Psychosocial Alterations part 1
1. Nurse
Michelle should know that the drainage is
normal 4
days after a sigmoid colostomy when
the stool
is:
a. Green
liquid
b. Solid
formed
c. Loose,
bloody
d.
Semiformed
2. Where
would nurse Kristine place the call light
for a male
client with a right-sided brain attack
and left
homonymous hemianopsia?
a. On the
client’s right side
b. On the
client’s left side
c. Directly
in front of the client
d. Where the client like
3. A male
client is admitted to the emergency
department
following an accident. What are the
first
nursing actions of the nurse?
a. Check
respiration, circulation,
neurological
response.
b. Align
the spine, check pupils, and check
for
hemorrhage.
c. Check
respirations, stabilize spine, and
check circulation.
d. Assess
level of consciousness and
circulation.
4. In
evaluating the effect of nitroglycerin, Nurse
Arthur
should know that it reduces preload and
relieves
angina by:
a.
Increasing contractility and slowing
heart rate.
b.
Increasing AV conduction and heart rate.
c.
Decreasing contractility and oxygen
consumption.
d.
Decreasing venous return through
vasodilation.
5. Nurse
Patricia finds a female client who is postmyocardial
infarction
(MI) slumped on the side
rails of
the bed and unresponsive to shaking or
shouting.
Which is the nurse next action?
a. Call for
help and note the time.
b. Clear
the airway
c. Give two
sharp thumps to the
precordium,
and check the pulse.
d.
Administer two quick blows.
6. Nurse
Monett is caring for a client recovering
from
gastro-intestinal bleeding. The nurse
should:
a. Plan
care so the client can receive 8
hours of
uninterrupted sleep each night.
b. Monitor
vital signs every 2 hours.
c. Make
sure that the client takes food and
medications
at prescribed intervals.
d. Provide
milk every 2 to 3 hours.
7. A male
client was on warfarin (Coumadin) before
admission,
and has been receiving heparin I.V.
for 2 days.
The partial thromboplastin time (PTT)
is 68
seconds. What should Nurse Carla do?
a. Stop the
I.V. infusion of heparin and
notify the
physician.
b. Continue
treatment as ordered.
c. Expect
the warfarin to increase the PTT.
d. Increase
the dosage, because the level is
lower than
normal.
8. A client
undergone ileostomy, when should the
drainage
appliance be applied to the stoma?
a. 24 hours
later, when edema has
subsided.
b. In the
operating room.
c. After
the ileostomy begin to function.
d. When the
client is able to begin self-care
procedures.
9. A client
undergone spinal anesthetic, it will be
important
that the nurse immediately position
the client
in:
a. On the
side, to prevent obstruction of
airway by
tongue.
b. Flat on
back.
c. On the
back, with knees flexed 15
degrees.
d. Flat on
the stomach, with the head
turned to
the side.
10. While
monitoring a male client several hours
after a
motor vehicle accident, which
assessment
data suggest increasing intracranial
pressure?
a. Blood
pressure is decreased from
160/90 to
110/70.
b. Pulse is
increased from 87 to 95, with an
occasional
skipped beat.
c. The
client is oriented when aroused
from sleep,
and goes back to sleep
immediately.
d. The
client refuses dinner because of
anorexia.
11. Mrs.
Cruz, 80 years old is diagnosed with
pneumonia.
Which of the following symptoms
may appear
first?
a. Altered
mental status and dehydration
b. Fever
and chills
c.
Hemoptysis and Dyspnea
d.
Pleuritic chest pain and cough
12. A male
client has active tuberculosis (TB). Which
of the
following symptoms will be exhibit?
a. Chest
and lower back pain
b. Chills,
fever, night sweats, and
hemoptysis
c. Fever of
more than 104°F (40°C) and
nausea
d. Headache
and photophobia
13. Mark, a
7-year-old client is brought to the
emergency
department. He’s tachypneic and
afebrile
and has a respiratory rate of 36
breaths/minute
and has a nonproductive cough.
He recently
had a cold. Form this history; the
client may
have which of the following
conditions?
a. Acute
asthma
b.
Bronchial pneumonia
c. Chronic
obstructive pulmonary disease
(COPD)
d.
Emphysema
14. Marichu
was given morphine sulfate for pain.
She is
sleeping and her respiratory rate is 4
breaths/minute.
If action isn’t taken quickly, she
might have
which of the following reactions?
a. Asthma
attack
b.
Respiratory arrest
c. Seizure
d. Wake up
on his own
15. A
77-year-old male client is admitted for elective
knee
surgery. Physical examination reveals
shallow
respirations but no sign of respiratory
distress.
Which of the following is a normal
physiologic
change related to aging?
a.
Increased elastic recoil of the lungs
b.
Increased number of functional
capillaries
in the alveoli
c.
Decreased residual volume
d.
Decreased vital capacity
16. Nurse
John is caring for a male client receiving
lidocaine
I.V. Which factor is the most relevant
to
administration of this medication?
a. Decrease
in arterial oxygen saturation
(SaO2) when
measured with a pulse
oximeter.
b. Increase
in systemic blood pressure.
c. Presence
of premature ventricular
contractions
(PVCs) on a cardiac
monitor.
d. Increase
in intracranial pressure (ICP).
17. Nurse
Ron is caring for a male client taking an
anticoagulant.
The nurse should teach the client
to:
a. Report
incidents of diarrhea.
b. Avoid
foods high in vitamin K
c. Use a
straight razor when shaving.
d. Take
aspirin to pain relief.
18. Nurse
Lhynnette is preparing a site for the
insertion
of an I.V. catheter. The nurse should
treat
excess hair at the site by:
a. Leaving
the hair intact
b. Shaving
the area
c. Clipping
the hair in the area
d. Removing
the hair with a depilatory.
19. Nurse
Michelle is caring for an elderly female
with
osteoporosis. When teaching the client, the
nurse
should include information about which
major
complication:
a. Bone
fracture
b. Loss of
estrogen
c. Negative
calcium balance
d. Dowager’s
hump
20. Nurse
Len is teaching a group of women to
perform
BSE. The nurse should explain that the
purpose of
performing the examination is to
discover:
a.
Cancerous lumps
b. Areas of
thickness or fullness
c. Changes
from previous examinations.
d. Fibrocystic masses
21. When
caring for a female client who is being
treated for
hyperthyroidism, it is important to:
a. Provide
extra blankets and clothing to
keep the
client warm.
b. Monitor
the client for signs of
restlessness,
sweating, and excessive
weight loss
during thyroid replacement
therapy.
c. Balance
the client’s periods of activity
and rest.
d.
Encourage the client to be active to
prevent constipation.
22. Nurse
Kris is teaching a client with history of
atherosclerosis.
To decrease the risk of
atherosclerosis,
the nurse should encourage the
client to:
a. Avoid
focusing on his weight.
b. Increase
his activity level.
c. Follow a
regular diet.
d. Continue
leading a high-stress lifestyle.
23. Nurse
Greta is working on a surgical floor. Nurse
Greta must
logroll a client following a:
a.
Laminectomy
b.
Thoracotomy
c.
Hemorrhoidectomy
d. Cystectomy.
24. A
55-year old client underwent cataract removal
with
intraocular lens implant. Nurse Oliver is
giving the
client discharge instructions. These
instructions
should include which of the
following?
a. Avoid
lifting objects weighing more than
5 lb (2.25
kg).
b. Lie on
your abdomen when in bed
c. Keep
rooms brightly lit.
d. Avoiding
straining during bowel
movement or
bending at the waist.
25. George
should be taught about testicular
examinations
during:
a. when
sexual activity starts
b. After
age 69
c. After
age 40
d. Before
age 20.
26. A male
client undergone a colon resection. While
turning
him, wound dehiscence with
evisceration
occurs. Nurse Trish first response is
to:
a. Call the
physician
b. Place a
saline-soaked sterile dressing on
the wound.
c. Take a
blood pressure and pulse.
d. Pull the
dehiscence closed.
27. Nurse
Audrey is caring for a client who has
suffered a
severe cerebrovascular accident.
During
routine assessment, the nurse notices
Cheyne-
Strokes respirations. Cheyne-strokes
respirations
are:
a. A
progressively deeper breaths followed
by
shallower breaths with apneic
periods.
b. Rapid,
deep breathing with abrupt
pauses
between each breath.
c. Rapid,
deep breathing and irregular
breathing
without pauses.
d. Shallow
breathing with an increased
respiratory
rate.
28. Nurse
Bea is assessing a male client with heart
failure.
The breath sounds commonly
auscultated
in clients with heart failure are:
a. Tracheal
b. Fine
crackles
c. Coarse
crackles
d. Friction
rubs
29. The
nurse is caring for Kenneth experiencing an
acute
asthma attack. The client stops wheezing
and breath
sounds aren’t audible. The reason for
this change
is that:
a. The
attack is over.
b. The
airways are so swollen that no air
cannot get
through.
c. The
swelling has decreased.
d. Crackles
have replaced wheezes.
30. Mike
with epilepsy is having a seizure. During
the active
seizure phase, the nurse should:
a. Place
the client on his back remove
dangerous
objects, and insert a bite
block.
b. Place
the client on his side, remove
dangerous
objects, and insert a bite
block.
c. Place
the client o his back, remove
dangerous
objects, and hold down his
arms.
d. Place
the client on his side, remove
dangerous
objects, and protect his head.
31. After
insertion of a cheat tube for a
pneumothorax,
a client becomes hypotensive
with neck
vein distention, tracheal shift, absent
breath
sounds, and diaphoresis. Nurse Amanda
suspects a
tension pneumothorax has occurred.
What cause
of tension pneumothorax should the
nurse check
for?
a.
Infection of the lung.
b. Kinked
or obstructed chest tube
c.
Excessive water in the water-seal
chamber
d.
Excessive chest tube drainage
32. Nurse
Maureen is talking to a male client; the
client
begins choking on his lunch. He’s coughing
forcefully.
The nurse should:
a. Stand
him up and perform the
abdominal
thrust maneuver from
behind.
b. Lay him
down, straddle him, and
perform the
abdominal thrust
maneuver.
c. Leave
him to get assistance
d. Stay
with him but not intervene at this
time.
33. Nurse
Ron is taking a health history of an 84 year
old client.
Which information will be most useful
to the
nurse for planning care?
a. General
health for the last 10 years.
b. Current
health promotion activities.
c. Family
history of diseases.
d. Marital
status.
34. When
performing oral care on a comatose client,
Nurse Krina
should:
a. Apply
lemon glycerin to the client’s lips
at least
every 2 hours.
b. Brush
the teeth with client lying supine.
c. Place
the client in a side lying position,
with the
head of the bed lowered.
d. Clean
the client’s mouth with hydrogen
peroxide.
35. A
77-year-old male client is admitted with a
diagnosis
of dehydration and change in mental
status. He’s
being hydrated with L.V. fluids.
When the
nurse takes his vital signs, she notes
he has a
fever of 103°F (39.4°C) a cough
producing
yellow sputum and pleuritic chest
pain. The
nurse suspects this client may have
which of
the following conditions?
a. Adult
respiratory distress syndrome
(ARDS)
b.
Myocardial infarction (MI)
c.
Pneumonia
d.
Tuberculosis
36. Nurse
Oliver is working in an outpatient clinic.
He has been
alerted that there is an outbreak of
tuberculosis
(TB). Which of the following clients
entering
the clinic today most likely to have TB?
a. A
16-year-old female high school
student
b. A
33-year-old day-care worker
c. A
43-yesr-old homeless man with a
history of
alcoholism
d. A
54-year-old businessman
37. Virgie
with a positive Mantoux test result will be
sent for a
chest X-ray. The nurse is aware that
which of
the following reasons this is done?
a. To
confirm the diagnosis
b. To
determine if a repeat skin test is
needed
c. To
determine the extent of lesions
d. To
determine if this is a primary or
secondary
infection
38. Kennedy
with acute asthma showing inspiratory
and
expiratory wheezes and a decreased forced
expiratory
volume should be treated with which
of the
following classes of medication right
away?
a.
Beta-adrenergic blockers
b.
Bronchodilators
c. Inhaled
steroids
d. Oral
steroids
39. Mr.
Vasquez 56-year-old client with a 40-year
history of
smoking one to two packs of cigarettes
per day has
a chronic cough producing thick
sputum,
peripheral edema and cyanotic nail
beds. Based
on this information, he most likely
has which
of the following conditions?
a. Adult
respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic
obstructive bronchitis
d.
Emphysema
Situation:
Francis, age 46 is admitted to the hospital with
diagnosis
of Chronic Lymphocytic Leukemia.
40. The
treatment for patients with leukemia is bone
marrow
transplantation. Which statement about
bone marrow
transplantation is not correct?
a. The
patient is under local anesthesia
during the
procedure
b. The
aspirated bone marrow is mixed
with
heparin.
c. The
aspiration site is the posterior or
anterior
iliac crest.
d. The
recipient receives
cyclophosphamide
(Cytoxan) for 4
consecutive
days before the procedure.
41. After
several days of admission, Francis becomes
disoriented
and complains of frequent
headaches.
The nurse in-charge first action
would be:
a. Call the
physician
b. Document
the patient’s status in his
charts.
c. Prepare
oxygen treatment
d. Raise the side rails
42. During
routine care, Francis asks the nurse,
“How can I
be anemic if this disease causes
increased
my white blood cell production?” The
nurse
in-charge best response would be that the
increased
number of white blood cells (WBC) is:
a. Crowd
red blood cells
b. Are not
responsible for the anemia.
c. Uses
nutrients from other cells
d. Have an
abnormally short life span of
cells.
43.
Diagnostic assessment of Francis would probably
not reveal:
a. Predominance
of lymhoblasts
b.
Leukocytosis
c. Abnormal
blast cells in the bone marrow
d. Elevated thrombocyte counts
44. Robert,
a 57-year-old client with acute arterial
occlusion
of the left leg undergoes an
emergency
embolectomy. Six hours later, the
nurse isn’t
able to obtain pulses in his left foot
using
Doppler ultrasound. The nurse
immediately
notifies the physician, and asks her
to prepare
the client for surgery. As the nurse
enters the
client’s room to prepare him, he
states that
he won’t have any more surgery.
Which of
the following is the best initial
response by
the nurse?
a. Explain
the risks of not having the
surgery
b.
Notifying the physician immediately
c.
Notifying the nursing supervisor
d.
Recording the client’s refusal in the
nurses’
notes
45. During
the endorsement, which of the following
clients
should the on-duty nurse assess first?
a. The
58-year-old client who was admitted
2 days ago
with heart failure, blood
pressure of
126/76 mm Hg, and a
respiratory
rate of 22 breaths/ minute.
b. The
89-year-old client with end-stage
right-sided
heart failure, blood pressure
of 78/50 mm
Hg, and a “do not
resuscitate”
order
c. The
62-year-old client who was admitted
1 day ago
with thrombophlebitis and is
receiving
L.V. heparin
d. The
75-year-old client who was admitted
1 hour ago
with new-onset atrial
fibrillation
and is receiving L.V. dilitiazem
(Cardizem)
46. Honey,
a 23-year old client complains of
substernal
chest pain and states that her heart
feels like “it’s
racing out of the chest”. She
reports no
history of cardiac disorders. The
nurse
attaches her to a cardiac monitor and
notes sinus
tachycardia with a rate of
136beats/minutes.
Breath sounds are clear and
the
respiratory rate is 26 breaths/minutes.
Which of
the following drugs should the nurse
question
the client about using?
a.
Barbiturates
b. Opioids
c. Cocaine
d.
Benzodiazepines
47. A
51-year-old female client tells the nurse incharge
that she
has found a painless lump in her
right
breast during her monthly selfexamination.
Which
assessment finding would
strongly
suggest that this client's lump is
cancerous?
a. Eversion
of the right nipple and mobile
mass
b.
Nonmobile mass with irregular edges
c. Mobile
mass that is soft and easily
delineated
d.
Nonpalpable right axillary lymph nodes
48. A
35-year-old client with vaginal cancer asks the
nurse,
"What is the usual treatment for this type
of
cancer?" Which treatment should the nurse
name?
a. Surgery
b.
Chemotherapy
c.
Radiation
d.
Immunotherapy
49.
Cristina undergoes a biopsy of a suspicious
lesion. The
biopsy report classifies the lesion
according
to the TNM staging system as follows:
TIS, N0,
M0. What does this classification mean?
a. No
evidence of primary tumor, no
abnormal
regional lymph nodes, and no
evidence of
distant metastasis
b.
Carcinoma in situ, no abnormal regional
lymph
nodes, and no evidence of distant
metastasis
c. Can't
assess tumor or regional lymph
nodes and
no evidence of metastasis
d.
Carcinoma in situ, no demonstrable
metastasis
of the regional lymph nodes,
and
ascending degrees of distant
metastasis
50. Lydia
undergoes a laryngectomy to treat
laryngeal
cancer. When teaching the client how
to care for
the neck stoma, the nurse should
include
which instruction?
a.
"Keep the stoma uncovered."
b.
"Keep the stoma dry."
c.
"Have a family member perform stoma
care
initially until you get used to the
procedure."
d.
"Keep the stoma moist."
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