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Thursday, August 1, 2013

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.”

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