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 o D. Diverticulitis 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 o D. The patient should limit fatty foods. Correct Answer: D. Air hunger Patients with pulmonary edema experience air hunger, anxiety, and agitation. Symptoms may also include coughing up blood or bloody froth; difficulty breathing when lying down (orthopnea); feeling of “air hunger” or “drowning” (this feeling is called Correct Answer: D. The patient should limit fatty foods. Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder. o Option A: The patient may maintain a moderate to a high-calorie diet, as a very low- calorie diet may increase the risk for gallstones that predisposes to cholecystitis. o Option B: Both animal fat and animal protein may contribute to the formation of gallstones. Vitamin C, which is abundant in plants and absent from meat affects the rate-limiting step in the catabolism of cholesterol to bile acids and is inversely related to the risk of gallstones and cholecystitis. Individuals consuming the most refined carbohydrates have a 60% greater risk for developing gallstones, compared with those who consumed the least. o Option C: Replacing sugary drinks with drinks high in fiber would reduce the risk of gallbladder stones by 15%. • 15. Question A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit? o A. Slow, deep respirations o B. Stridor o C. Bradycardia o D. Air hunger 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. Correct Answer: C. The patient will be admitted to the surgical unit and resection will be scheduled. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist. o Option A: Admitting the patient for Option A: The patient may present atypical symptoms based on risk factors, such as delirium or a decreasing level of consciousness. Option B: The diagnosis of pulmonary embolism should be sought actively in patients with respiratory symptoms UNEXPLAINED by an alternative diagnosis; symptoms may include productive cough and wheezing. Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of patients; however, a temperature higher than 39.5°C (103.1º) F is not from a pulmonary embolism. diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed. • 19. Question A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? o A. The patient will be admitted to the medicine unit for observation and medication. o B. The patient will be admitted to the day surgery unit for sclerotherapy. o C. The patient will be admitted to the surgical unit and resection will be scheduled. o D. The patient will be discharged home to follow- up with his cardiologist in 24 hours. Option A: According to three retrospective case reviews of childhood leukemia (in which 75% to 100% of the cases were acute lymphoblastic leukemia), common presenting signs and symptoms include fever (17% to 77%), lethargy (12% to 39%), and bleeding (10% to 45%). Option B: Requiring protective clothing is indicated to prevent infection if white blood cells are decreased. Protective garments consisting of gloves, Correct Answer: D. Check for signs of bleeding, including examination of urine and stool for blood. A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. aneurysm. Immediate surgery is the only recommended management. o Option B: Sclerotherapy, in which a solution is injected into a vein, causing it to collapse, scar, and fade, remains the primary treatment for the small- vessel varicose disease of the lower extremities. o Option D: The patient should not be discharged because the abdominal aneurysm • 20. Question A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan? o A. Monitor for fever every 4 hours. o B. Require visitors to wear respiratory masks and protective clothing. o C. Consider transfusion of packed red blood cells. o D. Check for signs of bleeding, including examination of urine and stool for blood. 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: B. The dose is too low This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore, erythemogenic or erythrogenic toxin, causes the pathognomonic rash as a consequence of local production of inflammatory mediators and alteration of the cutaneous cytokine milieu. This results in a sparse inflammatory response and dilatation of blood vessels, leading to the characteristic scarlet color of the rash. o Option B: The tongue may have a “strawberry”-like (red and bumpy) appearance, which is a characteristic sign of scarlet fever. On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). Red, edematous, exudative tonsils are typically observed if the infection originates in this area. o Option D: The throat and tonsils may be very red and sore with scarlet fever, and swallowing may be painful. The mucous membranes usually • 24. Question A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose? o A. It is the correct dose o B. The dose is too low o C. The dose is too high o D. The dose should be increased or decreased, depending on the symptoms Correct Answer: D. Normally, the testes descend by one year of age. Normally, the testes descend by one year of age. 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 Option A: Diphenhydramine is used to relieve red, irritated, itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies, or the common cold. Diphenhydramine is also used to relieve coughs caused by minor throat or airway irritation. Option C: Diphenhydramine comes as a tablet, a rapidly disintegrating (dissolving) tablet, a capsule, a liquid-filled capsule, a dissolving strip, powder, and a liquid to take by mouth. When diphenhydramine is used for the relief of allergies, cold, and cough symptoms, it is usually taken every 4 to 6 hours. Option D: Before you give a diphenhydramine product to a child, check the package label to find out how much medication the child should receive. Give the dose that matches the child’s age on the chart. Ask the child’s doctor if you don’t know how much medication to give the child. the correct dose is 150 mg/day. Divided into 3 doses per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should not be titrated based on symptoms without consulting a physician. • 25. Question The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate? o A. Normally, the testes are descended by birth. o B. The infant will likely require surgical intervention. o C. The infant probably has only one testis. o D. Normally, the testes descend by one year of age. 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. o Option A: A hydrocele can develop before birth. Normally, the testicles descend from the developing baby’s abdominal cavity into the scrotum. A sac accompanies each testicle, allowing fluid to surround the testicles. Usually, each sac closes and the fluid is absorbed. Sometimes, the fluid remains after the sac closes (noncommunicating hydrocele). The fluid is usually absorbed gradually within the first year of life. Correct Answer: C. No treatment is necessary; the fluid is reabsorbing normally. A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases, the fluid reabsorbs within the first few months of life and no treatment is necessary. group A beta-hemolytic streptococcal infection did not occur. Acute GN has been documented as a rare complication of hepatitis A. o Option D: Nephrotic syndrome does not cause acute glomerulonephritis. PSGN usually develops 1-3 weeks after acute infection with specific nephritogenic strains of group A beta-hemolytic streptococcus. The incidence of GN is approximately 5-10% in persons with pharyngitis and 25% in those with skin • 29. Question An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but the fluid is still visible on illumination. Which of the following actions is the physician likely to recommend? o A. Massaging the groin area twice a day until the fluid is gone. o B. Referral to a surgeon for repair. o C. No treatment is necessary; the fluid is reabsorbing normally. o D. Keeping the infant in a flat, supine position until the fluid is gone. Correct Answer: A. Inadequate tissue perfusion leading to nerve damage. Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest pain often is exacerbated by poor cardiac output. The condition is often But occasionally, the sac remains open (communicating hydrocele). The sac can change size or if the scrotal sac is compressed, fluid can flow back into the abdomen. Communicating hydroceles are often associated with inguinal hernia. o Option B: A hydrocele that doesn’t disappear on its own might need to be surgically removed, typically as an outpatient procedure. The surgery to remove a hydrocele (hydrocelectomy) can be done under general or regional anesthesia. An incision is made in the scrotum or lower abdomen to remove the hydrocele. If a hydrocele is found during surgery to repair an inguinal hernia, the surgeon might remove the hydrocele even if it’s causing no discomfort. o Option D: A baby’s hydrocele typically • 30. Question A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? o A. Inadequate tissue perfusion leading to nerve damage. o B. Fluid overload leading to compression of nerve tissue. o C. Sensation distortion due to psychiatric disturbance. o D. Inflammation of the skin on the hands and feet. 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 • 34. Question A patient who has been diagnosed with the vasospastic disorder (Raynaud’s disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient? o A. An adolescent male o B. An elderly woman o C. A young woman o D. An elderly man Correct Answer: C. young woman. Raynaud’s disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis. Vasospasm of the arteries reduces blood flow to the fingers and toes. In people who have Raynaud’s, the disorder usually affects the fingers. In about 40 percent of people who have Raynaud’s, it affects the toes. Rarely, the disorder affects the nose, ears, nipples, and lips. o Option A: Primary Raynaud’s usually develops before the age of 30. In primary Raynaud’s (also called Raynaud’s disease), the cause isn’t known. Primary Raynaud’s are more common and tend to be less severe than secondary Raynaud’s. o Option B: Secondary Raynaud’s usually develops after the age of 30. Secondary Raynaud’s is caused by an underlying disease, condition, or other factors. This type of Raynaud’s is often called Raynaud’s phenomenon. o Option D: Although anyone can develop the condition, Raynaud’s disease often begins between the ages 15 to 30, but it mostly affects women. If one has primary or secondary Raynaud’s, cold temperatures or stress can trigger “Raynaud’s attacks.” During an attack, little or no blood flows to affected body parts. • 35. Question A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms? o A. Myocardial infarction due to a history of atherosclerosis. o B. Pulmonary embolism due to deep vein thrombosis (DVT). o C. Anxiety attacks due to worries about her baby's health. o D. Congestive heart failure due to fluid overload. Correct Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT). In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. o Option A: Atherosclerosis is the disease primarily responsible for most acute coronary syndrome (ACS) cases. Approximately 90% of myocardial infarctions (MIs) result from an acute thrombus that obstructs an atherosclerotic coronary artery. Plaque rupture and erosion are considered to be the major triggers for coronary thrombosis. Following plaque erosion or rupture, platelet activation and aggregation, coagulation pathway activation, and endothelial vasoconstriction occur, leading to coronary thrombosis and occlusion. o Option C: There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first. 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. resection. o Option D: Continued participation will worsen the condition and the symptoms. The onset of OSD is Options A: The ability to move the spine through its full range of motion, both forward and backward, is called spinal flexibility. However, it is not included in routine adolescent exams. Options B: Leg length discrepancy or disparity is a condition in which the paired lower extremity limbs have a noticeably unequal length. Option C: Hypostatic or orthostatic blood pressure is a form of low blood pressure that happens when one is sitting or stands up suddenly. Correct Answer: D. Scoliosis. A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. usually gradual, with patients commonly complaining of pain in the tibial tubercle and/or patellar tendon region after repetitive activities. Typically, running or jumping activities that significantly stress the patellar tendon insertion upon the tibial tubercle aggravate the patient’s • 39. Question The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? o A. Spinal flexibility o B. Leg length disparity o C. Hypostatic blood pressure o D. Scoliosis • 40. Question A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent? 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? Option A: Making sure that the physician’s orders for antibiotics are written, instead of admitting orders, should be done. Option C: The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Option D: Parental presence is important for the adjustment of the child but not for the administration of medication. Correct Answer: B. A blood culture is drawn. Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. protection, and home exercises, can help ensure that patients are as active as possible. • 42. Question A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started? o A. The admission orders are written. o B. A blood culture is drawn. o C. A complete blood count with differential is drawn. o D. The parents arrive. • 43. Question A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms? o A. Possible fracture of the tibia. o B. Bruising of the gastrocnemius muscle. Correct Answer: A, B, and D. Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share Option B: Toddlers will often continue to walk on a muscle that is bruised or strained. Option C: The radius is found in the lower arm and is not relevant to this question. Option D: Toddlers rarely feign injury to be carried, and swelling indicates a physical injury. Correct Answer: A. Possible fracture of the tibia. The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture. o C. Possible fracture of the radius. o D. No anatomic injury, the child wants his mother to carry him. • 44. Question A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply. o A. Regular developmental screening is important to avoid secondary developmental delays. o B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. o C. Developmental milestones may be slightly delayed but usually will require no additional intervention. o D. Parent support groups are helpful for sharing strategies and managing health care issues. o E. Therapies and surgical interventions can cure cerebral palsy. 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. Option A: Coronary artery bypass grafting is the surgical repair of a diseased coronary artery. Option B: Angioplasty does not involve the placement of an internal cardiac defibrillator. An internal cardiac defibrillator is needed if the client has ventricular tachycardia or ventricular fibrillation because they detect and stop abnormal heartbeats or arrhythmias. Correct Answer: C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass graft is the surgical procedure to repair a diseased coronary artery. muscle protein (Dp427). These defects result in the various manifestations commonly associated with MD, such as weakness and pseudohypertrophy. o Option D: Minor variations notwithstanding, all types of MD have in common progressive muscle weakness that tends to occur in a proximal-to-distal direction, though there are some rare distal myopathies that cause predominantly distal weakness. The decreasing muscle strength in those who are affected may compromise the patient’s ambulation potential • 46. Question A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the o A. Surgical repair of a diseased coronary artery. o B. Placement of an automatic internal cardiac defibrillator. o C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow. o D. Non-invasive radiographic examination of the heart. o Option D: PTCA is not a radiographic examination of the heart. • 47. Question A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize: o A. They can expect the child will be mentally retarded. o B. Administration of thyroid hormone will prevent problems. o C. This rare problem is always hereditary. o D. Physical growth/development will be delayed. Correct Answer: B. Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement correct this condition. o Option A: Mental retardation can be prevented with early detection and treatment. Neurologic sequelae, characterized by spasticity, tremor, and hyperactive deep tendon reflexes, are found frequently in severe cretinism, but not in mild cretinism or acquired hypothyroidism. The severity of neurologic sequelae parallels mental retardation. Early therapy apparently prevents, in part, these sequelae. o Option C: Congenital hypothyroidism is caused by iodine deficiency and is occasionally exacerbated by naturally occurring goitrogens. In the majority of patients, CH is caused by abnormal development of the thyroid gland (thyroid dysgenesis) which is a sporadic disorder and accounts for 85% of cases, and the remaining 15% of cases are caused by dyshormonogenesis. The clinical features of congenital hypothyroidism are so subtle that many newborn infants remain undiagnosed at birth and delayed diagnosis leads to the most severe outcome of CH, mental retardation, emphasizing the importance of neonatal screening. 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 Option B: Heat lamps may cause burns in the skin inside the cast. Inspect the skin around the cast. If the skin becomes red or raw around the cast, contact a doctor. Option C: Do not handle the cast until it is dry because it might still break. It takes about one hour for fiberglass, and two to three days for plaster to become hard enough to walk on. Some physicians will give a “cast shoe” to wear over a walking cast. The cast shoe will help protect the bottom of the cast. Option D: Turning the child would ensure equal drying of the cast at all sides. Keep the cast dry. If the cast Correct Answer: A. Expose the cast to air and turn the child frequently The child should be turned every 2 hours, with the surface exposed to the air. Casts and splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle spasm. loss are the gastrointestinal tract, polyuria, and increased perspiration. o Option C: Hemorrhage is not a great risk in premature rupture of membranes. One of the complications of PROM is intraventricular hemorrhage. This is because blood vessels in the brain of premature infants are not fully developed, and are therefore weaker than that of term babies. Research shows that intraventricular hemorrhages (IVH) or brain bleeds are significantly reduced by steroid treatment, without an increase in either maternal• 51. Question A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should: o A. Expose the cast to air and turn the child frequently. o B. Use a heat lamp to reduce the drying time. o C. Handle the cast with the abductor bar. o D. Turn the child as little as possible. • 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. o B. Massage the fundus. o C. Offer a bedpan. o D. Check for perineal lacerations. Correct Answer: B. Massage the fundus The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Approximately 3% to 5% of obstetric patients will experience postpartum hemorrhage. Annually, these preventable events are the cause of one-fourth of maternal deaths worldwide and 12% of maternal deaths in the United States. o Option A: Vital signs should be checked after vaginal delivery, but in this situation, the nurse should prioritize prevention of bleeding. 20% of postpartum hemorrhage occurs in women with no risk factors, so physicians must be prepared to manage this condition at every delivery o Option C: The client’s fundus should be massaged first to prevent uterine atony and hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage. Brisk blood flow after delivery of the placenta unresponsive to transabdominal massage should prompt immediate action including bimanual compression of the uterus and use of uterotonic medications. Massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall o Option D: Perineal lacerations may be present but it is not a primary concern during uterine atony. Lacerations and hematomas due to birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Episiotomy increases the risk of blood loss and anal sphincter tears; this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor. 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. Correct Answer: D. Low self-esteem Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have low self-esteem, and have a great need to exercise control or power-over partners. o Option A: Being an alcoholic predisposes an individual to be a domestic abuser. To be o Option B: Improvement in airway obstruction should decrease the presence of wheezes. Wheezing most often is caused by an obstruction (blockage) or narrowing of the small bronchial tubes in the chest. It can also be caused by an obstruction in the larger airways or vocal cords. The tone of the wheeze can vary depending on which part of the respiratory system is blocked or narrowed. o Option C: There is no indication for suctioning. Suctioning is used to obtain mucus and other fluids (secretions) and cells from the windpipe (trachea) and large airways (bronchi) and is typically used in people who are on mechanical ventilation or have problems with nerves or muscles that make coughing less effective for bringing up secretions. o Option D: Hyperventilation does not produce high pitched wheezes that extend throughout exhalation. The lowered carbon dioxide levels in the blood can cause squeezing of the airways, which then results in wheezing. • 61. Question Which behavioral characteristic describes the domestic abuser? o A. Alcoholic o B. Overconfident o C. High tolerance for frustrations o D. Low self-esteem 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. Correct Answer: D. Safety Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan. Depression can be effectively treated in primary care settings using an evidence- based collaborative approach in which primary care providers are systematically supported by mental health providers in caring for a caseload of patients. Option A: Option A describes the preoperational stage. During this stage, young children can think about things symbolically. The preoperational stage is the second stage in Piaget’s theory of cognitive development. This stage begins around age 2, as children start to talk, and lasts until approximately age 7. 1 During this stage, children begin to engage in symbolic play and learn to manipulate symbols. Option C: In the formal operational stage, people develop the ability to think about abstract concepts, and logically test hypotheses. Option D: Option D describes the formal operational stage. The formal operational stage begins at approximately age twelve and lasts into adulthood. As adolescents enter this stage, they gain the ability to think in an abstract manner by manipulating ideas in their head, without any dependence on concrete manipulation. The child in the concrete operational stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects. • 67. Question The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? o A. Nutrition o B. Elimination o C. Activity o D. Safety 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 headaches, such as migraines. Pain relievers offer relief for occasional headaches. But Option A: Documentation is one of the nursing responsibilities. Option B: The nurse should perform neurologic checks. Option D: Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision Correct Answer: C. Take the patient’s vital signs. Taking vital signs is within the education and scope of practice for a nursing assistant. if one takes them more than a couple of days a week, they may trigger medication overuse headaches. o Option E: Complementary therapies are add- on therapies meant to be used along with traditional treatment, according to the National Center for Complementary and Integrative Health (NCCIH). Massage, spinal manipulation, and acupuncture are examples of complementary therapies that may be beneficial for people with migraines. o Option F: Medications such as estrogen supplements may actually trigger a migraine headache attack. Fluctuations in estrogen, • 73. Question The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant? o A. Document the seizure o B. Perform neurologic checks o C. Take the patient’s vital signs o D. Restrain the patient for protection • 74. Question You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? 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.”