Situation 1: A nurse who is assigned in a medical ward took time to be prepared with her task and give quality nursing care.
1. If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
a. Flexion of both upper and lower extremities
b. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
c. Flexion of elbows, extension of the knees, and plantar flexion of the feet
d. Extension of upper extremities, flexion of lower extremities
2.The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
a. Act as a vasoconstrictor
b. Act as a vasodilator
c. Block beta stimulation in the heart
d. Increase the heart rate
3. A client with alcoholic cirrhosis with ascites and portal hypertension is to receive neomydn. The desired effect of this drug is to;
a. Sterilize the bowel
b. Reduce abdominal distention
c. Decrease the serum ammonia
d. Prevent infection
4. A retention catheter for a male client is correctly taped if it is:
a. On the lower abdomen
b. On the umbilicus
c. Under the thigh
d. On the inner thigh
5. When assessing a client for Cournadin therapy, the condition that will eyclude this client from Coumadin therapy is:
a. Diabetes
b. Arthritis
c. Pregnancy
d. Peptic ulcer disease
6. Preparing for an intravenous pyelosram (IVP), the nurse instructs a 25-year-old male client to restrict her:
a. Fluid intake
b. Physical activity
c. Use of stimulants such as tobacco
d. Use of any medications
7. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?
a. Serosanguimeous drainage from the puncture site
b increased temperature and blood pressure
c. increased pulse and pallor
d. Hypotension and hypothermia
8. The nurse is collecting a urine specimen from a client who has been catheterized. When the urine begins to flow through ths catheter, the next action is to:
a. Inflate the catheter balloon with sterile water
b. Place the catheter tip into the specimen container
c. Connect the catheter into the drainage tubing
c. Place the catheter tip into the urine collection receptacle
9. During a retention catheter insertion or bladder irrigation, the nurse must use:
a. Sterils equipment and wear sterile gloves
b. Clean equipment and maintain surgical asepsis
c. Sterile equipment and maintain medical asepsis
d. Clean equipment and technique
10. If a client continues to hypoventilate, the nurse will continually assess for a complication of this condition;
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
Situation 2: Diabetes Meilitus is a common disease among Filipinos. Caring for these patients require meticulous assessment and follow-up.
11. The nurse will know a diabetic client understands exercise and its relation to glucose when he says that he eats bread and milk before, or juice or fruit during exercise activity because
a. Exercise enhances the passage of glucose Into muscle celts
b. Exercise stimulates pancreatic insulin production
c. A diabetic's muscle require more glucose during exercise
d. The pancreas utilizes more glucose during exercise
12. The ADA exchange diet is compiled of lists of foods. The statement that indicates the diabetic has an understanding of the purpose of these food lists is:
a. Exchanges are allowed within groups
b. Exchanges are allowed between groups
c. Only meat and fat exchanges can be interchanged
d. Vegetables and fruit exchanges can be Interchanged
13. The non-insulin-dependent diabetic who is obese is best controlled by weight
loss because obesity
a. Reduces the number of insulin receptors
b. Cause pancreatic islet cell exhaustion
c. Reduces insulin binding at receptor cites
d. Reduces pancreatic insulin production
14. A person with a diagnosis of adult diabetes (NIDDM) should understand the symptoms of a hyperglycemic reaction. The nurse wiiS know tills client understands if she says these symptoms are:
a. Thirst, poiyuria and decreased appetite
b. Flushed cheeks, acetone breath, and increased thirst
c. Nausea, vomiting and diarrhea
d. Weight gain, normal breath, and thirst
15. The diabetic client the nurse is counseling is a young man who occasionally goes drinking with his buddies. The nurse will know the client understands the diet when he says that when he consumes alcohol, he includes il as part of:
a. Protein
b. Simple carbohydrates
c. Complex carbohydrates
d. Fats
16. The nurse is teaching a Type 1 diabetic client about her diet, which is based on the exchange system. The nurse wiil know the dient has learned correctiy when she says that she can have as much as she wants of:
a. Lettuce
b. Tomato
c. Grapefruit juice
d. Skim milk
17. The nurse should evpiain to a dient with diabetes meliitus that self-monitoring of blood glucose is preferred to urine glucose testing because it is:
a. More accurate .
b. Easier to perform
c. Done by the cient
d. Not influenced by drugs
18.A client is diagnosed as having non-insulin-dependent diabetes mellitus how to
provide self-care to prevent infections of the feet. The nurse recognizes that the
teaching was effective when the client says, I should:
a. "Massage my feet and feet with oil or lotion."
b. "Apply heat intermittently to my feet and legs."
c. "Eat foods high in kilocalories of protein and carbohydrates."
d. "Control my diabetes through diet, exercise, and medication."
19. A client is admitted to the hospital with diabetic ketoadosis. The nurse understands that the elevated ketone level present with this disorder is caused by the incomplete oxidation of:
a. Fats
b. Protein
c. Potassium
d. Carbohydrates
20. A client with insulin-dependent diabetes is pjaced on an insulin pump. The most appropriate short-term goal in teaching this client to control the diabetes: " The client will:
a. Adhere to the medical regimen."
b. Remain normogtycemic for 3 weeks."
c. Demonstrate the correct use of the insulin pump."
d. List three self-care activities necessary to control the diabetes."
Situation 3: In the CCU, the nurse has a patient who needs to be,watched out.
21. To determine the status of a clients carotid pulse, the nurse should palpate:
a. In the lateral neck region
b. Immediately below the mandible
c. At the anterior necK, lateral to the trachea
d. At the base of the neck", along the clavicle
22. To help reduce a client's risk factors for a heart disease, the nurse, in discussing dietary guidelines, should teach the client to:
a. Avoid eating between meals
b. Decrease the amount of uhsaturated fat
c. Decrease the amount of fat-binding fiber
d. Increase the ratio of complex carbohydrates
23. The nurse would expect a client diagnosed as having hypertension to report
experiencing the most common symptom associated with this disorder, which is:
a. Fatigue
b. Headache
c. Nosebleeds
d. Flushed face
24. A client with a history of hypertension develops pedal edema and demonstrates dyspnea on exertion. The nurse recognizes that the client's dyspnea on exertion is probably;
a. Caused by cor pulmonale
b. A result of left ventricular failure
c. A result of right ventricular failure
d. Associated with wheezing and coughing
25. A client who has been admitted to the cardiac care unit with myocardial infarction complains of chest pain. The nursing intervention that would be most effective in relieving the client's pain would be to administer the ordered:
a. Morphine sulfate 2 mg IV
b. Oxygen per nasal cannula
c. Nitroglycerine sublingually
d. Lidocaine hydrochloride 50 mg IV bolus
26. The nurse admitting a client with a myocardial Infarction to ICU understands that the pain the client is experiencing is a result of:
a. Compression of the heart muscle
b. Release of myocardia! isoenzymes
c. Inadequate perfusion of the myocardium
d. Rapid vasodilation of the coronary arteries
27. A male client who is hospitalized following a myocardial infarction asks the nurse why he is receiving morphine. The nurse replies that morphine;
a. Dilates coronary blood vessels
b. Relieve pain and prevents shock
c. Helps prevent fibrillation of the heart
d. Decreases anxiety and restlessness
28. Several days following surgery a client develops pyrexia. The nurse should monitor the client for other adaptations related to the pyrexia including:
a. Dyspnea
b. Chest pain
c. Increased pulse rate
d. Elevated blood pressure
29. The nurse recognizes that a pacemaker is indicated when a client is
experiencing;
a. Angina
b. Chest pain
c. Heart block
d. Tachycardia
30. When assessing a client with a diagnosis of left ventricular failure (congestive heart failure), the nurse should expect to find:
a. Crushing chest pain
b. Dyspnea on exertion
c. Jugular vein distention
d. Extensive peripheral edema
Situation 4: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
31. After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
a. 3150ml
b. 3200 ml
c. 3650 ml
d. 3750ml
32. The dietary practice that will help a client reduce the dietary intake of sodium is
a. Increasing the use of dairy products
b. Using an artificial sweetener in coffee
c. Avoiding the use of carbonated beverages
d. Using catsup for cooking and flavoring foods
33. When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
a. Urinary output of 30 ml in an hour
b. Central venous pressure reading of 2 cm H20
c. Pulse rates of 120 and 110 in a 15- minute period
d. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
34. When monitoring for hypernatremia, the nurse should assess the client for:
a. Dry skin
b. Confusion
c. Tachycardia
d. Pale coloring
35. Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:
a. Urinary output
b. Abdominal girth
c. Serum ammonia level
d. Hepatic encephalopathy
36. A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;
a. A glass of water every hour until hydrated
b. Small frequent intake of juices, broth, or milk
c. Short-term NG replacement of fluids and nutrients
d. A rapid IV infusion of an electrolyte and glucose solution
37.The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full-thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
a. Weights every day .
b. Urinary output every hour
c. Blood pressure every 15 minutes
d. Extent of peripheral edema every 4 hours
38. A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
a. A rapid, thready pulse
b. Decreased peristalsis .
c. Respiratory congestion
d. An increased in temperature
39. The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
a. Filtration
b. Diffusion
c. Osmosis
d. Active Transport
40. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
a. 13 gtt/min
b. 16 gtt/min
c. 29 gtt/min
d. 32 gtt/min
Situation 5: Protection of self and patient can be done by supporting the body's immunity.
41. Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
a. Obtain vita! signs
b. Stop the transfusion
c. Assess the pain further
d. Increase the flow of normal saline
42.A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask:
a. "Have you bee sexually active lately?"
b, "Do you have a sore throat at the present time?"
c. "Have you been exposed recently to anyone with an infection?"
d. "When did you first notice that your temperature had gone up?"
43. The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
a. Has intercourse with just the spouse
b. Makes a donation of a pint of whole blood
c. Limits sexual contact to those without HIV antibodies
d. Uses a'condom each time there is a sexual intercourse
44. The knows that a positive diagnosis for HIV infection is made based on;
a. A history of high-risk sexual behaviors
b. Positive ELISA and Western blot tests
c. Evidence of extreme weight loss and high fever
d. Identification of an associated opportunistic infection
45. When taking the blood pressure of a client who has AIDS the nurse must;
a. Wear dean gloves
b. Use barrier techniques
c. Wear a mask and gown
d. Wash the hands thoroughly
46. The nurse should plan to teach the client with pancytopenia caused by a
chemotherapy to;
a. Begin a program of aggressive, strict mouth care
b. Avoid traumatic injuries and exposure to any infection
c. increase oral fluid intake to a minimum of 3000 ml daily
d. Report any unusual muscle cramps or tingling sensations in the extremities
47. An elderly client develops severe bone barrow depression from chemotheraphy for cancer of the prostate. The nurse should;
a. Monitor for signs of alopecia
b. Increase dally intake of fluids
c. Monitor Intake and output of fluids
d. Use a soft toothbrush for oral hygiene
48. A tuberculin skin test with purified protein derivative (PP!) tuberculin is performed as part of a routine physical examination. The nurse should instruct the client to make an appointment so the test can be read in:
a. 3 days
b. 5 days
c. 7 days
d. 10 days
49.A client is admitted with cellulites of the left teg a temperature of 103°F. The physician orders IV antibiotics. Before instituting this therapy, the nurse should;
a. Determine whether the client has allergies
b. Apply a warm, moist dressing over the area
c. Measure the amount of swelling in the client's leg
d. Obtain the results of the culture and sensitivity tests
50. Following multiple bee stings, a client has an anaphylactic reaction. The nurse is aware that the symptoms the client is experiencing are caused by;
a. Respiratory depression and cardiac standstill
b. bronchial constriction and decreased peripheral resistance
c. Decreased cardiac out and dilation of major biood vessels
d. Constriction of capillaries and decreased peripheral circulation
Situation 6: Following these diagnostic tests, Mr. Mangoni's physical discussed possible therapies with him. It was decided that a partial gastrectomy, vagotomy, and gastrojejunostomy would be performed.
51. Mr. Mangoni asks why the vagotomy is being done. You explain that a vagotomy is done in conjunction with a subtotal gastrectomy because the vagus nerve:
a. Stimulates increased gastric motility.
b. Decreases gastric motiiity, thereby preventing the movement of HCl out of the stomach.
c. Stimulates both increased gastric secretion and gastric motiiity.
d. Stimulates decreased gastric secretion, thereby increasing nausea and vomiting.
52. Which of the following nursing interventions would be included. in the preoperative period for Mr. Mangoni?
a. Insertion of a nasogastric tube on the morning of surgery.
b. Administration of Vallum 4 mg with 4 oz water 1 hour before surgery.
c. Detailed description of the possible complications that could happen postoperatively
d. Instructions to avoid taking pain medication too frequently in the first 2 postoperative days to avoid drug dependency.
53. Which of the following complications, would you primarily anticipate in Mr. Mangoni's postoperative period?
a. Thrombophlebitis from decreased mobility.
b. Abdominal distention due to air swallowing
c. Atelectasis due to shallow breathing
d. Urinary retention due to prolonged use of antichoiinergic medications.
54. The nurse would recognize drainage from the nasogastric tube after surgery as abnormal If:
a. It after 6 hours
b. It continued for a period greater than 12 hours.
c. ft turned greenish yeiiow in less than 24 hours.
d. It was dark red in the immediate postoperative period.
55. Which of the following statements would the nurse include in teaching regarding nasogastric tubes?
a. Nasogastric tubes should be irrigated with sterile water.
b. Client should be in sitting position with head slightly flexed for tube Insertion
c. When resistance is met while irrigating a nasogastric tube, pressure should be increased to complete that irrigation, and the physician should be notified at the completion. d. Ice chips- can be taken as often as desired to promote comfort in the
throat.
56. The nurse must observe for which of the following imbalances to occur with prolonged nasogastric suctioning?
a. Hypernatremia
b. Hyperkalemia
c. Metabolic alkalosis
d. Hypoproteinemia
57. Of the following mouth care measures by the nurse, which one should be used with caution when a client has a nasogastric tube?
a. Regularly brushing teeth and tongue with soft brush.
b. Sucking on ice chips to relieve dryness.
c. Occasionally rinsing mouth with a nonastringent substance and massaging gums.
d. Application of lemon juice and glycerine swabs to the lips.
58. The nurse tells Mr. Mangoni that the nasogastric tube will be removed:
a. Standardly on the fourth postoperative day.
b. When bowel sounds are established and the client has passed flatus or Stool
c. Thirty-six hours after the cessation of bloody drainage.
d. After 2 days of alternate clamping and unclamping of the tube.
59. Following surgery the nurse must observe for signs of pernicious anemia, which may be a problem after gastrectomy because:
a. The extrinsic factor is produced In the stomach.
b. The extrinsic factor is absorbed in the antral portion of the stomach.
c. The intrinsic factor Is produced in the stomach.
d. Decreased hydrochloric acid production Inhibits vitamin B12 reabsorption.
60.The nurse will usually ambulate the post gastrectomy patient beginning;
a. The day after surgery
b. Three to four days after surgery
c. After 4 days bedrest
d. immediately upon awakening .
Situation 7: Donald Lee, a 70-year-old retired businessman, went .to his ophthalmologist wilt's complaints of decreasing peripheral vision. Tonometry revealed increased intraocular pressures. Mr. Lee was admitted to the hospital with a diagnosis of open-angle glaucoma.
61. The signs and symptoms of open-angle glaucoma are related to:
a. An imbalance between the rats of secretion of intraocular fluids and the rate of absorption of aqueous humor.
b. A degenerative disease characterized by narrowing of the arterioles of the retina and areas of ischemia.
c. An infectious process that causes clouding and scarring of the cornea.
d. A dysfunction of aging in which the retina of the eye buckles from inadequate fluid pressures. .
62. Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range;
a. 5-10 mm Hg
b. 12-22 mm Hg
c. 10-20 cm H20
d. 20-30 mm Hg
63. While taking Mr. Lee's history, the nurse would be alerted to a sudden increase in intraocular pressure if he complained of;
a. Generalized decrease in peripheral vision over the past year.
b. Difficulty with close vision.
c. increasing discomfort in the left eye with radiation to his forehead and left
temple.
d. Halos around lights.
64. Client teaching about glaucoma should include a comparison of the two types. Open-angle, or chronic, glaucoma differs from close-angle, or acute, glaucoma in, that
a. Open-angle glaucoma occurs less frequently than closed-angle glaucoma.
b. Open-angle glaucoma's symptomatology Includes pain, severe headache, nausea, and vomiting; whereas closed-angle glaucoma has a slow, silent, and generally painless onset.
c. The obstruction to aqueous flow In open-angle glaucoma generally occurs somewhere in Schlemm's canal or aqueous veins. It does not narrow or close the angle of the anterior chamber, as in closed-angle glaucoma.
d. Open-angle glaucoma rarely occurs in families; however, there is a heredity predisposition for closed-angle glaucoma.
65. Piiocarpine is the drug of choice in the treatment of open-angle glaucoma. The expected outcome following administration would be:
a. Blocked action of cholinesterase at the cholinergic nerve endings, and therefore increased pupil size.
b. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid.
c. Impaired vision from decreased aqueous humor production.
d. Constriction of aqueous veins and therefore decreased venous pooling in the eye.
66. Bedrest is ordered for Mr, Lee because activity tends to increase intraocular pressure. Which of the following activities of daily living should he be instructed to avoid?
a. Watching television
b. Brushing teeth and hair
c. Seif-feeding
d. Passive range-of-motion exercises
67. To correctly instill pilocarpine in Mr. Lee's eyes, the nurse should gently pull down the lower lid of the eye and instill the drop:
a. Dirediy on the central surface of the cornea
b. On the inner canthus of the eye
c. into the conjunctive sac
d. Directly on the dilated pupil
68. Which of the following aspects of open angle glaucoma and its medical treatment is the most frequent cause of client noncompliance?
a. Loss of mobility due to severe-driving restrictions
b. The painful insidious progression of this type of glaucoma.
c. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
d. The frequent nausea and vomiting accompanying use of miotic drugs.
Situation 8: Gladys Meeker is a 30-year-oid advertising executive with a history of ulcerative colitis since age 22. Her chief complaint is severe abdominal cramping and 18- 20 stools per day for four days.
69. Blood and fluid loss from frequent diarrhea may cause hypovolemia. You can quickly assess volume depletion In Miss Meeker by;
a. Measuring the quantity and speciflc gravity of her urine output
b. Taking her blood pressure first supine, then sitting, noting any changes.
c. Comparing the client's present weight with her weight on her last admission.
d. Administering the oral water test.
70. The nurse would recognize other signs of hypovolemia, which include:
a. Dry mucous membranes and soft eyeballs.
b. Decreased hematocrit and hemoglobin
c. Decreased pulse rate and widened pulse pressure.
d, Dyspnea and crackles.
71. With severe diarrhea, electrolytes as well as fluid are lost. The nurse would conclude that the client is experiencing hypokalemia if which of the following were observed?
a. Spasms, diarrhea, irregular pulse.
b. Kussmaul breathing, thirst, furrowed tongue.
c. Apathy, weakness, GI disturbance
72. Three days after admission Ms. Meeker continued to have frequent stools. Her oral intake of both fluids and solids was poor. Her physician ordered parenteral hyperalimentation. While administering the ordered solution, It is important to remember that hyperalimentation solutions are:
a. Hypotonic solutions used primarily for hydration when hemoconcentration is present.
b. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma.
c. Alkalizing solutions used to treat metabolic acidosis, thus reducing cellular swelling.
d. Hyperosmoiar solutions used primarily to reverse negative nitrogen balance.
73.Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects from too rapid an infusion rate would the nurse expect Ms. Meeker to demonstrate?
a. Cellular dehydration and potassium depletion
b. Circulatory overload and hypoglycemia.
c. Hypoglycemia and hypovolemia.
d. Potassium excess and congestive heart failure.
74.Which of the following statements is correct regarding nursing care of Ms. Meeker while she is receiving hyperlimentation?
a. The client's urine should be tested for glucoseacetone every 8-12 hours.
b. The hyperlimentation subclavian line may be utilized for CVP readings and/or blood withdrawal.
c. Occlusive dressings at the catheter insertion site are changed every 48 hours using the clean technique.
d. Records of intake and output and daily weights should be kept. .
Situation 9: After 10 days of therapy, Ms. Meeker's physician decided to perform an iieostomy. For 3 days prior to surgery she was given neomycin. On the morning of surgery she catheterized and nasogastric tube was inserted.
75. Neomycin was administered by the nurse prior to surgery:
a. To decrease the incidence of postoperative atelectasis due to decreased depth of respirations.
b. To increase the effectiveness of the body's immunologic response following surgical trauma.
c. To reduce the incidence of wound infections by decreasing the number of intestinal organisms.
d. To prevent postoperative bladder atony due to catheterization.
76. Following iieostomy, the nurse would expect the drainage appliance to be applied to the stoma;
a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begins to function.
d. When the client is able to begin self-care procedures.
77.Which of the goals would be described to Ms. Meeker as the highest postoperative nursing priority?
a. Relief of pain to promote rest and relaxation.
b. Assisting the client with self-care activities.
c. Maintenance of fluid, electrolyte, and nutritional balances.
d. Skin care and control of odors.
78. During the early postoperative period, the nurse initiates ileostomy teaching with Ms. Meeker. The primary objective of this procedure is;
a. To facilitate maintenance of intake and output records
b. To control unpleasant odors.
c. To prevent excoriation of the skin around the stoma.
d. To reduce [he risk of postoperative wound infection.
79. After discharge, Ms. Meeker calls you at the hospital to report the sudden onset of abdominal cramps, vomiting, and watery discharge from her iieostomy. What would you advise?
a. Call the physician if symptoms persist for 24 hours.
b, Take 30 cc of m.o.m. (milk of magnesia).
c. NPO until vomiting stops.
d. Call the physician immediately.
Situation 10: Joseph Clifford, age 38, has extensive bums over much of his trunk and arms. He complains of intense pain during wound cleansing, dressing change, debridement, and physical therapy.
80. This pain most likely is related to:
a. Thermal stimulation
b. Menta! stimulation
c. Mechanical stimulation
d. Chemical stimulation
81. Mr. Clifford dreads physical therapy and resists activity; he has difficulty sleeping due to pain and fatigue after the treatments. He lacks appetite for food or fluid. Based on this information, his priority nursing diagnosis would be:
a. Activity Intolerance related to pain secondary to bums.
b. Altered Nutrition; Less Than Body Requirements related to pain secondary to bums.
c. Sleep Pattern Disturbance reiated to pain secondary to bums.
d. Pain related to bums.
82. Mr. Clifford continues to experience significant pain after his expensive bum wounds have healed - 6 months after his injury. He also expresses concern over possible loss of job and disfigurement. At this; stage, the nurse can most effectively intervene for his pain by:
a. Referring him for his counseling and occupational therapy.
b. Staying with him as much as possible and building trust
c. Providing cutaneous stimulation and pharmacoiogic therapy.
d. Providing distraction and guided imagery.
83. Eventually, Mr- Clifford's chronic pain and anxiety about his appearance did contribute to his losing his job and disrupting his plans for marriage.
He finally heeded the nurse's recommendation and sought treatment at a pain center, after which his pain subsided and he permitted his former fiancee to participate in his rehabilitation process, including looking for a new job.
Evaluation criteria for Mr. Clifford's successful rehabilitation should include which of the following:
a. The patient has no aftermath phase of his pain experience.
b. The patient experiences decreased frequency of acute pain episodes.
c. The patient continues normal growth and development with his support systems intact.
d. The patient develops increased tolerance for severe pain in the future.
84. Which of the following statements regarding pain is incorrect?
a. intractable pain may not be relieved by treatment.
b. Pain is an objective sign of a more serious problem.
c. Psychologic factors can contribute to a patient's pain perception.
d. Pain sensation is affected by a patient's anticipation of pain.
85. Billy Bragg, aged 5, received a small paper cut on his finger. His mother left him wash it and apply a smail amount of bacitracin and a Band-aid. She then let him watch TV and eat an apple Her intervention for pain are examples of:
a. Providing pharmacologic therapy
b. Providing control and distraction
c. Altering Billy's environment
d. Providing cutaneous stimulation
Situation 11: Mrs. Smith, age 64, has been diagnosed with COPD. Although she was hospitalized several times in the last year for acute respiratory failure, she is presently in stable condition.
86. The primary focus of care in the long-term nursing care for Mrs. Smith would be to:
a. Decrease activity to conserve functional Sung tissue.
b. Increase the frequency of postural drainage to every 2 hours he awake.
c. Increase the RV.
d. improve and maintain pulmonary ventilation and gas exchange.
87. Mrs. Smith's condition has changed over a period of days,, and her arterial blood studies now indicate she is again in acute respiratory failure. The primary nursing intervention most commonly required .in the care of patient with COPD who are in acute respiratory failure is to:
a. Establish initial stage of activity.
b. Discourage patient from sitting in Fowler's position in order to reduce work of heart.
c. Remove bronchia! secretions, and manage oxygen therapy.
d. Plan with family for home care.
88. Mrs. Smith has been treated aggressively for acute respiratory failure and has improved over the past four weeks. She experienced anxiety about being prepared for discharge. The nurse who cares for her should help her develop ways to cope with her chronic obstructive lung disease by:
a. Encouraging the family to take increased responsibility for the patients care.
b. Discouraging the patient from performing activities of daily living if they make her tired.
c. Teaching the patient relaxation techniques and breathing refraining exercises.
d. Protecting the patient from knowing the prognosis of her disease.
Situation 12: Mrs. Lippett, age 66, is experiencing sensory and perceptual problems that affect her right visual field (right homonymous hemianopia).
89. When placing a meal tray in front of Mrs. Lippett, the nurse should;
a. Place all the food on the right side of the tray.
b. Before leaving the room, remind the patient to look over all the tray.
c. Place food and utensils within the patient's left visual field.
d. Stay with the patient & periodically draw her attention of the food on the right side of the tray to prevent unilateral neglect
90. The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography?
a. "You will be put to sleep before the needle Is inserted."
b. "The test will take several hours."
c. "You may fee! a burning sensation when the dye is injected."
d. "There will be no complications."
91.What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
a. Expressive aphasia and paralysis on the right side of the body.
b. Expressive aphasia and paralysis on the left side of the body. .
c. Dysarthria and paralysis on the right side of the body.
d. Mixed aphasia and paralysis on the right side of the body.
92. What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
a. Wait for the patient to complete the sentence.
b. Immediately begin showing the patient various objects In the environment.
c. Leave the room and come back later.
d. Begin naming various objects that the patient could be referring to.
93. Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
a. "What would you like to do first, brush your teeth?"
b. "Where is y our toothbrush?"
c. "When would you like to have your bath?"
d. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
94. Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
a. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
b. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
c. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
d. On the back with no pillows used, with trochanter rolls and a footboard.
95.To prevent infection in a patient with a subdura! intracranial pressure monitoring system in place, the nurse should;
a. Use aseptic technique for the insertion site.
b. Use clean technique for cleansing connections and aseptic technique for the insertion site.
c. Use sterile technique when cleansing the insertion site
d. Close any leaks in the tubing with tape.
Situation 13: Mrs. Taylor, age 74, suffers from degenerative joint disease due to osteoarthritis and is admitted for a total joint replacement of the right hip.
96. During the preoperative period, the nurse should focus assessment primarily on:
a. Local and systemic infections
b. Self-care ability
c. Response to pain medications
d. Range of motion in the affected joint
97. Following arthroplasty, the nurse should maintain correct position of Mrs, Taylor's operative leg by:
a. Placing an abductor wedge or pillows between the legs.
b. Placing sandbags or pillows to Keep leg abducted.
c. Elevating the affected leg on two pillows or supports.
d. Positioning her supine and on the operative side.
98. When discussing physical activities with Mrs. Tayior, the nurse should instruct her to;
a. Avoid weight bearing until the hip is completely heated.
b. Intermittently cross and uncross legs several times daily.
c. Maintain hip flexion at 90 degrees when sitting.
d. Limit hip flexion to only 45 to 50 degrees.
99. Before discharge, the nurse reviews the signs and symptoms of joint dislocation with Mrs. Tayior. The nurse would determine that Mrs. Taylor understands the instructions by her identification of which of the following symptoms?
a. Positive Homan's sign and Inability to bear weight.
b. Painiess, sudden deformity of the affected hip joint.
c. Severe hip pain with shortening of the extremity.
d. Severe pain and swelling of the affected hip joint.
100. As part of treatment of gouty arthritis for Mrs. Martin, age 66, the physician orders antiuric acid medication to be given in large doses until the maximum safe dosage can be determined. The nurse would determine the maximum dosage and the need for dosage reduction by asking Mrs. Martin to report which of the following symptoms?
a. Bleeding gums and bruising
b. Nausea, vomiting, and diarrhea
c. Gastric irritation and heartburn
d. Blurred vision and nausea
