Answers and Rationale – TEST III Care of Clients with Physiologic and Psychosocial Alterations part 1

Answers and Rationale – TEST III Care of Clients with Physiologic and

Psychosocial Alterations part 1

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

105

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.