NCLEX-PN 3000 Questions with Answers and Rationales latest version, Exams of Nursing

Download NCLEX-PN 3000 Questions with Answers and Rationales latest version and more Exams Nursing in PDF only on Docsity! NCLEX-PN 3000 Questions with Answers and Rationaleslatest version The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? 1. Guillain-Barré syndrome 2. Rheumatic fever 3. Reye's syndrome 4. Scarlet fever - Correct Answer: 3 RATIONALES: Research shows a correlation between the use of aspirin during chickenpox and the development of Reye's syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever. A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the: 1. subarachnoid space. 2. area between the subarachnoid space and the dura mater. 3. area between the dura mater and the ligamentum flavum. 4. ligamentum flavum. - Correct Answer: 3 RATIONALES: For an epidural block, the nurse should anticipate that the anesthesiologist will inject a local anesthetic agent into the epidural space, located between the dura mater and the ligamentum flavum in the lumbar region of the spinal column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites. The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the nurse administer with each dose? - Correct Answer: 14 RATIONALES: To determine the total daily dosage, set up the following proportion: 25 kg/X = 1 kg/56 mg X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 ml/125 mg X = 14 ml. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? 1. Irrigate continuously until the solution becomes clear or all of the solution has been used. 4. Substituting an oral antidiabetic agent for insulin - Correct Answer: 2 RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing? 1. Planning 2. Data collection 3. Evaluation 4. Implementation - Correct Answer: 2 RATIONALES: During the data collection step of the nursing process, the nurse obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating the nursing diagnoses. During the planning step, the nurse designs methods to help resolve client problems and meet client needs. During evaluation, the nurse determines the effectiveness of nursing interventions in achieving client goals. During implementation, the nurse takes actions to meet the client's needs. The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G - Correct Answer: 3 RATIONALES: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate. Which finding in a neonate suggests hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering - Correct Answer: 1 RATIONALES: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, not hyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates with hypothermia. Neonates typically don't shiver. Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints? 1. Headache, blurred vision, and facial and extremity swelling 2. Abdominal pain, urinary frequency, and pedal edema 3. Diaphoresis, nystagmus, and dizziness 4. Lethargy, chest pain, and shortness of breath - Correct Answer: 1 RATIONALES: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia. The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter? 1. Family history of pressure ulcers 2. Presence of existing pressure ulcers 3. Potential areas of pressure ulcer development RATIONALES: Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology and shouldn't be considered normal results of aging. An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, andangina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemiaby ingesting: 1. 2 to 5 g of a simple carbohydrate. 2. 10 to 15 g of a simple carbohydrate. 3. 18 to 20 g of a simple carbohydrate. 4. 25 to 30 g of a simple carbohydrate. - Correct Answer: 2 RATIONALES: To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia. A 43-year-old man was transferring a load of firewood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which immediate order by the physician? 1. Lidocaine administration 2. Cardiac stress test 3. Serial liver enzyme testing 4. Tissue plasminogen activator (tPA) - Correct Answer: 4 RATIONALES: If 6 hours or less have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA. The client doesn't exhibit symptoms that indicate the use of lidocaine. Stress testing shouldn't be performed during the acute phase of an MI, but it may be ordered before discharge. Serial cardiac biomarkers, not serial liver enzymes, would be ordered for this client. A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene? 1. Explain that she can't give medical advice. 2. Inform the neighbor that she might require surgery. 3. Advise the neighbor to seek medical attention. 4. Tell the neighbor that she'll be fine because she was able to get through the night. - Correct Answer: 3 RATIONALES: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response. A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? 1. Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur 2. Sitting up for a few minutes before standing to minimize orthostatic hypotension 3. Notifying the physician if her thoughts don't normalize within 1 week 4. Expecting symptoms of tardive dyskinesia to occur and to be transient - Correct Answer: 2 RATIONALES: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. The antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk ofextrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately. One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic? 1. "You're behaving in an unacceptable manner, and you need to control yourself." 3. Cooked vegetables such as lima beans and corn 4. Frozen desserts such as ice cream - Correct Answer: 2 RATIONALES: The nurse should advise the mother to avoid giving her child large, round chunks of meat such as hot dog. The mother can safely give the toddler small pieces of banana; cooked vegetables, such as lima beans and corn; and frozen desserts such as ice cream. A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion? 1. Insulin 2. Hydrocortisone 3. Potassium 4. Hypotonic saline - Correct Answer: 2 RATIONALES: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution. A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most stronglysuggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved - Correct Answer: 4 RATIONALES: Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills. A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at: 1. 7:30 a.m. 2. 6:30 a.m. 3. 9 a.m. 4. 9:30 a.m. - Correct Answer: 1 RATIONALES: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach its maximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. Applying EMLA at 6:30 a.m. is too early. The other time options are too late for the local anesthetic to be effective. Which nursing action is essential when providing continuous enteral feeding? 1. Elevating the head of the bed at least 30 degrees 2. Positioning the client on the left side 3. Warming the formula before administering it 4. Hanging a full day's worth of formula at one time - Correct Answer: 1 RATIONALES: Elevating the head of the bed at least 30 degrees during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 8 hours. When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a commonallergen? 1. Bread 1. Restrain the child. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing. - Correct Answer: 3 RATIONALES: During a seizure, the nurse's first priority is to protect the child from injury. To prevent injury caused by uncontrolled movements, the nurse must remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure may cause injury. Once the seizure stops, the nurse should check for breathing and, if indicated, initiate rescue breathing. A 40-year-old client is admitted to the hospital for alcohol abuse for the third time in the past 9 months. The health care team recommends rehabilitative treatment for this client. Why was this treatment recommended? 1. It's the only option for controlling alcohol consumption. 2. It helps the client identify a new group of friends. 3. It helps the client understand the effects of alcohol on his body. 4. It helps the client identify the relationship between his problems and alcohol consumption. - Correct Answer: 4 RATIONALES: The purpose of rehabilitative treatment in alcoholism is to help the client identify the relationship between his problems and his alcohol consumption. Rehabilitative treatment promotes abstinence, not limiting or controlling consumption. It isn't intended to help the client identify a new group of friends or understand the effects of alcohol on his body. A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the back room, the waiter spits on the man's pizza. This is an example of a behavior typical of which disorder? 1. Obsessive-compulsive 2. Narcissistic 3. Passive-aggressive 4. Dependent - Correct Answer: 3 RATIONALES: This is an example of a negative attitude and passive-aggressive behavior in response to demands for adequate performance. People with this disorder won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive disorder involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self- worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted. A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infectioncaused by the protozoa. In planning the client's care, the nurse should focus on his need for: 1. pain management. 2. fluid replacement. 3. antiretroviral therapy. 4. high-calorie nutrition. - Correct Answer: 2 RATIONALES: The protozoal enteric infection caused by Cryptosporidium results in profuse watery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluid replacement. Pain management is also a concern in the care of a client with AIDS. However, with Cryptosporidium, the main concern is hydration. Antiretroviral therapy is most useful when a client with human immunodeficiency virus (HIV) doesn't have opportunistic infections. With the wasting associated with AIDS, high-calorie nutrition is important but with Cryptosporidium-related diarrhea, hydration takes precedence. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is: 1. erythema. 2. leukocytosis. 3. pressurelike pain. 4. swelling. - Correct Answer: 3 The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to: 1. teach children to cover mouths and noses when they sneeze. 2. have their children immunized against impetigo. 3. teach children the importance of proper hand washing. 4. isolate the child with impetigo from other members of the family. - Correct Answer: 3 RATIONALES: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing won't prevent its spread. Currently, there is no vaccine to prevent a child from contracting impetigo. Isolating the child with impetigo is unnecessary. A diabetic client develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect may these findings have on his need for insulin? 1. They will have no effect. 2. They will decrease the need for insulin. 3. They will increase the need for insulin. 4. They will cause wide fluctuations in the need for insulin. - Correct Answer: 3 RATIONALES: Insulin requirements are increased by growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications. A school-age child with terminal leukemia is admitted to the pediatric unit. The nurse must discuss advance directives with the child's parents. The nurse should include which information? 1. Positive appraisal of the child's prognosis 2. Chemotherapy options 3. Comfort care options 4. Bone marrow transplantation information - Correct Answer: 3 RATIONALES: The nurse shouldn't give a positive appraisal of the child's prognosis because doing so gives the parents false hope. The nurse must be honest about the child's prognosis and provide them accurate information about treatment options, which include palliative care, comfort care, and pain management. The physician — not the nurse — should discuss such treatment options as chemotherapy or bone marrow transplantation, if indicated. A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should formulate which nursing diagnosis? 1. Deficient knowledge related to food restrictions associated with anesthesia 2. Fear related to surgery 3. Risk for impaired skin integrity related to upcoming surgery 4. Ineffective coping related to the stress of surgery - Correct Answer: 1 RATIONALES: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia.The other options may be applicable but aren't related to the client's statement. The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to: 1. apply maximum bandages to allow for absorption of drainage. 2. wrap elastic bandages distally to proximally on dependent areas. 3. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. 4. put on sterile gloves only when removing bandages. - Correct Answer: 2 RATIONALES: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. Applying maximum bandages should be avoided because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb 1. Wear gloves when handling tissues containing sputum. 2. Wear a face mask at all times. 3. Keep the client in strict isolation. 4. When the client leaves the room for tests, have all people in contact with him wear a mask. 5. Keep the client's door open to allow fresh air into room and prevent social isolation. 6. Wash hands after direct contact with the client or contaminated articles. - Correct Answer: 1,2,6 RATIONALES: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative- pressure, private room, and the door should remain closed at all times to prevent the spread of infection. A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regional anesthesia during labor and delivery. If she were to receive this form of anesthesia, she might experience: 1. hypotension. 2. hypertension. 3. seizures. 4. renal toxicity. - Correct Answer: 1 RATIONALES: In a client with PIH, uteroplacental perfusion may be inadequate and gas exchange may be poor. Regional anesthesia increases the risk of hypotension resulting from sympathetic blockade, possibly causing fetal and maternal hypoxia. Hypertension, seizures, and renal toxicity aren't associated with regional anesthesia. A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to: 1. use an electric breast pump. 2. apply warm, moist compresses to the breasts. 3. breast-feed every 1½ to 3 hours. 4. wear a brassiere 24 hours per day. - Correct Answer: 3 RATIONALES: Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to engorgement. If the infant isn't ill or physically impaired and can breast-feed, the client shouldn't use an electric breast pump because this deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying warm, moist compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. A brassiere supports the breasts but doesn't prevent engorgement. A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? 1. Blood pressure 2. Respirations 3. Temperature 4. Cardiac rhythm - Correct Answer: 4 RATIONALES: The nurse should assess the client's cardiac rhythm using electrocardiography because an elevated serum potassium level may lead to a life- threatening cardiac arrhythmia. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level. A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique? 1. Restating 2. Reframing 3. Reflecting meaning. Damage to the parietal lobe affects the client's ability to identify special relationships with the environment. When damaged, the occipital lobe affects visual associations. The client can visualize objects but can't identify them. The frontal lobe acts as a storage area for memory. A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: 1. fold towels and pillowcases. 2. play cards with another client. 3. participate in a game of charades. 4. perform an aerobic exercise. - Correct Answer: 1 RATIONALES: Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. Cards, charades, and aerobic exercise are too complicated for a confused client. The nurse is caring for a 16-year-old pregnant client who is taking an iron supplement. Which instruction should the nurse include when teaching the adolescent about ferrous sulfate? Select all that apply: 1. Take the supplement with food. 2. Report black stools to the physician immediately. 3. Avoid taking the supplement with milk. 4. Avoid taking the supplement with antacids. 5. Avoid chewing the extended-release form of the drug. - Correct Answer: 3,4,5 RATIONALES: Because food delays absorption, the nurse should instruct the client to take the supplement between meals to increase absorption. The client should take the supplement with juice (preferably orange juice) or water, but not with milk or antacids. The nurse should also tell the client not to crush or chew extended-release forms of the drug. A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would bestprevent further regression in the client's personal hygiene? 1. Encouraging the client to perform as much self-care as possible 2. Making the client assume responsibility for physical care 3. Assigning a staff member to take over the client's physical care 4. Accepting the client's desire to go without bathing - Correct Answer: 1 RATIONALES: Clients with Alzheimer's-type dementia tend to fluctuate in their capabilities. Encouraging self-care to the extent possible helps increase the client's orientation and promotes a trusting relationship with the nurse. Making the client assume responsibility for physical care is unreasonable. Assigning a staff member to take over the client's physical care restricts the client's independence. Accepting the client's desire to go without bathing promotes poor hygiene. A client, age 20, is being treated for depression. During a conversation with the nurse, she states that her father raped her when she was 7 years old. She says she has nightmares about the experience and sometimes relives it. She also reveals that she fears older men. The client may be exhibiting signs of: 1. posttraumatic stress disorder (PTSD), delayed onset. 2. multiple personality disorder. 3. anxiety disorder. 4. schizophrenia. - Correct Answer: 1 RATIONALES: The client's memory of a traumatic childhood incident and her current symptoms (nightmares, flashbacks, and related fears) suggest that she has PTSD with delayed onset. The client doesn't occasionally lose track of her movements and actions, as in multiple personality disorder. Her anxiety isn't primary but results from severe emotional trauma. Although she experiences flashbacks, these aren't psychotic episodes, as in schizophrenia. In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by: 1. hypothyroidism. 2. hyperglycemia. 3. hypertension. The nurse is caring for a client with delirium. Which of the following is most important for the nurse to provide the client? 1. A safe environment 2. An opportunity to release frustration 3. Prescribed medications 4. Medications as needed, judiciously - Correct Answer: 1 RATIONALES: Providing a safe environment is the most important aspect of caring for a client with delirium. Although all other options are logical and appropriate, meeting the client's safety needs takes priority. The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of acolostomy. Based on the client's response, the surgeon should collaborate with which health team member? 1. Social worker 2. Staff nurse 3. Clinical educator 4. Enterostomal nurse - Correct Answer: 4 RATIONALES: The surgeon should collaborate with the enterostomal nurse who can address the client's concerns. The enterostomal nurse may schedule a visit from a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker don't need to be consulted in this situation. A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client? 1. A private room down the hall from the nurses' station 2. An isolation room close to the nurses' station 3. A semiprivate room with a 32-year-old client who has viral meningitis 4. A two-bed room with a client who previously had bacterial meningitis - Correct Answer: 2 RATIONALES: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease. Which psychological or personality factor is likely to predispose an individual to medication abuse? 1. Low self-esteem and unresolved rage 2. Desire to inflict pain upon one's self 3. Dependent personality disorder 4. Antisocial personality disorder - Correct Answer: 1 RATIONALES: Low self-esteem and repressed rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. Personality disorders don't predispose a client to medication abuse; however, personality disorders, especially the antisocial ones, may be intensified by abuse. Which detail of a client's drug therapy is the nurse legally responsible for documenting? 1. Peak concentration time of the drug 2. Safe ranges of the drug 3. Client's socioeconomic data 4. Client's reaction to the drug - Correct Answer: 4 RATIONALES: The nurse legally must document the client's reaction to the drug in addition to the time the drug was administered and the dosage given. The nurse isn't legally responsible for documenting the peak concentration time of the drug, safe drug ranges, or the client's socioeconomic data. centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors. The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? 1. Chills 2. Scant lochia rubra 3. Thirst and fatigue 4. Temperature of 100.2° F (37.9° C) - Correct Answer: 2 RATIONALES: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4° F (38° C) also are common at 24 hours postpartum. A client with chronic obstructive pulmonary disease, who has been receiving mechanical ventilation for the past 5 days, expresses to a nurse his desire to have treatment withdrawn. Which statement about the client's legal rights is true in this situation? 1. The nurse's assessment of the client and communication with the family guides the decision-making process. 2. The nurse is an advocate for the client and should encourage the client to accept his current treatment regimen. 3. The health care team must follow the treatment plan that was already established with client and family input. 4. The client has the right to refuse treatment at any time. - Correct Answer: 4 RATIONALES: Health care professionals must ensure a health care ethic that respects the role of the client in the decision-making process. According to the Patient's Bill of Rights, the client has the right to make decisions about his care at any time. The nurse should be a client advocate and be supportive of the decision he made. A client with newly diagnosed breast cancer asks the nurse, "Why me? I've always been a good person. What have I done to deserve this?" Which response by the nurse would be most therapeutic? 1. "Don't worry. You'll probably live longer than I will." 2. "I'm sure a cure will be found soon." 3. "You seem upset. Let's talk about something happy." 4. "Would you like to talk about this?" - Correct Answer: 4 RATIONALES: Listening, responding quickly, and providing support promote therapeutic communication. Offering to talk about the client's feelings validates those feelings and allows the client to express them. Options 1 and 2 ignore the client's feelings. Option 3 identifies the client's feelings but doesn't follow through by exploring them. The mother of a 3-year-old child is complaining that her son still throws temper tantrums when he doesn't get his way. How should the nurse advise the mother to respond? 1. Tell the mother to ignore the child because eventually he will stop having temper tantrums. 2. Tell the mother to promise him a new toy if he stops the tantrum. 3. Tell the mother to give in to his demands; he is only 3-years-old. 4. Tell the mother to mimic him so that he can see what his behavior looks like. - Correct Answer: 1 RATIONALES: This child is in Erikson's developmental stage of initiative versus guilt. Guilt develops when the child is made to feel bad about his behavior. Ignoring the negative behavior shows the child that he'll gain nothing through negative behavior such as temper tantrums. Promising the child a new toy or giving in to his demands will reinforce his negative behavior by rewarding his tantrums. Mimicking the child will make him feel guilty. A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves: 1. chemical barriers that act as spermicidal agents. 2. hormones that prevent ovulation. 3. mechanical barriers that prevent sperm from reaching the cervix. 6. Effectiveness of prior dose of medication - Correct Answer: 1,2,3,4,6 RATIONALES: The nurse needs to know when the last dose was administered. Some clients request pain medication earlier than is ordered by the physician. Pain, the fifth vital sign, should be assessed using a pain scale and documented in the nursing notes whenever a pain medication is given. Pain is usually reassessed about 30 minutes after the medication is given. Physicians commonly order several different types of pain medication based on the client's condition. The nurse should know which medication and which route was used to administer prior dosages. Evaluating the effectiveness of medications is also an important nursing function when managing the client's pain. Therefore, she should ask the client if the prior dose was helpful. The nurse should also note whether the client experienced any adverse effects of the medication. Most medications are ordered based on the client's admission weight, not current weight and height. A client's weight may fluctuate when he's in the hospital, so it's unlikely that the nurse will have the most current weight available. Also, taking steps to obtain the client's current weight postpones the pain treatment and can potentially worsen pain. The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? 1. Serum potassium level of 4.9 mEq/L 2. Serum sodium level of 135 mEq/L 3. Temperature of 99.2° F (37.3° C) 4. Urine output of 20 ml/hour - Correct Answer: 4 RATIONALES: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal data collection findings. A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collectiontime should: 1. start with the first voiding. 2. start after a known voiding that empties the bladder. 3. always be with first morning urine. 4. always be the last evening's void as the last sample. - Correct Answer: 2 RATIONALES: When initiating a 24-hour urine specimen, have the client void, and then start timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but it's commonly started in the morning. A client is receiving nitroglycerin ointment (Nitrol) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? 1. Heart rate 2. Respiratory rate 3. Blood pressure 4. Temperature - Correct Answer: 3 RATIONALES: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration. Which drugs may be abused because of tolerance and physiologic dependence? 1. Lithium (Lithobid) and divalproex (Depakote). 2. Verapamil (Calan) and chlorpromazine (Thorazine) 3. Alprazolam (Xanax) and phenobarbital (Luminal) 4. Clozapine (Clozaril) and amitriptyline (Elavil) - Correct Answer: 3 RATIONALES: Both benzodiazepines (such as alprazolam) and barbiturates (such as phenobarbital) are addictive, controlled substances. None of the other drugs listed are addictive substances.