Physiologic
and Psychosocial Alterations
1. Answer:
(C) Loose, bloody
Rationale:
Normal bowel function and softformed
stool
usually do not occur until around
the seventh
day following surgery. The stool
consistency
is related to how much water is
being
absorbed.
2. Answer:
(A) On the client’s right side
Rationale:
The client has left visual field
blindness.
The client will see only from the
right side.
3. Answer:
(C) Check respirations, stabilize spine,
and check
circulation
Rationale:
Checking the airway would be
priority,
and a neck injury should be
suspected.
4. Answer:
(D) Decreasing venous return through
vasodilation.
Rationale:
The significant effect of
nitroglycerin
is vasodilation and decreased
venous
return, so the heart does not have to
work hard.
5. Answer:
(A) Call for help and note the time.
Rationale:
Having established, by stimulating
the client,
that the client is unconscious rather
than sleep,
the nurse should immediately call
for help.
This may be done by dialing the
operator
from the client’s phone and giving
the
hospital code for cardiac arrest and the
client’s
room number to the operator, of if the
phone is
not available, by pulling the
emergency
call button. Noting the time is
important
baseline information for cardiac
arrest
procedure
6. Answer:
(C) Make sure that the client takes
food and
medications at prescribed intervals.
Rationale:
Food and drug therapy will prevent
the
accumulation of hydrochloric acid, or will
neutralize
and buffer the acid that does
accumulate.
7. Answer:
(B) Continue treatment as ordered.
Rationale:
The effects of heparin are
monitored
by the PTT is normally 30 to 45
seconds;
the therapeutic level is 1.5 to 2 times
the normal
level.
8. Answer:
(B) In the operating room.
Rationale:
The stoma drainage bag is applied
in the
operating room. Drainage from the
ileostomy
contains secretions that are rich in
digestive
enzymes and highly irritating to the
skin.
Protection of the skin from the effects of
these
enzymes is begun at once. Skin exposed
to these
enzymes even for a short time
becomes reddened, painful, and excoriated.
9. Answer:
(B) Flat on back.
Rationale:
To avoid the complication of a
painful
spinal headache that can last for
several
days, the client is kept in flat in a
supine
position for approximately 4 to 12
hours
postoperatively. Headaches are
believed to
be causes by the seepage of
cerebral
spinal fluid from the puncture site. By
keeping the
client flat, cerebral spinal fluid
pressures
are equalized, which avoids trauma
to the
neurons.
10. Answer:
(C) The client is oriented when
aroused
from sleep, and goes back to sleep
immediately.
Rationale:
This finding suggest that the level
of
consciousness is decreasing.
11. Answer:
(A) Altered mental status and
dehydration
Rationale:
Fever, chills, hemortysis, dyspnea,
cough, and
pleuritic chest pain are the
common
symptoms of pneumonia, but elderly
clients may
first appear with only an altered
lentil
status and dehydration due to a blunted
immune response.
12. Answer:
(B) Chills, fever, night sweats, and
hemoptysis
Rationale:
Typical signs and symptoms are
chills,
fever, night sweats, and hemoptysis.
Chest pain
may be present from coughing, but
isn’t
usual. Clients with TB typically have lowgrade
fevers, not
higher than 102°F (38.9°C).
Nausea,
headache, and photophobia aren’t
usual TB symptoms.
13.
Answer:(A) Acute asthma
Rationale:
Based on the client’s history and
symptoms,
acute asthma is the most likely
diagnosis.
He’s unlikely to have bronchial
pneumonia
without a productive cough and
fever and
he’s too young to have developed
(COPD) and
emphysema.
14. Answer:
(B) Respiratory arrest
Rationale:
Narcotics can cause respiratory
arrest if
given in large quantities. It’s unlikely
the client
will have asthma attack or a seizure
or wake up
on his own.
15. Answer:
(D) Decreased vital capacity
Rationale:
Reduction in vital capacity is a
normal
physiologic change includes decreased
elastic
recoil of the lungs, fewer functional
capillaries
in the alveoli, and an increased in
residual
volume.
16. Answer:
(C) Presence of premature ventricular
contractions
(PVCs) on a cardiac monitor.
Rationale:
Lidocaine drips are commonly used
to treat
clients whose arrhythmias haven’t
been
controlled with oral medication and who
are having
PVCs that are visible on the cardiac
monitor.
SaO2, blood pressure, and ICP are
important
factors but aren’t as significant as
PVCs in the
situation.
17. Answer:
(B) Avoid foods high in vitamin K
Rationale:
The client should avoid consuming
large
amounts of vitamin K because vitamin K
can
interfere with anticoagulation. The client
may need to
report diarrhea, but isn’t effect
of taking
an anticoagulant. An electric razornot
a straight
razor-should be used to prevent
cuts that
cause bleeding. Aspirin may increase
the risk of
bleeding; acetaminophen should be
used to
pain relief.
18. Answer:
(C) Clipping the hair in the area
Rationale:
Hair can be a source of infection
and should
be removed by clipping. Shaving
the area
can cause skin abrasions and
depilatories
can irritate the skin.
19. Answer:
(A) Bone fracture
Rationale:
Bone fracture is a major
complication
of osteoporosis that results
when loss
of calcium and phosphate increased
the
fragility of bones. Estrogen deficiencies
result from
menopause-not osteoporosis.
Calcium and
vitamin D supplements may be
used to
support normal bone metabolism, But
a negative
calcium balance isn’t a
complication
of osteoporosis. Dowager’s
hump
results from bone fractures. It develops
when
repeated vertebral fractures increase
spinal
curvature.
20. Answer:
(C) Changes from previous
examinations.
Rationale:
Women are instructed to examine
themselves
to discover changes that have
occurred in
the breast. Only a physician can
diagnose
lumps that are cancerous, areas of
thickness
or fullness that signal the presence
of a
malignancy, or masses that are fibrocystic
as opposed
to malignant.
21. Answer:
(C) Balance the client’s periods of
activity
and rest.
Rationale:
A client with hyperthyroidism
needs to be
encouraged to balance periods of
activity
and rest. Many clients with
hyperthyroidism
are hyperactive and complain
of feeling
very warm.
22. Answer:
(B) Increase his activity level.
Rationale:
The client should be encouraged to
increase
his activity level. aintaining an ideal
weight;
following a low-cholesterol, low
sodium
diet; and avoiding stress are all
important
factors in decreasing the risk of
atherosclerosis.
23. Answer:
(A) Laminectomy
Rationale:
The client who has had spinal
surgery,
such as laminectomy, must be log
rolled to
keep the spinal column straight when
turning.
Thoracotomy and cystectomy may
turn
themselves or may be assisted into a
comfortable
position. Under normal
circumstances,
hemorrhoidectomy is an
outpatient
procedure, and the client may
resume
normal activities immediately after
surgery.
24. Answer:
(D) Avoiding straining during bowel
movement or
bending at the waist.
Rationale:
The client should avoid straining,
lifting
heavy objects, and coughing harshly
because
these activities increase intraocular
pressure.
Typically, the client is instructed to
avoid
lifting objects weighing more than 15 lb
(7kg) – not
5lb. instruct the client when lying
in bed to
lie on either the side or back. The
client should
avoid bright light by wearing
sunglasses.
25. Answer:
(D) Before age 20.
Rationale:
Testicular cancer commonly occurs
in men
between ages 20 and 30. A male client
should be
taught how to perform testicular
self-
examination before age 20, preferably
when he
enters his teens.
26. Answer:
(B) Place a saline-soaked sterile
dressing on
the wound.
Rationale:
The nurse should first place salinesoaked
sterile
dressings on the open wound to
prevent
tissue drying and possible infection.
Then the
nurse should call the physician and
take the
client’s vital signs. The dehiscence
needs to be
surgically closed, so the nurse
should
never try to close it.
27. Answer:
(A) A progressively deeper breaths
followed by
shallower breaths with apneic
periods.
Rationale:
Cheyne-Strokes respirations are
breaths
that become progressively deeper
fallowed by
shallower respirations with
apneas
periods. Biot’s respirations are rapid,
deep
breathing with abrupt pauses between
each
breath, and equal depth between each
breath.
Kussmaul’s respirationa are rapid,
deep
breathing without pauses. Tachypnea is
shallow
breathing with increased respiratory
rate.
28. Answer:
(B) Fine crackles
Rationale:
Fine crackles are caused by fluid in
the alveoli
and commonly occur in clients with
heart
failure. Tracheal breath sounds are
auscultated
over the trachea. Coarse crackles
are caused
by secretion accumulation in the
airways.
Friction rubs occur with pleural
inflammation.
29. Answer:
(B) The airways are so swollen that no
air cannot
get through
Rationale:
During an acute attack, wheezing
may stop
and breath sounds become
inaudible
because the airways are so swollen
that air
can’t get through. If the attack is over
and
swelling has decreased, there would be
no more
wheezing and less emergent concern.
Crackles do
not replace wheezes during an
acute
asthma attack.
30. Answer:
(D) Place the client on his side,
remove
dangerous objects, and protect his
head.
Rationale:
During the active seizure phase,
initiate precautions
by placing the client on his
side,
removing dangerous objects, and
protecting
his head from injury. A bite block
should
never be inserted during the active
seizure
phase. Insertion can break the teeth
and lead to
aspiration.
31. Answer:
(B) Kinked or obstructed chest tube
Rationales:
Kinking and blockage of the chest
tube is a
common cause of a tension
pneumothorax.
Infection and excessive
drainage
won’t cause a tension
pneumothorax.
Excessive water won’t affect
the chest
tube drainage.
32. Answer:
(D) Stay with him but not intervene at
this time.
Rationale:
If the client is coughing, he should
be able to
dislodge the object or cause a
complete
obstruction. If complete obstruction
occurs, the
nurse should perform the
abdominal
thrust maneuver with the client
standing.
If the client is unconscious, she
should lay
him down. A nurse should never
leave a
choking client alone.
33. Answer:
(B) Current health promotion
activities
Rationale:
Recognizing an individual’s positive
health
measures is very useful. General health
in the
previous 10 years is important,
however,
the current activities of an 84 year
old client
are most significant in planning care.
Family
history of disease for a client in later
years is of
minor significance. Marital status
information
may be important for discharge
planning
but is not as significant for
addressing
the immediate medical problem.
34. Answer:
(C) Place the client in a side lying
position,
with the head of the bed lowered.
Rationale:
The client should be positioned in a
side-lying
position with the head of the bed
lowered to
prevent aspiration. A small amount
of
toothpaste should be used and the mouth
swabbed or
suctioned to remove pooled
secretions.
Lemon glycerin can be drying if
used for
extended periods. Brushing the teeth
with the
client lying supine may lead to
aspiration.
Hydrogen peroxide is caustic to
tissues and
should not be used.
35. Answer:
(C) Pneumonia
Rationale:
Fever productive cough and
pleuritic
chest pain are common signs and
symptoms of
pneumonia. The client with
ARDS has
dyspnea and hypoxia with
worsening
hypoxia over time, if not treated
aggressively.
Pleuritic chest pain varies with
respiration,
unlike the constant chest pain
during an
MI; so this client most likely isn’t
having an
MI. the client with TB typically has a
cough
producing blood-tinged sputum. A
sputum
culture should be obtained to confirm
the nurse’s
suspicions.
36. Answer:
(C) A 43-yesr-old homeless man with
a history
of alcoholism
Rationale:
Clients who are economically
disadvantaged,
malnourished, and have
reduced
immunity, such as a client with a
history of
alcoholism, are at extremely high
risk for
developing TB. A high school student,
day- care
worker, and businessman probably
have a much
low risk of contracting TB.
37. Answer:
(C ) To determine the extent of
lesions
Rationale:
If the lesions are large enough, the
chest X-ray
will show their presence in the
lungs.
Sputum culture confirms the diagnosis.
There can
be false-positive and false-negative
skin test
results. A chest X-ray can’t determine
if this is
a primary or secondary infection.
38. Answer:
(B) Bronchodilators
Rationale:
Bronchodilators are the first line of
treatment
for asthma because bronchoconstriction
is the
cause of reduced airflow.
Beta-
adrenergic blockers aren’t used to treat
asthma and
can cause broncho- constriction.
Inhaled
oral steroids may be given to reduce
the
inflammation but aren’t used for
emergency
relief.
39. Answer:
(C) Chronic obstructive bronchitis
Rationale:
Because of this extensive smoking
history and
symptoms the client most likely
has chronic
obstructive bronchitis. Client with
ARDS have
acute symptoms of hypoxia and
typically
need large amounts of oxygen.
Clients
with asthma and emphysema tend not
to have
chronic cough or peripheral edema.
40. Answer:
(A) The patient is under local
anesthesia
during the procedure Rationale:
Before the
procedure, the patient is
administered
with drugs that would help to
prevent infection
and rejection of the
transplanted
cells such as antibiotics,
cytotoxic,
and corticosteroids. During the
transplant,
the patient is placed under general
anesthesia.
41. Answer:
(D) Raise the side rails
Rationale:
A patient who is disoriented is at
risk of
falling out of bed. The initial action of
the nurse
should be raising the side rails to
ensure
patients safety.
42. Answer:
(A) Crowd red blood cells
Rationale:
The excessive production of white
blood cells
crowd out red blood cells
production
which causes anemia to occur.
43. Answer:
(B) Leukocytosis
Rationale:
Chronic Lymphocytic leukemia (CLL)
is
characterized by increased production of
leukocytes
and lymphocytes resulting in
leukocytosis,
and proliferation of these cells
within the
bone marrow, spleen and liver.
44. Answer:
(A) Explain the risks of not having the
surgery
Rationale:
The best initial response is to
explain the
risks of not having the surgery. If
the client
understands the risks but still
refuses the
nurse should notify the physician
and the
nurse supervisor and then record the
client’s
refusal in the nurses’ notes.
45. Answer:
(D) The 75-year-old client who was
admitted 1
hour ago with new-onset atrial
fibrillation
and is receiving L.V. dilitiazem
(Cardizem)
Rationale:
The client with atrial fibrillation has
the
greatest potential to become unstable and
is on L.V.
medication that requires close
monitoring.
After assessing this client, the
nurse
should assess the client with
thrombophlebitis
who is receiving a heparin
infusion,
and then the 58- year-old client
admitted 2
days ago with heart failure (his
signs and
symptoms are resolving and don’t
require
immediate attention). The lowest
priority is
the 89-year-old with end-stage
right-sided
heart failure, who requires timeconsuming
supportive
measures.
46. Answer:
(C) Cocaine
Rationale:
Because of the client’s age and
negative
medical history, the nurse should
question
her about cocaine use. Cocaine
increases
myocardial oxygen consumption and
can cause
coronary artery spasm, leading to
tachycardia,
ventricular fibrillation, myocardial
ischemia,
and myocardial infarction.
Barbiturate
overdose may trigger respiratory
depression
and slow pulse. Opioids can cause
marked
respiratory depression, while
benzodiazepines
can cause drowsiness and
confusion.
47. Answer:
(B) Nonmobile mass with irregular
edges
Rationale:
Breast cancer tumors are fixed,
hard, and
poorly delineated with irregular
edges. A
mobile mass that is soft and easily
delineated
is most often a fluid-filled benign
cyst.
Axillary lymph nodes may or may not be
palpable on
initial detection of a cancerous
mass.
Nipple retraction — not eversion —
may be a
sign of cancer.
48. Answer:
(C) Radiation
Rationale:
The usual treatment for vaginal
cancer is
external or intravaginal radiation
therapy.
Less often, surgery is performed.
Chemotherapy
typically is prescribed only if
vaginal
cancer is diagnosed in an early stage,
which is
rare. Immunotherapy isn't used to
treat
vaginal cancer.
49. Answer:
(B) Carcinoma in situ, no abnormal
regional
lymph nodes, and no evidence of
distant
metastasis
Rationale:
TIS, N0, M0 denotes carcinoma in
situ, no
abnormal regional lymph nodes, and
no evidence
of distant metastasis. No
evidence of
primary tumor, no abnormal
regional
lymph nodes, and no evidence of
distant
metastasis is classified as T0, N0, M0. If
the tumor
and regional lymph nodes can't be
assessed
and no evidence of metastasis exists,
the lesion
is classified as TX, NX, M0. A
progressive
increase in tumor size, no
demonstrable
metastasis of the regional
lymph
nodes, and ascending degrees of
distant
metastasis is classified as T1, T2, T3, or
T4; N0; and M1, M2, or M3.
50. Answer:
(D) "Keep the stoma moist."
Rationale:
The nurse should instruct the client
to keep the
stoma moist, such as by applying a
thin layer
of petroleum jelly around the edges,
because a
dry stoma may become irritated.
The nurse
should recommend placing a stoma
bib over
the stoma to filter and warm air
before it
enters the stoma. The client should
begin
performing stoma care without
assistance
as soon as possible to gain
independence
in self-care activities.
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