. Complaints of discomfort around the stoma. 105. A respectable lawyer is admitted to an acute care facility with epigastric pain. Since admission, the client has called the nurse every 15 minutes with one request or another. Which of the following could explain this client's behavior?

A. Repression. B. Somatization. C. Regression. D. Conversion. 106. Which of the following discharge instructions should the nurse give the parents of an infant with a temporary colostomy? A. Flush the stoma with tap water at least once a day. B. Allow the diaper to absorb the colostomy drainage. C. Give the infant plenty of liquids to drink. D. Expect the stoma to become dusky red within 2 weeks. 107. Which of the following laboratory tests is considered the most reliable indicator of renal function? A. BUN. B. Urinalysis. C. Serum potassium. D. Serum creatinine. 108. A client is being admitted to the labor unit. Because she's well advanced in labor, the nurse must prioritize the admission questions. Which information is most important to obtain when birth is imminent? A. Duration of previous labor. B. Frequency of contractions. C. Presence of bloody show. D. Expected due date. 109. Hormonal effects of the antipsychotic medications include which of the following? A. Retrograde ejaculation and gynecomastia. B. Dysmenorrhea and increased vaginal bleeding. C. Polydipsia and dysmenorrhea. D. Akinesia and dysphasia. 110. From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis? A. Incisional pain. B. Nausea. C. Progressive ambulation. D. Maintenance of a semi-Fowler's position. 111. To help promote independence in the area of feeding for a school-aged child in skeletal traction, the nurse would help the child choose which of the following meals? A. Carrot sticks, celery with cream cheese, roast beef and gravy, peas, gelatin, and milk in a cup. B. Chicken noodle soup with crackers, grilled cheese sandwich, cole slaw, and chocolate milk in a carton. C. Chicken nuggets with sauce, carrot sticks, French-fried potatoes, ice cream sandwich, and milk in a carton. D. Spaghetti and meat sauce, cherry cobbler, and apple juice in

a can. 112. For which type of schizophrenia should the nurse expect to provide the most physical care? A. Disorganized type. B. Catatonic type. C. Paranoid type. D. Undifferentiated type. 113. The nurse is caring for a client who undergoes a total right knee replacement. The nurse would anticipate which of the following activity orders for this client on the first postoperative day? A. Bed rest for 24 to 48 hours after surgery. B. Ambulate with walker twice a day. C. Up to chair with leg elevated. D. Dangle at bedside for 20 minutes. 114. The nurse is administering magnesium sulfate to a client with preeclampsia. The nurse explains to the client that this drug is given for which of the following reason? A. To prevent seizures. B. To reduce blood pressure. C. To slow the process of labor. D. To increase diuresis. 115. Prevention of preterm births is vital for which of the following reasons? A. It's costly to care for these neonates. B. These neonates are usually mentally retarded. C. Preterm birth causes high incidence of the neonatal deaths. D. These neonates usually wind up with long-term health care needs. 116. A client with multiple sclerosis has been prescribed baclofen. The nurse teaches the client about the action of the drug. Which of the following is an accurate instruction regarding this drug's action? A. "Baclofen will decrease your fatigue and help increase your energy levels. " B. "Baclofen will help relieve the muscle spasms that you have been experiencing. " C. "It is an antibiotic that will help treat your urinary tract infection. " D. "Taking this drug will help decrease the visual problems you have been having. " 117. Which of the following drugs may be abused because of tolerance and physiologic dependence? A. Lithium (Lithobid) and divalproex (Depakote). B. Verapamil (Calan) and chlorpromazine (Thorazine). C. Alprazolam (Xanax) and phenobarbital (Luminal). D. Clozapine (Clozaril) and amitriptyline (Elavil). 118. For a child receiving steroids in therapeutic doses over a long period, the nurse should pay more attention on which of the

following? A. Monitor the child's serum glucose level. B. Decrease the child's ingestion of potassium-rich foods. C. Give the drug on an empty stomach. D. Monitor the child's temperature to assess for infection. 119. A client is brought to the hospital after vomiting bright red blood and is admitted through the emergency department with a diagnosis of bleeding duodenal ulcer. While the client is bleeding, it will be essential for the nurse to assess frequently for signs of early shock. Which one of the following is an important indicator of early shock? A. Tachycardia. B. Dry, flushed skin. C. Increased urine output. D. Loss of consciousness. 120. Which of the following would the nurse do for a 4-year-old girl who has just had a lumbar puncture? A. Administer narcotic analgesic for insertion site pain. B. Encourage the parents to hold the child. C. Ensure the child lies flat for at least 8 hours. D. Place a sandbag over the puncture site for 3 hours. 121. A 15-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include which of the following? A. Violence on television. B. Passive parents. C. An internal locus of control. D. A single-parent family. 122. The nurse assesses the client to determine the cause of autonomic dysreflexia. Which of the following is the most common stimulus for an autonomic dysreflexia episode? A. Rising intracranial pressure. B. Bowel distention. C. Bladder distention. D. Anxiety. 123. The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate? A. Catheterization to protect the bladder from trauma. B. Perineal assessments for swelling and bleeding. C. Vital signs and fundal checks every 15 minutes. D. Time with the neonate to initiate breast-feeding. 124. While caring for a healthy neonate female, the nurse notices red stains on the diaper after the neonate voids. Which of the following should the nurse do? A. Call the physician to report the problem. B. Encourage the mother to feed the neonate to decrease dehydration.

C. Check the neonate's urine for hematuria. D. Do nothing because this is normal. 125. The nurse instructs the client with diabetes mellitus that it is vital to recognize and treat hypoglycemia promptly based on which of the following knowledge? A. Hypoglycemia can cause brain damage. B. Hypoglycemia necessitates increased insulin dosage. C. The client may become dehydrated quickly. D. The client may become confused, increasing the risk of injury. 126. The client with cirrhosis is put on a sodium-restricted diet and a diuretic. The nurse would expect to administer a potassiumsparing diuretic. Which of the follow is a potassium-sparing diuretic? A. Furosemide (Lasix). B. Spironolactone (Aldactone). C. Hydrochlorothiazide (HydroDIURIL). D. Ethacrynic acid (Edecrin). 127. During the first 3 months, which hormone is responsible for maintaining pregnancy? A. Human chorionic gonadotropin (HCG). B. Progesterone. C. Estrogen. D. Relaxin. 128. A client diagnosed with hyperthyroidism has been started on propylthiouracil (PTU) as drug therapy. The nurse should closely observe the client for which of the following side effects? A. Unusual bleeding or bruising. B. Hypertension. C. Hypokalemia. D. Peripheral edema. 129. An 89-year-old client is suffering from dementia of the Alzheimer's type. Which intervention would be most useful in managing his dementia? A. Provide a safe environment. B. Provide a stimulating environment. C. Avoid the use of touch. D. Use restraints whenever necessary. 130. For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which of the following acid-base imbalances? A. Respiratory alkalosis. B. Respiratory acidosis. C. Metabolic alkalosis. D. Metabolic acidosis. 131. Which of the following is normal neonate calorie intake? A. 90 to 100 calories per kilogram. B. 110 to 130 calories per kilogram. C. 30 to 40 calories per lb of body weight. D. At least 2mL per feeding.

132. The client has a newly positive Mantoux skin test although she does not have active tuberculosis. Which medical therapy would be appropriate for her? A. Reevaluating the client's condition every 6 months. B. Performing a repeat skin test every 6 months. C. Administering isoniazid for about 9 months. D. Administering isoniazid until the skin test reverts to negative. 133. The nurse discusses with the 4-year-old child and parents the plan of care that will be implemented when the child returns from the throat surgery. Which of the following interventions should the nurse emphasize? A. Need for frequent coughing. B. Use of acetylsalicylic acid for pain, as needed. C. Ability to have ice cream right after surgery. D. Use of sips of clear liquids when awake and alert. 134. Which of the following nursing measures would be most important to decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning? A. Inserting an indwelling urinary catheter to prevent possible soiling of the dressing. B. Accurately measuring drainage from the surgical drainage tube. C. Changing the surgical dressings using strict sterile technique. D. Monitoring the incision for signs of redness, swelling, and warmth. 135. Which of the following criteria would be a reliable indicator of improvement in a patient who has a diagnosis of anorexia nervosa? A. Electrolyte balance. B. Energy level. C. Fluid intake. D. Desire to eat. 136. A client with type 1 (insulin-dependent) diabetes mellitus who is a multigravida visits the clinic at 28 weeks' gestation. Which of the following instruction by the nurse is appropriate for the client? A. Nonstress testing is performed weekly until 32 weeks' gestation. B. Weekly fetal movement counts are made by the mother. C. Contraction stress testing is performed weekly. D. Induction of labor is begun at 34 weeks' gestation. 137. The client asks when he can stop taking the eye medication for his chronic open-angle glaucoma. Which would be the nurse's best response? A. "You can stop using the eye drops when your vision improves. " B. "You Need to use the eye drops only when you has symptoms. " C. "You can discontinue the eye drops after 2 months of normal eye examinations. "

D. "You must use the eye medication for the rest of his life. " 138. When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find? A. Toe-walking. B. Drooling. C. Facial grimacing. D. Wide-based gait. 139. At what gestational age would a primigravida expect to feel "quickening"? A. 12 weeks. B. 16 to 18 weeks. C. 20 to 22 weeks. D. By the end of the 26th week. 140. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to indicate her ineffective coping? A. Inability to make choices and decisions without advice. B. Showing interest only in solitary activities. C. Avoiding developing relationships. D. Recurrent self-destructive behavior with history of depression. 141. Which of the following pieces of equipment would do best job to help prevent external rotation of the client's right leg postoperatively? A. Sandbags. B. A high footboard. C. A rubber air ring. D. A metal bed cradle. 142. A 6-week-old female infant exhibits dry scaly skin and a protruding tongue after having trouble breast-feeding. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. Which of the following would be the nurse's best response? A. "We had the results of the newborn screen, but you did not bring the baby in for the 2-week checkup. " B. "We could not reach you at home to give you the results of tests taken at birth. " C. "Your baby had little need for thyroid hormone until she was 1 month old. " D. "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks. " 143. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? A. Monthly blood tests will be necessary. B. Report a sore throat or fever to the physician immediately. C. Blood pressure must be monitored for hypertension. D. Stop the medication when symptoms subside. 144. A client is diagnosed with a herniated lumbar disk at the L-

5 interspace. Which of the following symptoms would most likely be the one that first caused the client to seek health care? A. Loss of voluntary muscle control. B. Loss of bladder control. C. Back pain that is relieved with resting. D. Back pain that radiates to the shoulders. 145. Oxytocin (Pitocin) is administrated to a client during labor. Which of the following is the most serious adverse effect associated with oxytocin? A. Water intoxication. B. Tetanic contractions. C. Elevated blood pressure. D. Early decelerations of fetal heart rate. 146. Nursing care for a client after electroeonvulsive therapy (ECT) should include which of the following? A. Nothing by mouth for 24 hours after the treatment because of the anesthetic agent. B. Bed rest for the first 8 hours after a treatment. C. Assessment of short-term memory loss. D. No special care. 147. All of the following would be appropriate interventions for a client with acute epididymitis EXCEPT which of the following? A. Maintaining bed rest. B. Elevating the testes. C. Applying ice packs intermittently. D. Applying hot packs to the scrotum. 148. The mother of a 9-month-old asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. Which of the following would the nurse instruct the mother to do? A. Mix new foods with formula or breast milk. B. Mix new foods with more familiar foods. C. Offer new foods one at a time. D. Offer new foods after giving formula or breast milk. 149. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with which drug? A. Barbiturates. B. Amphetamines. C. Methadone. D. Benzodiazepines. 150. After 5 days of hospitalization, the client who is receiving morphine sulfate for pain control asks for more pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior? A. His morphine dosage is too high. B. His coping mechanisms are exhausted. C. He is becoming addicted to the narcotic.

D. He has developed tolerance to his narcotic dosage. Part Two You will have one hour and 50 minutes to complete Part Two. 151. A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time? A. Impaired skin integrity related to inability to move lower extremities. B. Impaired urinary elimination related to the effects of the epidural. C. Deficient knowledge related to lack of information about regional anesthesia. D. Risk for injury related to hypotension secondary to vasodilation and pooling in extremities. 152. Which of the following would the nurse teach the mother of a child with leukemia who has an absolute neutrophil count of 900/mm3? A. The child should wear gloves when in contact with others. B. The child should stay away from crowds of people. C. The child should eat raw fruits and vegetables. D. Anyone in direct contact with the child must wear a gown and mask. 153. The nurse notices muscle twitching in the hands and forearms of the client with pancreatitis. The nurse would report these symptoms immediately because clients with pancreatitis are at serious risk for which of the following problems? A. Hypermagnesemia. B. Hyperkalemia. C. Hypoglycemia. D. Hypocalcemia. 154. During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pains, and palpitations. The client also is pale and has a wide open mouth and raised eyebrows. What should the nurse do first? A. Assist with deep breathing into a paper bag. B. Orient the client to person, place, and time. C. Set limits for acting out delusional behaviors. D. Administer an anxiolytic agent IM. 155. The nurse palpates a multipara's fundus immediately after delivery of the placenta and assesses that it's boggy. The nurse massages the client's uterus until it's firm. Which medication would the nurse anticipate to administer if the uterus becomes boggy again? A. Rho(D) immune globulin (RhoGAM). B. Magnesium sulfate. C. Oxytocin (Pitocin). D. Ibuprofen. 156. The nurse is irrigating a client's colostomy when the client

complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first? A. Stop the flow of solution temporarily. B. Reposition the client on to her right side. C. Remove the irrigation tube. D. Massage the abdomen gently. 157. A neonate girl is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5F (35.8), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. The infant is placed under the radiant heater. What should the nurse do next? A. Review the pregnancy and delivery history. B. Call the pediatrician to report findings. C. Perform a full neonate assessment. D. Check the neonate's blood glucose level. 158. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is A. an example of presenting reality. B. reinforcing the client's delusions. C. focusing on emotional content. D. a nontherapeutic technique called mind reading. 159. When developing a plan of home care for the client with multiple sclerosis, the nurse should teach the client about which of the following complications most likely to occur? A. Ascites. B. Contractures. C. Fluid volume overload. D. Myocardial infarction. 160. A toddler with croup is given a vaponefrin updraft because of increasing respiratory distress. The nurse evaluates the treatment as being effective when see which of the following? A. The child's color is normal. B. The child's retractions are less severe. C. The child's heart rate is 100 bpm. D. The child's pulse oximeter reads 90. 161. The nurse instructs the client with hemorrhoids about how to decrease the discomfort. Which of the following interventions would be most likely recommended by the nurse? A. Decrease fiber in the diet. B. Decrease physical activity. C. Take laxatives to promote bowel movements. D. Use warm sitz baths. 162. When bandaging the burned client's hand, the nurse should pay more attention about which of the following? A. The bandage is free of elastic. B. The bandage material is moistened with sterile normal saline solution.

C. The hand and finger surfaces do not touch. D. The hand and fingers are not elevated above heart level. 163. A primigravida at 36 weeks' gestation tells the nurse that she has moderate breast tenderness. The nurse teaches the client with some suggestions for relief measures. Which of the following statements by the client suggests the nurse that the client needs further instructions? A. "I should wear a supportive bra at all times. " B. "I should clean my nipples with soap. " C. "I should change my sleeping positions. " D. "I should clean up the colostrum with water. " 164. Which of the following is an early symptom of glaucoma? A. Hazy vision. B. Loss of central vision. C. Blurred or "sooty" vision. D. Impaired peripheral vision. 165. On reviewing the child's laboratory results, the nurse notes a serum potassium level of 3.3mEq/L. Which of the following would the nurse encourage the child to drink? A. Cranberry juice. B. Apple juice. C. Grape juice. D. Orange juice. 166. A client undergoes extracorporeal shock wave lithotripsy (ESWL) to break up and remove renal calculi. Which of the following nursing measures is appropriate for the postoperative care of this client? A. Maintain client on strict bed rest for 48 hours after the procedure. B. Instruct client to anticipate a decrease in urinary output. C. Instruct client to anticipate hematuria for about 24 hours after the procedure. D. Limit fluid intake to 1000 mL/day until all stone fragments have been passed. 167. Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A. Applying cold to limit edema during the first 12 to 24 hours. B. Instructing the client on the use of sitz-baths if ordered. C. Instructing the client about the importance of perineal (Kegel) exercises. D. Instructing the client to use two or more peripads to cushion the area. 168. When preparing a client for a scheduled colonoscopy, which of the following nursing interventions would the nurse include? A. Inserting a nasogastric tube 12 hours before the procedure. B. Cleansing the bowel with laxatives or enemas. C. Administering an antibiotic to decrease the risk of infection.

D. Spraying a local anesthetic into the client's throat to calm the gag reflex. 169. A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot. " The infant's birth weight was 6 pounds, 10 ounces, and his current weight is 7 pounds, 4 ounces, falling below the 5th percentile on a standard growth chart. Which of the following data would the nurse identify as the priority? A. Frequency of regular checkups. B. Feeding pattern. C. Pattern of weight gain. D. Family dynamics. 170. A new mother is concerned because her breast-feeding neonate wants to "nurse all the time. " Which of the following responses best indicates the normal neonate's breast-feeding behavior? A. "Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings. " B. "Let me call the lactation consultant to make sure that your baby is feeding properly. " C. "Don't worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction. " D. "It seems as if your baby is hungry. Why don't you provide your baby with some formula after the feeding to make sure he's getting enough nourishment?" 171. After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis? A. Pain, fever, and abdominal rigidity. B. Diarrhea with fat in the stool. C. Palpitations, pallor, and diaphoresis after eating. D. Feelings of fullness and nausea after eating. 172. A voluntary client in a health care facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following? A. False imprisonment. B. Limit setting. C. Slander. D. Violation of confidentiality. 173. Which of the following signs or symptoms would lead the nurse to suspect that a 10-year-old child is experiencing early salicylate toxicity? A. Chest pain. B. Pink-colored urine. C. Slowed pulse rate. D. Dizziness. 174. Which of the following home care activities would be appropriate for a client with a laryngectomy?

A. Keep the stoma opening covered at all times. B. Participate in activities such as walking and golfing. C. Stay inside in an air-conditioned environment in the summer. D. Avoid showering; take tub baths instead. 175. A 14-year-old girl with Type 1 diabetes is monitoring her blood glucose level at home. Which of the following actions indicates that she understands appropriate care management strategies for a blood glucose level of 250 mg/dL? A. She will skip the next dose of insulin and drink fruit juice. B. She will take insulin and drink water. C. She will eat a high-carbohydrate meal and exercise. D. She will inject glucagon and rest. 176. Which of the following would the nurse expect to assess as presumptive signs of pregnancy? A. Amenorrhea and quickening. B. A positive pregnancy test and a fetal outline. C. Braxton Hicks contractions and Hegar's sign. D. Uterine enlargement and Chadwick's sign. 177. A client returns from a myelogram, for which an iodized oil (Pantopaque) was used. Which one of the following nursing measures would be included in his care? A. Bed rest with bathroom privileges. B. Restricted fluid intake. C. Head of the bed elevated 45 degrees. D. Assessment of lower extremity movement and sensation. 178. The nurse is caring for a client with mild active bleeding from placenta previa. Which of the following observations indicates that an emergency cesarean section may be necessary? A. Increased maternal blood pressure of 150/90 mmHg. B. Decreased amount of vaginal bleeding. C. Fetal heart rate of 80 beats per minute. D. Maternal heart rate of 65 beats per minute. 179. A client with stress incontinence asks the nurse what kind of diet she should follow at home. Which of the following diet regime would most likely be recommended by the nurse? A. Avoid alcohol and caffeine. B. Decrease fluid intake. C. Increase intake of fruit juice. D. Avoid milk products. 180. The nurse is caring for a client who is experiencing auditory hallucinations. What would be most critical for the nurse to assess? A. Possible hearing impairment. B. Family history of psychosis. C. Content of the hallucinations. D. Possible sella turcica tumors. 181. A 10-year-old child with appendicitis is being prepared for surgery. Which of the following would be the nurse's first action? A. Administer an enema. B. Insert a nasogastric tube.

C. Obtain vital signs. D. Administer antibiotics. 182. The client underwent a bowel resection and was in the post-anesthesia recovery unit for 1 hour. She returns from the recovery room with an intravenous line, a nasogastrie tube, and a Foley catheter in place. She complains of pain and asks for medication. What should the nurse do? A. Administer the ordered narcotic. B. Establish the location and severity of pain. C. Determine if she was medicated for pain in the postanesthesia recovery unit. D. Reposition her and give her a back rub. 183. A client is placed in full leather restraints. How often must the nurse check the client's circulation? A. Once per hour. B. Once per shift. C. Every 10 to 15 minutes. D. Every 2 hours. 184. A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. Which of the following is a risk factor for tuberculosis in this client? A. Male sex. B. The infant is in the 95th percentile for height and weight. C. His mother did not receive prenatal care until the second trimester of her pregnancy. D. Age. 185. The client is taking triamcinolone acetonide (Azmacort) inhalant to treat her bronchial asthma. Which of the following conditions is the client at increased risk for developing while taking this medication? A. Oral candidiasis. B. Hyperglycemia. C. Gastric ulcer. D. Fluid retention. 186. Which of the following would be LEAST appropriate to assess in a mother who is breast-feeding? A. The attachment of the neonate to the breast. B. The mother's comfort level with positioning the neonate. C. Audible swallowing. D. The neonate's lips smacking. 187. When developing a teaching plan for the family of a child with seizures, which of the following would the nurse include when discussing pharmacologic treatment? A. Medication is adjusted independently when side effects occur. B. Abrupt cessation of the medication must be avoided. C. Dosages will be decreased as the child grows older. D. Medication therapy is necessary for the rest of the child's life. 188. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube

will most likely be removed when the client demonstrates which of the following? A. Absence of nausea and vomiting. B. Absence of stomach drainage for 24 hours. C. Passage of mucus from the rectum. D. Passage of flatus and feces from the colostomy. 189. Which of the following indications is the primary use for electroconvulsive therapy (ECT) ? A. Severe agitation. B. Antisocial behavior. C. Noncompliance with treatment. D. Major depression with psychotic features. 190. The mother of a 2-year-old child tells the nurse that her baby is using a potty seat but is still having problems toilet-training. Which of the following suggestions by the nurse would he most appropriate? A. Offer the child more praise each time. B. Use a potty chair instead of a potty seat. C. Focus on the "accidents" that occur during training. D. Defer training until the child is developmentally ready. 191. A client has a total serum cholesterol level of 326 mg/dL. The nurse explains to the client that this level A. is normal and requires no further treatment. B. is high and will require dietary modification. C. is low and requires no further treatment. D. is borderline normal and may require dietary modification. 192. The nurse is teaching a group of couples in a childbirth class. The nurse describes normal labor, including the premonitory signs of labor. Which of the following comments from the client indicates that further teaching is necessary? A. "My membranes won't rupture until I'm ready to deliver. " B. "I may feel Braxton Hicks contractions as my pregnancy progresses. " C. "Lightening usually occurs 2 weeks before labor begins in a first pregnancy. " D. "I'll begin to see a bloody mucus vaginal discharge as my cervix begins to dilate. " 193. The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. What should be the nurse's priority response? A. Document findings and recheck in 1 hour. B. Elevate extremity on one pillow. C. Implement passive range-of-motion exercises. D. Notify the physician immediately. 194. The nurse teaches the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium (Synthroid) therapy. Which of the following signs and symptoms would indicate an overdose?

A. Anorexia. B. Constipation. C. Sweating. D. Sleepiness. 195. Which nursing action is most effective in defusing a client's impending violent behavior? A. Helping the client identify and express feelings of anxiety and anger. B. Involving the client in a quiet activity to divert attention. C. Leaving the client alone until he can talk about his feelings. D. Placing the client in seclusion. 196. A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). The nurse explains the procedure to the client. Which of the following statements by the nurse is most appropriate? A. "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter. " B. "PTCA involves cutting away blockages with a special catheter. " C. "PTCA involves passing a catheter through the coronary arteries to find blocked arteries. " D. "PTCA involves inserting grafts to divert blood from blocked coronary arteries. " 197. Which of the following would the nurse interpret as indicating that a child is receiving too much intravenous fluid too rapidly? A. Marked increase in abdominal girth. B. Evidence of protein in the urine. C. Dark amber colored urine. D. Moist crackles in the lung fields. 198. The nurse is developing a plan of care for a client with irondeficiency anemia. Which of the following would be an appropriate nursing diagnosis of the client? A. Excess fluid volume related to anemia. B. Imbalanced nutrition related to nausea. C. Activity intolerance related to fatigue. D. Impaired home maintenance related to neurological impairment. 199. A client is fully dilated. Which of the following actions would be inappropriate during the second stage of labor? A. Positioning the mother for effective pushing. B. Preparing for delivery of the baby. C. Assessing for rupture of membranes. D. Assessing vital signs every 15 minutes. 200. The nurse is preparing the client with a cerebrovascular accident for discharge to home. The nurse should recognize which of the following factors would most likely influence the client's continuing progress in rehabilitation at home? A. The family's ability to provide support to the client.

B. The client's ability to ambulate. C. The availability of a home health aide to care for the client. D. The frequency of follow-up visits with the physician. 201. Which of the following observations indicates that the mother of a child receiving home intravenous ampicillin therapy requires further teaching? A. The mother allows the antibiotic to run into the child's vein over a period of 30 minutes. B. The mother flushes the venous access site with heparin 20 minutes after giving the antibiotic. C. The mother stops the infusion when the area around the insertion site becomes hard and reddened. D. The mother calls the home care nurse because the antibiotic solution will not infuse. 202. Which of the following activities should the nurse discourage the client with a peptic ulcer? A. Chewing gum. B. Smoking cigarettes. C. Eating chocolate. D. Taking acetaminophen (Tylenol). 203. Which classification of drugs is the most potentially fatal if the client takes an overdose? A. Antihistamines. B. Dopaminergics. C. Phenothiazine antipsychotics. D. Tricyclic antidepressants. 204. A client with a long history of ulcerative colitis takes sulfasalazine (Azulfidine) to control the condition. The nurse would anticipate the client to have which nutritional deficit that can occur as a result of taking this drug? A. Colbalamin. B. Folic acid. C. Niacin. D. Iron. 205. An 18-year-old primagravida tells the nurse that the physician told her that she needed to increase her intake of thiamine (vitamin Bi) in her diet. Which of the following foods should the nurse instruct the client to consume more? A. Milk. B. Rice. C. Asparagus. D. Beef. 206. A client with peptic ulcer has been prescribed propantheline (Pro-Banthine) as part of the treatment. Which of the following side effects is associated with this medication? A. Nausea. B. Hypotension. C. Urinary frequency. D. Fatigue.

207. Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions? A. Hyperpyrexia, slow pulse, and weight gain. B. Tachycardia, weight loss, and mood swings. C. Hypotension, weight gain, and listlessness. D. Increased appetite, slowing of sensorium, and arrhythmias. 208. An adolescent client immobilized in a spica cast complains of having trouble breathing after meals. Which of the following actions would be best? A. Encourage the client to drink more between meals. B. Teach the adolescent purse&lip breathing. C. Give the client a laxative after meals. D. Offer the client small feedings several times a day. 209. Which of the following is the most appropriate activity for the nurse to assess motor strength for a neurologically injured client? A. Compare equality of hand grasps. B. Observe spontaneous movements. C. Observe the client feed himself. D. Ask the client to signal if he feels pressure applied to his feet. 210. A 19-year-old pregnant client tells the nurse she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize which of the following? A. The client may not take care of herself. B. The client may not be fit to take care of a child. C. The client needs to take up a second job. D. The client should be referred to community resources available for pregnant women. 211. A client with an incomplete small bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum? A. Maintain bed rest with bathroom privileges. B. Advance the tube 2 to 4 inches at specified times. C. Provide frequent mouth care. D. Provide ice chips for the client to suck. 212. A 40-year-old client is admitted to the psychiatric emergency department because of sleeping difficulty, poor judgment, and incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. Which diagnosis would the nurse suspect? A. Schizophrenia. B. Paranoid personality. C. Bipolar illness. D. Obsessive-compulsive disorder (OCD).

213. What activity orders would be appropriate for a client with an internal radium implant for cervical cancer? A. Out of bed as tolerated within the room. B. Bed rest with bathroom privileges. C. Bed rest in position of comfort. D. Bed rest with the head of the bed flat. 214. Which of the following would the nurse expect to include in a community health program designed to control sexually transmitted diseases (STDs)? A. Mass screening of all individuals. B. Location of the possible sources of infection. C. Treatment of those with the disease. D. Isolation of those suspected of having STDs. 215. The nurse has been teaching the client strategies to prevent a recurrence of hemorrhoids. One strategy is maintaining a high-fiber diet. Which of the following breakfast menus is appropriate for the client? A. Danish pastry, prune juice, coffee, and milk. B. Oatmeal, milk, grapefruit wedges, and bran muffin. C. Corn flakes, milk, white toast, and orange juice. D. Scrambled eggs, bacon, English muffin, and apple juice. 216. A 23-year-old client in the manic phase of bipolar disorder is admitted to the facility. Which of the following agents would be appropriate for this client? A. Bupropion (Wellbutrin) and lithium (Lithobid). B. Lithium (Lithobid) and valproic acid (Depakene). C. Haloperidol (Haldol) and fluphenazine (Prolixin). D. Risperidone (Risperdal) and clozapine (Clozaril). 217. A community nurse is teaching a sexuality class at a community center about human immunodeficiency virus (HIV) transmission. Which of the following behaviors would most likely to be recommended by the nurse as a measure to greatly reduce the risk of HIV transmission? A. Avoiding inhalant drugs. B. Avoiding prolonged sex. C. Using latex condoms with sexual intercourse. D. Douching before and after sexual intercourse. 218. In performing a routine fundal assessment, the nurse finds a client's fundus to be "boggy. " What action should the nurse take first? A. Call the physician. B. Massage the fundus. C. Assess lochia flow. D. Start methylergonovine as ordered. 219. A client who has been using crutches at home for t week reports that he is having trouble using the crutches because his armpits hurt and his fingers tingle. What would be the nurse's most appropriate response? A. "You need to do more arm exercises. It sounds like your

muscles need strengthening. " B. "That's normal. As you adjust to the crutches, the discomfort will diminish. " C. "Be sure to take your pain medication before ambulating. That will help your discomfort. " D. "Let me watch you ambulate. Your crutches or technique may need some adjustment. " 220. The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. The nurse explains to the client that the purpose of the tube feedings is to A. prevent pain from swallowing. B. prevent fistula development. C. ensure adequate intake. D. allow for adequate suture line healing. 221. Which of the following should the nurse include in a postoperative teaching plan for a client with a laryngectomy? A. Telling the client to speak by covering the stoma with a sterile gauze pad. B. Reassuring the client that normal eating will be possible after healing has occurred. C. Instructing the client to avoid coughing until the sutures are removed. D. Instructing the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin. 222. Which of the following signs and symptoms would alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy? A. Increased blood pressure and decreased pulse and respiratory rates. B. Sanguineous drainage from the chest tube at a rate of 50 mL per hour during the past 3 hours. C. Restlessness and shortness of breath. D. Urine output of 180 mL during the past 3 hours. 223. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy? A. Having the client take rapid, shallow breaths to decrease pain. B. Having the client lay on the left side while coughing and deep breathing. C. Teaching the client to use a folded blanket or pillow to splint the incision. D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions. 224. The overweight adolescent client tells the nurse that he would like to lose weight and asks the nurse's opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate? A. Exercising more often. B. Severely limiting calorie intake.

C. Participating in an adolescent weight-reduction program. D. Cutting clown on sweets and other snacks. 225. The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the plan of care? A. Encourage regular use of antidiarrheal medications. B. Incorporate frequent rest periods into the client's schedule. C. Have the client maintain a high-fiber diet. D. Wear a gown when providing direct client care. 226. A client has been told to take ibuprofen (Motrin, Advil) to relieve the pain of her rheumatoid arthritis. Which of the following statements indicates the client understands how to take this drug safely and effectively? A. "I should not take aspirin with this drug unless my physician says to. " B. "I should not take this drug with antacids or food products. " C. "I do not need to worry about this medicine irritating my stomach. " D. "I should notice the effects of this medicine within the first few days. " 227. A client who is planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse's best response? A. "Pregnancy is a human process; you don't have to worry. " B. "You practice good health habits; just follow them and you'll be fine. " C. "There is nothing you can do to have a healthy pregnaney; it's all up to nature. " D. "Folic acid, 400 mcg(1mcg= 10g), improves pregnancy outcomes by preventing certain complications. " 228. The nurse is reviewing discharge instructions with a client after an uncomplicated delivery. Which of the following symptoms is LEAST important in characterizing postpartum depression? A. Crying easily and feeling despondent. B. Loss of appetite and anxiety. C. Altered body image. D. Difficulty sleeping and poor concentration. 229. When caring for a client during the second stage of labor, which action would be least appropriate? A. Assisting the client with pushing. B. Ensuring the client's legs are positioned appropriately. C. Allowing the client clear liquids. D. Monitoring the fetal heart rate. 230. The client was admitted with severe head injury resulting from a motor vehicle accident. The client is presently unconscious. To facilitate rehabilitation when the client's condition allows, the nurse should A. maintain limbs in the position of function. B. apply restraints to arms and legs to control spasms.

C. exercise just the arms as the legs maintain their tone longer. D. notify physical therapy as soon as the physician orders passive range of motion. 231. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which of the following resources can best help the client adapt to the disease? A. The client's family. B. Support group. C. Pastoral care. D. Hospice care. 232. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development? A. Has perceptions based on reality. B. Assumes responsibility for actions. C. Generates new levels of awareness. D. Has maximum ability to solve problems and learn new skills. 233. Which of the following would the nurse expect to include in the plan of care for a client with diabetes who is in labor? A. Measuring urine output every 4 hours. B. Monitoring blood glucose levels every hour. C. Administering insulin subcutaneously every 4 hours. D. Checking deep tendon reflexes every 2 hours. 234. A client undergoes a total laryngectomy and tracheostomy formation. On discharge, which instruction should the nurse give to the client and family? A. "Clean the tracheostomy tube with alcohol and water. " B. "Family members should continue to talk to the client. " C. "Oral intake of fluids should be limited for 1 week only. " D. "Limit the amount of protein in the diet. " 235. The nurse notices that the client's pupils are fixed and dilated. What does this finding indicate? A. The client is permanently paralyzed. B. The client is going to be blind as a result of an injury. C. The client probably has meningitis. D. The client has received a significant brain injury. 236. When administering an intramuscular injection to a neonate, which of the following muscles would the nurse consider as the best injection site? A. Deltoid. B. Dorsogluteal. C. Ventrogluteal. D. Vastus lateralis. 237. The nurse is caring for a client with an acute bleeding cerebral aneurysm. Which of the following activities is not appropriate in nursing care? A. Position the client to prevent airway obstruction. B. Keep the client in one position to decrease bleeding. C. Administer IV fluid as ordered and monitor the client for signs

of fluid volume excess. D. Maintain the client in a quiet environment. 238. A client is receiving a radiation implant for the treatment of bladder cancer. Which of the following interventions is appropriate? A. Flush all urine down the toilet. B. Restrict the client's fluid intake. C. Place the client in a semiprivate room. D. Monitor the client for signs and symptoms of cystitis. 239. For a client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to A. prevent respiratory alkalosis. B. lower arterial pH. C. promote carbon dioxide elimination. D. maintain partial pressure of arterial oxygen (PaO2) above 80 mmHg. 240. The nurse formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands such as the following A. drinking more than 1,500 mL of fluid daily. B. eating a high-protein snack at bedtime. C. eating more than three large meals per day. D. being overweight. 241. A young adult had a significant reaction to the Mantoux test. What conclusion would the nurse make from the findings? A. The client has active tuberculosis. B. The client had active tuberculosis. C. The client has been exposed to tuberculosis. D. The client is immunocompromised. 242. An 8-year-old child with asthma is being switched from parenteral steroid therapy to a daily dose of oral prednisone. Which of the following instructions would the nurse give to the parents? A. Have the child take the dose with meals to prevent gastric irritation. B. Make sure the pill is given intact to maintain the enteric coating. C. Administer the dose before bedtime to minimize side effects. D. Give the medication according to the child's response. 243. The nurse is preparing to administer a unit of blood to a client who is anemic. After its removal from the refrigerator, the blood should be administered within A. 1 hour. B. 2 hours. C. 4 hours. D. 6 hours. 244. A client with a serum glucose level of 618mg/dL is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs, temperature of 100. 6F (38.1),

heart rate of 116 beats/minute, and blood pressure of 108/70mmHg. Based on these assessment findings, which nursing diagnosis takes highest priority? A. Deficient fluid volume related to osmotic diuresis. B. Decreased cardiac output related to elevated heart rate. C. Imbalanced nutrition. Less than body requirements related to insulin deficiency. D. Ineffective thermoregulation related to dehydration. 245. A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. What should the nurse do first? A. Auscultate for bowel sounds. B. Palpate the abdomen. C. Change the client's position. D. Insert a rectal tube. 246. A 30-year-old client with 7 months pregnancy reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? A. Suggesting that she walk for 1 hour twice per day. B. Advising her to take over-the-counter calcium supplements twice per day. C. Teaching her to dorsiflex her foot during the cramp. D. Instructing her to increase milk and cheese intake to 8 to 10 servings per day. 247. Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. Which nursing observation most suggests the client is bleeding? A. Prolonged partial thromboplastin time (PTT). B. Recent history of warfarin (Coumadin) usage. C. Diminished breath sounds. D. Orthostatic hypotension. 248. Signs and symptoms of retinal detachment include which of the following? A. Painless decrease in vision, a veil over the visual field, and flashing lights. B. A veil over the visual field, increased intraocular pressure, and yellow-green halos around visual images. C. Photophobia, yellow-green halos around visual images, and blurred vision. D. Unilateral eye inflammation, a cloudy cornea, and a moderately dilated pupil. 249. A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. Which of the following should be the nurse's overall goal of care? A. To help the client perform self-care activities. B. To help the client function effectively in her environment.

C. To help control the client's symptoms. D. To help the client participate in group therapy. 250. A client is diagnosed with hyperthyroidism. The clinical manifestations of hyperthyroidism are similar to which of the following? A. Hypovolemic shock. B. Adrenergic stimulation. C. Benzodiazepine overdose. D. Addison's disease. 251. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by cirrhosis? A. Dyspnea and fatigue. B. Ascites and orthopnea. C. Purpura and petechiae. D. Gynecomastia and testicular atrophy. 252. Most antipsychotic medications exert which of the following effects on the central nervous system (CNS) ? A. Stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors. B. Sedate the CNS by stimulating serotonin at the synaptic cleft. C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. D. Depress the CNS by stimulating the release of acetylcholine. 253. To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals which of the following? A. Elevational rubor. B. No rubor for 10 seconds after the maneuver. C. Dependent pallor. D. A 30-second filling time for the veins. 254. A client is recovering from coronary artery bypass grafting (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common, spontaneously resolving symptom? A. Depression. B. Ankle edema. C. Memory lapses. D. Dizziness. 255. A few days after a colectomy, a client suddenly develops chest pain, shortness of breath, and air hunger. The nurse knows she must further assess the client's chest pain to determine its origin. When determining whether the chest pain is cardiac or pleuritic in nature, the nurse knows that pleuritic chest pain typically A. is described as crushing and substernal. B. worsens with deep inspiration.

C. is relieved with nitroglycerin. D. is relieved when the client leans forward. 256. The physician has ordered the client to receive digoxin (Lanoxicaps) twice per day until a therapeutic level is attained. When the nurse takes the client's apical pulse on the 3rd day, the pulse is 58, and the client complains of nausea. What should the nurse do next? A. Administer the medication and leave a note on the chart for the physician. B. Order a serum digoxin level to be drawn. C. Administer the medication and medicate the client for nausea. D. Withhold the medication and notify the physician. 257. Which of the following is appropriate to include in a teaching plan for a 9-year-old who has had diabetes for several years? A. Beginning recognition of symptoms of hypoglycemia. B. Measurement of insulin accurately in the syringe. C. Beginning ability to give own injections with adult supervision. D. Assumption of responsibility for self-care. 258. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, which of the following interventions is appropriate? A. Administer oxygen. B. Have the client take deep breaths and cough. C. Place the client in high Fowler's position. D. Perform chest physiotherapy. 259. The nurse is performing a neurologic assessment on a client during a routine physical examination. To assess the Bakinski's reflex, indicate the point where the nurse would place the tongue blade to begin the stroke of the foot.

A. A B. B C. C D. D Multiple-correct answer item Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space

provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number. The nurse is teaching an adolescent with inflammatory bowel disease about treatment with corticosteroids. Which adverse effects are concerns for this client? 260. (Select A or B. ) Acne. 261. (Select A or B. ) Hirsutism. 262. (Select A or B. ) Mood swings. 263. (Select A or B. ) Growth spurts. 264. (Select A or B. ) Osteoporosis. 265. (Select A or B. ) Adrenal suppression. Answers and Rationales 1. A Prior to an upper gastrointestinal endoscopy, a local anesthetic is applied to the posterior pharynx. This results in temporary loss of the gag reflex which facilitates passage of the endoscope. The client is at risk for aspiration until the gag reflex returns. Therefore, monitoring the client for return of the gag reflex is a priority nursing assessment. 2. B The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step the nurse systematically collects data about the client or family. During the planning step the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step the nurse determines the effectiveness of the plan of care. 3. B Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy. 4. A The nurse must distinguish between the primigravida and multigravida cervical dilation to make a plan of care for the laboring client. Primigravidas will efface and then dilate, while multigravidas will efface and dilate at the same time. 5. B When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis. 6. B Most clients, even children, are aware when death appears imminent. The best policy is to answer the child's questions honestly, thus helping the child feel less isolated and alone. 7. C Varicella (chickenpox) characteristically has vesicles as the hallmark lesion. Impetigo has pustules. Syphilis's primary lesion is the chancre and, in rubella, the lesion is a maculopapular rash. 8. C Foot soaks macerate the skin and increase the risk for breaks. Water-soluble lotions are recommended to moisturize the

feet. Nail files are preferred over nail clippers or scissors. Antiperspirants may be used when foot perspiration exists. 9. D The eating problems associated with Parkinson's disease include dysphagia, aspiration, constipation, and risk of choking. Fluid overload, anorexia, and diarrhea aren't problems specifically related to Parkinson's disease. Drooling occurs with Parkinson's disease but doesn't take priority. 10. B Flail chest occurs when two or more adjacent ribs are fractured at two or more sites, resulting in a free-floating segment. This loss of chest wall stability causes respiratory impairment and notable paradoxical chest wall movement. Hemothorax or pneumothorax both decrease chest wall excursion on the affected side. A tension pneumothorax causes a mediastinal shift and tracheal deviation toward the unaffected side. 11. D A urine output below 1mL/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012. 12. A Caffeine should be avoided because it increases urine output. Clients need to maintain adequate fluid intake to avoid lithium toxicity. Clients should remain on medication even though they're feeling better. Don't limit or increase salt intake because the kidneys will hold onto lithium or excrete it if salt intake varies. 13. C Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency. 14. C Breast surgery can be psychologically traumatic to a woman, especially if she closely links her womanhood and sexuality to her breasts. With this in mind, the nurse must ask proactive questions regarding the client's feelings about her own breasts. Listing accomplishments or describing ambitions will give the nurse a general impression of the client's self-concept; however, at this point, the breast-related question is more valuable because of the nature of the illness and the proposed surgery. Eliciting information about the husband's comments doesn't focus on the nurse's assessment of the client's perception of herself. 15. C 35mg/x mL=25mg/mL, x=1.4mL. 16. B Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hypophosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased. 17. B Because of colloidal properties, oatmeal preparation baths often help relieve the itching associated with chicken pox. Calamine lotion can be used also. 18. A As a rule of practice, if intermittent catheterization for

urine retention typically yields 500mL or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of a client with urine retention. 19. A Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals--not given privacy. Exercise must be limited and supervised. 20. A Headache following a lumbar puncture is usually caused by cerebrospinal fluid (CSF) leakage. Increased fluid intake will help restore CSF volume. Antihypertensives don't address the problem. Roll lenses reduce light irritation to the eyes and ice may reduce site pain, but neither intervention addresses the problem of reduced CSF volume, which causes the headache. 21. C The goal during induction of labor is to produce a contractile pattern similar to that observed in spontaneous labor. The infusion of oxytocin is increased until a contractile pattern is achieved in which the contractions occur every 2 to 3 minutes with a duration of 40 to 60 seconds in a 10-minute period and the uterus relaxes between contractions. One of the complications of an induction is the risk of uterine rupture. The client scheduled to receive oxytocin is monitored for at least 20 minutes before initiation of the drug to establish a baseline fetal heart rate. Thereafter, the client is monitored in the same way as a client in spontaneous labor, which depends on the maternal and fetal responses to labor. 22. C In chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing--not chest breathing-- increases lung expansion. 23. D Hypothetical ethical situations--such as "What would you do if you found a wallet containing credit cards and identification?"-are used to test judgment. Proverb interpretation tests thinking. Spelling words backward and counting by serial sevens test concentration. 24. C Pain may be triggered by touching the face, being exposed to a cool breeze, having hair touch the face, talking, or chewing. 25. C One nursing goal for clients with febrile seizures is to maintain temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the

client's temperature. 26. C When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn't be permitted to eat as desired. Weighing the client daily, placing her on IO status, and drawing blood to determine electrolyte levels aren't part of a nutritional assessment. 27. D Children with sickle cell disease are prone to develop infections as a result of the necrosis of areas within the body and a generalized less-than-optimal health status. If the child with sickle cell anemia develops signs of infection, such as sore throat and fever, prompt evaluation is necessary because an infection can precipitate a crisis. 28. A As a response to shock, the renin-angiotensin-aldosterone system alters renal function by decreasing urine output and increasing reabsorption of sodium and water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve circulating volume. 29. A Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation. 30. C Feeding methods should produce the least tension possible on the sutures to promote effective healing of the cleft lip repair. Therefore, a rubber-tipped medicine dropper has been found to be a satisfactory method for feeding an infant who has had surgical repair of a cleft lip. 31. A IV push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Bretylium is used to treat ventricular fibrillation (VF) and unstable ventricular tachycardia (VT). Lidocaine is used to treat ventricular ectopy, VT, and VF. 32. B Denial is a defense mechanism commonly used by alcoholics. The CAGE questionnaire is a direct method of discovering whether the client is a substance abuser, but the client is likely to deny the problem regardless of whether he's familiar with this assessment tool. Distorted thought processes and the cost of alcohol are less likely to influence the client's use of denial. 33. A Vitamin A is important for the eye's ability to see color. The B complex vitamins play a role in many functions, including nerve conduction. Vitamins E and C have antioxidant properties and aid in wound healing. 34. D Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from

breast-feeding because of the strain on the mother's defective heart. 35. C When bending forward, a person who has idiopathic scoliosis has an obvious rib hump. The two sides of the back at the hips, ribs, or shoulders are not level. 36. A Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones. 37. A Apgar scores at 1 and 5 minutes after delivery estimate the severity of respiratory and neurologic depression. Studies have shown a high correlation between a low 5-minute Apgar score and the incidence of residual neurological damage. Apgar scores aren't used to determine the presence of congenital heart defects or the gestational age of the neonate. 38. D This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. The first two responses put the client in a defensive position and may set up a power struggle. The third response ignores the psychological implications of the client's actions. 39. A An exercise, such as the pelvic tilt, can help restore body alignment and alleviate backache. Squatting strengthens the pelvic muscles. Stretching and walking are good exercises but often don't relieve backache. 40. A Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease urine output and oral fluid intake. 41. A A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. 42. D CAD develops when fatty deposits line the walls of the coronary arteries, impeding blood flow and therefore decreasing cardiac output. Thermoregulatory disturbances aren't usually associated with CAD unless accompanied by heart failure. Impaired gas exchange may occur if the blood's oxygen-carrying capacity were altered, as in anemia, chronic obstructive pulmonary disease, or carbon monoxide poisoning. There would be a risk of injury if the client had sensory or motor deficits. 43. B The basis for these symptoms is most likely physiologic. There are two types of dysmenorrhea, primary and secondary. Primary, the most common type, is believed to be caused by an increased level of prostaglandins producing uterine hyperactivity and contractions. 44. C Hypertension would not be expected. Spinal shock produces massive vasodilation and subsequent pooling of blood in

the peripheral circulation. 45. C One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself. 46. B To maintain proper infusion rates and prevent line contamination, it is important to inspect the site carefully for fluid leakage or kinks in the tubing under the dressing. 47. D The dose is calculated by first determining the weight in kilograms: 15 pounds, 6.4 ounces is equal to 15. 4 pounds; 15.4 pounds divided by 2.2 is equal to 7 kg. Multiplying 10.3 mg by 7 kg equals 72.1 mg. In computing a daily dosage, the dose is multiplied by the number of times it will be given per day (72.1 mg6=432.6 mg/day). 48. C Some elderly people are not good candidates for crutch walking because they are not strong enough to use crutches or are not coordinated enough to walk safely with crutches. 49. A Neonates are obligate nose breathers and have no ability to breathe through their mouths. Therefore, blocked nares contribute to respiratory distress in the neonate. Nasal patency is unnecessary for neonate feeding. Nasal flaring may indicate respiratory distress. A deviated septum doesn't cause significant breathing difficulties. 50. D Clients with somatization are prone to "doctor shop" and have extensive medical records as a result of their multiple procedures and tests. Clients with somatization aren't usually cognitively impaired. These clients have coexisting anxiety and depression and no medical evidence to support a clear-cut diagnosis that is causing their symptoms. 51. B Theophylline ethylenediamide is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used. 52. A In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure. 53. D The nurse should suspect that a client has urinary retention when she is unable to void in an 8-hour period. Before calling the physician for an order to catheterize the client, the nurse should assess the client's bladder for distention. 54. A When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the neonate

than a forceps delivery. Cephalohematomas occur more often in assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period. 55. D Annual influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia. 56. C Readiness for weaning is an individual matter but is usually indicated when an infant begins to decrease the time spent nursing. The infant is then showing independence and will soon be ready to take a cup and learn a new skill. 57. B Propranolol hydrochloride is a -adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other dysrhythmias. 58. D A child with congenital hypothyroidism who is receiving thyroid replacement therapy should be regularly assessed for blood levels of thyroxine and triiodothyronine and also undergo frequent bone age surveys to ensure optimum growth. Results of bone age surveys would demonstrate growth, indicating that the medication was adequate and effective. 59. D People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention. Fluid retention can lead to decompensation and hospitalization. 60. D One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual. 61. C Knowledge of foot care is essential for the client with diabetes mellitus, especially a newly diagnosed diabetic, because of the risk for complications secondary to the effects of diabetes on the vascular and neurologic systems. Improper care may lead to serious debilitating complications. 62. A Psychosoeial factors should be suspected when pain persists beyond the normal tissue healing time and physical causes have been investigated. The other choices may or may not be correct but certainly aren't credible in all cases. 63. D Although clients cannot eliminate stress, they can improve their ability to cope with it. 64. C Allowing the preschool-aged child to give play injections can help to prepare the child to receive an injection. Preschoolers have a limited vocabulary. They express their feelings through play. They also use play to help cope with stress. 65. A Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address

the client's concerns. Telling her that she may be excessively worried isn't therapeutic. 66. D A water-soluble lubricant offsets dryness and enhances comfort during healing. The lubricant also prevents secretions from drying and crusting in the nose. 67. D When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self-care. 68. B The nurse should listen to the client's requests, express willingness to seriously consider the requests, and respond later. High-calorie finger foods should be offered to supplement the client's diet, if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. The nurse should set limits in a calm, clear, and self-confident tone of voice. 69. D A multidisciplinary approach to pain relief is needed for greatest effectiveness. In addition to the client, the nurse, and the physician, others who may be needed on the team include a social worker, an occupational therapist, a dietitian, and a psychologist or a psychiatrist. 70. A An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur. 71. A Weight gain will be slow and gradual because less food can be eaten at one time due to the decreased stomach size. More food and fluid will be tolerated as edema at the suture line decreases and healing progresses. The remaining stomach may stretch over time to accommodate more food. 72. C The nurse should first focus on meeting the client's immediate physical needs and preventing complications related to the catatonic state. The need for intervention from security personnel is unlikely. A magnesium sulfate drip isn't indicated. Nutritional status should be addressed after the client is fully assessed and admitted. 73. A The nurse's most appropriate action is to assess the infusion system to determine the cause of the inaccurate flow rate and to note the client's response to the decreased infusion, especially signs of hypoglycemia. The physician should be notified of the infusion discrepancy. 74. B Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing

care includes emotional support to reduce anxiety and management of symptoms. These signs aren't normal reactions to ovulatory stimulants and aren't signs of pregnancy. 75. A Until age 7 years, children are normally myopic and nearsighted. Additionally toddlers lack motor coordination and their depth perception is not well developed, placing them at risk for falling. 76. C Immune serum globulin is administered prophylactically to people exposed to hepatitis A. Hepatitis A vaccine (Vaqta) may be used in conjunction with immune globulin for immediate and longterm protection. 77. A Although talking about their experiences can be difficult, clients with PTSD can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. 78. A Muscle mass determines whether or not a muscle can be safely used as an injection site. The gluteal muscle enlarges in response to use in walking. After the child has been walking for a year, it should be safe to use the gluteus maximus for injections. 79. B The remaining testicle undergoes hyperplasia and produces enough testosterone to maintain sexual drive, libido, and secondary sexual characteristics. 80. B Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include. 81. D When a client exhibits magical thinking, he believes that his thoughts or wishes can control others or events. For example, the client may believe that through wishing he can make a plane fall from the sky. Ambivalence is the coexistence of positive and negative thoughts. Returning to an earlier stage of development is termed regression. A meaningless repetition of words is called echolalia. 82. B Oral food and fluids are withheld before surgery when a client receives general anesthesia primarily to help prevent vomiting and possible aspiration of stomach contents. 83. C A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age. Increased heart rate is an early indication of ensuing septic shock. 84. D Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia. 85. C It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important but not as important as developing trust and rapport. 86. C After a client has an amniotomy, the nurse should ensure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the

fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery. 87. B Anal excoriation is inevitable with profuse diarrhea, and meticulous perianal hygiene is essential. Sitz baths are comforting and cleansing. 88. C The nurse should suspect child abuse when the child's earegiver changes the story of the injury each time it is told. 89. D Clients with diverticulitis usually receive antibiotics. Anticholinergics may also be prescribed. 90. A An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect. 91. C Mood swings are thought to be related to the altered hormonal levels associated with pregnancy. The nurse should suggest that the patient try to avoid fatigue and stress because these factors can exacerbate mood swings. The patient doesn't need professional counseling unless symptoms of psychosis are present. Telling the patient to keep her feelings to herself or to decrease her narcissistic behaviors would be inappropriate. 92. C Clients undergoing pelvic surgery are at increased risk for thrombophlebitis postoperatively. Extensive pelvic surgery, such as that involved in an ileal conduit, removes lymph nodes from the pelvis and results in circulatory congestion from edema and stasis. 93. D Using only one syringe is recommended for the client taking regular insulin along with an intermediate-or long-acting insulin. Additionally, insulin types, such as protamine zinc, globin zinc, and NPH, contain an additional modifying protein that slows absorption. Therefore, a vial of insulin that does not contain the protein (ie, regular insulin) should never be contaminated with insulin that does have the added protein. 94. B Needle length depends on the amount of adipose tissue at the site and the angle at which the injection is given. 95. A These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort. 96. D The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings. 97. D In the event of wound evisceration, the first action would be to cover the wound with a sterile towel or dressing moistened with sterile normal saline solution to prevent possible infection and keep the protruding viscera moist.

98. D For a preschooler, psychological preparation for events is the joint responsibility of the physician, parents, and nurse, each playing a major role in caring for the child and meeting specific needs. 99. C Labor is divided into four stages: first stage, onset of labor to full dilation. second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition. 100. D The most effective health-promotion measure associated with glaucoma is annual intraocular pressure measurements after 40 years of age. People who are at risk for developing glaucoma, such as those with diabetes or hypertension, African Americans, and people with a family history of glaucoma, should have their intraocular pressure checked annually after 35 years of age. Glaucoma is insidious, basically asymptomatic, and must be diagnosed before the client becomes aware of any vision changes. 101. D The client may find security in the presence of a trusted person. Her fears are very real and she'll need the emotional support of caring professionals to overcome them. Telling the client she has to overcome her fears minimizes her feelings. Allowing the client to stay in her room doesn't help the client overcome her feelings of panic. 102. D The onset of the action of insulin is 1/2 to 1 hour. The peak action occurs in 2 to 4 hours. The child needs to be checked for a hypoglycemic reaction (shaking, feelings of anxiety, and decreased level of consciousness) 2 hours after the insulin is given. 103. D Tendency toward capillary fragility has nothing to do with thermoregulation. The hypothalamus is the site of temperature regulation. In preterm neonates, the CNS is poorly developed, so these neonates may be more prone to temperature instability. The large skin surface area provides the perfect medium for heat toss through evaporation and convection. Lack of SC and brown fat are also contributors to temperature instability. Without SC fat, there is nothing to insulate the infant from heat loss. Brown fat provides calories that help with heat production. 104. B Urine output below 30 mL/hour could indicate stomal edema which obstructs urine output. 105. C The client is exhibiting the defense mechanism of regression--a return to behavior characteristic of an earlier developmental level. Dependent, attention-getting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety. 106. C Because of decreased fluid reabsorption from the colon, the child with a colostomy benefits from a liberal fluid intake. Infants also dehydrate more quickly than adults do because of immature

kidneys, larger body surface area, and more fluid in the extracellular spaces. Therefore, the parents need instructions about giving the infant plenty of liquids to drink. 107. D Serum creatinine is the most reliable indicator of renal function. 108. D Because birth is imminent, the most important information is the expected due date because it will help the health care team prepare to meet the special needs of a preterm or postterm infant. The duration of previous labor, frequency of contractions, and presence of bloody show aren't significant because birth is imminent and these factors don't affect the provision of safe care during childbirth. 109. A Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren't hormonal effects. 110. A Breathing and coughing cause pain in clients with high abdominal incisions. Chest excursion decreases, which decreases coughing and deep-breathing efforts. Shallow breathing leads to hypoventilation and atelectasis. 111. C To promote self-feeding, the nurse should provide the child with foods that can be eaten with the fingers or that do not spill easily. 112. B In catatonic schizophrenia, the client exhibits little reaction to the environment, although periods of excitement may surface at times. Bizarre postures and the inability to feed, wash, and dress oneself are also evident in the catatonic type. Activities of daily living may be affected in varying degrees with the other types but to a lesser extent. 113. C Usual postoperative activity orders for a client with a total knee replacement include transferring the client out of bed to a chair on the first postoperative day. The affected leg is protected with a knee immobilizer and elevated while the client is up in the chair. 114. A The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium. 115. C Prematurity is the leading cause of neonatal deaths in the United States; other industrialized nations have fewer premature births and fewer neonatal deaths than the United States does. Although the other three answers are complications of prematurity, prevention is the outcome nurses must focus on while providing care to their clients. 116. B Baclofen is a central-acting skeletal muscle relaxant that

is used to decrease the spasticity experienced by individuals with multiple sclerosis. 117. C Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances. 118. A Steroid use tends to elevate glucose levels. The child should be monitored for increases. 119. A In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. 120. B After a lumbar puncture which is a traumatic procedure for a 4-year-old child, the child needs to be comforted by people she trusts. Thus, the nurse should encourage the parents to hold the child to provide the necessary support. 121. A Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence. 122. C The dysreflexia occurs from a sympathetic response to autonomic nervous system stimulation. A distended bladder is the most common cause. After placing the client in Fowler's position, the nurse should check the urinary catheter for patency. 123. A Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the plan of care during the fourth stage of labor. 124. D Female neonates may have some vaginal bleeding in the 1st or 2nd day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician doesn't need to be called. This bleeding is normal and doesn't indicate dehydration or hematuria. 125. A Hypoglycemia is dangerous because it can lead to permanent brain damage. Changes in cerebral function occur because the brain uses glucose for metabolism and is unable to use alternative sources of energy as well as glucose. Prompt treatment of hypoglycemia is essential to prevent cellular damage. 126. B Hypokalemia is an ongoing problem for a client with cirrhosis. When a diuretic is needed, the ideal choice is a potassiumsparing agent. Spironolactone is the diuretic of choice for clients with cirrhosis because it facilitates sodium excretion while conserving potassium. 127. A HCG is the hormone responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial HCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.

128. A When taking propylthiouracil (PTU), the client should report any unusual bleeding or bruising as this drug can cause bone marrow depression. Blood tests should be scheduled regularly to detect any hematological changes early. 129. A Providing a safe environment will ensure safety when a client has poor judgment, memory loss, and an unsteady gait. Overactivity and noise can overstimulate a client with dementia of the Alzheimer's type by causing agitation. The use of nonverbal communication techniques, such as touch, convey acceptance to the client and can be comforting. The use of restraints can increase a client's agitation. 130. C Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid-base bicarbonate is increased, and the pH becomes more alkaline. 131. B Calories per kg is the accepted way of determining appropriate nutritional intake for a neonate. The recommended calorie requirement is 110 to 130 calories per kg of neonate body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. 132. C Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months. 133. D Once the child is alert, he may have sips of clear liquids. Eating enhances the blood supply to the throat, which promotes rapid healing. However, the child should start with clear fluids. 134. C Wound infection can best be prevented by using strict sterile technique during dressing changes. 135. A The most reliable indicator of improvement in the patient with anorexia nervosa is electrolyte balance. As the patient starved herself, the body entered a hypometabolic state. Decreased nutrients and the loss of electrolytes through vomiting and laxative use contribute to electrolyte imbalances. As the patient begins eating and ceases purging, electrolyte begin returning to normal. 136. A For most clients with insulin-dependent diabetes mellitus, nonstress testing is done weekly until 32 weeks' gestation to assess fetal well-being. A nonreactive test may be followed by a contraction stress test (CST), but CST's aren't performed weekly because of the risks involved. The mother should make daily fetal movement counts beginning at 28 weeks' gestation. Labor may be induced for clients with large fetuses at 37 to 38 weeks' gestation. 137. D To control his increased intraocular pressure, the client will need to continue taking eye medications for the rest of his life. 138. A Spasticity can cause the toddler to stand or walk on his toes due to an upper motor neuron type of muscular weakness resulting in increased muscle tone. 139. C It's important for the nurse to distinguish between a client who is having her first baby and one who has already had a baby. For the client who is pregnant for the first time, quickening

occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations. 140. A Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, this isn't a typical response. 141. A It is best to support the client's leg in its proper anatomic position and to prevent external rotation by supporting the leg with sandbags. A trochanter roll can also be used. Sandbags should be placed along the length of the thigh and lower leg. 142. D With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth. 143. B A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/L, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. 144. C A typical symptom of a herniated lumbar disk is low back pain that is usually relieved by rest and aggravated by activity that causes an increase in fluid pressure in the spine, such as sneezing, coughing, lifting, and bending. Muscle weakness and sensory losses may occur, and there is generally a change in tendon reflexes. 145. B Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration. 146. C The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of

ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable. 147. D Intermittent ice application will enhance comfort and reduce swelling. 148. C Infants should be offered new foods one at a time. This gives the infant the chance to become gradually familiar with a variety of food tastes and textures and also helps identify any allergies or adverse reactions to a specific food. 149. C Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. 150. D Tolerance to a regular narcotic dose can develop with frequent use. The client experiences increased discomfort, asks for medication more frequently, and exhibits anxious and restless behavior, which are often misinterpreted as indicative of developing dependence or addiction. 151. D The highest priority of care for the client receiving an epidural anesthetic is monitoring blood pressure and preventing hypotension, which is a frequent complication of regional anesthesia. IV fluids are given before the epidural agent to increase blood volume and cardiac output and to minimize hypotension. 152. B The normal neutrophil count range is 3,000 to 5,000 cells/mm3. An absolute neutrophil count of 900/mm3 is low, placing the child at high risk for infection. Therefore, the nurse should instruct the mother to have the child avoid crowds because of the risk of exposure to infection. Additionally, siblings and others who have an active infection should stay away from the child. 153. D Hypocalcemia is a major potential complication of pancreatitis. Muscle twitching and irritability are primary symptoms of hypocaleemia. Calcium replacement must begin as soon as hypocalcemia is validated. 154. A Physiologic needs, particularly breathing, are the first priority during a panic attack. Restoring normal breathing patterns should relieve the other symptoms. Orientation usually is unnecessary because most clients respond to external control and reduced stimulation. During a panic attack, the client isn't likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but isn't the first priority. 155. C Oxytocin would be given to cause the uterus to maintain a firm contraction. When the uterus remains boggy, the myometrium isn't contracted, and bleeding occurs at the placental attachment site. Ibuprofen has anti-inflammatory properties but doesn't prevent a boggy uterus. RhoGAM is given to prevent Rh isoimmunization. Magnesium sulfate is given to stop preterm labor contractions because it causes the uterine smooth muscle to relax.

156. A The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. 157. D Maintenance of a blood sugar level at 50 mg or greater is required to ensure enough glucose for the brain and metabolism. Neonates who are cold stressed are at high risk for low blood sugars, a condition that requires immediate intervention to prevent damage to the neurologic system. Performing a full assessment, reviewing the pregnancy and delivery history, and contacting the pediatrician are done after the blood glucose level is obtained. 158. C The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic. 159. B Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. 160. B Vaponefrin is epinephrine in an inhalant form. It is given to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening. 161. D Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. 162. C When bandaging the client's fingers and hands, the nurse must ensure that skin surfaces do not touch. Allowing skin surfaces to touch interferes with normal healing and is likely to be irritating. 163. B The client needs further instructions when she says she should clean her nipples with soap. Soap can be extremely irritating to sensitive nipples. The client should wear a supportive bra at all times, change her sleeping position, and clean up the colostrum with water. 164. D In glaucoma, peripheral vision is impaired long before central vision is impaired. 165. D A serum potassium level of 3.3 mEq/L is low for a child; the normal range is 3.5 to 5.0 mEq/L. Because orange juice is the best source of potassium, the nurse would encourage its consumption. Additional sources of potassium are bananas, cantaloupe, grapefruit juice, tomato juice, honeydew melon, nectarines, and boiled and baked potatoes. 166. C It is normal for hematuria to occur for up to 24 hours after ESWL. Hematuria that occurs for longer than 24 hours should be reported to the physician. 167. D Using two or more peripads would do little to reduce the

pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration. 168. B A colonoscopy is the visual examination of the large bowel using a fiberoptic endoscope inserted into the client's rectum. Typically the client will be placed on a liquid diet 24 hours before the procedure and kept NPO after midnight the night before the procedure. The bowel is cleansed through the use of laxatives and enemas. 169. B Because the infant falls below the 5th percentile on a standard growth chart, failure to thrive, a term applied to an infant who is not growing at an acceptable rate, must be considered. Information about feeding patterns including type and amounts of food needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth is slowed. 170. A Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breastfeeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding infant. 171. A Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. 172. A Confining a voluntary client against his will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated. 173. D Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use. 174. B The client should be encouraged to participate in activities such as walking, golfing, and other moderate recreational sports. 175. B A blood glucose level of 250 mg/dL is indicative of diabetic ketoacidosis. The client should take insulin to lower glucose levels, drink water to prevent dehydration, and contact her health care provider. 176. A Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators-for example, uterine enlargement, Chadwick's sign, a positive pregnancy test, Braxton Hicks contractions, and Hegar's sign. Positive signs and objective indicators such as fetal outline on

ultrasound confirm pregnancy. 177. D Neurologic status in the lower extremities is assessed frequently, as is the client's ability to void. This is done to determine if there is any nerve impairment. 178. C A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean delivery to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate. 179. A Clients with stress incontinence should be encouraged to avoid alcohol and caffeine products because both are bladder stimulants. 180. C To prevent the client from harming himself or others, the nurse should encourage the client to reveal the content of auditory hallucinations. 181. C Any child going to surgery needs a current set of vital signs documented on the chart. 182. B Thorough assessment of the client's pain is always the first step in treating pain. 183. C Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities. 184. D Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. 185. A Azmacort inhalant is a corticosteroid. Use of a steroid inhalers can cause the client to develop oral candidiasis (thrush). It is important that the client rinse his or her mouth after use of the inhaler. 186. D Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A neonate who is smacking his lips isn't well attached and can injure the mother's nipples. 187. B Abrupt cessation of the medication must be avoided because sudden drug withdrawal most commonly leads to status epilepticus, a life-threatening emergency situation. 188. D A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. 189. D ECT is indicated for depression. ECT isn't indicated for severe agitation, antisocial behavior, or treatment noncompliance. 190. D The most common reason for failed toilet-training is that the child is simply not developmentally ready for training. Even with appropriate rewards and proper equipment, the child who is not

ready for training will not be able to learn voluntary control. 191. B A total serum cholesterol level of 326 mg/dL is high. A client with a cholesterol level of 326 will require dietary modifications and may be placed on lipid-lowering medication. 192. A Most clients' membranes will rupture before the time of delivery, but approximately 12% will rupture before the onset of labor. Premonitory signs of labor include Braxton Hicks contractions; lightening (which usually occurs 2 weeks before labor begins in a first pregnancy); cervical changes, including the softening and ripening; bloody mucus vaginal discharge (bloody show); rupture of the membranes; a sudden burst of energy; weight loss; increased backache; and diarrhea, indigestion, nausea, or vomiting. 193. D The absence of a pulse, decreased sensation in the extremity, and increasing edema are all indicative of compromised neurovascular status due to compartment syndrome. Loss of pulse or sensation must be reported immediately to the physician. An escharotomy or fasciotomy may need to be performed to release pressure in the extremity. Other assessments to note include the temperature, capillary refill time, and movement or increasing pain of the affected extremity. 194. C Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss are all signs indicating levothyroxine (Synthroid) overdose. 195. A In many instances, the nurse can defuse impending violence by helping the client identify and express feelings of anger and anxiety. Statements such as, "What happened to get you this angry?" may help the client discuss feelings rather than act on them. 196. A PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. 197. D Moist crackles in the lung fields are an indication that fluid is accumulating in the lungs due to overhydration or too-rapid delivery of fluids. 198. C Fatigue is commonly experienced by clients with irondeficiency anemia due to reduced oxygen-carrying capacity from low hemoglobin. The fatigue may lead to the client's inability to participate in activity. 199. C In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time. 200. A The strong support of family members is frequently identified as an important factor that influences a stroke client's continuing progress in rehabilitation after discharge. Discharge planning should prepare the client and family for the many changes necessary when the client returns home. 201. B When administering intravenous antibiotics, heparin or saline should be used to flush the intravenous line as soon as the

infusion is completed so that the line remains patent. Waiting for 20 minutes is too long. 202. B Cigarette smoking should be avoided because of its stimulatory effect on gastric secretions. Nicotine also increases the release of epinephrine, which leads to vasoconstriction. 203. D Tricyclic antidepressants can create fatal cardiac arrhythmias. Overdose of the other medications is rarely fatal. 204. B Clients who take sulfasalazine are susceptible to developing impaired folic acid absorption. Common clinical manifestations of a folic acid deficiency are gastrointestinal disturbances such as anorexia, nausea, vomiting, and a smooth, beefy red tongue. The client should be encouraged to eat food high in folic acid such as green leafy vegetables, meat, fish, legumes, and whole grains. 205. A Good sources of thiamin include pork, liver, milk, potatoes, enriched cereals, and enriched breads. Rice, asparagus, and beef aren't good sources of thiamine. 206. A A common side effect of propantheline, an antichoiinergic, is nausea. Other common side effects include blurred vision, dry mouth, vomiting, and urinary retention. 207. B Stimulants produce mood swings, weight loss, and tachyeardia. The other symptoms indicate CNS depression. 208. D A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm resulting in decreased chest expansion and subsequent possible respiratory distress. Because the client's complaints are associated with meals, offering small frequent meals provides nutritional support while minimizing distention. 209. A Comparing equality of hand grasps is a technique used to assess motor strength. 210. D The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly, but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily solve this situation. 211. B Once the intestinal tube has passed into the duodenum, it is usually advanced as ordered 2 to 4 inches every 30 to 60 minutes. This, along with gravity and peristalsis, enables passage of the tube forward. 212. C Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Schizophrenia doesn't exhibit mood swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is commonly accompanied by grandiosity. OCD is a preoccupation with rituals and rules. 213. D The client with a cervical implant is kept on strict bed rest, flat in bed. Limitation of movement is designed to prevent

accidental displacement or implant dislodgment. Client knowledge and understanding are critical to compliance with these restrictions. 214. B Community health measures for controlling STDs most commonly focus on locating the sources of infection. Doing so allows the infected person to identify the person's sexual contacts and urge them to get treatment. 215. B Oatmeal, grapefruit wedges, and bran muffins are all high-fiber foods. 216. B Lithium and valproic acid are the drugs of choice for manic depression. Wellbutrin is an antidepressant, not an antimanic. Haloperidol, fluphenazine, clozapine, and risperidone are antipsychotic agents. 217. C Using a latex condom in conjunction with a spermicide during sexual intercourse greatly reduces the risk of HIV transmission. Because HIV is most concentrated in blood and vaginal and seminal fluids, protective measures during intercourse are necessary to prevent transmission. 218. B The nurse should begin to massage the uterus so that the uterus will be stimulated to contract. Lochia flow can be assessed while the uterus is being massaged. The client shouldn't be left while the nurse calls the physician. If the fundus remains boggy and the uterus continues to bleed, the nurse should use the call light to ask another nurse to call the physician. An order for methylergonovine may be obtained at this time if needed, or the nurse may administer methylergonovine as written. 219. D The nurse should reevaluate the client's use of his crutches because pressure on the axillae from the crutches can lead to "crutch paralysis" secondary to pressure on the brachial plexus nerves. This pressure can result from crutches that are used inappropriately or sized incorrectly. 220. D A nasogastric tube is usually inserted during surgery to instill food and fluids postoperatively. The tube allows the suture line to heal adequately, minimizes contamination of the pharyngeal and esophageal suture lines, and prevents fluid from leaking through the wound into the trachea before healing occurs. Normal oral feedings are resumed as soon as the nasogastric tube is removed, usually within 10 days after surgery. 221. B Normal eating is possible once the suture line has healed. 222. C Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. 223. C A folded bath blanket or pillow placed over the incision will be most effective in helping the client cough and deep breathe after a cholecystectomy. 224. C Weight loss treatment modalities that include peer involvement have been proven to be the most successful approach with obese adolescents. This is because peer support is critical to

adolescents, especially with an all-encompassing problem such as obesity. 225. B It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be ordered. 226. A Ibuprofen can be irritating to the stomach and should not be taken with other drugs that are known gastric irritants such as aspirin. 227. D When counseling a client who is planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The nurse should provide information but not prescribe the drug. It's the client's responsibility to ask the health care provider about a prescription. Telling the client not to worry ignores the client's needs. Practicing good health habits is important for any person. Telling the client that it's up to nature is inaccurate. 228. C A variety of symptoms characterize postpartum blues, including loss of appetite, crying easily, despondency, difficulty sleeping and concentrating, feeling let down, and anxiety. Perceiving an altered body image is normal in pregnancy and the postpartum period because of the physiologic changes that take place at these times. 229. C During this time, the client is usually offered ice chips rather than clear liquids. Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate. 230. A Maintaining the client's limbs in the position of function decreases the likelihood of contractures. There's no evidence that the client is experiencing spasms, and the nurse would exercise the arms and legs as long as injuries permit. The longer rehabilitation is delayed, the more difficult it is. 231. B Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease- related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life. 232. C Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development--not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30. 233. B Because metabolic changes occur during labor and

delivery, close monitoring of the diabetic client's blood glucose level, every hour during the labor, is necessary. 234. B Commonly, family members are reluctant to talk to a client who has had a total laryngectomy and no longer can speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client and family to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing. 235. D When the client has received an injury to the midbrain, the pupils become fixed and dilated, an ominous sign. Paralysis, blindness, and meningitis have clinical manifestations other than fixed and dilated pupils. 236. D The vastus lateralis muscle of the thigh is preferred for administering intramuscular injections to infants because there is less danger of injuring nerves, blood vessels, or bony structures at this site. 237. B The nurse shouldn't keep the client in one position but rather carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding. 238. D Cystitis is the most common adverse reaction associated with radiation therapy; symptoms include dysuria, frequency, urgency, and nocturia. Clients with radiation implants require a private room. Urine of clients with radiation implants for bladder cancer should be sent to the radioisotopes laboratory for monitoring. It's recommended that fluid intake be increased. 239. C The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mmHg; 60 mmHg will adequately oxygenate most clients. 240. D Conditions that increase oxygen demands include being overweight, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 mL of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals per day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic

bronchitis should eat small, frequent meals (up to six per day). 241. C A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis. 242. A Prednisone causes severe gastric upset. Therefore, it should be given with food. 243. C After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. Options A and B are incorrect because the client could experience fluid overload if the blood is administered too rapidly. Option D is incorrect because of the extended time out of refrigeration and risk of contamination and growth of bacteria. 244. A A serum glucose level of 618 mg/dL indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition. Less than body requirements isn't appropriate. A temperature of 100. 6F isn't life-threatening, eliminating ineffective thermoregulation as the top priority. 245. A If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation, and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort. 246. C Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours per day during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a balanced diet, calcium supplements or additional servings of high-calcium foods may be unnecessary. 247. D Bleeding is a volume-loss problem, which causes a drop in blood pressure. As the bleeding persists and the body's ability to compensate declines, orthostatic hypotension becomes evident. A prolonged PTT and a history of warfarin usage are causes of bleeding but aren't evidence of bleeding. As bleeding persists and the client's level of consciousness declines, breathing will become more shallow and breath sounds will diminish; however, this is a late and unreliable manifestation of bleeding.

248. A A client with retinal detachment has a painless decrease in vision and vision that is cloudy or smoky with flashing lights. The client may also indicate that a curtain or veil is over the visual field. Intraocular pressure is normal or low. Photophobia, yellow-green halos around visual images, and blurred vision may occur with digoxin toxicity. Unilateral eye inflammation, cloudy cornea, and a moderately dilated pupil that isn't reactive to light may occur with glaucoma. 249. B A client with panic disorder typically confines movements to increasingly smaller areas to avoid confronting fears, which may dominate her life and limit everyday activities. The overall goal of care is to help the client function within her environment as effectively as possible. Panic disorder with agoraphobia doesn't impair ability to perform self-care activities. Controlling symptoms isn't the overall goal; furthermore, helping the client function effectively will help control symptoms. Although participation in group therapy may help the client control symptoms, encouraging such participation isn't the overall goal of nursing care. 250. B Hyperthyroidism is a hypermetabolic state characterized by signs, such as tachycardia, systolic hypertension, and anxiety--all seen in adrenergic (sympathetic) stimulation. Manifestations of hypovolemic shock, benzodiazepine overdose, and Addison's disease are more similar to a hypometabolic state. 251. C A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver. 252. C The exact mechanism of antipsychotic medication action is unknown, but it appears to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. They don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release. 253. C If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves. 254. A For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, chest discomfort from the incision, dyspnea, and anorexia. Depression typically resolves on its own and doesn't require medical intervention. Ankle edema rarely follows CABG surgery and may indicate right-sided heart failure; because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition after CABG

surgery that should be reported immediately to the physician. 255. B Pleuritic chest pain is typically described as intermittent, sharp, and very painful and is aggravated with deep inspiration or movement. Crushing, substernal chest pain that is relieved by nitroglycerin is usually of cardiac origin. Leaning forward typically relieves pain associated with pericarditis. 256. D Withholding the medication and notifying the physician is the first step in treating what very well may be digitalis toxicity. Continuing to administer digoxin may result in heart block, while obtaining a serum level doesn't treat the problem. 257. C Children who are from eight to ten years old are developmentally ready to begin to give their own injections with adult supervision. Their fine motor skills are developed enough to accomplish this skill. 258. C The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively, but may not immediately retieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema. 259. D To test for the Babinski reflex, use a tongue blade to slowly stroke the lateral side of the under side of the foot. Start at the heel and move towards the great toe. The normal response in an adult is planter flexion of the toes. Upward movement of the great toe and fanning of the little toes, called the Babinski reflex, is abnormal. 260. A 261. A 262. A 263. B 264. A 265. A Adverse effects of corticosteroids include acne, hirsutism, mood swings, osteoporosis, and adrenal suppression. Steroid use in children and adolescents may cause delayed growth, not growth spurts.