TEST III - Care of Clients with Physiologic and Psychosocial Alterations part 1

TEST III - Care of Clients with Physiologic and

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."