NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022), Exams of Nursing

Download NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022) and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022) 1. 1. Question A nurse was instructed by a physician to give clarithromycin (Biaxin) for a child whose BSA is 0.55 m2. The usual adult dose is 500 mg. Biaxin is available in an oral suspension. The 100ml bottle is labeled 50 mg/ml. How many ml would the nurse give per dose? Fill in the blanks. Record your answer using one decimal place. o Answer: Correct answer: (3.2) mL. o 3.2 mL. Formula: BS A Formula: BSA Formula: Rationale: o Use the BSA formula first then the standard formula as shown above. o To get the child’s dose, multiply 0.55m2(child’s BSA) to 500 mg (usual adult dose) to get 275. o Divide 275 with 1.7 m2to get 161.76 mg. o Use the standard formula above. o Divide 161.76 mg (desired pedia dose) with 50 mg (drug on hand) and multiply by 1 ml (vehicle) to get 3.2 ml. Computation: • 2. Question A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first? o A. Blood sugar check o B. CT scan o C. Blood cultures o D. Arterial blood gases Correct Answer: A. Blood sugar check With a history of diabetes, the first response should be to check blood sugar levels. o Option B: Performing a CT scan at this stage of assessment is unnecessary. A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross- sectional images (slices) of the bones, blood vessels, and soft tissues inside the body. CT scan images provide more detailed information than plain X-rays do. o Option C: A blood culture test helps the doctor figure out if the client has a kind of infection that is in the bloodstream and can affect the entire body. Doctors call this a systemic infection. The test checks a sample of the blood for bacteria or yeast that might be causing the infection. o Option D: An arterial blood gas (ABG) test measures oxygen and carbon dioxide levels in the blood. It also measures the body’s acid- base (pH) level, which is usually in balance when healthy. Option A: Contacting the provider is unnecessary and may take time. A pediatric patient must have folks with them inside the room, so asking the child’s folks would be the most appropriate intervention. Option B: The child may have not yet developed his writing abilities. Some children are able to write their names at age 4, but some typically developing children still aren’t ready until well into age. Option C: Asking a coworker would be inappropriate and against the patient’s confidentiality. Correct Answer: D. Ask the father who is in the room the child’s name. In this case, you can determine the name of the child by the father’s statement. You should not withhold the medication from the child after identification. o Option B: Never give an IM injection in the gluteal muscles to avoid the risk of sciatica nerve damage. o Option D: The vastus medialis muscle is a part of the quadriceps muscle group, located on the front of the thigh.• 6. Question A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do? o A. Contact the provider o B. Ask the child to write their name on paper o C. Ask a coworker about the identification of the child o D. Ask the father who is in the room the child’s name • 7. Question A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings? o A. Elevated serum calcium o B. Low serum parathyroid hormone (PTH) o C. Elevated serum vitamin D o D. Low urine calcium Correct Answer: A. Elevated serum calcium The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. The chronic excessive resorption of calcium from bone caused by excessive parathyroid hormone can result in osteopenia. o Option B: Parathyroid hormone levels may be high or normal but not low. The main effects of parathyroid hormone are to increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidney, and increasing renal production of 1,25- dihydroxyvitamin D-3 (calcitriol), which increases intestinal absorption of calcium. o Option C: The body will lower the level of vitamin D in an attempt to lower calcium. Vitamin D levels should be measured in the evaluation of primary hyperparathyroidism. Vitamin D deficiency (a 25- hydroxyvitamin D level of less than 20 ng per milliliter) can cause secondary hyperparathyroidism, and repletion of vitamin D deficiency can help to reduce parathyroid hormone levels. o Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones. In addition, the chronically increased excretion of calcium in the urine can predispose to the formation of renal stones. • 8. Question A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended? o A. A diet high in grains Correct Answer: B. Contaminated food Correct Answer: A. Bowel perforation Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate advancing peritonitis. One of the most serious complications of colonoscopy is endoscopic perforation of the colon, which has been reported as between 0.03% and 0.7%. Although colonoscopic perforation (CP) occurs rarely, it can be associated with high mortality and morbidity rates. o Option B: Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea, anorexia, weight loss, and dehydration. Isolated cases can occur, but viral gastroenteritis more commonly occurs in outbreaks within close communities such as daycare centers, nursing facilities, and cruise ships. Many different viruses can lead to symptomatology, though in routine clinical practice the true causative virus is generally not identified. o Option C: If the patient is age 50 or older and at average risk of colon cancer — he has no colon cancer risk factors other than age — the doctor may recommend a colonoscopy every 10 years or sometimes sooner to screen for colon cancer. Colonoscopy is one option for colon cancer screening. o Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis. • 11. Question A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission? o A. Sexual contact with an infected partner o B. Contaminated food o C. Blood transfusion o D. Illegal drug use Correct Answer: A. A history of hepatitis C five years previously Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is commonly transmitted via body fluids such as blood, semen, and vaginal secretions. [1] Consequently, sexual contact, accidental needle sticks or sharing of needles, blood transfusions, and organ transplantation are routes for HBV infection. Option C: Before widespread screening of the blood supply in 1992, hepatitis C was also spread through blood transfusions and organ transplants. Now, the risk of transmission to recipients of blood or blood products is extremely low. Option D: Today, most people become infected with hepatitis B, C, or D by sharing needles, syringes, or any other equipment used to prepare and inject drugs. Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. HAV is a single-stranded, positive-sense, linear RNA enterovirus of the Picornaviridae family. In humans, viral replication depends on hepatocyte uptake and synthesis, and assembly occurs exclusively in the liver cells. Virus acquisition results almost exclusively from ingestion (eg, fecal-oral transmission) • 12. Question A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this? o A. A history of hepatitis C five years previously o B. Cholecystitis requiring cholecystectomy one year previously o C. Asymptomatic diverticulosis o D. Crohn's disease in remission Option B: Cholecystitis is the inflammation of the gallbladder. This condition does not transmit through bodily fluids. Option C: Diverticulosis is when pockets called diverticula form in the wall of the digestive tract. The inner layer of the intestine pushes through weak spots in the outer lining. This pressure makes them bulge out, making little pouches. Option D: Crohn’s disease is an inflammatory bowel disease. It causes inflammation of the digestive tract. This disease does not transmit through the blood. hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. o Option B: Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve Correct Answer: A. Naproxen sodium (Naprosyn) Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Naproxen is used to relieve pain from various conditions such as headache, muscle aches, tendonitis, dental pain, and menstrual cramps. It also reduces pain, swelling, and joint stiffness caused by arthritis, bursitis, and gout attacks. • 13. Question A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient? o A. Naproxen sodium (Naprosyn) o B. Calcium carbonate o C. Clarithromycin (Biaxin) o D. Furosemide (Lasix) Correct Answer: C. A patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary for a Option A: Physical findings in patients with pulmonary edema are notable for tachypnea and tachycardia. Patients may be sitting upright, they may demonstrate air hunger, and they may become agitated and confused. Patients usually appear anxious and diaphoretic. Option B: Auscultation of the lungs usually reveals fine, crepitant rales, but rhonchi or wheezes may also be present. Rales are usually heard at the bases first; as the condition worsens, they progress to the apices. Option C: Cardiovascular findings are usually notable for S3, accentuation of the pulmonic component of S2, and jugular venous distention. Auscultation of murmurs can help in the diagnosis of acute valvular disorders manifesting with pulmonary edema. “paroxysmal nocturnal dyspnea” if it causes you to wake up 1 to 2 hours after falling asleep and struggle to catch your breath). • 16. Question A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure? o A. A patient admitted for myocardial infarction without cardiac muscle damage. o B. A postoperative coronary bypass patient, recovering on schedule. o C. A patient with a history of ventricular tachycardia and syncopal episodes. o D. A patient with a history of atrial tachycardia and fatigue. Option A: A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. Option B: A patient recovering well from coronary bypass would not need the device. Option D: Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort. patient with significant ventricular symptoms, such as tachycardia resulting in syncope. Option A: Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. MRI contrast agents are gadolinium chelates with different stability, viscosity, and osmolality. Gadolinium is a relatively very safe contrast; however, it rarely might cause allergic reactions in patients. Options C: Open MRI scanners and anti-anxiety medications are available for patients with Correct Answer: B. The patient has a pacemaker The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Patients with cardiac implantable electronic devices or CIED are at risk for inappropriate device therapy, device heating/movement, and arrhythmia during MRI. These patients must be scheduled in a CIED blocked slot or scheduled with electrophysiology nurse or technician support. But nowadays MRI conditional cardiac implantable electronic devices are widely available. • 17. Question A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient? o A. The patient is allergic to shellfish. o B. The patient has a pacemaker. o C. The patient suffers from claustrophobia. o D. The patient takes antipsychotic medication. Correct Answer: B. The patient suddenly complains of chest pain and shortness of breath. Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for claustrophobia. Claustrophobic patients might refuse to complete the MRI scan and need sedation. These patients need to be well informed about the MRI scan procedure. The recommendation is that a physician has a discussion with them about the details in advance. Using Larger and opener MRI systems might be helpful in claustrophobic patients. o Option D: Psychiatric medication is not a contraindication to MRI scanning. MRI helps in high- resolution investigations of soft tissues without the use of ionizing radiation. This safe modality currently becomes the imaging technique of choice for diagnosing musculoskeletal, neurologic, and cardiovascular disease. However, there are restrictions and • 18. Question A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? o A. The patient is somnolent with decreased response to the family. o B. The patient suddenly complains of chest pain and shortness of breath. o C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. o D. The patient has a fever, chills, and loss of a petite. o Option A: The anterior fontanel is closed in a 4-year- old child. The average closure time of the anterior fontanelle ranges from 13 to 24 months. Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will closer sooner compared to female infants. Correct Answer: B. Repeated vomiting Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life- threatening. Repeated vomiting can be an early sign of pressure as the vomiting center within the medulla is stimulated. chemotherapy gowns, eye protection e.g.; goggles, N95 respirator, and shoe covers will be worn according to the task being performed with a Chemotherapy/Biotherapy agent or excreta of a patient who has received a Chemotherapy/Biotherapy agent within the last 48 hours. o Option C: Transfusion of red cells is indicated for severe anemia. Blood transfusions represent one of the most important forms of supportive care for patients with leukemia. Cancer is the major cause of transfusion. One-third of transfused patients have a malignant disease, • 21. Question A nurse in the emergency department is observing a 4- year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern? o A. Bulging anterior fontanel o B. Repeated vomiting o C. Signs of sleepiness at 10 PM o D. Inability to read short words from a distance of 18 inches Correct Answer: A. Small blue-white spots are visible on the oral mucosa. Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. Near the end of the prodrome, Koplik spots (ie, bluish-gray specks or “grains of sand” on a red base) appear on the buccal mucosa opposite the second molars. The Koplik spots generally are first seen 1-2 days before the appearance of the rash and last until 2 days after the rash appears. This enanthem begins to slough as the rash appears. Although this is the pathognomonic enanthem of measles, its absence does not exclude the diagnosis. o Option B: The body rash typically begins on the face and travels downward. Blanching, o Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old. Young toddlers have a sleep schedule supplemented by two naps a day. Toddler sleep problems are compounded by separation anxiety and a fear of missing out, which translates to stalling techniques and stubbornness at bedtime. o Option D: The average 4-year-old child cannot read yet, so this too is normal. At 4, many children just aren’t ready to sit still and focus on a book for long. Others may learn the mechanics of reading but aren’t cognitively • 22. Question A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)? o A. Small blue-white spots are visible on the oral mucosa. o B. The rash begins on the trunk and spreads outward. o C. There is low-grade fever. o D. The lesions have a "teardrop-on-a-rose- petal" appearance. o Option A: Bacteria called group A Streptococcus or group A strep cause scarlet fever. The bacteria sometimes make a poison (toxin), which causes a rash- the “scarlet” of scarlet fever. As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness. The circulating toxin, produced by GABHS and often referred to as Correct Answer: C. Petechiae occur on the soft palate. Petechiae on the soft palate is characteristic of rubella infection. images below). Within 48 hours, they coalesce into patches and plaques that spread cephalocaudally to the trunk and extremities, including the palms and soles, while beginning to regress cephalocaudally, starting from the head and neck. Lesion density is greatest above the shoulders, where macular lesions may coalesce. The eruption may also be petechial or ecchymotic in nature. o Option C: High fever (may spike to more than 104°F) is often present. The first sign of measles is usually a high fever (often >104o F [40o C]) that typically lasts 4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the classic triad of conjunctivitis (see the image below), cough, and coryza (the “3 Cs”). o Option D: “Teardrop on a rose petal” refers to the lesions found in varicella (chickenpox). The characteristic chickenpox • 23. Question A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? o A. Scarlet fever is caused by infection with group A Streptococcus bacteria. o B. "Strawberry tongue" is a characteristic sign. o C. Petechiae occur on the soft palate. o D. The pharynx is red and swollen. Correct Answer: C. The tumor extended beyond the kidney but was completely resected. Option A: The testes usually descend by one year of age. Most of the time, a boy’s testicles descend by the time he is 9 months old. Undescended testicles are common in infants who are born early. The problem occurs less in full-term infants. Option B: Surgical intervention is unnecessary; the testes descend by one year of age. The testicles will descend normally at puberty and surgery is not needed. Testicles that do not naturally descend into the scrotum are considered abnormal. An undescended testicle is more likely to develop cancer, even if it is brought into the scrotum with surgery. Cancer is also more likely in the other testicle. Option C: In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. stimulated. The exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. If not, a full assessment will determine the appropriate treatment. • 26. Question A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage? o A. The tumor is less than 3 cm. in size and requires no chemotherapy. o B. The tumor did not extend beyond the kidney and was completely resected. o C. The tumor extended beyond the kidney but was completely resected. o D. The tumor has spread into the abdominal cavity and cannot be resected. Option A: The mass is solid at presentation and usually >10 cm. Option B: This option describes stage 1, wherein the tumor is limited to the kidney and completely resected. Option D: In stage IV, hematogenous metastasis has occurred with spread beyond the abdomen. The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, the residual non-hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis. o Option B: Functional changes include proteinuria, hematuria, reduction in GFR (ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The decreased GFR and avid distal nephron salt and water retention result in the expansion of intravascular volume, edema, and, frequently, systemic hypertension. Correct Answer: A, B, & C Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea-colored” urine caused by large amounts of red blood cells. Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and RBC casts are present. • 27. Question A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply. o A. Urine specific gravity of 1.040 o B. Urine output of 350 ml in 24 hours o C. Brown ("tea-colored") urine o D. Generalized edema Option A: No congenital condition predisposes to glomerulonephritis. Noninfectious causes of acute GN may be divided into primary renal diseases, systemic diseases, and miscellaneous conditions or agents. Option C: Viruses may cause acute glomerulonephritis but rarely. Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B virus (HBV), rubella, rickettsiae (as in scrub typhus), parvovirus B19, and mumps virus are accepted as viral causes only if it can be documented that a recent Correct Answer: B. Prior infection with group A Streptococcus within the past 10-14 days. Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine, and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis. o Option C: This is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients, often manifesting as smoky-, coffee-, or cola- colored urine. o Option D: There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis. Most often, the patient is a boy, aged 2-14 years, who suddenly develop puffiness of the eyelids and • 28. Question Which of the following conditions most commonly causes acute glomerulonephritis? o A. A congenital condition leading to renal dysfunction. o B. Prior infection with group A Streptococcus within the past 10-14 days. o C. Viral infection of the glomeruli. o D. Nephrotic syndrome. Option B: Fluid overload is not characteristic of PVD. Assess the heart for murmurs or other abnormalities. Investigate all peripheral vessels, including carotid, abdominal, and femoral, for pulse quality and bruit. Note that the dorsalis pedis artery is absent in 5-8% of normal subjects, but the posterior tibial artery usually is present. Both pulses are absent in only about 0.5% of patients. Exercise may cause the obliteration of these pulses. Option C: There is nothing to indicate a psychiatric disturbance in the patient. Option D: Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation. The skin may have an atrophic, shiny appearance and may demonstrate trophic changes, including alopecia; dry, scaly, or erythematous skin; chronic pigmentation changes; and brittle nails. extremity in a dependent position, so that perfusion is enhanced by the effects of gravity. o Option B: Overweight is a risk factor that is subject to lifestyle change and can reduce risk significantly. The terms “overweight” and “obesity” refer to body weight that’s greater than what is considered healthy for a certain height. Correct Answer: A. Family history of heart disease. A family history of heart disease is an inherited risk factor that is not subject to a lifestyle change. Having a first-degree relative with heart disease has been shown to significantly increase risk. • 31. Question A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis? o A. Family history of heart disease o B. Overweight o C. Smoking o D. Age Option A: Claudication refers to muscle pain due to lack of oxygen that’s triggered by activity and relieved by rest. Option B: This most often occurs during activity when demand increases in muscle tissue. Option C: The condition is also called intermittent claudication because the pain usually isn’t constant. It Correct Answer: A, C, & D. Claudication describes the pain experienced by a patient with a peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue becomes hypoxic, causing cramping, weakness, and discomfort. o Option C: Smoking can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn’t allow enough oxygen to reach the body’s tissues. o Option D: Advancing age increases the risk of atherosclerosis but is not a hereditary factor. As one gets older, the risk for atherosclerosis increases. Genetic or lifestyle factors cause plaque to build up in the arteries as one ages. By the time one is middle- aged or older, enough plaque has built up to cause signs or symptoms. In men, the risk increases after • 32. Question Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply: o A. It results when oxygen demand is greater than oxygen supply. o B. It is characterized by pain that often occurs during rest. o C. It is a result of tissue hypoxia. o D. It is characterized by cramping and weakness. o E. It always affects the upper extremities. Correct Answer: C. Avoid crossing the legs. Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient. o Option A: Walking barefoot is not advised, as foot protection is important to avoid the trauma that may lead to serious infection. o Option B: Heating pads can cause injury, which can also increase the risk of infection. o Option D: Skin lesions at risk for infection should be examined and treated by a physician. begins during exercise and ends with rest. As claudication worsens, however, the pain may occur during rest. o Option D: Claudication is pain caused by too little blood flow to muscles during exercise. Most often this pain occurs in the legs after walking at a certain pace and for a certain amount of time — depending on the severity of the condition. Option E: Pain in the shoulders, biceps, and forearms may occur, but less often. • 33. Question A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in the instructions? o A. Walk barefoot whenever possible. o B. Use a heating pad to keep feet warm. o C. Avoid crossing the legs. o D. Use antibacterial ointment to treat skin lesions at risk of infection. Option A: Air embolism is not a concern. Thrombosis is an important part of the normal hemostatic response that limits hemorrhage caused by microscopic or macroscopic vascular injury. Physiologic thrombosis is counterbalanced by intrinsic antithrombotic properties and fibrinolysis. Under normal conditions, a thrombus is confined to the immediate area of injury and does not obstruct flow to critical areas, unless the blood vessel lumen is already diminished, as it is in atherosclerosis. Option C: Both hemostasis and thrombosis depend on the coagulation cascade, vascular wall integrity, and platelet response. Several cellular factors are responsible for thrombus formation. When a vascular Correct Answer: B. Cerebral hemorrhage. Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. The success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. o Option D: According to 2017 American Heart Association (AHA) data, heart failure affects an estimated 6.5 million Americans aged 20 years and older. [31] With improved survival of patients with acute myocardial infarction and with a population that continues to age, heart failure will continue to increase in prominence as a major health problem in the United States. • 36. Question Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy? o A. Air embolus. o B. Cerebral hemorrhage. o C. Expansion of the clot. o D. Resolution of the clot. Option B: In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape. Option C: Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time. Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size. Correct Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle. In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion of the neck and causing the chin to point to the opposing side. insult occurs, an immediate local cellular response takes place. Platelets migrate to the area of injury, where they secrete several cellular factors and mediators. These mediators promote clot formation. o Option D: Thrombolytic therapy does not lead to the expansion of the clot, but to resolution, • 37. Question An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation? o A. Torticollis, with shortening of the sternocleidomastoid muscle. o B. Craniosynostosis, with premature closure of the cranial sutures. o C. Plagiocephaly, with flattening of one side of the head. o D. Hydrocephalus, with increased head size. • 38. Question An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood- Schlatter disease. Which of the following statements about the disease is correct? o A. The condition was caused by the student's competitive swimming schedule. o B. The student will most likely require surgical intervention. o C. The student experiences pain in the inferior aspect of the knee. o D. The student is trying to avoid participation in physical education. Correct Answer: C. The student experiences pain in the inferior aspect of the knee. Osgood-Schlatter disease occurs in adolescents in the rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. o Option A: Swimming is not a likely cause. OSD is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. The pain associated will be localized to the tibial tubercle and occasionally the patellar tendon itself. o Option B: The condition is usually self-limited, responding to ice, rest, and analgesics. OSD is a self- limiting condition. In a study by Krause et al, 90% of patients treated with conservative care were relieved of all of their symptoms approximately 1 year after the onset of symptoms. [3] After skeletal maturity, patients may continue to have problems kneeling. This typically is due to tenderness over an unfused tibial tubercle ossicle or a bursa that may require resection. o Option D: Continued participation will worsen the condition and the symptoms. The o A. Low self-esteem o B. Unemployment o C. Self-blame for the injury to the child o D. Single status Correct Answer: C. Self-blame for the injury to the child. The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. Abusers typically blame others, especially their partners, for the mistakes in their lives. This is related to hypersensitivity, but they are not necessarily alike. This occurs because most abusive people don’t hold themselves as being accountable for the actions they commit. Instead, they’ll try to shift the blame to the person that they have abused and somehow say they “deserved it” or that they were forced into a corner. o Option A: Basically, domestic violence offenders always feel the need to be in control of their victims. The less in control an offender feels, the more they want to hurt others. o Option B: One study suggests that unemployment can cause an increase in child neglect because parents have more limited access to the resources required to provide for a child’s basic needs, such as clothing, food, and medical care. o Option D: A “favorite” of abusers is to isolate their partners from family or friends. This type of isolation is often very common and often represents the first step in an abusive relationship. The abusive partner will attempt to set up an “us versus them” attitude and will begin isolating family members. This can work through the abuser’s use of jealousy, controlling behavior, or veiled concern. • 41. Question A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate? o A. The child has a poor chance of recovery without joint deformity. o B. Most children progress to adult rheumatoid arthritis. o C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. o D. Physical activity should be minimized. Correct Answer: C. Nonsteroidal anti- inflammatory drugs are the first choice in treatment. Nonsteroidal anti-inflammatory drugs are an important first-line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. o Options A: Advances in treatment over the last 20 years—especially the introduction of early use of intra- articular steroids, methotrexate, and biologic medications—have dramatically improved the prognosis for children with arthritis. Almost all children with JIA lead productive lives. However, many patients, particularly those with a polyarticular disease, may have problems with the active disease throughout adulthood, with sustained remission attained in a minority of patients. o Option B: Children with the systemic-onset disease tend to either respond completely to medical therapy or develop a severe polyarticular course that tends to be refractory to medical treatment, with disease persisting into adulthood. o Option D: Physical activity is an integral part of therapy. Encourage patients to be as active as possible. Bed rest is not a part of the treatment. In fact, the more active the patient, the better the long- term prognosis. Children may experience increased pain during routine physical activities. As a result, these children must be allowed to self-limit their activities, particularly during physical education classes. A consistent physical therapy program, with attention to stretching exercises, pain modalities, joint and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones. o Option A: During a developmental screening, a short test is given to see if the child has specific developmental delays, such as motor or movement delays. If the results of the screening test are cause for concern, then the doctor will make referrals for developmental and medical evaluations. o Option B: Cerebral palsy (CP) is a group of disorders that affect a person’s ability to move and maintain balance and posture. CP is the most common motor disability in childhood. Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles. CP is caused by abnormal brain development or damage to the developing brain that affects a person’s ability to control his or her muscles. o Option C: Delayed developmental milestones definitely need interventions and constant follow ups. Developmental monitoring (also called surveillance) means tracking a child’s growth and development over time. If any concerns about the child’s development are raised during monitoring, then a developmental screening test should be given as soon as possible. o Option D: Both early intervention and school- aged services are available through a special education law —the Individuals with Disabilities Education Act (IDEA). Part C of IDEA deals with early intervention services (birth through 36 months of age), while Part B applies to services for school- aged children (3 through 21 years of age). Even if the child has not been diagnosed with CP, he or she may be eligible for IDEA services. o Option E: Cerebral palsy has no cure, but treatment can improve the lives of those who have the condition. After a CP diagnosis is made, a team of health professionals works with the child and family to develop a plan to help the child reach his or her full potential. Common treatments include medicines; surgery; braces; and physical, occupational, and speech therapy. No single treatment is the best one for all children with CP. Before deciding on a treatment Option B: DMD carriers are females who have a normal dystrophin gene on one X chromosome and an abnormal dystrophin gene on the other X chromosome. Most carriers of DMD do not themselves have signs and symptoms of the disease, but a minority do. Option C: Advances in molecular biology techniques illuminate the genetic basis underlying all MD: defects in the genetic code for dystrophin, a 427-kd skeletal Correct Answer: A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease. The recessive Duchenne gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier. plan, it is important to talk with the child’s doctor to understand all the risks and benefits. • 45. Question A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information? o A. Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease. o B. Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease. o C. Each child has a 1 in 4 (25%) chance of developing the disorder. o D. Sons only have a 1 in 4 (25%) chance of developing the disorder. o Option D: The growth and development of an infant with congenital hypothyroidism can be normal if it is detected and treated early. In overt hypothyroidism, the severe impairment of linear growth leads to dwarfism, which is characterized by limbs that are • 48. Question A priority goal of involuntary hospitalization of the severely mentally ill client is o A. Re-orientation to reality o B. Elimination of symptoms o C. Protection from harm to self or others o D. Return to independent functioning Correct Answer: C. Protection from self-harm and harm to others. Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled. o Option A: Mentally ill clients should be kept safe first before reorienting them back to reality. In keeping with emergent mental health public policy and nursing professional ethics, the articulated aims of deinstitutionalization included returning individuals to home communities to restore freedom and autonomy and reducing or eliminating nursing practices grounded in punishment that was being societally reconceptualized as harmful. o Option B: Gradual elimination of the symptoms is not the primary goal in the hospitalization of a mentally ill client. There are two important concepts of psychological treatment. First, although it is called “psychological” treatment, the ultimate effect of these treatments is to bring some changes in the very delicate change in the structure and function of neurons by changing the way a person habitually thinks and behaves. They also promote the healing of Option B: Denial is a defense mechanism proposed by Anna Freud which involves a refusal to accept reality, thus blocking external events from awareness. If a situation is just too much to handle, the person may respond by refusing to perceive it or by denying that it exists. Option C: This statement refers to projection, which is when an individual attributes her negative self-concept onto others. Correct Answer: A. “I don’t remember anything about what happened to me.” Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-esteem. the brain by reducing the stress experienced by the patients in daily life. In psychological treatment, all treatment effects come from the effort to take new behavior and adopt new ways of thinking. o Option D: The client should be kept safe from himself and others first before he can return to independent functioning. The measurement of functional capacity in mental illness is an important recent development. Determination of functional capacity may serve as a surrogate marker for real-world functioning, thereby aiding • 49. Question A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”? o A. “I don’t remember anything about what happened to me.” o B. “I’d rather not talk about it right now.” o C. “It’s the other entire guy’s fault! He was going too fast.” o D. “My mother is heartbroken about this.” o Option D: This statement refers to the identification, which is when the client identifies herself with an image that she sees is ideal to our ego.• 50. Question The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time? o Altered tissue perfusion o Risk for fluid volume deficit o High risk for hemorrhage o Risk for infection Correct Answer: D. Risk for infection Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn. Rupture of membranes results from a variety of factors that ultimately lead to accelerated membrane weakening. This is caused by an increase in local cytokines, an imbalance in the interaction between matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and protease activity, and other factors that can cause increased intrauterine pressure. o Option A: There should be little or no alteration in perfusion after premature rupture of the membranes. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient. When diminished tissue perfusion becomes chronic, it can result in tissue or organ damage or death. o Option B: There may be a risk for deficient fluid volume, but it is not a priority. Fluid volume deficit (FVD) or hypovolemia is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid o A. AGN is a streptococcal infection that involves the kidney tubules. o B. The disease is easily transmissible in schools and camps. o C. The illness is usually associated with chronic respiratory infections. o D. It is not “caught” but is a response to a previous B-hemolytic strep infection. Correct Answer: D. It is not “caught” but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease. o Option A: Acute glomerulonephritis comprises a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium. o Option B: The disease is most commonly caused by Streptococcus species. Glomerulonephritis may develop a week or two after recovery from a strep throat infection or, rarely, a skin infection (impetigo). To fight the infection, the body produces extra antibodies that can eventually settle in the glomeruli, causing inflammation. o Option C: Acute glomerulonephritis is usually associated with staphylococcal infection. Infections with other types of bacteria, such as staphylococcus and pneumococcus, viral infections, such as chickenpox, and parasitic infections, such as malaria, can also result in acute glomerulonephritis. Acute glomerulonephritis that results from any of these infections is called postinfectious glomerulonephritis. • 54. Question The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral Option A: Episodes of vomiting should be reported, but it is not the priority and is currently being managed with intravenous infusions. Once clinically significant dehydration is present, effective and safe strategies for rehydration are required. Additionally, following rehydration there may be a risk of recurrence of dehydration and appropriate fluid management may reduce the likelihood of that event. Option B: Crying and irritability is a normal reaction of an infant who is unwell. Option C: Vigorous sucking is a good sign in an infant who has episodes of vomiting. Correct Answer: D. No measurable voiding in 4 hours. The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. Successful management of acute hyperkalemia involves protecting the heart from arrhythmias with the administration of calcium, shifting potassium (K+) into the cells, and enhancing the elimination of K+ from the body. intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately? o A. 3 episodes of vomiting in 1 hour. o B. Periodic crying and irritability. o C. Vigorous sucking on a pacifier. o D. No measurable voiding in 4 hours. • 55. Question While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action? o A. Check vital signs. Option A: A bedside commode for a client with acute MI should be provided, but it does not prevent Valsalva maneuver alone. Option C: Antidysrhythmics do not prevent Valsalva maneuver. Antidysrhythmic agents, which are also known as antiarrhythmic agents, are a broad category of medications that help ameliorate the spectrum of cardiac arrhythmias to maintain normal rhythm and conduction in the heart. Option D: A client with acute MI can be given bathroom privileges with assistance. Correct Answer: B. Administer stool softeners every day as ordered. Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the Valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate. o B. Administer stool softeners every day as ordered. o C. Administer antidysrhythmics prn as ordered. o D. Maintain the client on strict bed rest. • 58. Question On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to: o A. Give the client orientation materials and review the unit rules and regulations. o B. Introduce him/her and accompany the client to the client’s room. o C. Take the client to the day room and introduce her to the other clients. o D. Ask the nursing assistant to get the client’s vital signs and complete the admission search. Correct Answer: C. “I have to turn my head to see my room.” Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in Correct Answer: B. Introduce him/herself and accompany the client to the client’s room. Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. o Option A: The client is still confused and fearful. Orientation should be postponed until he is calm. They can deliver effective, safe care by assessing risk and building a rapport with the patient during the admission process; utilizing crisis prevention strategies, including appropriate medication administration, environmental, psychobiological, counseling, and health teaching interventions; and employing conflict resolution techniques. o Option C: The client should be taken to a calm environment with less stimuli so he could feel safe and become calmer. o Option D: Taking the client’s vital signs while he is still fearful would further aggravate his feelings of insecurity and fear. Utilizing the nursing process, the nurse can provide effective therapeutic interventions to promote safety for both the patient and the nurse. • 59. Question During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? o A. “I have constant blurred vision.” o B. “I can’t see on my left side.” o C. “I have to turn my head to see my room.” o D. “I have specks floating in my eyes.” Correct Answer: A. Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning. Option A: Central vision is one of the most common signs of glaucoma. The fluid inside the eye, called aqueous humor, usually flows out of the eye through a mesh-like channel. If this channel gets blocked, the liquid builds up. Sometimes, experts don’t know what causes this blockage. But it can be inherited, meaning it’s passed from parents to children. Option B: The peripheral field of vision is most often lost in a client with glaucoma. The increased pressure in the eye, called intraocular pressure, can damage the optic nerve, which sends images to the brain. If the damage worsens, glaucoma can cause permanent vision loss or even total blindness within a few years. Option D: Patchy blind spots in the peripheral or central vision of both eyes is a symptom of open-angle glaucoma. It is caused by the drainage channels in the eye becoming gradually clogged over time. along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabecular meshwork. If left untreated or undetected blindness results in the affected eye. • 60. Question A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client: o A. Has increased airway obstruction. o B. Has improved airway obstruction. o C. Needs to be suctioned. o D. Exhibits hyperventilation. Option B: Before performing the tests, the client should be informed first and she must give her consent. Separate written consent for HIV testing is not recommended. General informed consent for medical care that notifies the patient that an HIV test will be performed unless the patient declines (opt-out screening) should be considered sufficient to encompass informed consent for HIV testing. Option C: Discussion about the risks can come after determining if the client is HIV positive or not. Increased HIV vulnerability is often associated with legal and social factors, which increases exposure to risk situations and creates barriers to accessing Correct Answer: A. Counsel the woman to consent to HIV screening The client”s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome. o Option C: Aerobic exercise is any type of cardiovascular conditioning and is inappropriate for a client who has a leg cast. o Option D: Isotonic exercise is one method of muscular exercise and it is not recommended for a client who has leg cast. • 63. Question A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?A. Counsel the woman to consent to HIV screening. o A. Counsel the woman to consent to HIV screening. o B. Perform tests for sexually transmitted diseases. o C. Discuss her high risk for cervical cancer. o D. Refer the client to a family planning clinic. Option A: Changing client assignments is unnecessary. The nurse may wait for the child to calm down. Option C: Time outs are usually not appropriate for a toddler, especially if she is in a new environment. Option D: The behavior shown by the toddler is normal and she does not need any additional attention. Correct Answer: B. Explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool. effective, quality and affordable HIV prevention, testing and treatment services. o Option D: Family planning could come after the HIV screening has results. For women with HIV who want to become pregnant, use of antiretroviral prophylaxis during pregnancy can reduce mother-to-child transmission of HIV. Afterwards, family planning services that promote healthy timing and spacing of pregnancies are important to reduce the risk of adverse pregnancy outcomes such as low birth weight, preterm birth, and infant mortality.• 64. Question A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse? o A. Arrange to change client care assignments. o B. Explain that this behavior is expected. o C. Discuss the appropriate use of “time-out”. o D. Explain that the child needs extra attention. Correct Answer: B. They are able to think logically in organizing facts. Option A: Most children, even school-aged children, are fearful of a strange bed and new surroundings. Option C: The presence of other toddlers might help the client calm down and adjust with the environment. Option D: Unfamiliar toys and games would least likely affect the toddler’s behavior. Correct Answer: B. Separation from parents Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. • 65. Question While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? o A. Strange bed and surroundings. o B. Separation from parents. o C. Presence of other toddlers. o D. Unfamiliar toys and games. • 66. Question While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age? o A. They are able to make simple associations of ideas. o B. They are able to think logically in organizing facts. o C. Interpretation of events originates from their own perspective. o D. Conclusions are based on previous experiences. Option B: Lying flat or in a supine position would be difficult for the client and may induce increased cardiac workload. Option C: Left lateral position may increase the client’s cardiac workload. Option D: Low Fowler’s may not be sufficient enough to support the client’s cardiac workload. Correct Answer: A. High Fowler’s Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac workload and facilitates breathing. o Option C: Dress-up and props are recommended for preschool. When a child plays together with others and has interest in both the activity and other children involved in playing they are participating in cooperative play. o Option D: Chess is recommended for school- age to adolescent stage. During the school-age years, you’ll see a change in your child. He or she will move from playing alone to having multiple friends and social groups. • 69. Question A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? o A. High Fowler’s o B. Supine o C. Left lateral o D. Low Fowler’s • 70. Question The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is: o A. Urinary output of 30 ml per hour o B. No complaints of thirst o C. Increased hematocrit o D. Good skin turgor around burn Correct Answer: A. Urinary output of 30 ml per hour For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces. o Option B: Relying on the client’s thirst would not create accurate results. The steady intravascular fluid loss due to these sequences of events requires sustained replacement of intravascular volume in order to prevent end- organ hypoperfusion and ischemia. o Option C: An increase in hematocrit suggests vascular space fluid losses. Reduced cardiac output is a hallmark in this early post-injury phase. The reduction in cardiac output is the combined result of decreased plasma volume, increased afterload and decreased cardiac contractility, induced by circulating mediators. o Option D: A good skin turgor is not an accurate indicator of adequate fluid replacement. The goal of fluid management in major burn injuries is to maintain the tissue perfusion in the early phase of burn shock, in which hypovolemia finally occurs due to steady fluid extravasation from the intravascular compartment. • 71. Question What is the priority nursing diagnosis for a patient experiencing a migraine headache? o A. Acute pain related to biologic and chemical factors o B. Anxiety related to change in or threat to health status o C. Hopelessness related to deteriorating physiological condition o D. Risk for Side effects related to medical therapy Correct Answer: A. Acute pain related to biologic and chemical factors The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management. o Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension headaches are common for people that struggle with severe anxiety or anxiety disorders. Tension headaches can be described as a heavy head, migraine, head pressure, or feeling like there is a tight band wrapped around their head. These headaches are due to a tightening of the neck and scalp muscles. o Option C: Hopelessness should be addressed as part of the nursing care plan, but it does not require urgency. Hopelessness can result when someone is going through difficult times or unpleasant experiences. A person may feel overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to multiple stresses and losses. He or she might think that challenges are unconquerable or that there are no solutions to the problems and may not be able to mobilize the energy needed to act on his or her own behalf. o Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization • 72. Question You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? Select all that apply. Correct Answer: D. “It’s OK to take over-the- counter medications.” A patient with a seizure disorder should not take over-the- counter medications without consulting with the physician first. o Option A: Alcohol is not allowed for patients with seizures because it increases the risk of Option A: The RN should perform the complete initial assessment. Option C: Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins. Option D: Padded side rails are controversial in terms of whether they actually provide safety and may embarrass the patient and family. Correct Answer: B. Set up oxygen and suction equipment The LPN/LVN can set up the equipment for oxygen and suction. o A. Complete admission assessment o B. Set up oxygen and suction equipment o C. Place a padded tongue blade at the bedside o D. Pad the side rails before the patient arrives • 75. Question A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene? o A. “You should avoid consumption of all forms of alcohol.” o B. “Wear your medical alert bracelet at all times.” o C. “Protect your loved one’s airway during a seizure.” o D. “It’s OK to take over-the-counter medications.” Option B: A medical alert bracelet bears the message that the wearer has an important medical condition that might require immediate attention. Option C: One of the priorities during a seizure is to prevent obstruction of the airway by turning the client into a side-lying position to allow drainage to flow.