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CONCEPT KEY ANSWERS with RATIONALIZATIONS

FINAL COMPREHENSIVE EXAMINATION – LEVEL 4

1. B) Superego - Rationale: This shows a weak sense of moral consciousness. According to Freudian
theory, personality disorders stem from a weak superego.
2. C) “You seem upset. I am going to be here with you; perhaps you will want to talk about it”
Rationale: The client needs to have his or her feelings acknowledged, with encouragement to discuss
feelings, and be reassured about the nurse’s presence.
3. D) Crises usually resolved in 4-6 weeks. Rationale: Part of the definition of a crisis is a time span of
4-6 weeks.
4. C) Take the client to the bathroom at regular intervals. Rationale: The client is most likely
confused, rather than exhibiting acting-out, hostile behavior. Frequent toileting will allow urination in an
appropriate place.
5. D) Take the client to the assigned room. Rationale: The client needs basic, simple orientation that
directly relates to the here-and-now, and does not require verbal interaction.
6. A) What food she likes. Rationale: Although all options may appear correct. A is the best because it
focuses on a range of possible positive reinforcers, a basis for an effective behavior modification program.
It can lead to concrete, specific nursing interventions right away and provides a therapeutic use of
“control” for the 16-year-old.
7. A) Do not bring it up unless the client asks.
Rationale: The nurse needs to wait and see: do not “jump the gun”; do not assume that the client wants to
know now.
8. D) Anger. Rationale: The woman is experiencing an actual loss and will probably exhibit many of the
same symptoms as a person who has lost someone to death.
9. C) “I don’t see anyone coming.” Rationale: This option is an example of pointing out reality- the
nurse’s perception.
10. B) “Tell me what you think the therapist means.”
Rationale: This response asks information that the nurse can use. If the client understands the statement,
the nurse can support the therapist when focusing on connection between food, love, and mother. If the
client does not understand the statement, the nurse can help get clarification from the therapist.
11. C) “Have you discussed your feelings with your husband?” Rationale: This option redirects the
client to talk to her husband.
12. D) Acting overly solicitous toward the child. Rationale: This is an example of reaction formation, a
coping mechanism.
13. A) Focus on the feelings conveyed rather than the thoughts expressed. Rationale: Often the
verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged.
14. D) solitary play. Rationale: Autistic children do best with solitary play because they typically do not
interact with others in a socially comprehensible and acceptable way.
15. A) “Tell me about your hate.” Rationale: The nurse is asking the client to clarify and further discuss
feelings.
16. C) Denial. Rationale: Denial is the act of avoiding disagreeable realities by ignoring them.
17. B) Denial. Rationale: Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas
on death and dying. Denial is a typical grief response, and usually is a first reaction.

18. D) The woman is experiencing a normal bereavement reaction. Rationale: Shock and anger are
commonly the primary initial reactions.
19. A) Solitary activity, such as walking with the nurse, to decrease stimulation. Rationale: This
option avoids external stimuli, yet channels the excess motor activity that is often part of the manic phase.
20. B) “It usually takes 2-3 weeks to be effective.” Rationale: The patient needs a brief, factual
answer.
21. C) Trihexyphenidyl HCI (Artane). Rationale: Trihexyphenidyl HCI (Artane) is often used to
counteract side effect of pseudoparkinsonism, which often accompanies the use of phenothiazine, such
as chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
22. D) A structured environment, to minimize regressive behaviors. Rationale: Persons with
dementia needs sameness, consistency, structure, routine, and predictability.
23. A) Delusion. Rationale: This is a false belief developed in response to an emotional need.

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24. D) Maintain constant awareness of the client’s whereabouts. Rationale: The client must be
constantly observed.
25. B) Anorexia, insomnia. Rationale: The appetite is diminished and sleeping is affected to a client with
depression.
26. A) Acknowledge that the word has some special meaning for the client. Rationale: It is important
to acknowledge a statement, even if it is not understood.
27. D) Rationalization. Rationale: Rationalization is the process of constructing plausible reasons for
one’s responses.
28. C) Delusion of persecution. Rationale: The client has ideas that someone is out to kill her.
29. D) Voiding. Rationale: A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding
problems)
30. A) Give the parents time alone with the body. Rationale: This allows the parents/family to grieve
over the loss of the child, by going through the steps of leave taking.
31. B) Seizures, suicidal tendencies. Rationale: Assess for suicidal tendencies, especially during early
therapy. There is an increased risk of seizures in debilitated client and those with a history of seizures.
32. D) Tell the client that the nurse needs a partner for an activity. Rationale: The nurse helps to
activate by doing something with the client.
33. C) “Take a nice, big, deep breath and then let me hear you count to five.” Rationale: Preschool
children commonly experience fears and fantasies regarding invasive procedures. The nurse should
attempts to momentarily distract the child with a simple task that can be easily accomplished while the
child remains in the side-lying position. The suppository can be slipped into place while the child is
counting, and then the nurse can praise the child for cooperating, while holding the buttocks together to
prevent expulsion of the suppository.
34. A) Hypertensive crisis. Rationale: This is the more inclusive answer, although diet restrictions
(answer1) are important, their purpose is to prevent hypertensive crisis (answer 2).
35. D) Ask the mother what she thinks. Rationale: This comes closest to beginning to focus on family-
centered approach to intervene in the “conspiracy of silence”. This is therefore the best among the
options.
36. A) Acknowledge that this is the client’s belief but not the nurse’s belief. Rationale: The nurse
should neither challenge nor use logic to dispel an irrational belief.
37. D) Regard the comment seriously and notify the teen’s primary health care provider and
parents. Rationale: Any threat to the safety of oneself or other should always be taken seriously and
never disregarded by the nurse.
38. C) A person who is an alcoholic. Rationale: The likelihood of multiple contributing factors may make
this person at higher risk for suicide. Some factors that may exist are physical illness related to
alcoholism, emotional factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and
economic problems related to employment.
39. B) Control unacceptable impulses or feelings. Rationale: A ritual, such as compulsive
handwashing, is an attempt to allay anxiety caused by unconscious impulses that are frightening.
40. D) Maintain a therapeutic environment. Rationale: This is the most neutral answer by process of
elimination.
41. B) Allow the mother to continue her present behavior while sitting quietly with her. Rationale:
This option allows a normal grief response (anger).
42. C) Provide external controls. Rationale: Personality disorders stem from a weak superego, implying
a lack of adequate controls.
43. C) “I understand. You will be able to cooperate best if you know what is going on, so I will find
out how I can arrange to have your glasses and hearing aid available to you in the recovery
room.” Rationale: The client will be easier to care for if he has his hearing aid and glasses.
44. A) A staff member has frequent contacts with the client. Rationale: Frequent contacts at times of
stress are important, especially when a client is isolated.
45. B) “This isn’t the purpose of either of you being here.” Rationale: This response is aimed at
redirecting the inappropriate behavior.
46. D) Provide a night-light and a big clock. Rationale: This option is best to decrease confusion and
disorientation to place and time.
47. C) “What will be different?” Rationale: This option helps the woman to think through and elaborate
on her own thoughts and prognosis.

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48. B) Signs of grief reaction. Rationale: It is mostly likely that grief would be expressed because of
object loss.
49. D) Bring up neutral topics. Rationale: Neutral, nonthreatening topics are best in attempting to
encourage a response.
50. C) Providing motor outlets for aggressive, hostile feelings. Rationale: It is important to externalize
the anger away from self.
51. B- A distended bladder usually displaces the fundus upward and toward the right.
52. B- In the immediate postpartum period, slower than normal pulse rate can be anticipated as a result
of a combination of factors- horizontal position, emotional relief and satisfaction, enforced rest after
labor and delivery.
53. C- Retention of the urine with the overflow will be manifested in small, frequent voiding. The bladder
should be palpated for distention.
54. D- Parenting can only begin when the baby and the mother get to know each other. To promote
normal development, the nurse should provide time for the parent-child interaction.
55. B- Cephalhematuma is a collection of blood between the skull bone and the periosteum as a result of
trauma. It resolves spontaneously in 3-6 weeks.
56. A- Parents need support and reassurance that their child is not permanently damaged.
57. B – The nurse fulfilled the expectation set forth in the Nurse Practice Act, which includes teaching. T
in this case, the nurse had knowledge of dietary needs and their relation to the client’s well-being
during pregnancy.
58. C – The growing uterus exerts pressure on the mesentery slowing peristalsis, more water is
reabsorbed, and constipation results.
59. B - Rupture of membranes and the gush of fluid can carry the umbilical cord downward. Immediate
placement in the lithotomy position and inspection may lead to identifications of prolapsed and
prevention of fetal distress.
60. C – Hypertonic contractions of the uterus, if allowed to continue, can lead to uterine rupture.
Therefore, the infusion should be discontinued so the hypertonic contractions cease.
61. A – As cervical dilatation nears complication, labor is intensified with an increase in pain and energy.
62. C – A relaxed uterus is the most common cause of bleeding in the early post-partum phase. The
uterus can be returned to a state of firmness by intermittent gentle fundal massage.
63. D – Goodell’s sign is the only probable sign; the other choices are presumptive signs.
64. C – HCG in the urine confirms the pregnancy. The urine test is 97% to 99% accurate. False positive
and negative are possible. Home test are considered less accurate, most likely due to error in use.
65. C – The nurse must find out the eating habits of the client before she can advise. A basic principle of
the teaching-learning process is to access the learner by obtaining history.
66. B – Organ meat and dried fruits are high in iron. Spinach is also a good source.
67. A – Swelling of the face is an indication of toxemia.
68. C – Slight temporary enlargement of the breast may cause sensations of weight and tingling. As
pregnancy advances, the areola becomes darker in color. Colostrums, precursor of breast milk, may
appear spontaneously in the second half of pregnancy.
69. C – Urinary frequency is caused by the pressure of the growing uterus on the bladder. Sugar in the
urine may be due to deceased renal threshold for sugar. Vaginal bleeding may indicate abortion.
Albuminuria and facial swelling are associated with toxemia.
70. B – Bulk and fluid help increase peristalsis. Laxative and suppositories should not be used in
pregnancy preventing is more desirable than treatment.
71. D – Shivering increases the metabolic rate, which intensifies the body’s need for oxygen and raises
the body temperature.
72. C – Protect him from injury to his head or extremities during seizure.
73. C – Febrile convulsions are not necessarily associated with major neurologic problems but often
accompany fever. Such convulsion may be partially accounted for by the overall brain immaturity in
children.
74. A – Meningococcal meningitis is identified by its epidemic nature and purpuric skin rash. It is treated
with sulfadiazine.
75. C – A serious complication of meningococcal meningitis due to bilateral adrenal hemorrhage. The
resultant acute adrenocortical insufficiency causes profound shock, petechiae and ecchymotic
lesions, vomiting, and hypotension.
76. D – In small children, the Eustachian tube is shorter, wider, and straighter. Pulling the auricle down
and back facilitates passage of fluid to the drum.
77. B – The middle ear contains three ossicles – malleus, incus, and stapes, which with the tympanic
membrane and oval window form an amplifying system.
78. C- Babies with Down syndrome have decrease muscle tone, which compromises respiratory
expansion as well as the adequate drainage of mucus. These factors contribute to increased
susceptibility to upper respiratory tract infection.
79. D – Is a common clinical manifestation. It is readily observable when present.

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80. B - Parent’s responses to their children may greatly influence decisions regarding future care.
Learning about their child and Down syndrome can help lessen guilt feelings.
81. B – Babies with Down syndrome have high incidence of congenital heart disease, especially atrial
defect.
82. C – When parents can verbalize the need to change plans they have made for their infant, it usually
signifies that they are beginning to face reality.
83. B – For a child who is moderately retarded, simple repetitive task provide all the challenge needed.
84. C – When one’s efforts toward meeting a goal are blocked or thwarted, frustration results. The child
with moderate retardation may be constantly thwarted in trying to meet his need.
85. B – Dark red, “currant jelly” stool indicates bowel necrosis from gangrene.
86. C – Only the affected portion of the intestine is resected, and an end to end anastomosis of the
remaining healthy intestinal segments is done.
87. A – Intussusceptions are the telescoping or invagination of one part of the intestine into a more distal
portion.
88. C – Although all these goals are important, the client is especially at risk for dehydration and
electrolyte imbalance because of vomiting associated with intussusceptions.
89. D – The naso gastric tube may be obstructed, causing the abdominal distention. Inserting a rectal
tube is contraindicated because the client has had lower intestinal tract surgery.
90. D – Separation anxiety begins at about 8 months of age and can cause extreme distress for the infant
in this age group.
91. C – With her history of HPN, cerebral hemorrhage is the probable cause of CVA.
92. B – Offering the bedpan q4h is the first step in initiating bladder training, which is part of rehabilitation.
Catheters can cause bladder infections and should be avoided when possible.
93. D – In expressive aphasia, the client is able to recognize objects but is unable to use the correct
words.
94. B – The occipital lobe holds the visual center, the medulla deals with essential functions, and the
parietal lobe deals mainly with sensory function.
95. D – Encourage her to speak at any possible opportunity. Although time consuming, it is more
therapeutic for the client.
96. A – Have the family continue to encourage the client’s effort. If the aphasia is expressive, she may
choose another word to communicate her needs.
97. C – Keeping the client positioned in semi-Fowler’s position is important to prevent aspiration, a
frequent complication post CVA.
98. A – Initial damage to any tissue creates edema and impairs functioning. As the cerebral edema
decreases, muscle function begins to return and can improve for a period of up to 6 months.
99. C – Rehabilitation is a goal that is worked on as soon as the planning of care begins.
100. C – With the help of significant others or family, rehabilitation effort are continued over the long
term, resulting in a more optimal recovery.

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