TEST IV - Care of Clients with Physiologic and Psychosocial Alterations part 2

TEST IV - Care of Clients with Physiologic and

Psychosocial Alterations part 2

51. Stacy’s mother states to the nurse that it is hard

to see Stacy with no hair. The best response for

the nurse is:

a. “Stacy looks very nice wearing a hat”.

b. “You should not worry about her hair,

just be glad that she is alive”.

c. “Yes it is upsetting. But try to cover up

your feelings when you are with her or

else she may be upset”.

d. “This is only temporary; Stacy will regrow

new hair in 3-6 months, but may

be different in texture”.

52. Stacy has beginning stomatitis. To promote oral

hygiene and comfort, the nurse in-charge

should:

a. Provide frequent mouthwash with

normal saline.

b. Apply viscous Lidocaine to oral ulcers as

needed.

c. Use lemon glycerine swabs every 2

hours.

d. Rinse mouth with Hydrogen Peroxide.

53. During the administration of chemotherapy

agents, Nurse Oliver observed that the IV site is

red and swollen, when the IV is touched Stacy

shouts in pain. The first nursing action to take is:

a. Notify the physician

b. Flush the IV line with saline solution

c. Immediately discontinue the infusion

d. Apply an ice pack to the site, followed by

warm compress.

54. The term “blue bloater” refers to a male client

which of the following conditions?

a. Adult respiratory distress syndrome

(ARDS)

b. Asthma

c. Chronic obstructive bronchitis

d. Emphysema

55. The term “pink puffer” refers to the female

client with which of the following conditions?

a. Adult respiratory distress syndrome

(ARDS)

b. Asthma

c. Chronic obstructive bronchitis

d. Emphysema

56. Jose is in danger of respiratory arrest following

the administration of a narcotic analgesic. An

arterial blood gas value is obtained. Nurse Oliver

would expect the paco2 to be which of the

following values?

a. 15 mm Hg

b. 30 mm Hg

c. 40 mm Hg

d. 80 mm Hg

57. Timothy’s arterial blood gas (ABG) results are as

follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm

Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result

represents which of the following conditions?

a. Metabolic acidosis

b. Metabolic alkalosis

c. Respiratory acidosis

d. Respiratory alkalosis

58. Norma has started a new drug for hypertension.

Thirty minutes after she takes the drug, she

develops chest tightness and becomes short of

breath and tachypneic. She has a decreased level

of consciousness. These signs indicate which of

the following conditions?

a. Asthma attack

b. Pulmonary embolism

c. Respiratory failure

d. Rheumatoid arthritis

Situation: Mr. Gonzales was admitted to the hospital

with ascites and jaundice. To rule out cirrhosis of the

liver:

59. Which laboratory test indicates liver cirrhosis?

a. Decreased red blood cell count

b. Decreased serum acid phosphate level

c. Elevated white blood cell count

d. Elevated serum aminotransferase                             

60. 60.The biopsy of Mr. Gonzales confirms the

diagnosis of cirrhosis. Mr. Gonzales is at

increased risk for excessive bleeding primarily

because of:

a. Impaired clotting mechanism

b. Varix formation

c. Inadequate nutrition

d. Trauma of invasive procedure

61. Mr. Gonzales develops hepatic encephalopathy.

Which clinical manifestation is most common

with this condition?

a. Increased urine output

b. Altered level of consciousness

c. Decreased tendon reflex

d. Hypotension

62. When Mr. Gonzales regained consciousness, the

physician orders 50 ml of Lactose p.o. every 2

hours. Mr. Gozales develops diarrhea. The nurse

best action would be:

a. “I’ll see if your physician is in the

hospital”.

b. “Maybe you’re reacting to the drug; I

will withhold the next dose”.

c. “I’ll lower the dosage as ordered so the

drug causes only 2 to 4 stools a day”.

d. “Frequently, bowel movements are

needed to reduce sodium level”.                    

63. Which of the following groups of symptoms

indicates a ruptured abdominal aortic

aneurysm?

a. Lower back pain, increased blood

pressure, decreased red blood cell (RBC)

count, increased white blood (WBC)

count.

b. Severe lower back pain, decreased blood

pressure, decreased RBC count,

increased WBC count.

c. Severe lower back pain, decreased blood

pressure, decreased RBC count,

decreased RBC count, decreased WBC

count.

d. Intermitted lower back pain, decreased

blood pressure, decreased RBC count,

increased WBC count.

64. After undergoing a cardiac catheterization, Tracy

has a large puddle of blood under his buttocks.

Which of the following steps should the nurse

take first?

a. Call for help.

b. Obtain vital signs

c. Ask the client to “lift up”

d. Apply gloves and assess the groin site

65. Which of the following treatment is a suitable

surgical intervention for a client with unstable

angina?

a. Cardiac catheterization

b. Echocardiogram

c. Nitroglycerin

d. Percutaneous transluminal coronary

angioplasty (PTCA)

66. The nurse is aware that the following terms used

to describe reduced cardiac output and

perfusion impairment due to ineffective

pumping of the heart is:

a. Anaphylactic shock

b. Cardiogenic shock

c. Distributive shock

d. Myocardial infarction (MI)

67. A client with hypertension asks the nurse which

factors can cause blood pressure to drop to

normal levels?

a. Kidneys’ excretion to sodium only.

b. Kidneys’ retention of sodium and water

c. Kidneys’ excretion of sodium and water

d. Kidneys’ retention of sodium and

excretion of water

68. Nurse Rose is aware that the statement that

best explains why furosemide (Lasix) is

administered to treat hypertension is:

a. It dilates peripheral blood vessels.

b. It decreases sympathetic

cardioacceleration.

c. It inhibits the angiotensin-coverting

enzymes

d. It inhibits reabsorption of sodium and

water in the loop of Henle.

69. Nurse Nikki knows that laboratory results

supports the diagnosis of systemic lupus

erythematosus (SLE) is:

a. Elavated serum complement level

b. Thrombocytosis, elevated sedimentation

rate

c. Pancytopenia, elevated antinuclear

antibody (ANA) titer

d. Leukocysis, elevated blood urea nitrogen

(BUN) and creatinine levels

70. Arnold, a 19-year-old client with a mild

concussion is discharged from the emergency

department. Before discharge, he complains of a

headache. When offered acetaminophen, his

mother tells the nurse the headache is severe

and she would like her son to have something

stronger. Which of the following responses by

the nurse is appropriate?

a. “Your son had a mild concussion,

acetaminophen is strong enough.”

b. “Aspirin is avoided because of the

danger of Reye’s syndrome in children or

young adults.”

c. “Narcotics are avoided after a head

injury because they may hide a

worsening condition.”

d. Stronger medications may lead to

vomiting, which increases the

intracarnial pressure (ICP).”

71. When evaluating an arterial blood gas from a

male client with a subdural hematoma, the

nurse notes the Paco2 is 30 mm Hg. Which of

the following responses best describes the

result?

a. Appropriate; lowering carbon dioxide

(CO2) reduces intracranial pressure (ICP)

b. Emergent; the client is poorly

oxygenated

c. Normal

d. Significant; the client has alveolar

hypoventilation

72. When prioritizing care, which of the following

clients should the nurse Olivia assess first?

a. A 17-year-old client’s 24-hours

postappendectomy

b. A 33-year-old client with a recent

diagnosis of Guillain-Barre syndrome

c. A 50-year-old client 3 days

postmyocardial infarction

d. A 50-year-old client with diverticulitis

73. JP has been diagnosed with gout and wants to

know why colchicine is used in the treatment of

gout. Which of the following actions of

colchicines explains why it’s effective for gout?

a. Replaces estrogen

b. Decreases infection

c. Decreases inflammation

d. Decreases bone demineralization                              

74. Norma asks for information about osteoarthritis.

Which of the following statements about

osteoarthritis is correct?

a. Osteoarthritis is rarely debilitating

b. Osteoarthritis is a rare form of arthritis

c. Osteoarthritis is the most common form

of arthritis

d. Osteoarthritis afflicts people over 60

75. Ruby is receiving thyroid replacement therapy

develops the flu and forgets to take her thyroid

replacement medicine. The nurse understands

that skipping this medication will put the client

at risk for developing which of the following lifethreatening

complications?

a. Exophthalmos

b. Thyroid storm

c. Myxedema coma

d. Tibial myxedema

76. Nurse Sugar is assessing a client with Cushing's

syndrome. Which observation should the nurse

report to the physician immediately?

a. Pitting edema of the legs

b. An irregular apical pulse

c. Dry mucous membranes

d. Frequent urination

77. Cyrill with severe head trauma sustained in a car

accident is admitted to the intensive care unit.

Thirty-six hours later, the client's urine output

suddenly rises above 200 ml/hour, leading the

nurse to suspect diabetes insipidus. Which

laboratory findings support the nurse's suspicion

of diabetes insipidus?

a. Above-normal urine and serum

osmolality levels

b. Below-normal urine and serum

osmolality levels

c. Above-normal urine osmolality level,

below-normal serum osmolality level

d. Below-normal urine osmolality level,

above-normal serum osmolality level

78. Jomari is diagnosed with hyperosmolar

hyperglycemic nonketotic syndrome (HHNS) is

stabilized and prepared for discharge. When

preparing the client for discharge and home

management, which of the following statements

indicates that the client understands her

condition and how to control it?

a. "I can avoid getting sick by not becoming

dehydrated and by paying attention to

my need to urinate, drink, or eat more

than usual."

b. "If I experience trembling, weakness,

and headache, I should drink a glass of

soda that contains sugar."

c. "I will have to monitor my blood glucose

level closely and notify the physician if

it's constantly elevated."

d. "If I begin to feel especially hungry and

thirsty, I'll eat a snack high in

carbohydrates."

79. A 66-year-old client has been complaining of

sleeping more, increased urination, anorexia,

weakness, irritability, depression, and bone pain

that interferes with her going outdoors. Based

on these assessment findings, the nurse would

suspect which of the following disorders?

a. Diabetes mellitus

b. Diabetes insipidus

c. Hypoparathyroidism

d. Hyperparathyroidism                 

80. Nurse Lourdes is teaching a client recovering

from addisonian crisis about the need to take

fludrocortisone acetate and hydrocortisone at

home. Which statement by the client indicates

an understanding of the instructions?

a. "I'll take my hydrocortisone in the late

afternoon, before dinner."

b. "I'll take all of my hydrocortisone in the

morning, right after I wake up."

c. "I'll take two-thirds of the dose when I

wake up and one-third in the late

afternoon."

d. "I'll take the entire dose at bedtime."

81. Which of the following laboratory test results

would suggest to the nurse Len that a client has

a corticotropin-secreting pituitary adenoma?

a. High corticotropin and low cortisol levels

b. Low corticotropin and high cortisol levels

c. High corticotropin and high cortisol

levels

d. Low corticotropin and low cortisol levels

82. A male client is scheduled for a transsphenoidal

hypophysectomy to remove a pituitary tumor.

Preoperatively, the nurse should assess for

potential complications by doing which of the

following?

a. Testing for ketones in the urine

b. Testing urine specific gravity

c. Checking temperature every 4 hours

d. Performing capillary glucose testing

every 4 hours

83. Capillary glucose monitoring is being performed

every 4 hours for a client diagnosed with

diabetic ketoacidosis. Insulin is administered

using a scale of regular insulin according to

glucose results. At 2 p.m., the client has a

capillary glucose level of 250 mg/dl for which he

receives 8 U of regular insulin. Nurse Mariner

should expect the dose's:

a. onset to be at 2 p.m. and its peak to be

at 3 p.m.

b. onset to be at 2:15 p.m. and its peak to

be at 3 p.m.

c. onset to be at 2:30 p.m. and its peak to

be at 4 p.m.

d. onset to be at 4 p.m. and its peak to be

at 6 p.m.

84. The physician orders laboratory tests to confirm

hyperthyroidism in a female client with classic

signs and symptoms of this disorder. Which test

result would confirm the diagnosis?

a. No increase in the thyroid-stimulating

hormone (TSH) level after 30 minutes

during the TSH stimulation test

b. A decreased TSH level

c. An increase in the TSH level after 30

minutes during the TSH stimulation test

d. Below-normal levels of serum

triiodothyronine (T3) and serum

thyroxine (T4) as detected by

radioimmunoassay

85. Rico with diabetes mellitus must learn how to

self-administer insulin. The physician has

prescribed 10 U of U-100 regular insulin and 35

U of U-100 isophane insulin suspension (NPH) to

be taken before breakfast. When teaching the

client how to select and rotate insulin injection

sites, the nurse should provide which

instruction?

a. "Inject insulin into healthy tissue with

large blood vessels and nerves."

b. "Rotate injection sites within the same

anatomic region, not among different

regions."

c. "Administer insulin into areas of scar

tissue or hypotrophy whenever

possible."

d. "Administer insulin into sites above

muscles that you plan to exercise heavily

later that day."

86. Nurse Sarah expects to note an elevated serum

glucose level in a client with hyperosmolar

hyperglycemic nonketotic syndrome (HHNS).

Which other laboratory finding should the nurse

anticipate?

a. Elevated serum acetone level

b. Serum ketone bodies

c. Serum alkalosis

d. Below-normal serum potassium level                       

87. For a client with Graves' disease, which nursing

intervention promotes comfort?

a. Restricting intake of oral fluids

b. Placing extra blankets on the client's bed

c. Limiting intake of high-carbohydrate

foods

d. Maintaining room temperature in the

low-normal range

88. Patrick is treated in the emergency department

for a Colles' fracture sustained during a fall.

What is a Colles' fracture?

a. Fracture of the distal radius

b. Fracture of the olecranon

c. Fracture of the humerus

d. Fracture of the carpal scaphoid

89. Cleo is diagnosed with osteoporosis. Which

electrolytes are involved in the development of

this disorder?

a. Calcium and sodium

b. Calcium and phosphorous

c. Phosphorous and potassium

d. Potassium and sodium                            

90. Johnny a firefighter was involved in

extinguishing a house fire and is being treated to

smoke inhalation. He develops severe hypoxia

48 hours after the incident, requiring intubation

and mechanical ventilation. He most likely has

developed which of the following conditions?

a. Adult respiratory distress syndrome

(ARDS)

b. Atelectasis

c. Bronchitis

d. Pneumonia

91. A 67-year-old client develops acute shortness of

breath and progressive hypoxia requiring right

femur. The hypoxia was probably caused by

which of the following conditions?

a. Asthma attack

b. Atelectasis

c. Bronchitis

d. Fat embolism

92. A client with shortness of breath has decreased

to absent breath sounds on the right side, from

the apex to the base. Which of the following

conditions would best explain this?

a. Acute asthma

b. Chronic bronchitis

c. Pneumonia

d. Spontaneous pneumothorax

93. A 62-year-old male client was in a motor vehicle

accident as an unrestrained driver. He’s now in

the emergency department complaining of

difficulty of breathing and chest pain. On

auscultation of his lung field, no breath sounds

are present in the upper lobe. This client may

have which of the following conditions?

a. Bronchitis

b. Pneumonia

c. Pneumothorax

d. Tuberculosis (TB)         

94. If a client requires a pneumonectomy, what fills

the area of the thoracic cavity?

a. The space remains filled with air only

b. The surgeon fills the space with a gel

c. Serous fluids fills the space and

consolidates the region

d. The tissue from the other lung grows

over to the other side           

95. Hemoptysis may be present in the client with a

pulmonary embolism because of which of the

following reasons?

a. Alveolar damage in the infracted area

b. Involvement of major blood vessels in

the occluded area

c. Loss of lung parenchyma

d. Loss of lung tissue

96. Aldo with a massive pulmonary embolism will

have an arterial blood gas analysis performed to

determine the extent of hypoxia. The acid-base

disorder that may be present is?

a. Metabolic acidosis

b. Metabolic alkalosis

c. Respiratory acidosis

d. Respiratory alkalosis          

97. After a motor vehicle accident, Armand an 22-

year-old client is admitted with a pneumothorax.

The surgeon inserts a chest tube and attaches it

to a chest drainage system. Bubbling soon

appears in the water seal chamber. Which of the

following is the most likely cause of the

bubbling?

a. Air leak

b. Adequate suction

c. Inadequate suction

d. Kinked chest tube

98. Nurse Michelle calculates the IV flow rate for a

postoperative client. The client receives 3,000 ml

of Ringer’s lactate solution IV to run over 24

hours. The IV infusion set has a drop factor of 10

drops per milliliter. The nurse should regulate

the client’s IV to deliver how many drops per

minute?

a. 18

b. 21

c. 35

d. 40

99. Mickey, a 6-year-old child with a congenital

heart disorder is admitted with congestive heart

failure. Digoxin (lanoxin) 0.12 mg is ordered for

the child. The bottle of Lanoxin contains .05 mg

of Lanoxin in 1 ml of solution. What amount

should the nurse administer to the child?

a. 1.2 ml

b. 2.4 ml

c. 3.5 ml

d. 4.2 ml

100. Nurse Alexandra teaches a client about elastic

stockings. Which of the following statements,

if made by the client, indicates to the nurse

that the teaching was successful?

a. “I will wear the stockings until the

physician tells me to remove them.”

b. “I should wear the stockings even when I

am sleep.”

c. “Every four hours I should remove the

stockings for a half hour.”

d. “I should put on the stockings before

getting out of bed in the morning.”