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Tuesday, July 30, 2013

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.

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