Wednesday, July 12, 2006
A very tricky question...
ANSWER ME IF U CAN!
The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. What is the primary rationale for tube feedings in this situation?
(1) Prevent pain from swallowing.
(2) Ensure adequate intake.
(3) Prevent fistula development.
(4) Allow for adequate suture line healing.
The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. What is the primary rationale for tube feedings in this situation?
(1) Prevent pain from swallowing.
(2) Ensure adequate intake.
(3) Prevent fistula development.
(4) Allow for adequate suture line healing.
Monday, July 10, 2006
Answer w/ Rationale
Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack.
Question of the Day #3
The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. The reason for this change is that:
A. the attack is over.
B. the airways are so swollen that no air can get through.
C. the swelling has decreased.
D. crackles have replaced wheezes.
A. the attack is over.
B. the airways are so swollen that no air can get through.
C. the swelling has decreased.
D. crackles have replaced wheezes.
Answer w/ Rationale
Rationale: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances.
Question of the Day #2
A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care?
A. Assessing the client's temperature every 8 hours
B. Placing the client in respiratory isolation
C. Monitoring the client's fluid intake and output
D. Wearing gloves during all client contact
A. Assessing the client's temperature every 8 hours
B. Placing the client in respiratory isolation
C. Monitoring the client's fluid intake and output
D. Wearing gloves during all client contact
Rationale #2 MS
30 Q Rationale - MS
1. d Rationale: Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
2. b Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia.
3. d Rationale: Clinical signs of right-sided heart failure include jugular vein distention, dependent peripheral edema, hepatomegaly, splenomegaly, ascites, nausea, vomiting, weakness, dizziness, and syncope. Respiratory acidosis, hypertension, and dyspnea are associated with left-sided heart failure.
4. c Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
5. d Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab
6. a Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
7. d Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
8. d Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
9. b Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
10. a Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
11. d Rationale: 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.
12. d Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
13. c Rationale: Cardiac output is the total amount of blood ejected by the heart per minute. It's determined by multiplying the client's heart rate by his stroke volume. Stroke volume is the amount of blood ejected with each beat. Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole. Heart rate is the number of beats per minute.
14. b Rationale: To relieve anginal pain, the client should place nitroglycerin tablets under the tongue (sublingually) and shouldn't consume fluids with the medication. All other statements made by this client reflect an accurate understanding of nitroglycerin use.
15. b Rationale: The client should avoid consuming large amounts of vitamin K because it can interfere with anticoagulation. The client may need to report diarrhea, but it isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen (Tylenol) should be used for pain relief.
16. d Rationale: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension.
17. a Rationale: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
18. c Rationale: 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 relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
19. c Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. d Rationale: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.
21. d Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
22. a Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
23. a Rationale: Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
24. b Rationale: When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
25. a Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
26. b Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
27. b Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
28. d Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
29. b Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
30. a Rationale: A murmur that indicates heart disease is commonly accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and periorbital edema aren't associated with murmurs and heart disease.
1. d Rationale: Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
2. b Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia.
3. d Rationale: Clinical signs of right-sided heart failure include jugular vein distention, dependent peripheral edema, hepatomegaly, splenomegaly, ascites, nausea, vomiting, weakness, dizziness, and syncope. Respiratory acidosis, hypertension, and dyspnea are associated with left-sided heart failure.
4. c Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
5. d Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab
6. a Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
7. d Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
8. d Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
9. b Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
10. a Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
11. d Rationale: 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.
12. d Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
13. c Rationale: Cardiac output is the total amount of blood ejected by the heart per minute. It's determined by multiplying the client's heart rate by his stroke volume. Stroke volume is the amount of blood ejected with each beat. Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole. Heart rate is the number of beats per minute.
14. b Rationale: To relieve anginal pain, the client should place nitroglycerin tablets under the tongue (sublingually) and shouldn't consume fluids with the medication. All other statements made by this client reflect an accurate understanding of nitroglycerin use.
15. b Rationale: The client should avoid consuming large amounts of vitamin K because it can interfere with anticoagulation. The client may need to report diarrhea, but it isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen (Tylenol) should be used for pain relief.
16. d Rationale: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension.
17. a Rationale: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
18. c Rationale: 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 relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
19. c Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. d Rationale: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.
21. d Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
22. a Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
23. a Rationale: Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
24. b Rationale: When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
25. a Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
26. b Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
27. b Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
28. d Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
29. b Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
30. a Rationale: A murmur that indicates heart disease is commonly accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and periorbital edema aren't associated with murmurs and heart disease.
Rationale #1 Fundamentals of Nursing
1. d Rationale: Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
2. b Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia.
3. d Rationale: Clinical signs of right-sided heart failure include jugular vein distention, dependent peripheral edema, hepatomegaly, splenomegaly, ascites, nausea, vomiting, weakness, dizziness, and syncope. Respiratory acidosis, hypertension, and dyspnea are associated with left-sided heart failure.
4. c Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
5. d Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab
6. a Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
7. d Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
8. d Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
9. b Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
10. a Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
11. d Rationale: 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.
12. d Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
13. c Rationale: Cardiac output is the total amount of blood ejected by the heart per minute. It's determined by multiplying the client's heart rate by his stroke volume. Stroke volume is the amount of blood ejected with each beat. Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole. Heart rate is the number of beats per minute.
14. b Rationale: To relieve anginal pain, the client should place nitroglycerin tablets under the tongue (sublingually) and shouldn't consume fluids with the medication. All other statements made by this client reflect an accurate understanding of nitroglycerin use.
15. b Rationale: The client should avoid consuming large amounts of vitamin K because it can interfere with anticoagulation. The client may need to report diarrhea, but it isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen (Tylenol) should be used for pain relief.
16. d Rationale: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension.
17. a Rationale: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
18. c Rationale: 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 relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
19. c Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. d Rationale: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.
21. d Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
22. a Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
23. a Rationale: Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
24. b Rationale: When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
25. a Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
26. b Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
27. b Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
28. d Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
29. b Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
30. a Rationale: A murmur that indicates heart disease is commonly accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and periorbital edema aren't associated with murmurs and heart disease.
2. b Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia.
3. d Rationale: Clinical signs of right-sided heart failure include jugular vein distention, dependent peripheral edema, hepatomegaly, splenomegaly, ascites, nausea, vomiting, weakness, dizziness, and syncope. Respiratory acidosis, hypertension, and dyspnea are associated with left-sided heart failure.
4. c Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
5. d Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab
6. a Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
7. d Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
8. d Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
9. b Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
10. a Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
11. d Rationale: 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.
12. d Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
13. c Rationale: Cardiac output is the total amount of blood ejected by the heart per minute. It's determined by multiplying the client's heart rate by his stroke volume. Stroke volume is the amount of blood ejected with each beat. Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole. Heart rate is the number of beats per minute.
14. b Rationale: To relieve anginal pain, the client should place nitroglycerin tablets under the tongue (sublingually) and shouldn't consume fluids with the medication. All other statements made by this client reflect an accurate understanding of nitroglycerin use.
15. b Rationale: The client should avoid consuming large amounts of vitamin K because it can interfere with anticoagulation. The client may need to report diarrhea, but it isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen (Tylenol) should be used for pain relief.
16. d Rationale: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension.
17. a Rationale: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
18. c Rationale: 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 relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
19. c Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. d Rationale: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.
21. d Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
22. a Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
23. a Rationale: Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
24. b Rationale: When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
25. a Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
26. b Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
27. b Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
28. d Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
29. b Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
30. a Rationale: A murmur that indicates heart disease is commonly accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and periorbital edema aren't associated with murmurs and heart disease.
Friday, July 07, 2006
30 Med Surge Q's
MS Q's (Cardiovascular)
* Answers w/ Rationale to be posted after 2-3 days...
1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?
A. "The pain lasted for about 45 minutes."
B. "The pain resolved after I ate a sandwich."
C. "The pain worsened when I took a deep breath."
D. "The pain occurred while I was mowing the lawn."
2. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
A. right-sided heart failure.
B. acute pulmonary edema.
C. pneumonia.
D. cardiogenic shock.
3. A client with a history of chronic obstructive pulmonary disease (COPD) develops right-sided heart failure. Which symptom is common in this disorder?
A. Respiratory acidosis
B. Hypertension
C. Dyspnea
D. Jugular vein distention
4. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms
5. A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
A. negative history of tonic-clonic seizures.
B. ampule of naloxone (Narcan) at the bedside.
C. continuous electrocardiogram (ECG) monitoring.
D. up-to-date activated partial thromboplastin time (APTT) result in his record.
6. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence
7. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength
8. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain
9. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.
10. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility
11. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD)?
A. neffective thermoregulation
B. Impaired gas exchange
C. Risk for injury
D. Decreased cardiac output
12. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:
A. hypertension.
B. high urine output.
C. dry mucous membranes.
D. pulmonary crackles.
13.A client with severe left-sided heart failure has a decrease in the total amount of blood ejected per minute. This quantity is known as:
A. stroke volume.
B. ejection fraction.
C. cardiac output.
D. heart rate.
14. Which statement from a client who takes nitroglycerin (Nitrostat) as needed for anginal pain indicates that further teaching is necessary?
A. "I store the tablets in a dark bottle."
B."I take the tablet with a full glass of water."
C. "I check for my tongue to tingle when I take a tablet."
D. "I'll go to the hospital if three tablets, 5 minutes apart, don't relieve the pain."
15. The nurse is caring for a client taking an anticoagulant. The nurse should teach the client to:
A. report incidents of diarrhea.
B. avoid foods high in vitamin K.
C. use a straight razor when shaving.
D. take aspirin for pain relief.
16. In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:
A. vestibular dysfunction.
B. sudden vascular fluid shifting.
C. postural hypotension.
D. bradyrhythmia.
17. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
A. realize the surgeon has the right to refuse to care for the client.
B. advise the surgeon to arrange for an alternate cardiac surgeon.
C. tell the client that she can donate her own blood for the procedure.
D. inform the client that her decision could shorten her life.
18. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
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.
19. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
A. narrowing complex.
B. widening complex.
C. amplitude increase.
D. amplitude decrease.
21. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
22. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
23. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
C. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
24. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature?
A. Oral
B. Rectal
C. Axillary
D. Tympanic
25. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion
26. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. a skin rash.
B. peripheral edema.
C. a dry cough.
D. postural hypotension.
27. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.
28. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly
29. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis
30. Murmurs that indicate heart disease are commonly accompanied by other symptoms such as:
A. dyspnea on exertion.
B. subcutaneous emphysema.
C. thoracic petechiae.
D. periorbital edema.
* Answers w/ Rationale to be posted after 2-3 days...
1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?
A. "The pain lasted for about 45 minutes."
B. "The pain resolved after I ate a sandwich."
C. "The pain worsened when I took a deep breath."
D. "The pain occurred while I was mowing the lawn."
2. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
A. right-sided heart failure.
B. acute pulmonary edema.
C. pneumonia.
D. cardiogenic shock.
3. A client with a history of chronic obstructive pulmonary disease (COPD) develops right-sided heart failure. Which symptom is common in this disorder?
A. Respiratory acidosis
B. Hypertension
C. Dyspnea
D. Jugular vein distention
4. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms
5. A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
A. negative history of tonic-clonic seizures.
B. ampule of naloxone (Narcan) at the bedside.
C. continuous electrocardiogram (ECG) monitoring.
D. up-to-date activated partial thromboplastin time (APTT) result in his record.
6. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence
7. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength
8. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain
9. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.
10. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility
11. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD)?
A. neffective thermoregulation
B. Impaired gas exchange
C. Risk for injury
D. Decreased cardiac output
12. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:
A. hypertension.
B. high urine output.
C. dry mucous membranes.
D. pulmonary crackles.
13.A client with severe left-sided heart failure has a decrease in the total amount of blood ejected per minute. This quantity is known as:
A. stroke volume.
B. ejection fraction.
C. cardiac output.
D. heart rate.
14. Which statement from a client who takes nitroglycerin (Nitrostat) as needed for anginal pain indicates that further teaching is necessary?
A. "I store the tablets in a dark bottle."
B."I take the tablet with a full glass of water."
C. "I check for my tongue to tingle when I take a tablet."
D. "I'll go to the hospital if three tablets, 5 minutes apart, don't relieve the pain."
15. The nurse is caring for a client taking an anticoagulant. The nurse should teach the client to:
A. report incidents of diarrhea.
B. avoid foods high in vitamin K.
C. use a straight razor when shaving.
D. take aspirin for pain relief.
16. In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:
A. vestibular dysfunction.
B. sudden vascular fluid shifting.
C. postural hypotension.
D. bradyrhythmia.
17. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
A. realize the surgeon has the right to refuse to care for the client.
B. advise the surgeon to arrange for an alternate cardiac surgeon.
C. tell the client that she can donate her own blood for the procedure.
D. inform the client that her decision could shorten her life.
18. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
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.
19. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
A. narrowing complex.
B. widening complex.
C. amplitude increase.
D. amplitude decrease.
21. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
22. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
23. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
C. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
24. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature?
A. Oral
B. Rectal
C. Axillary
D. Tympanic
25. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion
26. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. a skin rash.
B. peripheral edema.
C. a dry cough.
D. postural hypotension.
27. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.
28. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly
29. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis
30. Murmurs that indicate heart disease are commonly accompanied by other symptoms such as:
A. dyspnea on exertion.
B. subcutaneous emphysema.
C. thoracic petechiae.
D. periorbital edema.
Fundamentals of Nursing
The Nursing Process - 26 questions...
*lifted fromNCLEX-RN Brunner Suddarth
> answers & rationale to be posted after 2-3 days...
> passing rate 18/26
> Score 17-19 = fair
20-23 = v. good
24-26 = excellent
1. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process?
A. Assessment
B. Analysis
C. Implementation
D. Evaluation
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. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
4. The nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the blood?
A. pH
B. Pao2
C. Paco2
D. HCO3_
5. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
A. change his own dressing.
B. walk in the hallway.
C. walk from his room to the end of the hall and back before discharge.
D. eat a special diet.
6. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
7. A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?
A. Anxiety
B. Risk for injury
C. Activity intolerance
D. Impaired physical mobility
8. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.
9. A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is the correctly written client outcome for this nursing diagnosis?
A. By discharge, the client correctly identifies three potassium-rich foods.
B. The client knows the importance of consuming potassium-rich foods daily.
C. Before discharge, the client knows which food sources are high in potassium.
D. The client understands all complications of the disease process.
10. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain
11. A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client the nurse should question which physician order?
A. "Monitor urine output every hour."
B. "Infuse I.V. fluids at 83 ml/hr"
C. "Administer oxygen by nasal cannula at 3 L/minute"
D. "Draw samples for hemoglobin and hematocrit every 6 hours."
12. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility
13. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion
14. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly
15. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis
16. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence
17. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms
18. The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
19. The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?
A. General health for the past 10 years
B. Current health promotion activities
C. Family history of diseases
D. Marital status
20. Which clinical characteristic affects client compliance?
A. Drug knowledge
B. Psychosocial factors
C. Nurse-client relationship
D. Disease duration and severity
21. When monitoring a client's central venous pressure (CVP), the nurse knows that a normal CVP measurement is:
A. 2 cm H20.
B. 1 mm Hg.
C. 10 mm Hg.
D. 5 cm H20.
22. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
23. Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?
A. Security
B. Elimination
C. Safety
D. Belonging
24. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.
25. A client is admitted with acute chest pain. When obtaining the health history, which question will be most helpful for the nurse to ask?
A. "Do you need anything now?"
B. "Why do you think you had a heart attack?"
C. "What were you doing when the pain started?"
D. "Has anyone in your family been sick lately?"
26. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength
*lifted fromNCLEX-RN Brunner Suddarth
> answers & rationale to be posted after 2-3 days...
> passing rate 18/26
> Score 17-19 = fair
20-23 = v. good
24-26 = excellent
1. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process?
A. Assessment
B. Analysis
C. Implementation
D. Evaluation
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. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
4. The nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the blood?
A. pH
B. Pao2
C. Paco2
D. HCO3_
5. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
A. change his own dressing.
B. walk in the hallway.
C. walk from his room to the end of the hall and back before discharge.
D. eat a special diet.
6. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
7. A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?
A. Anxiety
B. Risk for injury
C. Activity intolerance
D. Impaired physical mobility
8. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.
9. A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is the correctly written client outcome for this nursing diagnosis?
A. By discharge, the client correctly identifies three potassium-rich foods.
B. The client knows the importance of consuming potassium-rich foods daily.
C. Before discharge, the client knows which food sources are high in potassium.
D. The client understands all complications of the disease process.
10. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain
11. A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client the nurse should question which physician order?
A. "Monitor urine output every hour."
B. "Infuse I.V. fluids at 83 ml/hr"
C. "Administer oxygen by nasal cannula at 3 L/minute"
D. "Draw samples for hemoglobin and hematocrit every 6 hours."
12. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility
13. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion
14. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly
15. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis
16. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence
17. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms
18. The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
19. The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?
A. General health for the past 10 years
B. Current health promotion activities
C. Family history of diseases
D. Marital status
20. Which clinical characteristic affects client compliance?
A. Drug knowledge
B. Psychosocial factors
C. Nurse-client relationship
D. Disease duration and severity
21. When monitoring a client's central venous pressure (CVP), the nurse knows that a normal CVP measurement is:
A. 2 cm H20.
B. 1 mm Hg.
C. 10 mm Hg.
D. 5 cm H20.
22. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
23. Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?
A. Security
B. Elimination
C. Safety
D. Belonging
24. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.
25. A client is admitted with acute chest pain. When obtaining the health history, which question will be most helpful for the nurse to ask?
A. "Do you need anything now?"
B. "Why do you think you had a heart attack?"
C. "What were you doing when the pain started?"
D. "Has anyone in your family been sick lately?"
26. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength
Answer w/ Rationale
D. Red, swollen skin with inflammation spreading to surrounding tissues
Rationale: Cellulitis is an inflammation of soft tissues that can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.
Rationale: Cellulitis is an inflammation of soft tissues that can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.
Question of the Day #1
Q of the Day #1
When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
A. Painful skin that is swollen and pale in color
B. Cold, red skin
C. Small, localized blackened area of skin
D. Red, swollen skin with inflammation spreading to surrounding tissues
When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
A. Painful skin that is swollen and pale in color
B. Cold, red skin
C. Small, localized blackened area of skin
D. Red, swollen skin with inflammation spreading to surrounding tissues
Thursday, July 06, 2006
NLE leaked exam questions ?
June 2006 NLE Leakage ???
60. Nurse Budek will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates? [2]
A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII
61. A client with Cataract is about to undergo surgery. Nurse Budek is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient? [1]
A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery
62. Nurse Budek is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Budek to make? [4]
A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.
63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Budek expect the doctor to prescribe? [2]
A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
64. Which of the following is the appropriate nursing diagnosis? [1]
A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting
65. Approximately how much fluid is lost in acute weight loss of .5kg? [1]
A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml
66. Postural Hypotension is [1]
A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
67. Which of the following measures will not help correct the patient’s condition [1]
A. Offer large amount of oral fluid intake to replace fluid lost
B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval
68. After nursing intervention, you will expect the patient to have [1]
1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed
A. 1,3
B. 2,4
C. 1,3,4
D. 2,3,4
SITUATION: [ From JUN 2005 NLE ] A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease? [1]
A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy
70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by [1]
A. Injurious chemical substances
B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain
71. The patient was prescribed with levodopa. What is the action of this drug? [1]
A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites
72. You are discussing with the dietician what food to avoid with patients taking levodopa? [3]
A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food
73. One day, the patient complained of difficulty in walking. Your response would be [2]
A. You will need a cane for support
B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk
SITUATION: [ From JUN 2005 NLE ] Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
74. The nurse will assess a loss of ability in which of the following areas? [2]
A. Balance
B. Judgment
C. Speech
D. Endurance
75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from: [1]
A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia
76. The nurse is aware that in communicating with an elderly client, the nurse will [1]
A. Lean and shout at the ear of the client
B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice
77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching? [1]
A. I know the hallucinations are parts of the disease
B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room
78. Which of the following is most important discharge teaching for Mr. Dela Isla [2]
A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
79. What is the action of this drug? [4]
A. Increases glandular secretion for clients affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction
80. What should the nurse caution the client when using this medication [4]
A. Avoid hazardous activities like driving, operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose
81. Which of the following drugs are not compatible when taking Probanthine? [4]
A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol
82. What should the nurse tell clients when taking Probanthine? [4]
A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia
83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder? [4]
A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma
SITUATION : [ From DEC 2000 NLE ] Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco? [1]
A. Level of awareness and response to pain
B. Papillary reflexes and response to sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of respiration
85. Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment? [1]
A. Hand bell and extra bed linen
B. Sandbag and trochanter rolls
C. Footboard and splint
D. Suction machine and gloves
86. What is the rationale for giving Mr. Franco frequent mouth care? [1]
A. He will be thirsty considering that he is doesn’t drink enough fluids
B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence? [1]
A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse? [4]
A. Expressive aphasia is prominent on clients with right sided weakness
B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected
SITUATION : [ From JUN 1988 NLE ] a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
89. Which result of the lab test will be significant to the diagnosis? [1]
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care would include all of the following except? [1]
A. Consent signed by the father
B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries
91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to : [3]
A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle
92. Common anesthesia for appendectomy is [3]
A. Spinal
B. General
C. Caudal
D. Hypnosis
93. Post op care for appendectomy include the following except [1]
A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise
94. Peritonitis may occur in ruptured appendix and may cause serious problems which are [2]
1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock
A. 1 and 2
B. 2 and 3
C. 1,2,3
D. All of the above
95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication? [1]
A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon
96. NGT was connected to suction. In caring for the patient with NGT, the nurse must [2]
A. Irrigate the tube with saline as ordered
B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips
97. When do you think the NGT tube be removed? [1]
A. When patient requests for it
B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
98. What do you call a STROKE that manifests a bizarre behavior? [4]
A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses
99. The main difference between chronic and organic brain syndrome is that the former [2]
A. Occurs suddenly and reversible
B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible
100. Which behavior results from organic psychoses? [4]
A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect
60. Nurse Budek will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates? [2]
A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII
61. A client with Cataract is about to undergo surgery. Nurse Budek is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient? [1]
A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery
62. Nurse Budek is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Budek to make? [4]
A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.
63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Budek expect the doctor to prescribe? [2]
A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
64. Which of the following is the appropriate nursing diagnosis? [1]
A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting
65. Approximately how much fluid is lost in acute weight loss of .5kg? [1]
A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml
66. Postural Hypotension is [1]
A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
67. Which of the following measures will not help correct the patient’s condition [1]
A. Offer large amount of oral fluid intake to replace fluid lost
B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval
68. After nursing intervention, you will expect the patient to have [1]
1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed
A. 1,3
B. 2,4
C. 1,3,4
D. 2,3,4
SITUATION: [ From JUN 2005 NLE ] A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease? [1]
A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy
70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by [1]
A. Injurious chemical substances
B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain
71. The patient was prescribed with levodopa. What is the action of this drug? [1]
A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites
72. You are discussing with the dietician what food to avoid with patients taking levodopa? [3]
A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food
73. One day, the patient complained of difficulty in walking. Your response would be [2]
A. You will need a cane for support
B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk
SITUATION: [ From JUN 2005 NLE ] Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
74. The nurse will assess a loss of ability in which of the following areas? [2]
A. Balance
B. Judgment
C. Speech
D. Endurance
75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from: [1]
A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia
76. The nurse is aware that in communicating with an elderly client, the nurse will [1]
A. Lean and shout at the ear of the client
B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice
77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching? [1]
A. I know the hallucinations are parts of the disease
B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room
78. Which of the following is most important discharge teaching for Mr. Dela Isla [2]
A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
79. What is the action of this drug? [4]
A. Increases glandular secretion for clients affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction
80. What should the nurse caution the client when using this medication [4]
A. Avoid hazardous activities like driving, operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose
81. Which of the following drugs are not compatible when taking Probanthine? [4]
A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol
82. What should the nurse tell clients when taking Probanthine? [4]
A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia
83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder? [4]
A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma
SITUATION : [ From DEC 2000 NLE ] Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco? [1]
A. Level of awareness and response to pain
B. Papillary reflexes and response to sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of respiration
85. Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment? [1]
A. Hand bell and extra bed linen
B. Sandbag and trochanter rolls
C. Footboard and splint
D. Suction machine and gloves
86. What is the rationale for giving Mr. Franco frequent mouth care? [1]
A. He will be thirsty considering that he is doesn’t drink enough fluids
B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence? [1]
A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse? [4]
A. Expressive aphasia is prominent on clients with right sided weakness
B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected
SITUATION : [ From JUN 1988 NLE ] a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
89. Which result of the lab test will be significant to the diagnosis? [1]
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care would include all of the following except? [1]
A. Consent signed by the father
B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries
91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to : [3]
A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle
92. Common anesthesia for appendectomy is [3]
A. Spinal
B. General
C. Caudal
D. Hypnosis
93. Post op care for appendectomy include the following except [1]
A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise
94. Peritonitis may occur in ruptured appendix and may cause serious problems which are [2]
1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock
A. 1 and 2
B. 2 and 3
C. 1,2,3
D. All of the above
95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication? [1]
A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon
96. NGT was connected to suction. In caring for the patient with NGT, the nurse must [2]
A. Irrigate the tube with saline as ordered
B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips
97. When do you think the NGT tube be removed? [1]
A. When patient requests for it
B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
98. What do you call a STROKE that manifests a bizarre behavior? [4]
A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses
99. The main difference between chronic and organic brain syndrome is that the former [2]
A. Occurs suddenly and reversible
B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible
100. Which behavior results from organic psychoses? [4]
A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect
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