Health Alert!!!




Key Facts about Swine Influenza (Swine Flu)

What is Swine Influenza?
Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu viruses cause high levels of illness and low death rates in pigs. Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to outbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was first isolated from a pig in 1930.

How many swine flu viruses are there?
Like all influenza viruses, swine flu viruses change constantly. Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge. Over the years, different variations of swine flu viruses have emerged. At this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. However, most of the recently isolated influenza viruses from pigs have been H1N1 viruses.
Swine Flu in Humans

Can humans catch swine flu?
Swine flu viruses do not normally infect humans. However, sporadic human infections with swine flu have occurred. Most commonly, these cases occur in persons with direct exposure to pigs (e.g. children near pigs at a fair or workers in the swine industry). In addition, there have been documented cases of one person spreading swine flu to others. For example, an outbreak of apparent swine flu infection in pigs in Wisconsin in 1988 resulted in multiple human infections, and, although no community outbreak resulted, there was antibody evidence of virus transmission from the patient to health care workers who had close contact with the patient.
How common is swine flu infection in humans?
In the past, CDC received reports of approximately one human swine influenza virus infection every one to two years in the U.S., but from December 2005 through February 2009, 12 cases of human infection with swine influenza have been reported. 

What are the symptoms of swine flu in humans?
The symptoms of swine flu in people are expected to be similar to the symptoms of regular human seasonal influenza and include fever, lethargy, lack of appetite and coughing. Some people with swine flu also have reported runny nose, sore throat, nausea, vomiting and diarrhea.

Can people catch swine flu from eating pork?
No. Swine influenza viruses are not transmitted by food. You can not get swine influenza from eating pork or pork products. Eating properly handled and cooked pork and pork products is safe. Cooking pork to an internal temperature of 160°F kills the swine flu virus as it does other bacteria and viruses.

How does swine flu spread?
Influenza viruses can be directly transmitted from pigs to people and from people to pigs. Human infection with flu viruses from pigs are most likely to occur when people are in close proximity to infected pigs, such as in pig barns and livestock exhibits housing pigs at fairs. Human-to-human transmission of swine flu can also occur. This is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus. People may become infected by touching something with flu viruses on it and then touching their mouth or nose.

What do we know about human-to-human spread of swine flu?
In September 1988, a previously healthy 32-year-old pregnant woman was hospitalized for pneumonia and died 8 days later. A swine H1N1 flu virus was detected. Four days before getting sick, the patient visited a county fair swine exhibition where there was widespread influenza-like illness among the swine.

In follow-up studies, 76% of swine exhibitors tested had antibody evidence of swine flu infection but no serious illnesses were detected among this group. Additional studies suggest that one to three health care personnel who had contact with the patient developed mild influenza-like illnesses with antibody evidence of swine flu infection.
How can human infections with swine influenza be diagnosed?
To diagnose swine influenza A infection, a respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer. Identification as a swine flu influenza A virus requires sending the specimen to CDC for laboratory testing. 

What medications are available to treat swine flu infections in humans?
There are four different antiviral drugs that are licensed for use in the US for the treatment of influenza: amantadine, rimantadine, oseltamivir and zanamivir. While most swine influenza viruses have been susceptible to all four drugs, the most recent swine influenza viruses isolated from humans are resistant to amantadine and rimantadine. At this time, CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine influenza viruses.

What other examples of swine flu outbreaks are there?
Probably the most well known is an outbreak of swine flu among soldiers in Fort Dix, New Jersey in 1976. The virus caused disease with x-ray evidence of pneumonia in at least 4 soldiers and 1 death; all of these patients had previously been healthy. The virus was transmitted to close contacts in a basic training environment, with limited transmission outside the basic training group. The virus is thought to have circulated for a month and disappeared. The source of the virus, the exact time of its introduction into Fort Dix, and factors limiting its spread and duration are unknown. The Fort Dix outbreak may have been caused by introduction of an animal virus into a stressed human population in close contact in crowded facilities during the winter. The swine influenza A virus collected from a Fort Dix soldier was named A/New Jersey/76 (Hsw1N1).
Is the H1N1 swine flu virus the same as human H1N1 viruses?
No. The H1N1 swine flu viruses are antigenically very different from human H1N1 viruses and, therefore, vaccines for human seasonal flu would not provide protection from H1N1 swine flu viruses. 
Swine Flu in Pigs

How does swine flu spread among pigs? 
Swine flu viruses are thought to be spread mostly through close contact among pigs and possibly from contaminated objects moving between infected and uninfected pigs. Herds with continuous swine flu infections and herds that are vaccinated against swine flu may have sporadic disease, or may show only mild or no symptoms of infection.

What are signs of swine flu in pigs? 
Signs of swine flu in pigs can include sudden onset of fever, depression, coughing (barking), discharge from the nose or eyes, sneezing, breathing difficulties, eye redness or inflammation, and going off feed.

How common is swine flu among pigs? 
H1N1 and H3N2 swine flu viruses are endemic among pig populations in the United States and something that the industry deals with routinely. Outbreaks among pigs normally occur in colder weather months (late fall and winter) and sometimes with the introduction of new pigs into susceptible herds. Studies have shown that the swine flu H1N1 is common throughout pig populations worldwide, with 25 percent of animals showing antibody evidence of infection. In the U.S. studies have shown that 30 percent of the pig population has antibody evidence of having had H1N1 infection. More specifically, 51 percent of pigs in the north-central U.S. have been shown to have antibody evidence of infection with swine H1N1. Human infections with swine flu H1N1 viruses are rare. There is currently no way to differentiate antibody produced in response to flu vaccination in pigs from antibody made in response to pig infections with swine H1N1 influenza.

While H1N1 swine viruses have been known to circulate among pig populations since at least 1930, H3N2 influenza viruses did not begin circulating among US pigs until 1998. The H3N2 viruses initially were introduced into the pig population from humans. The current swine flu H3N2 viruses are closely related to human H3N2 viruses.

Is there a vaccine for swine flu? 
Vaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu. The seasonal influenza vaccine will likely help provide partial protection against swine H3N2, but not swine H1N1 viruses.




Practice Test

Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.

____ 1. What problem or disorder is a major cause of disability in adults under age 54 years in the United States?
a. Accidents
b. Morbid obesity
c. Coronary artery disease
d. Diabetes mellitus type 2


____ 2. How is a handicap different from an impairment, as defined by the World Health Organization?
a. An impairment may be temporary and a handicap is usually permanent.
b. Handicaps only involve mobility and an impairment may involve any organ structure or function.
c. Impairments are physical abnormalities and handicaps are societal values placed on individuals with impairments.
d. Handicaps are societal attempts to improve the functional ability of a person with an impairment, allowing more mainstream integration.


____ 3. The client who is a paraplegic is scheduled to participate in a rehabilitation program. She tells her nurse, “I don't understand why I should do rehabilitation. After all, my paralysis will not go away nor will it get better.” What is the nurse’s best response?
a. “Your doctor, one of the best in the specialty, ordered rehabilitation, and he does know what is best for you.”
b. “When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.”
c. “Rehabilitation will teach you how to maintain the functional ability you have.”
d. “You are right. I will cancel the orders for rehabilitation.”


____ 4. Which statement regarding disability and chronic illness is true?
a. Disabilities and chronic illnesses occur most often in young adults.
b. Accidents are responsible for more chronic and disabling conditions than chronic disease.
c. In the United States, one in seven persons experiences activity limitations because of chronic health problems.
d. Men experience more disability than women, but women experience a higher incidence of chronic illness than men.


____ 5. What is the most important information concerning elimination to assess for the client who is to undergo rehabilitation?
a. What was the client's usual bowel elimination pattern before the injury or illness?
b. Does the client have at least one bowel movement each day?
c. Can the client transfer from the wheelchair to the toilet?
d. Does the client have diarrhea?


____ 6. Which factor determines how independent a client can become with elimination?
a. Complication of the medication regimen
b. Degree of manual dexterity
c. Consistency of the stool
d. Volume of urine


____ 7. Which laboratory test abnormality in a client with a disabling condition alerts a nurse to an increased risk for skin breakdown?
a. Low serum albumin level
b. High serum transferrin level
c. Low serum carboxyhemoglobin
d. High serum hematocrit


____ 8. The client is scheduled for a functional assessment using the Functional Independence Measure (FIM). He asks the nurse, “What is the purpose of the FIM?” What is the nurse’s best response?
a. “It is a tool that is used to determine your level of independence.”
b. “It measures how you should be able to perform various tasks.”
c. “It is a tool to measure the severity of your disability.”
d. “It is a test the nurse manager uses to determine staffing patterns.”


____ 9. What is the priority nursing diagnosis for a client in a rehabilitation program after a stroke that caused extensive right-sided weakness?
a. Self-Care Deficit—Partial
b. Risk for Impaired Skin Integrity
c. Constipation
d. Impaired Physical Mobility


____ 10. Which client condition increases the chance for a problem with the technique needed for learning transfer?
a. The client has gained weight.
b. The client has aphasia.
c. The client is incontinent.
d. The client has minimal sensation in the lower extremities.


____ 11. The nurse is performing passive range-of-joint motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. What is the nurse’s best action?
a. Splint the joint and continue the passive range of motion to the shoulder only.
b. Progressively increase the joint motion 5 degrees beyond the resistance each day.
c. Apply weights to the right distal extremity before initiating any joint exercise.
d. Move the joint only to the point at which resistance is met.


____ 12. Which intervention should the nurse implement and reinforce to prevent a client with reduced mobility from having increased susceptibility to bone fractures?
a. Apply a foot support when the client is in bed.
b. Encourage the client to perform weight-bearing activities.
c. Increase the amount of calcium-rich foods in the diet.
d. Ensure the continuous use of pressure-relieving devices.


____ 13. The use of intermittent self-catheterization is inappropriate for which of the following clients with a flaccid bladder?
a. The client older than 85 years of age
b. The client who is blind
c. The client who is confused
d. The client who is a paraplegic


____ 14. Which action should the nurse implement to prevent pressure ulcer formation in a bedridden client?
a. Assessing serum albumin and transferrin levels
b. Measuring the ulcer diameter and depth every shift
c. Changing the gauze dressing whenever drainage is observed
d. Applying antibiotic ointment to all excoriated skin areas


____ 15. Which nursing intervention should the nurse implement to prevent venous stasis and thrombus formation in a client undergoing rehabilitation after a stroke?
a. Range-of-motion exercises
b. Foot support while in bed
c. Increased dietary calcium intake
d. Avoidance of sudden position changes


____ 16. Which activity plan would best conserve a client's energy without compromising the client's physical or mental health?
a. Reducing hygiene activities and restricting visitors
b. Ensuring that the client toilets before and after any other planned activity
c. Scheduling energy-intensive activities at the time of day when the client has higher energy levels
d. Scheduling as many activities as possible within a small block of time to allow the client a longer, uninterrupted rest period


____ 17. The client in a rehabilitation program has been using the bladder training techniques of the Valsalva and Credé maneuvers. When a nurse catheterizes this client immediately after voiding, the residual volume is 50 mL. What is the nurse’s best action?
a. Notify the physician.
b. Insert an indwelling catheter.
c. Document the finding as the only action.
d. Modify or extend the bladder-training program.


____ 18. The client at home who is using intermittent self-catheterization is concerned about the cost of sterile straight catheters. What is the nurse’s best response?
a. “I will explore whether or not you qualify for money to purchase these necessary supplies.”
b. “Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.”
c. “If you can treat the catheters by boiling them, you can reuse them up to 10 times each.”
d. “You can reuse the catheters here at home. Only clean technique, rather than sterile technique, is needed.”


____ 19. The client is at risk for a urinary tract infection. Which of the following beverages is the client encouraged to drink?
a. Carbonated beverages
b. Citrus juices
c. Milk
d. Tomato juice


____ 20. The older client is getting out of bed for the first time. The nurse should be alert for which of the following complications?
a. Deep vein thrombosis
b. Dyspnea
c. Orthostatic hypotension
d. Pulmonary embolism


____ 21. Prior to discharge, the case manger or occupational therapist visits the client’s home. Of the following, which one is of primary importance?
a. Accessibility to the home
b. Space requirements
c. Wheelchair accessibility
d. Doorway width


____ 22. What is the normal number of autosomal chromosomes for humans?
a. 42
b. 44
c. 46
d. 48


____ 23. You are looking at a small piece of single-stranded DNA with the base sequence of ACCTGAACGTCGCTA. What would be the sequence of the complementary strand of RNA?
a. TGGACTTGCAGCGAT
b. ACCTGAACGTCGCTA
c. UGGACUUGCAGCGAU
d. ACCUGAACGUCGCUA


____ 24. Approximately how many genes are estimated currently to compose the human genome?
a. 35,000
b. 100,000
c. 500,000
d. Over one million


____ 25. Which substance is present in a nucleotide but not in a nucleoside?
a. Uracil
b. Nitrogen
c. Phosphorus
d. Pentose (ribose) sugar


____ 26. What is the best meaning for the term gene expression?
a. The location of a specific gene allele on a specific autosomal chromosome
b. The specific trait or protein coded for by a single gene is actually present
c. The ability of a single gene to code for more than one trait or characteristic
d. The loss of a trait or characteristic from one family generation to the next generation


____ 27. In which phase of the cell cycle is DNA visible as chromosome structures?
a. G1
b. G2
c. M
d. S


____ 28. What is the expected result of a “silent” point mutation?
a. Total disruption of the gene reading frame, no production of protein
b. Replacement of one amino acid with another in the final gene product
c. Replacement of an amino acid codon with a “stop” codon, resulting in a truncated protein product
d. No change in amino acid sequence and no change in the composition of the protein product


____ 29. What is the function of ribosomes (also known as ribosomal RNA) in protein synthesis?
a. Serves as an adaptor molecule able to transport a specific amino acid to the site of protein synthesis (peptide chain elongation) in the correct sequence
b. Serves as the coordinator molecule to allow proper reading of the mRNA and placement of the correct amino acid in the sequence by the tRNAs
c. Allows interpretation of the two strands of DNA to determine which is the "sense" strand and which is the "antisense" strand
d. Allows further processing of synthesized proteins (post-translational modification) in order to ensure that the final product is physiologically active


____ 30. What makes a “frameshift” mutational event more serious than a “point” mutational event?
a. Frameshift mutations occur primarily in germline cells and point mutations occur only in somatic cells.
b. Frameshift mutations result in the deletion or addition of whole chromosomes (aneuploidy) and point mutations are undetectable at the chromosome level.
c. When the mutations occur in expressed genes, frameshift mutations always result in disruption of the gene function, whereas a point mutation can be silent.
d. The rate of frameshift mutations increases with aging as the function of DNA repair mechanisms declines, whereas the rate of point mutations is unchanged with age.


____ 31. What is the difference between DNA transcription for DNA synthesis and DNA transcription for protein synthesis?
a. Transcription for DNA synthesis is rapidly followed by the process of translation.
b. Transcription for protein synthesis has “greater fidelity” than does transcription for DNA synthesis.
c. Transcription for protein synthesis occurs only in cells undergoing mitosis and transcription for DNA synthesis occurs in both dividing and nondividing cells.
d. Transcription for DNA synthesis occurs with both the “sense” and the “antisense” strands, whereas transcription for protein synthesis occurs with only the “sense” strand.


____ 32. What is the correct interpretation of the statement, “the HFE gene locus is 6p21”?
a. Both alleles of the HFE gene are equally expressed.
b. The HFE gene is inherited from the paternal chromosome line.
c. The HFE gene is located on the “short arm” of chromosome number 6.
d. There is a somatic cell mutation involving gene damage on chromosome 6.


____ 33. Which statement regarding genotype and phenotype is true?
a. For autosomal recessive traits, the phenotype is the same as the genotype.
b. The only trait in which phenotype always follows genotype is physiologic gender.
c. When a phenotype is fully penetrant, the trait is expressed in the heterozygous person.
d. Genotype changes as a person ages, whereas phenotype is not affected by the aging process.


____ 34. What are the expected blood types of children from a mother who is AA for blood type and a father who is BB for blood type?
a. All children will have type O blood.
b. All children will have type AB blood.
c. 50% of the children will have type A blood and 50% of the children will have type B blood.
d. 25% will have type A blood, 50% will have type AB blood, and 25% will have type B blood.


____ 35. Which statement is a criterion for an autosomal dominant pattern of inheritance for a specific trait or characteristic that is highly penetrant?
a. Unaffected family members do not transmit the trait to their children.
b. Genotypes of individuals expressing the trait must be homozygous.
c. The trait appears only among male offspring of female carriers.
d. Carriers for the trait do not necessarily express the trait.


____ 36. How are “gene penetrance” and “gene expressivity” different?
a. With penetrance, the gene is either expressed completely or is not expressed at all. With expressivity, the gene is always expressed but the degree of expression can range from minor to extreme.
b. Penetrance and expressivity are both related to “gene dosage.” With penetrance, only one copy of the gene is expressed and, with expressivity, more than one copy of the gene can be expressed.
c. Gene penetrance and gene expressivity are merely different terms for the same concept, overexpression of recessive alleles.
d. Penetrance refers to the actual gene structure in the DNA and expressivity refers to the chromosome locus of the gene.


____ 37. Which statement or condition best demonstrates the concept of “multifactorial inheritance”?
a. A mutation in a single gene results in the expression of problems in a variety of tissues and organs.
b. The susceptibility to a problem is inherited as a single gene trait but development of the problem is related to environmental conditions.
c. A mutated gene is inherited but the results of expression of that gene are not evident until middle or late adulthood.
d. Several genes are responsible for the mechanism of hearing and a mutation in any one of them results in hearing impairment.


____ 38. When constructing a pedigree around a specific health problem, what is the minimal number of generations needed to assess the presence or absence of a genetic factor in disease development accurately?
a. 1
b. 2
c. 3
d. 4


____ 39. In constructing a pedigree for a man whose maternal grandfather has Huntington’s disease, you include the man’s maternal grandparents, his parents, his mother’s only sister, his three sisters and one brother, and his twin sons. Which pedigree symbol and position would represent his mother’s sister?
a. The circle on the highest horizontal line above the client’s symbol
b. The square on the horizontal line directly above the client’s symbol
c. The circle on the horizontal line above the client’s symbol that does not directly touch the vertical line leading to the client
d. The square on the same horizontal line as the client’s symbol that directly touches the vertical line leading to the client’s mother


____ 40. The client, whose mother has Huntington’s disease, is considering genetic testing but is not sure whether she really wants to know if she has the mutation. She asks what you would do if your mother had the disease. What is your best response?
a. “I would have the test so I could decide whether to have children or to adopt children.”
b. “I can only tell you the benefits and the risks of testing. You must make this decision yourself.”
c. “Because there is no cure for this disease and testing would not be beneficial, I would not have the test.”
d. “You need to check with your brothers and sisters to determine whether testing for this disease would be appropriate for you”


____ 41. The client who has been found to have a mutation in the BRCA1 gene allele and an increased risk for breast and ovarian cancer has asked you to be present when she discloses this information to her grown daughter. What is your role in this situation?
a. Primary health care provider
b. Genetic counselor
c. Client advocate
d. Client support


____ 42. What should you tell the client who has been found to have a genetic mutation that increases the risk for colon cancer who says he does not want any of his family to know about this result?
a. “It is required by law that you inform your siblings and your children about this result so that they also can be tested and monitored for colon cancer.”
b. “It is not necessary to tell your siblings, because they are adults, but you should tell your children so that they can be tested before they decide to have children of their own.”
c. “It is not required that you tell anyone about this result; however, because your siblings and children may also be at risk for colon cancer, you should think about how this information might help them.”
d. “It is your decision to determine with whom, if anyone, you discuss this test result; however, if you do not tell any of your family members and they get colon cancer, you would be responsible for their developing the disease.”


____ 43. Which is the most important goal of triage?
a. Assigning each client to the most appropriate treatment area
b. Giving priority of care to the most critically ill or injured clients
c. Providing a through assessment of the client
d. Obtaining a complete history of the client’s past medical-surgical history


____ 44. What is a correct statement regarding the major role of the triage nurse?
a. Provide a through and comprehensive assessment of each client.
b. Be able to splint and perform minor procedures.
c. Perform rapid assessment to determine priority of care.
d. Provide psychological support to family members.


____ 45. What is the primary survey?
a. Airway, breathing, circulation, head to toe assessment
b. Airway, breathing, circulation, neurologic assessment
c. Airway and cervical spine control, breathing, circulation, disability, exposure
d. Airway and cervical spine control, breathing, circulation, head to toe assessment


____ 46. A 67-year-old male presents to the ED complaining of chest pain. His heart rate is 120 beats/min, his blood pressure is 100/68 mm Hg, and his respiratory rate is 20 breaths/min. His is short of breath and diaphoretic. In a three-tiered triage model, how should the nurse prioritize this client?
a. Emergent
b. Urgent
c. Nonurgent
d. Dormant


____ 47. Which of the following statements is true regarding critical incident stress debriefing (CISD)?
a. CISD should not occur until several months have passed since the incident.
b. CISD consists of a group leader who is the main speaker.
c. CISD encourages group discussion.
d. CISD is limited to health care providers.


____ 48. Which of the following statements are true regarding post-traumatic stress disorder (PTSD)?
a. Individuals suffering from PTSD may display physical manifestations.
b. Professional “burnout” is rare secondary to PTSD.
c. Critical incident stress management is the only method to deal with PTSD.
d. Manifestations of PTSD are purely psychological.


____ 49. A woman presents to the emergency department after working outdoors in the sun all day. The nurse suspects heat exhaustion after his initial interview and assessment of the client. Which of the following symptoms would support his diagnosis?
a. Confusion
b. Normal body temperature
c. Elevated body temperature
d. Hypertension


____ 50. What is the highest priority of care in the prehospital setting for clients suffering from heat exhaustion (after airway assessment)?
a. Start intravenous fluids to hydrate the client.
b. Immerse the client in ice water.
c. Remove the client from physical activity and put him or her in a cool place.
d. Wait for paramedics to arrive and place the client in an air-conditioned vehicle.


____ 51. Which of the following statements is true regarding coral snake envenomation?
a. The toxic effects of coral snake venom are seen immediately.
b. Coagulopathy occurs in severe cases.
c. Pain at the bite site is severe.
d. Early symptoms of envenomation include nausea, vomiting, headache, and pallor.


____ 52. The primary first aid intervention in the prehospital setting for a black widow spider bite is the application of ice. Which statement provides the best rationale for this intervention?
a. Ice inhibits the action of neurotoxin.
b. Ice reduces swelling in the affected extremity.
c. Ice decreases venous return from the affected extremity.
d. Ice decreases the pain associated with spider bites.


____ 53. When caring for a client who has suffered a spider bite, which medication order might the nurse expect from the physician?
a. Antibiotics
b. Antispasmodics
c. Antimalarials
d. Tetanus toxoid


____ 54. Which of the clients listed below would be most susceptible to hypothermia?
a. A 17-year-old female with type 2 diabetes
b. A 10-year-old female with asthma
c. A 56-year-old male with a history of alcohol and tobacco abuse
d. A 76-year-old male with hypertension


____ 55. Mild hypothermia is defined a core body temperature of
a. 35° to 37° C
b. 32° to 35° C
c. 28° to 32° C
d. 24° to 28° C


____ 56. A 60-year-old male presents to the emergency department with hypothermia. He is shivering, has muscular incoordination, and is slow to respond questions. What stage of hypothermia is manifested by this client?
a. Frostbite
b. Mild hypothermia
c. Moderate hypothermia
d. Severe hypothermia


____ 57. A client suffering from severe hypothermia also is noted to have a cool, numb foot. The foot is blue in color and does not blanch. What degree of frostbite would this be?
a. First-degree frostbite
b. Second-degree frostbite
c. Third-degree frostbite
d. Fourth-degree frostbite


____ 58. The key factor in the pathophysiology of a near drowning in salt water is that aspirated water
a. Washes surfactant out of the lungs
b. Causes an osmotic gradient that draws water into the alveoli
c. Decreases lung compliance
d. Increases the work of breathing, leading to hypoxia


____ 59. A 50-year-old mountain climber is brought to the emergency department after a climb complaining of headache, nausea and vomiting, and “feeling winded.” The nurse suspects which altitude-related illness?
a. High-altitude cerebral edema (HACE)
b. Acute mountain sickness (AMS)
c. High-altitude pulmonary edema (HAPE)
d. High-altitude mountain sickness (HAMS)


____ 60. A 50-year-old mountain climber is brought to the emergency department after a climb complaining of headache, nausea and vomiting, and “feeling winded.” What medication would the nurse expect the physician to order?
a. Furosemide (Lasix)
b. Acetazolamide (Diamox, Apo-Acetazolamide)
c. Atropine sulfate
d. Ketorolac tromethamine (Toradol)

 
Answer Section

MULTIPLE CHOICE

 1. ANS: A
Although stroke is the leading cause of disability in the United States, costing more than $30 billion each year in medical costs and loss of productivity, many younger adults are disabled from accidents rather than from disease.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 2. ANS: C
A handicap is a preventable and reversible disturbance at the societal level that is experienced by a person with a disability or impairment. It is a negative value that is ascribed to the person, the disability, or the impairment. A handicap is often described by what a person is perceived to be unable to perform.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Psychosocial Integrity

 3. ANS: C
There are many purposes for participating in rehabilitation programs, including disability prevention, maintenance of functional ability, and restoration of function. Without the special knowledge learned through rehabilitation, the client with a newly acquired disability may never learn the skills needed to prevent long-term problems or conserve energy.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 4. ANS: C
In the United States, approximately 50% of the population has one or more chronic health problems, and about 35 million people (one in seven) experience some activity limitations because of their chronic health problems.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 5. ANS: A
Rehabilitation strategies for bowel training or habits are established based on what is normal for that specific client.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 6. ANS: B
Being able to manage independently the steps involved in toileting requires a high degree of manual dexterity with regard to the arms and hands.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 7. ANS: A
A low serum albumin level indicates less than adequate nutrition, especially of proteins, which greatly increases the risk for skin breakdown and reduces the rate of wound healing. Protein is a critical nutrient for stimulating DNA synthesis, cell division, and tissue repair.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 8. ANS: C
The Functional Independence Measure is a uniform data set used for outcome data collection in the United States. The FIM attempts to quantify what the person actually does, whatever the diagnosis or impairment. Categories for assessment are self-care, sphincter control, mobility, locomotion, communication, and cognition.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 9. ANS: B
The client already has a self-care deficit and impaired physical mobility related to the stroke. These problems greatly increase the risk for the client to experience skin breakdown, complicating or interfering with the recovery and rehabilitation efforts.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 10. ANS: A
With impaired mobility and use of a wheelchair, the client tends to gain weight. The increased weight requires greater upper body strength for movement and hinders the client's ability to become independent in transfer.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 11. ANS: D
Moving a joint beyond the point at which either the client feels pain or resistance is met can damage the joint.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 12. ANS: B
Although increasing the intake of calcium is good, this alone will not reduce the client's susceptibility to bone fractures. Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fractures.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 13. ANS: C
Clients of any age with a variety of impairments and disabilities can participate in intermittent self-catheterization. The two main requirements are that the client be cognitively intact and can reach the area.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 14. ANS: A
Assessing serum and transferrin levels helps determine the client's nutritional status and allows the care providers to alter diet, as needed, to prevent pressure ulcers. All other actions on this list are treatment-oriented rather than prevention-oriented.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 15. ANS: A
Range-of-motion exercises involve skeletal muscle contraction of the upper and lower extremities. Muscle contraction promotes venous return, preventing stasis and thrombus formation.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 16. ANS: C
Some of the best techniques for energy conservation include spacing activities with a rest period in between and individualizing the scheduling of more energy-intensive activities to the time of day when the client knows or feels that his or her energy levels are higher.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Physiological Integrity

 17. ANS: C
The goals of a bladder-training program are to avoid the use of an indwelling catheter and keep the residual volume at less than 100 mL.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 18. ANS: D
At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 19. ANS: D
Some organisms, such as Escherichia coli, grow best in an acidic environment. Fluids that promote an acidic urine include cranberry juice, prune juice, bouillon, tomato juice, and water.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 20. ANS: C
The older client with cardiac disease or on antihypertensive medications is particularly at risk for this complication.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 21. ANS: A
The most important requirement is the ability to get the client inside the home.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 22. ANS: B
Humans have 46 chromosomes (23 pairs). One pair, the sex chromosomes, codes for the sexual differentiation and development of the individual. The other 22 pairs (44 chromosomes) code for everything other than sexual differentiation and are known as autosomes.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 23. ANS: C
RNA is similar to DNA except that it is single-stranded and the base thymine (T) does not exist in RNA. Instead, every place the base thymine would be present in DNA, the base uracil (U) is placed in RNA. The RNA complementary to a segment of DNA would have an A wherever the DNA strand has a T, a C wherever the DNA strand has a G, a G wherever the DNA has a C, and a U wherever the DNA strand has an A.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 24. ANS: A
The amount of DNA present in human cells is enormous; however, most of it (about 95%) consists of noncoding regions. Only about 5% of human cellular DNA makes up the genes. It appears that we have, at most, about 35,000 genes and not the millions originally thought by the amount of DNA present.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 25. ANS: C
A nucleoside is an individual base connected to a pentose sugar. In order to have nucleosides form a strand of DNA by connecting them together, phosphorus is added, converting the nucleoside into a nucleotide.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 26. ANS: B
All human genes are present in every cell that has a nucleus; however, not all genes are active in all cells. Even though skin cells contain the gene for insulin, this gene is only turned on (active) in pancreatic beta cells. We know this because we can only find the protein insulin in those cells. Thus, the gene for insulin in pancreatic beta cells is expressed, but it is silent in skin cells (not expressed).

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 27. ANS: C
During the reproductive resting state of G0 and during the interphase of the cell cycle, the DNA is present in a loose helix that is not dense and is so fine that it cannot be seen with an ordinary microscope. During the M phase of the cell cycle, when the cell actually divides, the DNA coils up very tightly into thick, dense, temporary structures that can be stained and seen with an ordinary microscope.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 28. ANS: D
Some amino acids have more than one DNA code or triplet of bases. For example, glycine is coded for by the triplets CCA, CCG, CCT, and CCC. If a mutation in the DNA changed the “normal” triplet for glycine from CCT to CCA, the resulting mutated triplet would still code for glycine. Thus, there would be no amino acid difference in the final protein even though one base was exchanged for another as a result of a mutation in the DNA.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 29. ANS: B
Ribosomes are present in the cytoplasm and uncover the codons on the mRNA so that the correct amino acids are placed into newly synthesized protein chains.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 30. ANS: C
A point mutation is a single-base substitution. Often, this substitution does not disrupt protein synthesis, although the expressed protein may have one amino acid different than a protein made from a nonmutated gene. Frameshift mutations either delete one or more bases from the gene (most common) or add one or more bases to a gene. This deletion or addition of bases disrupts the correct “reading” of the gene and the wrong amino acids are placed into the protein. The protein made in this way does not resemble the correct protein and will not function.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 31. ANS: D
Transcription for both DNA synthesis and RNA synthesis uses many of the same enzymes and three of the four same bases. When transcription occurs for DNA synthesis, both strands (the sense and the antisense strands) of DNA are completely copied. For protein synthesis, only the strand that actually contains the gene (the sense strand) is copied. The entire strand isn’t copied—only the area where the specific gene is located.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 32. ANS: C
The gene locus is the specific chromosome location of a particular gene.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 33. ANS: A
Genotype refers to the exact alleles of a single gene trait. Phenotype refers to the observable characteristics present when a gene is expressed. For recessive traits, because both alleles must be the same (homozygous) for the gene to be expressed, the phenotype and the genotype are the same. Dominant traits are expressed in the phenotype, even when the person’s genotype is heterozygous for the alleles.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 34. ANS: B
Because the parents are each homozygous for the two blood type alleles, each parent will contribute a different allele for blood type. The mother will always contribute an A allele and the father with always contribute a B allele. Thus, the genotypes for blood type for any of their children will always be heterozygous with one A allele and one B allele. The A and B alleles for blood type are each dominant (co-dominant) and would both be expressed in the child’s phenotype as type AB blood.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 35. ANS: A
With a highly penetrant dominant trait, if a person has one allele, he or she would express the trait and have a 50% risk of transmitting it to his or her children. A person who does not express the trait does not have the allele and could not transmit the trait to his or her children.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 36. ANS: A
A dominant gene may be present and normal (or abnormal) and not expressed consistently in all people who have that gene or allele. This situation is referred to as reduced penetrance. The gene is present but either is or is not expressed. Expressivity refers to variation in degree of expression. The gene (and its alleles) is present and expressed, but in some people the phenotype may be so slight that the trait is barely seen, and in other people the phenotype may be so strong it cannot be missed.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 37. ANS: A
Multifactorial inheritance indicates an interaction between a genetic predisposition and the environment. Although the predisposition to developing a health problem may be inherited, whether or not the problem is ever expressed is determined by environmental influences, including lifestyle. Such disorders tend to appear more frequently in families but are not expressed as traditional inheritance patterns. The presence of these problems is also called “familial clustering.” Some common adult health problems that are multifactorial include hypertension, obesity, diabetes mellitus, and some types of cancer.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 38. ANS: C
At least three generations of family members need to be explored to even begin to rule in (or out) a possible genetic origin to a health problem. Such a problem could be identified in three generations if it had an autosomal dominant pattern of inheritance. If the problem is the result of a recessive gene or an X-linked gene, more than three generations would be needed to establish a pattern of inheritance.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 39. ANS: C
Squares are the symbols for males and circles symbolize the females in a kinship. Therefore, B and D are incorrect because they do not indicate the correct gender. All people who belong to one generation in a family share a horizontal line. The client’s mother’s sister would be on the same line as the client’s mother. His mother and her sister can be distinguished in this pedigree because only his mother would be part of the vertical line connecting this generation to the client.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 40. ANS: B
Any level of genetic counseling requires the counselor to be “nondirective.” The counselor must ensure that the client has adequate and accurate information upon which to base the decision but cannot suggest or direct the client to test or not to test. The client may wish to discuss the issue with his or her family but, ultimately, the decision about testing can only be made by the client.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

 41. ANS: D
You are supporting the client emotionally while she tells her daughter the information she has learned about the test results. You are not interpreting the results nor are you counseling the client or her daughter about what steps to take next.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

 42. ANS: C
This situation represents an ethical dilemma. The client does have the right to disclose or not disclose the information discovered by genetic testing. However, in this instance, disclosure could allow other people to check their health status and take preventive actions against the development of cancer. The client cannot be forced to disclose the results but should be encouraged to consider disclosure. The response described in C keeps the issue open for discussion later. There is no national or final legal point of view on the resolution of this controversy.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

 43. ANS: B
The concept of emergency department (ED) triage is based upon sorting clients into priority levels depending on illness or injury severity. The key concept is that the most serious clients who present to the ED receive the quickest evaluation and treatment.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

 44. ANS: C
The triage nurse should perform a rapid assessment to determine triage priority. The triage nurse should not be assigned tasks or have responsibilities to specific clients that will draw him or her away from the triage area.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

 45. ANS: C
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E. A, airway and cervical spine control, B, breathing, C, circulation, D, disability, E, exposure.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 46. ANS: A
In a three-tiered triage model of emergent, urgent, and nonurgent, the client in the emergent triage category has a condition that may pose an immediate threat to life or limb and is given the highest priority. The urgent triage category is for clients who should be treated quickly but who do not have an immediate threat to life if they are not. Clients categorized as nonurgent generally can tolerate several hours of waiting time without a significant risk of deterioration.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 47. ANS: C
CISD is comprised of a team of specially trained individuals who come together quickly to deal with the emotional needs of health team members who have participated in a devastating or disturbing incident. Sessions generally last from 1 to 3 hours. CISD group leaders encourage group discussion by asking a series of questions designed to make everyone involved explain their part of the story and/or how the incident personally affected them.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Evaluation
MSC: Client Needs Category: Psychosocial Integrity

 48. ANS: A
PTSD may occur in health care providers after an extremely emotional incident. It may be manifested by multiple psychological and physical effects such as flashbacks, avoidance, diminished interest in previously enjoyable events, detachment, and physical manifestations including rapid heart rate and insomnia and other physiologic effects of anxiety. Individuals suffering from PTSD may have difficulty in relating in their usual way to family and friends and may ultimately experience professional “burnout.”

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Evaluation
MSC: Client Needs Category: Psychosocial Integrity

 49. ANS: B
In heat exhaustion, clients have normal mental status with the presence of flu-like symptoms. The client may have orthostatic hypotension and tachycardia. The client’s body temperature is not significantly elevated.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 50. ANS: C
Initial treatment of a client suffering from heat exhaustion consists of terminating the physical activity that promoted the exhaustion and moving the individual to a cool place.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 51. ANS: D
The toxic effects of coral snake venom are not seen immediately. The effects may be delayed for up to 12 to 13 hours after a bite, but then rapid clinical deterioration occurs. Unlike pit viper envenomation, pain at the bite site may be only mild and transient. Swelling is unlikely. Early symptoms consist of headache, nausea, vomiting, pallor, and abdominal pain. Paresthesias, numbness, and mental status changes also occur. Total flaccid paralysis may occur late. The victim may have difficulty speaking, swallowing, and breathing.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 52. ANS: A
Ice inhibits the action of neurotoxin and should be the first intervention provided to a client bitten by a black widow spider.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Psychological Integrity

 53. ANS: D
Tetanus toxoid should be administered to any person suffering a bite, regardless of type. If the client has had a tetanus toxoid booster in the past 5 years, this is not necessary.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and Maintenance  

 54. ANS: C
Risk factors for cold injuries are obviously clients who do not have protection from the cold (e.g., the homeless). Clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite. Any previous history of frostbite also increases a client’s susceptibility to a cold-related injury.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 55. ANS: B
Mild hypothermia is considered a core body temperature of 32° to 35° C. Moderate hypothermia is considered a core body temperature of 28° to 32° C. Severe hypothermia is a core body temperature below 28° C.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 56. ANS: B
Mild hypothermia is manifested by shivering, dysarthria, muscular incoordination, and impaired cognitive abilities. Clients with moderate to severe hypothermia may be confused, stuporous, or even unconscious. Shivering has stopped. Bradycardia and hypotension may be present.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 57. ANS: C
Third-degree frostbite appears as small blisters that contain dark fluid. The affected body part is cool, numb, blue or red, and does not blanch. First-degree frostbite involves hyperemia and edema formation. With second-degree frostbite, large fluid-filled blisters develop, with some skin necrosis. In fourth-degree frostbite, there are no blisters or edema and the body part is numb, cold, and bloodless.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 58. ANS: B
Salt water is a hypertonic fluid that creates an osmotic gradient, which draws protein-rich fluid from the vascular space into the alveoli. This causes impaired alveolar ventilation and resultant intrapulmonary shunting, which compounds the hypoxic state.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 59. ANS: B
The typical client with acute mountain sickness complains of throbbing headache and nausea and vomiting, and may also complain of feeling chilled, irritable, and apathetic. The syndrome produces effects similar to those of an alcohol-induced hangover. The client may complain of dyspnea, both on exertion and at rest.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 60. ANS: B
The oral medication acetazolamide (Diamox, Apo-Acetazolamide) is used to prevent and treat acute mountain sickness. Acetazolamide is a carbonic anhydrase inhibitor that acts by causing a bicarbonate diuresis that induces metabolic acidosis. The acidotic state increases respiratory rate and helps clients acclimate faster to a high altitude. Dexamethasone (Decadron, Deronil) may also be helpful in the treatment of moderate to severe acute mountain sickness.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and Maintenance  








Practice Test

Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.

____ 1. Which action by the nurse demonstrates understanding of a best practice intervention for client education?
a. Breaking complex skills into small parts
b. Using only visual and oral educational aids
c. Providing standardized educational information
d. Using client goals developed by the nursing staff


____ 2. How have recent changes in health care delivery affected practice settings for medical-surgical nurses?
a. Third-party payment systems have restricted the delivery of medical-surgical nursing services to acute care hospitals.
b. Managed care organizations prefer less expensive care delivered by unlicensed personnel.
c. Medical-surgical nursing is practiced in community centers and long-term care facilities.
d. The delivery of medical-surgical nursing practice is now limited to adults only.


____ 3. Which of the following nursing home facilities offers the residents a range of services from independent living to skilled nursing care?
a. Skilled nursing facilities
b. Chronic care facilities
c. Residential facilities
d. Nursing facilities


____ 4. Which client is likely to require transitional subacute care before being discharged home?
a. The client with stable human immunodeficiency virus infection
b. The client with a progressive neurologic disease
c. The client requiring deep wound management
d. The client who is ventilator dependent


____ 5. A nurse is caring for an older client who has just been admitted to the hospital. Upon admission the client becomes increasingly confused, agitated, and combative. What action should the nurse take to minimize relocation stress syndrome in this client?
a. Reorient the client frequently to his or her location.
b. Obtain a certified sitter to remain with the client.
c. Speak to the client as little as possible to avoid overstimulation.
d. Provide adequate sedation for all procedures to avoid fear-provoking situations.


____ 6. An older client confides feeling a loss of control over life after having a mild stroke. What would be the best action the nurse could take to support this client?
a. Explain to the client that such feelings are normal, but that he or she must have realistic expectations for rehabilitation.
b. Encourage the client to perform as many tasks as possible and to participate in decision making.
c. Further assess the client’s mental status for other signs of denial.
d. Obtain an order for physical and occupational therapy.


____ 7. Which behavior exhibited by an older adult client should alert the nurse to the possibility that the client is experiencing delirium?
a. The client becomes confused within 24 hours after hospital admission.
b. The client displays a cheerful attitude despite a poor prognosis.
c. The client becomes depressed and sleeps most of the day.
d. The client begins to use slurred speech.


____ 8. Which statement regarding chronic pain is true?
a. Physiologic adaptation occurs so that manifestations of tachycardia and elevated blood pressure are not present.
b. The person with chronic pain experiences local nerve adaptation so that the intensity of chronic pain diminishes over time.
c. Chronic pain allows for better psychosocial adaptation over time, and the client has a reduction in the perception of pain.
d. Morphine and morphine agonists are not effective for chronic pain because the cells involved in neuromodulation are no longer responsive.


____ 9. The client with cholecystitis also has pain in the right shoulder blade area. The client expresses concern that a new problem is occurring. What is the nurse’s best response to this client situation?
a. Reposition the client on the left side and then check the muscle strength, capillary refill, and touch sensation in the right hand and arm.
b. Explain to the client that problems in the gallbladder area often are transmitted by nerves in the area with many branches and can be felt as pain in the shoulder area.
c. Withhold the next dose of analgesic until the source of the pain is identified.
d. Notify the physician of the new complaint.


____ 10. An unconscious client who has just been involved in a motor vehicle accident is brought to the emergency department. Which presenting clinical manifestation makes the nurse suspicious of an opioid overdose rather than increased intracranial pressure as a cause of the unconsciousness?
a. Pinpoint pupils
b. Respiratory depression
c. Hyporeflexive deep tendon reflexes
d. Evidence that the client has vomited


____ 11. Which intervention is compatible with the goals for end-of-life care?
a. Administering a flu shot
b. Preventing the client with COPD from smoking
c. Performing passive range-of-motion exercises to prevent contractures
d. Permitting the client with diabetes mellitus to have a serving of ice cream


____ 12. Which statement regarding disability and chronic illness is true?
a. Disabilities and chronic illnesses occur most often in young adults.
b. Accidents are responsible for more chronic and disabling conditions than chronic disease.
c. In the United States, one in seven persons experiences activity limitations because of chronic health problems.
d. Men experience more disability than women, but women experience a higher incidence of chronic illness than men.


____ 13. The client who has been found to have a mutation in the BRCA1 gene allele and an increased risk for breast and ovarian cancer has asked you to be present when she discloses this information to her grown daughter. What is your role in this situation?
a. Primary health care provider
b. Genetic counselor
c. Client advocate
d. Client support


____ 14. What is the primary survey?
a. Airway, breathing, circulation, head to toe assessment
b. Airway, breathing, circulation, neurologic assessment
c. Airway and cervical spine control, breathing, circulation, disability, exposure
d. Airway and cervical spine control, breathing, circulation, head to toe assessment


____ 15. What statement best describes the basic concept of mass causality triage?
a. “The greatest good for the greatest amount of people”
b. “First come, first served”
c. “Women and children first”
d. “First priority to the most critical”


____ 16. A client has suffered a snakebite (North American pit viper) to a lower extremity. What would be the most appropriate nursing intervention?
a. Apply ice to the bite site immediately.
b. Attempt to capture the snake for later identification.
c. Immobilize the extremity in a position of function.
d. Incise the bite and suck out the venom.


____ 17. The primary first aid intervention in the prehospital setting for a black widow spider bite is the application of ice. Which statement provides the best rationale for this intervention?
a. Ice inhibits the action of neurotoxin.
b. Ice reduces swelling in the affected extremity.
c. Ice decreases venous return from the affected extremity.
d. Ice decreases the pain associated with spider bites.


____ 18. What effect would an infusion of 200 mL of albumin have on a healthy client's plasma osmotic and hydrostatic pressures?
a. Increased osmotic pressure, increased hydrostatic pressure
b. Increased osmotic pressure, decreased hydrostatic pressure
c. Decreased osmotic pressure, increased hydrostatic pressure
d. Decreased osmotic pressure, increased hydrostatic pressure


____ 19. Which specific condition triggers the "thirst" center in the hypothalamus?
a. Hyperosmolar extracellular fluid
b. Hypo-osmolar extracellular fluid
c. Elevated serum potassium level
d. Decreased serum potassium level


____ 20. Why is sterile pure water not usually ordered as an intravenous fluid?
a. It would suppress the client's natural thirst reflex.
b. It would cause red blood cells to swell and break.
c. It would cause red blood cells to shrink and crenate.
d. It would cause overstimulated ADH secretion.


____ 21. Which intervention is most important for the nurse to teach the client who has lymphedema in her right arm from a mastectomy 1 year ago?
a. “Exercise your arm and use it during tasks that occur at the level of your chest or higher.”
b. “Be sure to use sunscreen or protective clothing to reduce the risk of injuring this arm.”
c. “Reduce your salt intake to prevent excess water retention.”
d. “Do not expose the right arm to temperature extremes.”


____ 22. Which is the most important question the nurse should ask the client who has been diagnosed with isotonic dehydration to identify a possible cause of the fluid imbalance?
a. “Do you take diuretics or 'water pills'?”
b. “What and how much do you normally eat over a day's time?”
c. “How many bowel movements do you usually have each day?”
d. “Have you or any member of your family been diagnosed with diabetes mellitus?”


____ 23. Which intervention for the client with overhydration-induced confusion is most likely to relieve the confusion?
a. Measuring intake and output
b. Slowing the IV flow rate to 50 mL/hour
c. Administering diuretic agents as prescribed
d. Placing the client in modified Trendelenburg position (feet and legs elevated; head and chest flat)


____ 24. Which nursing intervention would be most effective in preventing injury in a hospitalized client with hypocalcemia of long duration?
a. Teaching the client to wear shoes when ambulating
b. Applying antiembolic stockings on the client's legs
c. Placing an egg-crate mattress on the client’s bed
d. Using a lift sheet when moving the client in bed


____ 25. The client with hypophosphatemia who is undergoing intravenous phosphorus replacement suddenly has a positive Trousseau sign. What is the correct interpretation of this finding?
a. The client is dehydrated.
b. The hypophosphatemia is worsening.
c. The phosphorus replacement is causing hypocalcemia.
d. Rehydration is too rapid and overhydration is occurring.


____ 26. What adjustment in transfusion therapy needs to be made in order to deliver packed red blood cells (PRBCs) through a PICC?
a. The transfusion set does not contain a filter.
b. The PRBCs must be delivered with the use of a pump.
c. Ringer’s lactate rather than normal saline must be the primary infusion fluid.
d. Each unit of PRBCs must be completely infused within 1 hour of starting the transfusion.


____ 27. Which complication should the nurse assess for in a client receiving epidural therapy with either an opioid or a local anesthetic agent?
a. Numbness and tingling at the insertion site
b. Loss of consciousness
c. Urinary retention
d. Constipation


____ 28. Why does a change in blood pH usually result in an abnormality of one or more blood electrolyte levels?
a. Because an increase in blood pH level stimulates the thirst reflex, the person then ingests hypotonic fluids to excess, resulting in a dilution of all other serum electrolytes.
b. A change in the pH is a change in the hydrogen ion concentration, which causes a corresponding change in the ability of the intestinal mucosa to absorb ingested electrolytes.
c. Because hydrogen ions carry a positive charge, a change in the pH requires a corresponding change in the amount of other positive and negative charges to maintain electroneutrality of the blood.
d. Because hydrogen ions and potassium ions exist in the blood in a balanced, reciprocal relationship, an increase or decrease in the blood pH requires a corresponding decrease or increase in potassium ions.


____ 29. The handgrasps of the client with acidosis have diminished since the previous assessment 1 hour ago. What is the nurse’s best first action?
a. Assess the client's rate, rhythm, and depth of respiration.
b. Measure the client's pulse and blood pressure.
c. Document the findings as the only action.
d. Notify the physician.


____ 30. Which client is at greatest risk for the development of metabolic acidosis?
a. 56-year-old man with chronic asthma
b. 36-year-old man hiking in the Canadian Rockies
c. 36-year-old woman on a carbohydrate-free diet
d. 56-year-old woman self-medicating with sodium bicarbonate for gastroesophageal reflux


____ 31. The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM and the client's normal oral medications (consisting of digoxin, 0.125 mg, Colace, 300 mg, and Feostat, 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse’s best action?
a. Hold all medications.
b. Administer all medications orally.
c. Administer all medications parenterally.
d. Administer digoxin with minimal water and hold the other drugs.


____ 32. The client who has received ketamine hydrochloride during a surgical procedure has all of the following manifestations and behaviors. Which one alerts the nurse to a dissociative reaction?
a. Hypoventilation and decreased oxygen saturation
b. Presence of hives on the skin around the IV site
c. Crying because the pain at the surgical site has increased
d. Pulling out the IV because he sees bugs in the solution bag


____ 33. The client returning to the clinic for a follow-up visit 3 weeks after abdominal surgery is concerned because she can feel small, uneven lumps under the suture line of the incision. What is the nurse’s best response?
a. “Avoid touching those areas because you may dislodge the blood clots that keep your incision from bleeding.”
b. “What you are feeling is growth of new tissue proceeding at different rates in the incision.”
c. “Those are the deep stitches the surgeon placed, and they will eventually be absorbed and disappear.”
d. “Keep the incision covered for as long as those lumps can be felt.”


____ 34. How do immune system cells differentiate between normal, healthy body cells and non-self cells within the body?
a. All normal, healthy body cells are considered part of the immune system.
b. Immune system cells recognize normal healthy body cells by the presence of the nucleus, a structure that is lacking in non-self cells.
c. Non-self cells express surface proteins that are different from normal, healthy body cells and recognized as “foreign” by immune system cells.
d. Non-self cells are easily identified by the immune system cells, because non-self cells are much larger than normal, healthy body cells.


____ 35. The 28-year-old client has a deep puncture wound on his foot from stepping on a nail. When the nurse prepares to give him a tetanus toxoid vaccination, he says he does not need another tetanus shot because he had a tetanus shot just 1 year ago. What is the nurse’s best response?
a. “You need this vaccination because the strain of tetanus changes every year.”
b. “I will check with the doctor. You probably do not need another vaccination now.”
c. “Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago.”
d. “Tetanus is a more serious disease among younger people because it can be spread to others by sexual transmission, so it is best to take this vaccination now.”


____ 36. The 95-year-old nursing home client has a productive cough and night sweats. When she is tested for tuberculosis with a PPD, the injection site does not have a skin response of induration by 48 hours after the injection. What is the correct interpretation of this finding?
a. The test is negative and airborne precautions are not necessary because the client does not have tuberculosis.
b. The test is negative; however, airborne precautions are still necessary until other test results for tuberculosis are also negative.
c. The test is negative and airborne precautions are still necessary because the client probably has a bacterial pneumonia.
d. The test is negative and airborne precautions are not necessary because the client has sufficient antibodies against the tuberculosis bacillus.


____ 37. The older adult client taking NSAIDs for rheumatoid arthritis now has pitting edema of both legs. What is the nurse’s best first action?
a. Assess the client’s pulse, blood pressure, and breath sounds.
b. Instruct the client to weigh herself daily and keep a diary.
c. Document the finding as the only action.
d. Notify the physician immediately.


____ 38. What is the most important precaution or action the nurse should teach a client newly diagnosed with systemic lupus erythematosus (SLE)?
a. Monitoring urine output
b. Being immunized yearly against influenza
c. Assessing skin daily for open areas or rashes
d. Avoiding the use of hair dyes and having permanents


____ 39. The client who has AIDS is admitted with cryptosporidiosis. Which clinical manifestation should the nurse expect the client to have?
a. Persistent watery diarrhea and abdominal cramping
b. Productive cough with dyspnea and low-grade fever
c. Red, pruritic rash that bleeds easily with light pressure
d. Thick, white coating on the tongue and oral mucous membranes


____ 40. Which is the most important precaution for the nurse to take when administering pentamidine (Pentam) intravenously to a client with pneumocystis pneumonia?
a. Monitoring intake and output
b. Checking the IV site hourly for phlebitis
c. Assessing the client hourly for manifestations of hypoglycemia
d. Assessing deep tendon reflexes and handgrip strength bilaterally


____ 41. A health care professional has been occupationally exposed to HIV through a needle stick injury from a client who is HIV-positive and has a low viral load. What drug regimen should the nurse be prepared to initiate?
a. No regimen is necessary
b. Zidovudine (Retrovir) 100 mg every 4 hours for 24 hours
c. Zidovudine (Retrovir) and lamivudine (Epivir) for 4 weeks
d. Zidovudine (Retrovir) and lamivudine (Epivir) for 1 year


____ 42. The client who has just been diagnosed as HIV-positive asks if he poses a health hazard to his co-workers in the secretarial pool. What is the nurse’s best response?
a. “The only time you could make someone else sick is when you have Pneumocystis pneumonia.”
b. “As long as you are taking your antiviral medications, you cannot transmit the virus to your co-workers.”
c. “Unless your blood or other body fluids comes into contact with your co-workers, you are not a health risk to them.”
d. “You should inform your co-workers of your HIV status so that they can take proper precautions to reduce their risk.”


____ 43. With which client should the nurse be alert to the possibility of latex hypersensitivity?
a. 38-year-old man allergic to shellfish
b. 28-year-old woman with spina bifida
c. 68-year-old man with total hip replacement
d. 38-year-old woman taking oral contraceptives


____ 44. How is a type V hypersensitivity reaction different from all other types of known hypersensitivities?
a. It is cell-mediated rather than antibody-mediated.
b. This type of reaction is an immediate response rather than a delayed response.
c. The result of the reaction is a stimulatory response to normal tissues rather than an inhibitory response.
d. Type V reactions result in more severe tissue-damaging responses than does any other type of hypersensitivity reaction.


____ 45. Which characteristic of a tumor indicates that it is benign rather than malignant?
a. It does not cause pain.
b. It is less than 2 cm in size.
c. It is surrounded by a capsule.
d. It causes the sensation of itching.


____ 46. The 36-year-old client who has a suspicious mammogram says that her mother died of bone cancer when she was 40 years old. Which is the most important question for the nurse to ask this client next?
a. “Have any other members of your family had bone cancer?”
b. “Did your mother ever have any other type of cancer?”
c. “How old were you when you started your periods?”
d. “Did your mother have regular mammograms?”


____ 47. What cancer screening or prevention activity is most important to include when examining the client, a 20-year-old man who has Down syndrome?
a. Encouraging him to eat more fruit and leafy green vegetables
b. Teaching him how to perform self testicular examination
c. Assessing his skin for bruises and petechiae
d. Testing his stool for occult blood


____ 48. The client who has developed a wound infection after surgery is being discharged to home and is prescribed to take a course of antibiotics. Which statement made by the client indicates correct understanding of the antibiotic regimen?
a. “If my temperature is normal for 3 days in a row, the infection is gone and I can stop taking my medicine.”
b. “If my temperature goes above 100° F for 2 days, I should take twice as much medicine.”
c. “When my incision stops draining, I will no longer need to take the antibiotics.”
d. “Even if I feel completely well, I should take the medication until it is gone.”


____ 49. A client has all of the following family and personal factors. Which one greatly increases the risk for the client to develop respiratory problems?
a. The client has long-standing hypertension.
b. The client’s father died of lung cancer at age 82.
c. The client’s sister has a child with cystic fibrosis.
d. The client has a deficiency of alpha1-antitrypsin.


____ 50. The client with long-standing pulmonary problems is classified as having class III dyspnea. Based on this classification, what type of assistance will you need to provide for ADLs?
a. Dyspnea is minimal and no assistance is required.
b. The client may complete activities of daily living without assistance but requires rest periods during performance.
c. The client is severely dyspneic with activity and requires assistance for some but not all tasks.
d. The client is severely dyspneic at rest and cannot participate in any self-care.


____ 51. Which technique should you teach the caregiver and client with a tracheostomy to reduce the risk for aspiration during feeding/eating?
a. Encourage the client to swallow as fast as possible to limit the time the client is at risk for aspiration.
b. Tell the client and family to keep the phone nearby during feedings to shorten the time it takes to dial 911.
c. Teach the client/caregiver to thicken liquids and avoid foods that generate thin liquids during chewing.
d. Instruct the client/caregiver to inflate the cuff maximally during and for 1 hour after the feeding.


____ 52. What is the priority teaching focus for the client being discharged home after a fixed centric occlusion for a mandibular fracture?
a. Keeping wire cutters close at hand
b. Eating at least 6 soft or liquid meals each day
c. Using an irrigating device for oral care 4 times a day
d. Sleeping in a semisitting position for the first week after surgery


____ 53. Which conditions or factors in a 64-year-old man diagnosed with head and neck cancer are most likely to have contributed to this health problem?
a. He quit school at age 16 and has worked in a butcher shop for over 40 years.
b. He uses chewing tobacco and drinks beer daily.
c. His father also had head and neck cancer.
d. His hobby is oil painting.


____ 54. Your client with asthma is receiving aminophylline intravenously. Which manifestation alerts you to the possibility of aminophylline toxicity?
a. Pulse oximetry of 93%
b. Increased restlessness
c. Hourly urine output of 45 mL
d. Heart rate increase from 72 to 84 beats per minute


____ 55. Which clinical manifestation in a client with long-standing COPD alerts you to the possibility of cor pulmonale?
a. Pursed-lip breathing occurs when the client is at rest.
b. The client's neck muscles are enlarged and prominent.
c. The client's ECG shows tall, peaked T waves and an absent U wave.
d. Jugular venous distention is present when the client is in a sitting position.


____ 56. The client with lung cancer is scheduled for surgery and is receiving oxygen for hypoxia. The client tells you that the sensation of air hunger is worse. What is your best first action?
a. Notify the physician.
b. Increase the oxygen flow rate.
c. Document the observation as the only action.
d. Attempt to calm the client using guided imagery.


____ 57. You are the only licensed health care professional assigned to a small medical-surgical unit with 12 beds. Two unlicensed assistive personnel are also working on this unit. Which of these four clients with respiratory problems should be assigned to you rather than to the unlicensed assistive personnel?
a. 82-year-old woman receiving steroid therapy for pulmonary fibrosis whose pulse oximetry is 92%
b. 35-year-old woman receiving intravenous aminophylline for asthma whose pulse oximetry is 92% and whose FEV1 is 50% of expected
c. 55-year-old man with chronic obstructive lung disease whose pulse oximetry is 88% and who has the following arterial blood gas values: pH, 7.35; HCO3–, 36 mEq/L; PCO2, 65 mm Hg; PO2, 78 mm Hg
d. 50-year-old man 2 days postoperative from a pneumonectomy for lung cancer whose pulse oximetry is 92% and whose chest tube is draining 200 mL/8-hour shift


____ 58. Which intervention should the nurse urge a client with a cold to use to avoid spreading the infection to other family members?
a. “Wash your hands after blowing your nose or sneezing.”
b. “Use a dishwasher or boiling water to clean all dishes and utensils you have used.”
c. “Have the other members of your family wear masks until all cold manifestations have subsided.”
d. “Humidify the air in your home with a humidifier or by running hot shower water to produce steam.”


____ 59. Which person is a greatest risk for developing nosocomial pneumonia?
a. The 60-year-old client receiving mechanical ventilation
b. The 40-year-old client receiving antibiotics for a surgical wound infection
c. The 60-year-old client in traction for a fractured femur who also has a cold
d. The 40-year-old client with type 2 diabetes who has a 50 pack-year smoking history


____ 60. The client with active tuberculosis has started therapy with isoniazid and rifampin. He reports that his urine now has an orange color. What is the nurse’s best action?
a. Document the report as the only action.
b. Obtain a specimen for culture.
c. Test the urine for occult blood.
d. Notify the physician.


____ 61. Which statement made by a client’s spouse indicates the need for more teaching about prevention of a pulmonary embolism at home after major abdominal surgery?
a. “While he is awake, I will make sure he gets up and walks for at least 5 minutes every 2 hours.”
b. “He is prone to constipation, so I will increase the amount of fiber in his meals every day.”
c. “I will massage his feet and legs twice a day to help blood return.”
d. “I will check his breathing rate and level twice a day.”


____ 62. The client with a pulmonary embolism is receiving an intravenous heparin drip. The nurse should make certain which agent is readily available?
a. Fresh-frozen plasma
b. Protamine sulfate
c. Cryoprecipitate
d. Vitamin K


____ 63. What is the most important intervention for the client with ARDS?
a. Antibiotic therapy
b. Bronchodilators
c. Oxygen therapy
d. Diuretic therapy


____ 64. A nurse is starting a new shift and assessing the client who has an oral endotracheal tube in place. Which finding requires immediate intervention?
a. The client has been intubated for four days.
b. The endotracheal tube is midline in the mouth.
c. The endotracheal tube is taped to the lower jaw.
d. The client has hydrocolloid membrane on the skin of the cheeks.


____ 65. The pressure reading on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the correct action to take for this problem?
a. Determine whether there is an air leak in the client’s endotracheal tube cuff.
b. Increase the tidal volume by at least 100 mL or by the client’s weight in kg.
c. Assess the client’s oxygen saturation to determine the adequacy of oxygenation.
d. Disconnect the ventilator from the client and use a manual resuscitation bag until the machine has been checked.


____ 66. A client brought to the emergency room following a myocardial infarction is found to be hypotensive. What effect from baroreceptor stimulation on this client’s heart rate would be expected?
a. The heart rate would increase.
b. The heart rate would decrease.
c. There would be no effect on heart rate.
d. The heart rate would vacillate between accelerations and deceleration.


____ 67. Which conditions would lead to an increase in stroke volume?
a. Increased preload, increased afterload
b. Increased preload, decreased afterload
c. Decreased preload, increased afterload
d. Decreased preload, decreased afterload


____ 68. A client’s cardiac status is being observed by telemetry monitoring. A nurse observes a P wave that changes in shape in lead II. What conclusion can the nurse make from this?
a. The P wave is originating from an ectopic focus.
b. The P wave is firing twice from the sinoatrial (SA) node.
c. There is no real P wave.
d. The P wave is normal.


____ 69. The client is experiencing sinus bradycardia with hypotension and dizziness. Which of the following drugs/agents should the nurse be prepared to administer?
a. Atropine
b. Digoxin
c. Lidocaine
d. Metoprolol


____ 70. A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes with a heart rate of 35 beats/min on the monitor. What physical assessment parameter would be important to incorporate for this client?
a. Assess for pulmonary rales.
b. Assess for acute hypertension.
c. Assess for confusion or syncope.
d. Assess for the presence of a gallop rhythm.


____ 71. The health care provider is planning to treat a client who has symptomatic, infranodal, third-degree heart block following cardiac surgery with temporary pacing. Which type of pacing would be most appropriate for this client?
a. Global pacing
b. Universal pacing
c. Synchronous pacing
d. Asynchronous pacing


____ 72. A client has been admitted to the acute care unit for an exacerbation of heart failure. Which of the following nursing actions should be performed first?
a. Assessment of respiratory and oxygenation status
b. Monitoring of serum electrolyte levels
c. Administration of intravenous fluids
d. Insertion of a Foley catheter


____ 73. The client with hypercholesterolemia and atherosclerosis reports skin flushing and itching while taking nicotinic acid. What is the nurse’s best response?
a. “Take this product with meals.”
b. “Take this product at bedtime.”
c. “Avoid taking aspirin with this product.”
d. “Avoid smoking cigarettes while taking this product.”


____ 74. What instructions should be given to a client who is about to begin treatment with an HMG-CoA reductase inhibitor such as simvastatin?
a. “This drug can cause constipation.”
b. “Take this drug on an empty stomach.”
c. “Report any muscle tenderness to your health care provider.”
d. “You may experience flushing of the skin with this medication.”


____ 75. A client in the hyperdynamic phase of septic shock has been admitted to the intensive care unit. What complication should the nurse be alert for as shock progresses from the hyperdynamic to the hypodynamic phase?
a. Acute respiratory distress syndrome
b. Acute bowel obstruction
c. Ventricular tachycardia
d. Seizure activity


____ 76. What drug therapy should the nurse prepare to administer to a client in the hyperdynamic phase of septic shock?
a. Heparin
b. Vitamin K
c. Corticosteroids
d. Clotting factors, platelets, and plasma


____ 77. The client is being discharged after a percutaneous transluminal coronary angioplasty (PTCA) and is prescribed to take a calcium channel blocking agent. Which precaution should the nurse stress when teaching that is specific for this drug therapy?
a. “Change positions slowly.”
b. “Avoid crossing your legs.”
c. “Weigh yourself daily.”
d. “Decrease salt intake.”


____ 78. The 37-year-old male client has a hemoglobin level of 22.1 g/dL. What is the nurse’s best action?
a. Document the report as the only action.
b. Institute infection precautions.
c. Institute bleeding precautions.
d. Notify the physician.


____ 79. Which clinical manifestation is common to all types of anemia regardless of cause or pathologic mechanism?
a. Jaundiced sclera and roof of the mouth
b. Hypertension and peripheral edema
c. Tachycardia at basal activity levels
d. Increased PaCO2


____ 80. The client has anemia and all the following clinical manifestations. Which manifestation indicates to the nurse that the anemia is a long-standing problem?
a. Headache
b. Clubbed fingers
c. Circumoral pallor
d. Orthostatic hypotension


____ 81. Which problem or condition is most likely to stimulate a crisis in a person who has sickle cell trait?
a. Becoming pregnant
b. Shoveling snow when the temperature is at 0 degrees
c. Having surgery under general anesthesia for colon cancer
d. Having a cast placed on the wrist after sustaining a simple fracture


____ 82. Which clinical manifestation or assessment finding indicates effectiveness of the therapy for the client with polycythemia vera?
a. Hematocrit of 65%
b. Bilateral darkening of the conjunctiva
c. Blood pressure change from 180/150 to 160/90
d. Unplanned weight loss of 6 lb over a month’s time


____ 83. Which precaution should the nurse teach the client who is prescribed to take thalidomide (Thalomid) as part of her treatment plan for multiple myeloma?
a. “Avoid high-fiber foods to prevent diarrhea.”
b. “Use multiple forms of birth control to prevent birth defects.”
c. “Drink plenty of fluids to prevent the development of diabetes mellitus.”
d. “Avoid crowds and sick people to prevent contraction of contagious infections.”


____ 84. The client being discharged home after a bone marrow transplantation for leukemia asks why protection from injury is so important. What is the nurse’s best response?
a. “The transplanted bone marrow cells are very fragile and trauma could result in rejection of the transplant.”
b. “Trauma is likely to result in loss of skin integrity, increasing the risk for infection when you are already immunosuppressed.”
c. “Platelet recovery is slower than white blood cell recovery and you remain at risk longer for bleeding than you do for infection.”
d. “The medication regimen after transplantation includes drugs that slow down cell division, making healing after any injury more difficult.”


____ 85. A nurse is assessing a client for pain sensation using a sharp or dull instrument. What technique should be used to obtain valid results?
a. Test the client first with eyes open, then with eyes closed.
b. Test the client for dull sensation first, followed by sharp.
c. Test the client for sharp sensation first, followed by dull.
d. Test the client for sharp and dull sensation randomly.


____ 86. A client is admitted with a brain attack (stroke). On neurologic assessment, a nurse notes that the client’s arms, wrists, and fingers have become flexed, and there is internal rotation and plantar flexion of the legs. What would be the nurse’s best action?
a. Notify the health care team members.
b. Determine the client’s advance directive status.
c. Reposition the client to prevent contractures.
d. Document the finding as the only action.


____ 87. What nursing action addresses the age-related changes of sensory perception for an older adult client admitted to a general medical floor?
a. Using a call button that requires only minimal pressure to activate
b. Providing a clock and calendar to minimize dementia onset
c. Ensuring that paths are free from equipment
d. Admitting the client to the room closest to the nursing station


____ 88. A nurse is preparing a teaching plan for a client with migraine headaches who is receiving a beta blocker to help manage this disorder. What instructions would be appropriate to relay to this client?
a. “Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.”
b. “Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.”
c. “This drug will relieve the pain during the aura phase soon after a headache has started.”
d. “This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.”


____ 89. What statement made by a client with newly diagnosed epilepsy indicates that further teaching concerning the drug regimen is necessary?
a. “I will avoid alcohol.”
b. “I will wear a medical alert bracelet.”
c. “I will let my doctor know about this drug when I receive a new prescription other conditions.”
d. “I can miss up to two pills if I run out of them or they make me ill.”


____ 90. Which of the following is the correct rationale for monitoring peripheral oxygenation saturation in the client with encephalitis?
a. It will prevent increased intracranial pressure.
b. It will prevent permanent neurologic disabilities.
c. It will alert the clinician to hypoxia and possible secondary brain damage.
d. It will prevent inadequate amounts of oxygen in the circulating blood from causing brain hypoxia.


____ 91. Which statement indicates that the family has a good understanding of the changes in motor movement associated with Parkinson’s disease?
a. “I can never tell what he’s thinking—he hides behind a frozen face.”
b. “She drools all the time just so I can’t take her out anywhere.”
c. “I think this disease makes him nervous—he perspires all the time.”
d. “I can offer smaller meals with bite-size portions and a liquid supplement.”


____ 92. Which nursing intervention will assist in preventing respiratory complications in the client with Parkinson’s disease?
a. Keeping an oral airway at the bedside.
b. Ensuring a fluid intake of at least 3 L/day.
c. Teaching the client pursed-lip breathing techniques.
d. Maintaining the backrest elevation at greater than 30 degrees.


____ 93. A nurse is caring for a client experiencing spinal shock after a spinal cord injury. What clinical manifestation would indicate the resolution of spinal shock?
a. The return of reflex activity
b. Normalization of the pupillary reflex
c. Return of bowel and bladder continence
d. Tingling in the extremities below the lesion


____ 94. A nurse is to assess proprioceptive function in the lower extremities in a client with a suspected spinal cord injury. What assessment technique should the nurse use?
a. Ask the client to flex and extend the feet and knees.
b. With the client’s eyes closed, move the client’s toe up or down.
c. Apply resistance while the client plantar flexes the legs and feet.
d. Apply pinprick to the lower extremities and compare bilaterally.


____ 95. Within 4 hours after a cervical spinal injury, the client can discriminate light touch and position of the arms but cannot perform any motor function. What is the nurse’s interpretation of this finding?
a. The client is likely to have a full recovery from this injury.
b. The spinal cord has experienced a complete injury.
c. The spinal cord injury is posterior.
d. The spinal cord injury is anterior.


____ 96. A client has multiple sclerosis (MS) of the relapsing-remitting type. What clinical course of the disease should the nurse expect in this client?
a. An absence of periods of remission
b. Attacks becoming increasingly frequent
c. Absence of active disease manifestations
d. Gradual neurologic symptoms without remission


____ 97. A nurse has instructed the client with myasthenia gravis to take drugs on time and to eat meals 45 to 60 minutes after taking the anticholinesterase drugs. The client asks why the timing of meals is so important. What is the nurse’s best response?
a. “This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke.”
b. “This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling.”
c. “These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals.”
d. “These drugs cause nausea and vomiting. By waiting for a while after you take the medication, you are less likely to vomit.”


____ 98. Which of the following statements made by a client with peripheral polyneuropathy indicates correct understanding of injury prevention?
a. “I will change positions slowly.”
b. “I will avoid wearing cotton or wool socks.”
c. “Because I now bleed more easily, I will use an electric razor.”
d. “Because my feet are always cold, I will use a hot water bottle on them at night.”


____ 99. What statement by the client indicates her understanding of treatment for pain related to Guillain-Barré syndrome?
a. “I can use the button on the pump as often as I want to get more pain medication.”
b. “Aspirin will help me when I have pain from this disease.”
c. “A combination of morphine and distraction seems to help bring me relief right now.”
d. “I should not have any pain as a result of impaired motor movement while acutely ill.”


____ 100. Which statement or behavior by a client after a stroke indicates to the nurse that the client is adjusting to the residual limitations from the stroke?
a. The client uses the unaffected side to perform passive range-of-motion exercises on the affected side.
b. The client states the goal of regaining all sensory and motor function within 6 months.
c. The client says that she is well and nothing has happened.
d. The client smiles continually while awake.


____ 101. Which assessment finding alerts the nurse to the possibility that the client has a paralysis of the medial rectus muscle for the right eye? The client is unable to
a. Turn the right eye in toward the nose.
b. Lift the right upper eyelid.
c. Move the right eye downward.
d. Move the right eye upward.


____ 102. Which client is at greatest risk for developing vision problems?
a. 28-year-old woman in the postpartum phase of pregnancy
b. 28-year-old man who has diabetes mellitus
c. 58-year-old man who takes aspirin daily for anticoagulation
d. 58-year-old woman using topical ointments daily for dry skin


____ 103. The client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which of the following actions should the nurse teach the client to prevent orthostatic hypotension?
a. “Change positions slowly.”
b. “Take your pulse rate at least four times daily.”
c. “Apply pressure to the inside corner of your eye when putting the drops into the eye.”
d. “Be sure to lie down for at least 10 minutes after putting the drops into your eyes.”


____ 104. The client has just returned from having surgery for a scleral buckling procedure to repair a large retinal detachment in the right eye. Sulfahexafluoride gas was used intraocularly. What postoperative position should the nurse use for this client?
a. Completely supine with sandbags to prevent the head from turning to either side
b. On the nonoperative side in the Trendelenburg position
c. On the operative side in the Trendelenburg position
d. On the abdomen with the affected eye up


____ 105. For which type of foreign object in the ear canal is irrigation contraindicated?
a. Dried beans
b. Live insect
c. Pencil eraser
d. Cerumen


____ 106. In assessing the hand function and ROM of a client, the nurse notes that the client is able to oppose each finger to the thumb when making a fist. What conclusion can the nurse make from this finding?
a. The client’s hand ROM is not seriously restricted.
b. The client’s hand ROM is severely limited.
c. The client’s hand has nerve entrapment.
d. The client’s hand has weakness.


____ 107. The most serious complication of a pelvic fracture is which of the following?
a. Infection
b. Delayed union
c. Hypovolemic shock
d. Impaired skin integrity


____ 108. The nurse notes that the skin around the client’s skeletal traction pin site is swollen, red, and crusty, with dried drainage. What is the nurse’s priority action?
a. Decrease the traction weight.
b. Apply a new dressing.
c. Document the finding as the only action.
d. Notify the physician.


____ 109. What client instructions would be appropriate after a barium swallow?
a. “Sit in bed with your head elevated to allow the barium to pass through.”
b. “You may have stools that are darker in appearance for a few days.”
c. “You may not eat or drink anything for 6 hours after the test.”
d. “Drink plenty of fluids.”


____ 110. Which statement regarding oral candidiasis is true?
a. It is an inflammatory mucocutaneous disease.
b. It is an acute bacterial infection of the gingiva.
c. It is a complication of long-term antibiotic therapy.
d. It is a risk factor for the development of oral cancer.


____ 111. Which statement made by the client concerning the risk of oral cancer indicates a need for further teaching?
a. “I will brush my teeth and floss regularly.”
b. “I will begin a smoking cessation program.”
c. “I will limit my intake of alcoholic beverages.”
d. “I can still use chewing tobacco since I stopped smoking.”


____ 112. The most accurate method of diagnosing gastroesophageal reflux disease (GERD) is which of the following?
a. Endoscopy
b. Schilling’s test
c. 24-hour ambulatory pH monitoring
d. Stool testing for occult blood


____ 113. In caring for a client with a rolling hernia, the nurse should be alert for which potential complication?
a. Reflux
b. Vomiting
c. Pneumonia
d. Obstruction


____ 114. The nurse is caring for a client who has undergone esophageal dilation for achalasia. Two hours later, the client develops chest and shoulder pain. What would be the nurse’s best action?
a. Administer an analgesic.
b. Document the finding as the only action.
c. Reposition the client.
d. Notify the physician.


____ 115. On assessment, the nurse notes the presence of bloody nasogastric tube drainage from a client who underwent an esophagogastrostomy 2 days ago. What conclusion should the nurse draw from this assessment?
a. The client’s nasogastric tube requires irrigation.
b. The drainage is as expected for this time period.
c. The client’s nasogastric tube requires repositioning.
d. The client has developed bleeding at the suture line.


____ 116. What complication should the emergency department nurse anticipate in the client with a chemical injury to the esophagus after ingestion of an alkaline substance?
a. Infection
b. Stricture
c. Aspiration
d. Perforation


____ 117. A client with peptic ulcer disease vomits undigested food after eating breakfast. The nurse notes abdominal distention. What intervention should the nurse anticipate will be implemented for this client?
a. Insertion of a nasogastric tube
b. Insertion of a jejunostomy tube
c. Administration of an antiemetic
d. Administration of H2-receptor antagonists


____ 118. What teaching regarding postoperative care should the nurse provide for the client undergoing herniorrhaphy?
a. “You should avoid solid foods for the first 48 hours after surgery.”
b. “After surgery, you should take deep breaths, but avoid coughing.”
c. “You will not be able to ambulate for 2 days after the surgery.”
d. “Place Steri-Strips over the incision if you note any separation.”


____ 119. A client prescribed polyethylene glycol solution (GoLYTELY) in preparation for colorectal surgery asks why drinking this solution is necessary. What is the nurse’s best response?
a. “This solution provides electrolytes directly to the bowel.”
b. “This solution is given to relax the bowel and facilitate removal of the tumor.”
c. “This solution will clear the bowel of feces and reduce the chance of infection.”
d. “This solution is optional, but drinking it will make the surgery easier to tolerate.”


____ 120. A client with a mechanical bowel obstruction reports that the abdominal pain that was previously intermittent and colicky is now more constant. What would be the nurse’s priority action?
a. Measure the abdominal girth.
b. Notify the health care provider.
c. Place the client in a knee-chest position.
d. Medicate the client with an opioid analgesic.


____ 121. The laboratory data reveal a decreased fecal urobilinogen concentration. What clinical manifestation would accompany this laboratory finding?
a. Clay-colored stools
b. Petechiae
c. Asterixis
d. Melena


____ 122. A client with an esophagogastric tube suddenly experiences acute respiratory distress. What should be the nurse’s immediate action?
a. Call the physician.
b. Cut the balloon ports and remove the tube.
c. Place the client in an upright position and apply oxygen.
d. Reduce the balloon pressure slightly using the sphygmomanometer.


____ 123. The physician has ordered vasopressin for a client with bleeding esophageal varices. What is the action of vasopressin in the control of bleeding?
a. Constriction of preportal splanchnic arterioles
b. Inducing the release of clotting factors II, VII, IX, and X
c. Increasing portal pressure, thus decreasing portal blood flow
d. Decreasing contraction of smooth muscle in the vascular bed


____ 124. Which of the following menus would be most appropriate for a client with cholelithiasis?
a. Two eggs, two slices of toast with margarine, and a glass of whole milk
b. Grilled cheese sandwich, steamed vegetables with butter, and coffee
c. Roast chicken, baked potato, and skim milk
d. Baked fish, steamed broccoli, and tea


____ 125. What body mass index (BMI) should older adults have?
a. Less than 21
b. Between 20 and 24
c. Between 24 and 27
d. Greater than 30


____ 126. The client has a deficiency of all the following pituitary hormones. Which one should be addressed first?
a. Growth hormone
b. Luteinizing hormone
c. Thyroid-stimulating hormone
d. Follicle-stimulating hormone


____ 127. The client scheduled for a partial thyroidectomy for hyperthyroidism asks the nurse why she is being given an iodine preparation before surgery. What is the nurse’s best response?
a. “To make the surgery as sterile as possible.”
b. “To stimulate storage of thyroid hormones for use after surgery.”
c. “To replace the thyroid hormones that will be eliminated as a result of the surgery.”
d. “To decrease the blood vessels in the thyroid and prevent excessive bleeding during surgery.”


____ 128. Which clinical manifestation indicates to the nurse that treatment for the client with hypothyroidism is effective?
a. The client is thirsty.
b. The client’s weight has been the same for 3 weeks.
c. The client’s total white blood cell count is 6000 cells/mm3.
d. The client has had a bowel movement every day for 1 week.


____ 129. Which client is at greatest risk for hyperparathyroidism?
a. 28-year-old client with pregnancy-induced hypertension
b. 45-year-old client receiving dialysis for end-stage renal disease
c. 55-year-old client with moderate congestive heart failure after myocardial infarction
d. 60-year-old client on home oxygen therapy for chronic obstructive pulmonary disease


____ 130. Which assessment finding in the client with diabetes mellitus indicates that the disease is damaging the kidneys?
a. The presence of ketone bodies in the urine during acidosis
b. The presence of glucose in the urine during hyperglycemia
c. The presence of protein in the urine during a random urinalysis
d. The presence of white blood cells in the urine during a random urinalysis


____ 131. The client with type 2 diabetes is prescribed to take the antidiabetic agent nateglinide (Starlix). Which statements made by the client indicates correct understanding of this therapy?
a. “I'll take this medicine with my meals.”
b. “I'll take this medicine 15 minutes before I eat.”
c. “I'll take this medicine just before I go to bed.”
d. “I'll take this medicine as soon as I wake up in the morning.”


____ 132. Which clinical manifestation in a client with uncontrolled diabetes mellitus should the nurse expect as a result of the presence of ketoacid in the blood?
a. Increased rate and depth of respiration
b. Extremity tremors followed by seizure activity
c. Oral temperature of 102° F (38.9° C)
d. Severe orthostatic hypotension


____ 133. Which laboratory value indicates inadequate functioning of a transplanted pancreas?
a. Total white blood cell count <5000/mm3>30 mg/dL
d. Elevated bilirubin level


____ 134. What is the priority nursing diagnosis for the older adult client who has very thin skin on the backs of the hands and arms?
a. Risk for Injury
b. Risk for Infection
c. Risk for Disuse Syndrome
d. Risk for Imbalanced Body Temperature: hyperthermia


____ 135. What question should the nurse ask to determine a possible trigger for the worsening of a client's psoriatic lesions?"
a. “Have you eaten a large amount of chocolate lately?”
b. “Have you been under a lot of stress lately?”
c. “Have you used a public shower recently?”
d. “Have you been out of the country recently?”


____ 136. A nurse discovers that one of your long-term residents has a fungal infection (candidiasis) beneath both breasts. What strategy should the nurse use to prevent spread of this infection?
a. Move the client into a private room.
b. Wash your hands after caring for this client.
c. Wear gloves when providing personal care.
d. Do not allow pregnant staff or visitors into the room.


____ 137. The client is a 35-year-old African American woman who had a breast biopsy 1 year ago and was diagnosed with benign breast disease. Now, the incision site is elevated, dark, and protrudes beyond her breast skin. What is the nurse’s interpretation of these findings?
a. The client has formed a keloid, consisting of collagen and ground substance, as a result of surgical injury to the skin.
b. There is a high probability that skin cancer has developed as a result of surgical injury to the skin (Koebner phenomenon).
c. The benign breast disease has undergone malignant transformation to breast cancer and become locally invasive.
d. The change in the breast biopsy scar represents chronic inflammatory changes that accompany deep and persistent infection.


____ 138. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?
a. Increased urine output, decreased urine specific gravity
b. Increased peripheral edema, decreased blood pressure
c. Decreased peripheral pulses, slow capillary refill
d. Decreased serum sodium level, increased hematocrit


____ 139. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?
a. Seasonal asthma
b. Hepatitis B 10 years ago
c. Myocardial infarction 1 year ago
d. Kidney stones within the last 6 month


____ 140. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?
a. Increased wound pain 30 to 40 minutes after drug application
b. Presence of small, pale pink bumps in the wound beds
c. Decreased white blood cell count
d. Increased serum creatinine level


____ 141. The client is taking a medication for an endocrine problem that inhibits aldosterone secretion and release. To what complications of this therapy should the nurse be alert?
a. Dehydration, hypokalemia
b. Dehydration, hyperkalemia
c. Overhydration, hyponatremia
d. Overhydration, hypernatremia


____ 142. Which statement made by the client who has a recurrent urinary tract infection indicates correct understanding regarding antibiotic therapy?
a. “If my urine becomes lighter and clear, the infection is gone and I can stop taking my medicine.”
b. “Even if I feel completely well, I should take the medication until it is gone.”
c. “When my urine no longer burns, I will no longer need to take the antibiotics.”
d. “If my temperature goes above 100° F, I should take twice as much medicine.”


____ 143. A client with suspected diminished renal functioning has come to the outpatient clinic for an appointment. What laboratory test would be most accurate in assessing this client’s renal reserve?
a. 24-hour urine for creatinine clearance
b. Serum blood urea nitrogen level
c. Urine specific gravity
d. Serum sodium level


____ 144. Which measure would be appropriate for the nurse to take in caring for a client with chronic renal failure receiving dialysis via a right arm fistula?
a. Take the client’s blood pressure in both arms.
b. Take the client’s blood pressure in the left arm only.
c. Place the right arm in a sling to protect it from injury.
d. Have the client perform active ROM arm exercises to aid blood flow to the fistula.


____ 145. What instruction should the nurse provide to the client who is scheduled to have an abdominal ultrasound for evaluation of uterine size and shape?
a. “Do not eat or drink after midnight.”
b. “Completely evacuate your bowels before this procedure.”
c. “Do not urinate within an hour of having the test, because a full bladder is needed for best test results.”
d. “Have someone drive you to and from the test because you will be sleepy from the anesthesia.”


____ 146. Which statement made by the client preparing to have a cervical biopsy indicates a need for clarification regarding the follow-up care needed?
a. “I will not lift objects weighing more than 10 pounds for about 2 weeks.”
b. “I will refrain from having intercourse for 48 hours.”
c. “I will rest for 24 hours after the procedure.”
d. “I will use napkins rather than tampons.”


____ 147. The client who has just been diagnosed with invasive infiltrating ductal carcinoma asks what this means. What is the nurse’s best response?
a. “The cancer has spread from the breast ducts into surrounding breast tissue.”
b. “The cancer has spread from the breast into local lymph nodes and channels.”
c. “The cancer has spread from the breast into surrounding tissues and organs.”
d. “The cancer has spread from the breast into distant tissues and organs.”


____ 148. Which pathologic description of a breast cancer would the nurse interpret as being indicative of a better prognosis for long-term survival?
a. Poorly differentiated; 20% of cells in S phase; estrogen receptor negative
b. Moderately differentiated; 50% of cells in S phase; estrogen receptor negative
c. Undifferentiated; 50% of cells in S phase; estrogen receptor positive
d. Highly differentiated; 10% of cells in S phase; estrogen receptor positive


____ 149. The client asks how soon after a mastectomy she can engage in sexual activity. What is the nurse’s best response?
a. “You may engage in sexual activity as soon as you are comfortable.”
b. “You should wait until 3 months have passed before resuming sexual activity.”
c. “You may safely engage in sexual activity as soon as the incision has healed completely.”
d. “You should undergo counseling or therapy before you consider having sex again.”


____ 150. Which complication of therapy should the nurse teach to the client prescribed to receive radiation for vaginal cancer?
a. Perineal hypopigmentation
b. Delay of spontaneous menopause
c. Development of vaginal adhesions or stenosis
d. Relaxation of pelvic floor muscles, causing urinary incontinence

 
 
Answer Section

MULTIPLE CHOICE

 1. ANS: A
Best practices for adult learning include the following: breaking complex skills and information into small parts; assessing willingness to learn, including family/significant others in the education as appropriate; assessing factors that may influence learning, such as educational level; using psychomotor skills in addition to visual aids to enhance learning; and providing the client with a contact for follow-up questions.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: N/A

 2. ANS: C
Medical-surgical nursing is practiced in a wide variety of settings. Although hospitals remain the largest employer of nurses, community-based integrated health care centers and long-term care facilities also require nurses with medical-surgical nursing experience.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 3. ANS: C
Residential facilities, which include rest homes and assisted living or continuing care facilities, can provide a continuum of services ranging from independent living to skilled care. Nursing facilities provide custodial care; skilled nursing facilities and chronic care facilities provide services requiring licensed health care professionals.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 4. ANS: C
Although clients requiring subacute care can encompass all these conditions, transitional care is considered an alternative to a prolonged hospital stay before discharge home or to a long-term care facility. Transitional subacute care is provided to the client with a deep wound that requires continued management before discharge. The stable client with HIV infection would receive medical/surgical subacute care, whereas the client who is ventilator dependent or who has a progressive neurologic disorder would require chronic subacute care.

DIF: Cognitive Level: Application TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

 5. ANS: A
There are many nursing interventions that can be helpful to older adults who experience relocation stress syndrome. If the client becomes confused, agitated, or combative, the nurse should reorient the client to his or her surroundings. The nurse also can encourage family members to visit often, keep familiar objects at the client’s bedside, and work to establish a trusting relationship with the client.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Psychosocial Integrity

 6. ANS: B
Older adults can experience a number of losses that affect their sense of control over their lives, including a decrease in physical mobility. The nurse should support the client’s self-esteem and increase feelings of competency by encouraging activities that assist in maintaining some degree of control, such as participation in decision making and performing tasks they can manage.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Psychosocial Integrity

 7. ANS: A
Delirium is characterized by acute confusion that is usually short term. Delirium can result from placement in unfamiliar surroundings, such as being hospitalized.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Psychological Integrity

 8. ANS: A
The pain manifestations of tachycardia and increased blood pressure occur with acute pain as a result of activation of the stress response. The stress response uses much energy and is a relatively short-term response, with physiologic adaptation occurring over time. The absence of tachycardia or blood pressure changes in a client with chronic pain do not correlate to a decreased perception of intensity of pain.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 9. ANS: B
Many types of visceral pain can be felt in body areas other than the originating site; this is known as referred pain. Pain originating in the gallbladder can be referred to the right posterior shoulder. The client should be reassured that this is normal and medicated appropriately.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Psychosocial Integrity

 10. ANS: A
Morphine and other opioids bind tightly to the mu (µ) opioid receptor, which causes pupillary constriction. Head injuries resulting in increased intracranial pressure cause pupillary dilation. A symptom of withdrawal from opioids is pupillary dilation.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 11. ANS: D
The goals of end-of-life care are to control distressing symptoms, promote meaningful interactions between the client and significant others, and facilitate a peaceful death. Measures that prolong life are discontinued when they interfere with the client's comfort or pleasure.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Psychosocial Integrity

 12. ANS: C
In the United States, approximately 50% of the population has one or more chronic health problems, and about 35 million people (one in seven) experience some activity limitations because of their chronic health problems.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 13. ANS: D
You are supporting the client emotionally while she tells her daughter the information she has learned about the test results. You are not interpreting the results nor are you counseling the client or her daughter about what steps to take next.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

 14. ANS: C
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E. A, airway and cervical spine control, B, breathing, C, circulation, D, disability, E, exposure.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 15. ANS: A
Triage for a mass causality incident differs from “civilian” triage in that its main goal is to provide the most effective care for the greatest number of people. Clients are classified into one of four categories: emergent, urgent, nonurgent, or expected to die. Clients who are classified as expected to die would not be assigned first priority in a mass causality situation.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 16. ANS: C
The affected extremity should be immobilized in a position of function to limit the spread of venom. The extremity should not be elevated but should be kept below the level of the heart.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 17. ANS: A
Ice inhibits the action of neurotoxin and should be the first intervention provided to a client bitten by a black widow spider.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Psychological Integrity

 18. ANS: A
The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to increased hydrostatic pressure in the plasma volume.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 19. ANS: A
The thirst mechanism is triggered when the osmoreceptors of the hypothalamus detect that the extracellular fluid is hyperosmolar, especially when the serum sodium level is elevated. Other conditions that trigger the thirst centers include hypotension and hypoxemia.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 20. ANS: B
Pure water is hypotonic compared to normal body fluids. Thus if water were administered intravenously, the plasma would become hypotonic compared with red blood cells. The red blood cells would take up the hypotonic fluid, swell, and lyse open.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Safe, Effective Care Environment;  

 21. ANS: A
Skeletal muscle contractions facilitate flow in lymph channels. Keeping the arm at chest level or higher prevents stasis of lymph fluid from gravitational forces.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 22. ANS: A
Misuse or overuse of diuretics is a common cause of isotonic dehydration.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance/Safe, Effective Care Environment;

 23. ANS: C
Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating the fluid excess is the best way to reduce confusion.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 24. ANS: D
Prolonged hypocalcemia results in loss of bone calcium, making the bones brittle and fragile. Using a lift sheet when moving the client rather than grasping or pulling the client helps prevent fractures.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Safe, Effective Care Environment;  

 25. ANS: C
Calcium and phosphorus exist in the blood in a balanced, reciprocal relationship. When the blood level of one increases, the other decreases. Thus, rapid correction of hypophosphatemia can cause hypocalcemia.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 26. ANS: B
Infusion of packed red blood cells is considerable slower through a PICC. The blood product is cold and viscous. The length of the PICC adds resistance and may prevent the blood from infusing within the 4-hour limitation. Therefore, a pump is needed to ensure adequate flow rates.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;  

 27. ANS: C
Urination is a complex physiologic action requiring sensory and motor neural input. Both opioid and local anesthetic agents alter the sensory portion of innervation to the bladder and urethra.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 28. ANS: C
The blood pH is a measure of the concentration of the blood hydrogen ion concentration. Hydrogen ions are cations expressing a positive charge. In order for body fluids to remain electrically neutral, an increase in hydrogen ion concentration requires fewer other positive ions and more negative ions for balance. The reverse is true for decreased hydrogen ion concentration.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 29. ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of the acidosis. Muscle weakness can lead to severe respiratory insufficiency.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Safe, Effective Care Environment;  

 30. ANS: C
One cause of acidosis is a strict, low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance/Physiological Integrity;

 31. ANS: D
Regularly scheduled cardiac medications should be administered on schedule. If taken with a few small sips of water at least 2 hours before surgery, this medication should not increase the risk of intraoperative or postoperative aspiration.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 32. ANS: D
Ketamine hydrochloride induces dissociative reactions such as hallucinations, distorted images, and irrational behavior during emergence from the anesthesia.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 33. ANS: B
Tissue healing and growth of new cells proceed at different rates along the incision. Small, firm lumps are usually new blood vessels or new collagen bases. They eventually smooth out without intervention when the scar is mature.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Psychosocial Integrity/Physiological Integrity

 34. ANS: C
Normal, healthy body cells all express surface proteins that are unique to the person, coded by the major histocompatibility genes. Non-self cells express different cell surface proteins. Immune system cells can distinguish between their own surface proteins and all others.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 35. ANS: B
When people have been “boosting” their tetanus antibodies on a regularly scheduled basis, they should have sufficient circulating antibodies to mount a defense against exposure to tetanus. If this client’s medical records substantiate that he did indeed receive a tetanus toxoid booster 1 year ago, he does not need another one now.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 36. ANS: B
The PPD test for tuberculosis relies on a cell-mediated immune response in the skin to react with the tuberculosis protein for a positive result. Adults who are very old may not have enough of a cell-mediated immune response to demonstrate a positive reaction to a PPD, a condition called anergy. Airborne precautions are needed when clinical manifestations of tuberculosis are present and the results of more definitive testing are unknown or such testing has not yet been performed.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 37. ANS: A
NSAIDs increase sodium and water retention. This action can pose a life-threatening health hazard to clients who are older or who have coexisting renal or cardiac disease. For some clients, the edema may be the only problem. For other clients, the extra retained fluid may lead to hypertension, heart failure, and pulmonary edema. The client’s cardiovascular status should be assessed before any decision is made to keep or discontinue the current therapy.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 38. ANS: A
SLE is a connective tissue disorder that most profoundly affects tissues and organs that are highly vascular. The leading cause of death in clients with SLE is kidney disease.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 39. ANS: A
Cryptosporidiosis is a protozoal infection causing gastroenteritis. Clients experience mild to voluminous diarrhea.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 40. ANS: C
This drug can induce a rapid and severe state of hypoglycemia that can be fatal. Clients receiving IV pentamidine should be monitored no less than every hour for subjective symptoms of hypoglycemia and blood glucose level.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;  

 41. ANS: C
This combination of antiretroviral medications is recommended by the CDC for prophylaxis against occupational exposure to HIV when the source client is HIV-positive and has a low viral burden. The regimen is recommended for a duration of at least 4 weeks.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and Maintenance  

 42. ANS: C
HIV transmission requires significant contact with contaminated body fluids. If his co-workers are immunocompetent, even the client’s opportunistic infection will have no physical impact on these people.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 43. ANS: B
People who have spina bifida have lifelong exposure to latex products and frequently develop latex hypersensitivities. Such people are at an increased risk for an anaphylactic reaction when they have major surgery, especially abdominal surgery, and the surgeons use latex gloves when entering the abdominal cavity.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;  

 44. ANS: C
Type V hypersensitivity reactions are known as “stimulatory” responses. Currently, the classic example of a type V hypersensitivity is Graves’ disease, in which the person makes a large amount of antibody that binds to the thyroid-stimulating hormone receptor (TSHr-Ab) on thyroid tissue. The binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid gland and causing severe hyperthyroid symptoms.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 45. ANS: C
Benign tumors are made up of normal cells growing in the wrong place or growing at a time when they are not needed. They grow by expansion rather than invasion and often are encapsulated. The size and the fact that it is painless does not mean that the tumor is benign. Additionally, the presence of any sensation (such as itching) does not rule out malignancy.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: N/A

 46. ANS: B
Primary bone cancer is extremely uncommon among adults. Breast cancer often spreads to the bone. Many laypersons do not understand that breast cancer in the bone is still breast cancer. The client would be very young to have breast cancer; however, hereditary breast cancer occurs at young ages. It would be very important to know whether this client’s mother had breast cancer.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance/Physiological Integrity

 47. ANS: C
All the screening and prevention activities are appropriate; however, people with Down syndrome have an increased lifetime risk for the development of leukemia.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 48. ANS: D
Antibiotic therapy is most effective when the client takes the prescribed medication for the entire course and not just when symptoms are present. A major nursing responsibility is to reinforce to clients the necessity of completing the antibiotic regimen to ensure that the organism is eradicated.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance  

 49. ANS: D
Alpha1-antitrypsin is an enzyme in the lungs that limits the activity of other protein- destroying enzymes in the lungs. Without this limitation, those protein-destroying enzymes break down the collagen and elastin in the lungs, dramatically increasing the risk for developing emphysema at an early age. Other types of severe pulmonary problems are also more common among individuals who are deficient in alpha1-antitrypsin.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 50. ANS: B
Class III dyspnea occurs during usual activities, such as showering, but the client does not require assistance from others. Dyspnea is not present at rest.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;  

 51. ANS: C
Thin liquids are hard to control and can slip past the epiglottis and into the trachea. Thicker liquids remain as a bolus that the client can control during breathing so that he or she does not attempt to swallow during an inhalation.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and Maintenance  

 52. ANS: A
Aspiration is possible if the client vomits with the wires in place. The vomitus may not be able to move out of the mouth fast enough through the closed teeth and could obstruct the upper airway, as well as move into the trachea.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Health Promotion and Maintenance  

 53. ANS: B
Many environmental risk factors contribute to the development of head and neck cancer, although the actual cause is unknown. There does not appear to be a genetic predisposition to this type of cancer. The two most important risk factors are tobacco and alcohol use, especially in combination. Other risk factors include chewing tobacco, pipe smoking, marijuana, voice abuse, chronic laryngitis, exposure to industrial chemicals or hardwood dust, and poor oral hygiene.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 54. ANS: B
Methylxanthine, including aminophylline, stimulates the sympathetic nervous system. Manifestations of toxicity include CNS irritability, restlessness, tachycardia, nausea and vomiting, palpitations, and dizziness.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 55. ANS: D
Neck veins are normally distended (jugular venous distention) only when a person is supine. Usually, the neck veins flatten when a person sits at a 30-degree angle or higher. Jugular venous distention in a full sitting position is associated with right-sided heart failure, a characteristic of cor pulmonale.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 56. ANS: B
Depending on the location of the tumor, dyspnea can increase quickly. The client should be provided with sufficient oxygen to reduce the hypoxia and its associated symptoms.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Safe, Effective Care Environment;  

 57. ANS: B
This client's condition is the least stable and she is receiving a medication intravenously that has a narrow therapeutic range, with great risk for toxicity.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;  

 58. ANS: A
Cold viruses are shed in nasal and bronchial secretions. Handwashing after events that place viruses on the hands reduces the risk that the viruses will be spread directly or indirectly to others. Dishes need only to be washed in hot, sudsy water. The mouth has more protective mechanisms to prevent viral infection than do either the nose or the conjunctiva of the eye. Masks worn by others have not been proven effective in preventing the spread of colds and may give family members a false sense of security. Humidifying the air promotes comfort but does not inhibit viral spread.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 59. ANS: A
Mechanical ventilation in a hospitalized client is a high risk for the development of nosocomial pneumonia. The endotracheal tube or the tracheostomy tube provides direct access of hospital flora to the respiratory tract. Such pneumonia is termed ventilation-acquired pneumonia (VAP).

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 60. ANS: A
Rifampin normally turns urine orange color. No action is needed.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 61. ANS: C
It is possible that massaging the feet and legs could promote venous return; however, there is a greater danger of loosening a clot that may have formed in the deep veins of the legs, which would allow it to move. Thus, after surgery, the feet and legs of a client should never be massaged.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category Health Promotion and Maintenance  

 62. ANS: B
Protamine sulfate is an antidote for heparin.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 63. ANS: C
Although the client with ARDS may not respond to oxygen therapy to the same degree as clients who have other types of respiratory problems, oxygen is still the most important intervention. Without oxygen therapy, the client with ARDS will always die of respiratory failure.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Physiological Integrity

 64. ANS: C
The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;  

 65. ANS: C
A widely fluctuating pressure reading is one indication of inadequate flow and oxygenation. The client may be air hungry” from hypoxia. Check the client’s oxygen saturation to determine the adequacy of oxygenation and, if the saturation is less than adequate, increase the flow rate setting on the ventilator.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Assessment/Evaluation 
MSC: Client Needs Category: Physiological Integrity

 66. ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the SA node, and this results in an increase in heart rate.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 67. ANS: B
An increased preload increases contractility; decreased afterload reduces the amount of resistance to ejection of blood from the left ventricle. Both changes together increase stroke volume of the left ventricle.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 68. ANS: A
If the P wave is firing consistently from the SA node, the P wave will have a consistent shape in a given lead. If the impulse is from an ectopic focus, then the P wave will vary in shape in that lead.

DIF: Cognitive Level: N/A TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 69. ANS: A
Atropine is a cholinergic antagonist that inhibits parasympathetic-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 70. ANS: C
A heart rate of 40 beats/min or below, with widened QRS complexes, should alert the nurse to the possibility that the AV block is infranodal and a ventricular escape focus is pacing the ventricles. This could have hemodynamic consequences and the client is at risk of inadequate cerebral perfusion. The nurse should assess for lightheadedness, confusion, syncope, and seizure activity.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 71. ANS: D
Asynchronous pacing is most often used for clients who are profoundly bradycardic because it is found in clients with infranodal blocks or in those who are asystolic. This type of pacing fires at a fixed rate, regardless of the client’s intrinsic rhythm.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 72. ANS: A
Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 73. ANS: A
Nicotinic acid causes an increased release of prostaglandins, resulting in vasodilation. Taking the drug with meals minimizes this side effect.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Intervention
MSC: Client Needs Category: Physiological Integrity

 74. ANS: C
This class of drugs can cause myopathy. Muscle tenderness should be reported to the client’s health care provider.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 75. ANS: A
As septic shock progresses to the hypodynamic phase, acute respiratory distress syndrome (ARDS), a potentially fatal complication, can develop.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 76. ANS: A
During the hyperdynamic phase of septic shock, clients are beginning to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 77. ANS: A
Calcium channel blocking agents cause systemic vasodilation and postural (orthostatic) hypotension.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 78. ANS: D
The normal range for hemoglobin in adult males of this age is 14 to 18 g/dL. This client's hemoglobin level is elevated, which could indicate possible chronic hypoxia or polycythemia vera.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 79. ANS: C
The client with anemia has some degree of tissue hypoxia. A compensatory mechanism to increase tissue oxygenation is to increase cardiac output by increasing heart rate.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 80. ANS: B
Clubbing of the fingers requires prolonged hypoxia (many months to years) to develop.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 81. ANS: C
The person who has sickle cell trait usually has less than 40% of his or her total hemoglobin as Hgb S. Although these cells could still become sickled, hypoxic conditions would have to be severe for this to occur to the level of sickle cell crisis. Such individuals are most vulnerable to crisis during prolonged surgery under anesthesia.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

 82. ANS: C
Measures that effectively reduce erythrocyte concentration and blood viscosity also reduce blood pressure.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 83. ANS: B
Thalidomide is a potent teratogen and has been known to cause severe birth defects after even one exposure of the drug. Both women and men who are taking this drug are urged to use multiple forms of contraception to prevent exposing a fetus to this drug.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance  

 84. ANS: C
Platelets recover more slowly than other blood cells after bone marrow transplantation. Thus, the client is still thrombocytopenic at home and remains at risk for excessive bleeding after any trauma of injury.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

 85. ANS: D
The proper assessment technique for assessing pain sensation is to test the client for sharp and dull sensation randomly to prevent the client from anticipating the type of stimulus that will follow.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 86. ANS: A
The client is demonstrating decorticate posturing that is seen with interruption in the corticospinal pathway. This finding is abnormal, and a sign that the client’s condition has deteriorated. The physician, charge nurse, and other team members should be notified immediately of this change in status.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;  

 87. ANS: C
Dementia and confusion are not common phenomena among older adults. However, physical impairment related to illness can be expected; providing opportunity for hazard-free ambulation will maintain strength and mobility.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Safe, Effective Care Environment;  

 88. ANS: B
Beta blockers are prescribed as a prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected and the client should monitor these side effects.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Intervention
MSC: Client Needs Category: Physiological Integrity

 89. ANS: D
The nurse needs to emphasize that antiepileptic drugs must be taken even if seizure activity has stopped. Discontinuing the medication can predispose the client to seizure activity and status epilepticus.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 90. ANS: C
Early detection of inadequate circulating oxygen can allow the clinician to intervene before hypoxic brain damage occurs.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 91. ANS: D
A masklike face, drooling, and excess perspiration are common to clients with Parkinson’s disease. Changes in facial expression or a masklike facies in a Parkinson’s disease client can be misinterpreted. Because chewing and swallowing can be problematic, small, frequent meals and a supplement are better for meeting the client’s nutritional needs.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Psychosocial Integrity

 92. ANS: D
Elevation of the backrest will help prevent aspiration.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 93. ANS: A
The resolution of spinal shock is signaled by the return of reflex activity. Note that spinal shock and neurogenic shock are not interchangeable terms and describe different pathologic phenomena.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 94. ANS: B
The proper technique for testing proprioception is to ask the client to close his or her eyes. Move the client’s toe up or down and ask the client to identify the position of the digit.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance  

 95. ANS: D
With a spinal cord injury to the anterior portion of the cervical spine, the client may retain some sensory function (touch, vibration, and position are in the posterior portion) but may not have motor function and pain and temperature sensation. Whether the injury is permanent or temporary cannot be ascertained at this time.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 96. ANS: B
The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 97. ANS: A
The skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that the majority of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Health Promotion and Maintenance  

 98. ANS: A
The autonomic dysfunction associated with peripheral polyneuropathy causes orthostatic hypotension.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance  

 99. ANS: C
Typical pain from GBS is often not relieved by medication other than opiates and distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance  

 100. ANS: A
Adjustment to the limitations imposed by a health problem such as a stroke involves acceptance of the event and active participation in rehabilitative activities.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 101. ANS: A
Contraction of the medial rectus muscle turns the eye toward the nose.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 102. ANS: B
The hyperglycemia that characterizes diabetes mellitus causes numerous vascular problems in the eye and damages the nerves. Diabetes mellitus is a major cause of blindness in Canada and the United States. Although good control of blood glucose levels delays visual problems, it does not eliminate it in the diabetic population.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 103. ANS: C
Nasal punctal occlusion during eye drop instillation keeps the drug in contact with the eye structures longer and decreases systemic absorption and side effects.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 104. ANS: D
Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It will float to the highest position. The client should be positioned so that the gas will float up and against the newly reattached retina.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 105. ANS: A
Irrigating the ear canal containing dried beans or any other vegetable matter is contraindicated because the irrigating fluid can cause the matter to swell and become more impacted.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Intervention
MSC: Client Needs Category: Physiological Integrity

 106. ANS: A
In assessing hand ROM, if the client can oppose each finger to the thumb when making a fist, the client’s hand ROM is not seriously restricted.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 107. ANS: C
With a pelvic fracture, there can be internal organ damage, resulting in bleeding and hypovolemic shock. The nurse monitors the client’s vital signs, skin color, and level of consciousness.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 108. ANS: D
These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 109. ANS: D
The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 110. ANS: C
Antibiotic therapy can destroy the normal flora that usually prevents fungal infections. Long-term treatment with antibiotics predisposes clients to candidiasis.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 111. ANS: D
Tobacco in any form increases the risk of oral cancer. The client should be educated to eliminate all tobacco products.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

 112. ANS: C
The most accurate method of diagnosing gastroesophageal reflux disease is 24-hour ambulatory pH monitoring.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 113. ANS: D
A rolling hernia causes the fundus and portions of the stomach’s greater curvature to roll into the thorax next to the esophagus, predisposing the client to volvulus, obstruction, and strangulation.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 114. ANS: D
The client may be experiencing complications of the procedure, such as bleeding and perforation. These complications require immediate intervention.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 115. ANS: D
The initial nasogastric drainage appears bloody, but should turn a yellow-green color by the end of the first postoperative day. If the bloody color continues, it may indicate bleeding at the suture line.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 116. ANS: D
Although all these complications are possible, ingestion of alkaline substances is dangerous because of their potential to penetrate the esophagus fully, leading to perforation.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 117. ANS: A
Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

 118. ANS: B
The client should change positions and take deep breaths to facilitate lung expansion, but should avoid coughing, which can place stress on the incision line.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

 119. ANS: C
Polyethylene glycol solution is an isosmotic solution that overwhelms the absorptive capacity of the small bowel, clearing the bowel of feces and decreasing the amount of bacteria present, and thereby reducing the risk of infection.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

 120. ANS: B
A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The health care provider should be notified immediately.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 121. ANS: A
When fecal urobilinogen levels are decreased as a result of biliary cirrhosis, the stools become light- or clay-colored.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 122. ANS: B
In case of respiratory compromise in a client with an esophagogastric tube, the nurse should immediately cut both ports with a pair of scissors that is kept at the bedside and remove the tube.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 123. ANS: A
Vasopressin acts to cause contraction of smooth muscle in the vascular bed, constricting preportal splanchnic arterioles and decreasing blood flow to the abdominal organs, which in turn reduces portal pressure and portal blood flow.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 124. ANS: C
Clients with cholelithiasis should avoid foods high in cholesterol, such as whole milk and butter, fried foods, and gas-forming vegetables.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 125. ANS: C
Older adults should have a BMI between 24 and 27.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 126. ANS: C
A deficiency of thyroid-stimulating hormone (TSH) is the most life-threatening deficiency of the hormones listed in this question. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones, whose functions are essential for life.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 127. ANS: D
Iodine preparations decrease the size and vascularity of the thyroid gland, reducing the risk for hemorrhage and the potential for thyroid storm during surgery.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 128. ANS: D
Hypothyroidism decreases gastrointestinal motility significantly. One of the parameters that clients can use to determine if changes in the dose of thyroid replacement should be adjusted is the frequency of bowel movements. A bowel movement every day is a strong indication that the dose of thyroid replacement hormone is adequate.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 129. ANS: B
Clients who have chronic renal failure do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, which triggers overstimulation of the parathyroid glands.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 130. ANS: C
Urine should not contain protein, and the presence of proteinuria in a diabetic marks the beginning of renal problems known as diabetic nephropathy, which progresses eventually to end-stage renal disease. Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be filtered into the urine.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 131. ANS: B
Nateglinide is a D-phenylalanine derivative that causes the beta cells of the pancreas to undergo depolarization and release a small amount of preformed insulin. The peak action occurs about 20 minutes after ingestion. To have the best action and prevent hypoglycemia, clients are instructed to take the drug about 15 minutes before eating.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 132. ANS: A
Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

 133. ANS: B
Most pancreas transplants are anastomosed to the bladder and drain pancreatic enzymes into the urine. When the pancreas is rejected or functioning inadequately, the level of pancreatic enzymes in the urine decreases by 25% or more.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Assessment/Analysis  
MSC: Client Needs Category: Physiological Integrity

 134. ANS: A
The thinning skin, with a decreased attachment between the dermis and the epidermis, is at an increased risk for injury in response to even minimal trauma or shearing events.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Physiological Integrity

 135. ANS: B
Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 136. ANS: B
The organism that causes this infection lives on the skin of most adults. Good handwashing is all that is needed to prevent its spread to other people, although the client will need medication to clear her active infection and moisture management to prevent its recurrence.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 137. ANS: A
A keloid is a benign, noninfectious, overgrowth of a scar from an excessive accumulation of collagen and ground substance after skin trauma. Although anyone can form a keloid, the propensity is more common among people with dark skin.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 138. ANS: A
The “fluid remobilization” phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 139. ANS: C
It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

 140. ANS: D
Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;  

 141. ANS: B
Aldosterone is a mineralocorticoid that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and potassium reabsorption.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 142. ANS: B
Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course and not just when symptoms are present.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 143. ANS: A
A 24-hour creatinine clearance test is necessary to detect changes in renal reserve. Creatinine clearance is a measure of the glomerular filtration rate. The ability of the glomeruli to act as a filter is decreased in renal disease.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 144. ANS: B
The blood pressure should be taken in the left arm only to prevent occlusion of the dialysis fistula.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation  
MSC: Client Needs Category: Physiological Integrity

 145. ANS: C
The scan is noninvasive and painless. The abdominal and pelvic organs are better visualized with the bladder full during the scan.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity

 146. ANS: B
The risk for infection and bleeding requires that the client refrain from vaginal intercourse for 2 weeks (at least) after this procedure.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity

 147. ANS: A
The term invasive when applied to infiltrating ductal carcinoma means that the cancer cells are no longer confined to ductal tissue but have spread into surrounding breast tissue. This term alone, however, does not indicate that the disease has spread beyond the breast itself.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Psychosocial Integrity/Physiological Integrity

 148. ANS: D
Lower grade malignancies are less aggressive and have a better chance for long-term survival. Lower grade malignancies are slower growing (have a smaller percentage of cells in the S phase) and more closely resemble the differentiated breast tissue from which they arose. Estrogen receptor–positive tumors respond better to adjuvant therapy, and the client usually has a longer survival rate. In addition, estrogen receptor–positive tumors can be treated with hormonal manipulation techniques.

DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

 149. ANS: A
Sexual intercourse can be resumed whenever the client is comfortable. Until the incision is healed, clients should be taught how to protect the incision and avoid contact with the surgical site during intercourse.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Psychosocial Integrity/Physiological Integrity

 150. ANS: C
Radiation treatment causes local inflammation, leading to the development of fibrotic tissue changes that cause adhesions and/or stenosis. Without intervention, these changes can decrease the size and elasticity of vaginal tissues, limiting or inhibiting vaginal intercourse.

DIF: Cognitive Level: Application or higher  
TOP: Nursing Process Step: Implementation/Intervention 
MSC: Client Needs Category: Physiological Integrity/Psychosocial Integrity