51. Answer:
(D) “This is only temporary; Stacy
will
re-grow new hair in 3-6 months, but
may be
different in texture”.
Rationale:
This is the appropriate
response.
The nurse should help the
mother how
to cope with her own feelings
regarding
the child’s disease so as not to
affect the
child negatively. When the hair
grows back,
it is still of the same color and
texture.
52. Answer:
(B) Apply viscous Lidocaine to
oral ulcers
as needed.
Rationale:
Stomatitis can cause pain and
this can be
relieved by applying topical
anesthetics
such as lidocaine before
mouth care.
When the patient is already
comfortable,
the nurse can proceed with
providing
the patient with oral rinses of
saline
solution mixed with equal part of
water or
hydrogen peroxide mixed water
in 1:3
concentrations to promote oral
hygiene.
Every 2-4 hours.
53. Answer:
(C) Immediately discontinue the
infusion
Rationale:
Edema or swelling at the IV site
is a sign
that the needle has been
dislodged
and the IV solution is leaking
into the
tissues causing the edema. The
patient
feels pain as the nerves are
irritated
by pressure and the IV solution.
The first
action of the nurse would be to
discontinue
the infusion right away to
prevent
further edema and other
complication.
54. Answer:
(C) Chronic obstructive bronchitis
Rationale:
Clients with chronic obstructive
bronchitis
appear bloated; they have large
barrel
chest and peripheral edema,
cyanotic
nail beds, and at times,
circumoral
cyanosis. Clients with ARDS are
acutely
short of breath and frequently
need
intubation for mechanical ventilation
and large
amount of oxygen. Clients with
asthma don’t
exhibit characteristics of
chronic
disease, and clients with
emphysema
appear pink and cachectic.
55. Answer:
(D) Emphysema
Rationale:
Because of the large amount of
energy it
takes to breathe, clients with
emphysema
are usually cachectic. They’re
pink and
usually breathe through pursed
lips, hence
the term “puffer.” Clients with
ARDS are
usually acutely short of breath.
Clients
with asthma don’t have any
particular
characteristics, and clients with
chronic
obstructive bronchitis are bloated
and
cyanotic in appearance.
56. Answer:
D 80 mm Hg
Rationale:
A client about to go into
respiratory
arrest will have inefficient
ventilation
and will be retaining carbon
dioxide.
The value expected would be
around 80
mm Hg. All other values are
lower than
expected.
57. Answer:
(C) Respiratory acidosis
Rationale:
Because Paco2 is high at 80 mm
Hg and the
metabolic measure, HCO3- is
normal, the
client has respiratory acidosis.
The pH is
less than 7.35, academic, which
eliminates
metabolic and respiratory
alkalosis
as possibilities. If the HCO3- was
below 22
mEq/L the client would have
metabolic
acidosis.
58. Answer:
(C) Respiratory failure
Rationale:
The client was reacting to the
drug with
respiratory signs of impending
anaphylaxis,
which could lead to
eventually
respiratory failure. Although
the signs
are also related to an asthma
attack or a
pulmonary embolism, consider
the new
drug first. Rheumatoid arthritis
doesn’t
manifest these signs.
59. Answer:
(D) Elevated serum
aminotransferase
Rationale:
Hepatic cell death causes
release of
liver enzymes alanine
aminotransferase
(ALT), aspartate
aminotransferase
(AST) and lactate
dehydrogenase
(LDH) into the circulation.
Liver
cirrhosis is a chronic and irreversible
disease of the
liver characterized by
generalized
inflammation and fibrosis of
the liver
tissues.
60. Answer:
(A) Impaired clotting mechanism
Rationale:
Cirrhosis of the liver results in
decreased
Vitamin K absorption and
formation
of clotting factors resulting in
impaired
clotting mechanism.
61. Answer:
(B) Altered level of consciousness
Rationale:
Changes in behavior and level
of
consciousness are the first sins of
hepatic
encephalopathy. Hepatic
encephalopathy
is caused by liver failure
and
develops when the liver is unable to
convert
protein metabolic product
ammonia to
urea. This results in
accumulation
of ammonia and other toxic
in the
blood that damages the cells.
62. Answer:
(C) “I’ll lower the dosage as
ordered so
the drug causes only 2 to 4
stools a
day”.
Rationale:
Lactulose is given to a patients
with
hepatic encephalopathy to reduce
absorption
of ammonia in the intestines
by binding
with ammonia and promoting
more
frequent bowel movements. If the
patient
experience diarrhea, it indicates
over dosage
and the nurse must reduce
the amount
of medication given to the
patient.
The stool will be mashy or soft.
Lactulose
is also very sweet and may
cause
cramping and bloating.
63. Answer:
(B) Severe lower back pain,
decreased
blood pressure, decreased RBC
count,
increased WBC count.
Rationale:
Severe lower back pain
indicates
an aneurysm rupture, secondary
to pressure
being applied within the
abdominal
cavity. When ruptured occurs,
the pain is
constant because it can’t be
alleviated
until the aneurysm is repaired.
Blood
pressure decreases due to the loss
of blood.
After the aneurysm ruptures, the
vasculature
is interrupted and blood
volume is
lost, so blood pressure wouldn’t
increase.
For the same reason, the RBC
count is decreased
– not increased. The
WBC count
increases as cell migrate to the
site of
injury.
64. Answer:
(D) Apply gloves and assess the
groin site
Rationale:
Observing standard precautions
is the
first priority when dealing with any
blood
fluid. Assessment of the groin site is
the second
priority. This establishes where
the blood
is coming from and determines
how much
blood has been lost. The goal in
this
situation is to stop the bleeding. The
nurse would
call for help if it were
warranted
after the assessment of the
situation.
After determining the extent of
the
bleeding, vital signs assessment is
important.
The nurse should never move
the client,
in case a clot has formed.
Moving can
disturb the clot and cause
rebleeding.
65. Answer:
(D) Percutaneous transluminal
coronary
angioplasty (PTCA)
Rationale:
PTCA can alleviate the blockage
and restore
blood flow and oxygenation.
An
echocardiogram is a noninvasive
diagnosis
test. Nitroglycerin is an oral
sublingual
medication. Cardiac
catheterization
is a diagnostic tool – not a
treatment.
66. Answer:
(B) Cardiogenic shock
Rationale:
Cardiogenic shock is shock
related to
ineffective pumping of the
heart.
Anaphylactic shock results from an
allergic
reaction. Distributive shock results
from
changes in the intravascular volume
distribution
and is usually associated with
increased
cardiac output. MI isn’t a shock
state,
though a severe MI can lead to
shock.
67. Answer:
(C) Kidneys’ excretion of sodium
and water
Rationale:
The kidneys respond to rise in
blood
pressure by excreting sodium and
excess
water. This response ultimately
affects
sysmolic blood pressure by
regulating
blood volume. Sodium or water
retention
would only further increase
blood
pressure. Sodium and water travel
together
across the membrane in the
kidneys;
one can’t travel without the
other.
68. Answer:
(D) It inhibits reabsorption of
sodium and
water in the loop of Henle.
Rationale:
Furosemide is a loop diuretic
that
inhibits sodium and water
reabsorption
in the loop Henle, thereby
causing a
decrease in blood pressure.
Vasodilators
cause dilation of peripheral
blood
vessels, directly relaxing vascular
smooth
muscle and decreasing blood
pressure.
Adrenergic blockers decrease
sympathetic
cardioacceleration and
decrease
blood pressure. Angiotensinconverting
enzyme
inhibitors decrease
blood
pressure due to their action on
angiotensin.
69. Answer:
(C) Pancytopenia, elevated
antinuclear
antibody (ANA) titer
Rationale:
Laboratory findings for clients
with SLE
usually show pancytopenia,
elevated
ANA titer, and decreased serum
complement
levels. Clients may have
elevated
BUN and creatinine levels from
nephritis,
but the increase does not
indicate
SLE.
70. Answer:
(C) Narcotics are avoided after a
head injury
because they may hide a
worsening
condition.
Rationale:
Narcotics may mask changes in
the level
of consciousness that indicate
increased
ICP and shouldn’t
acetaminophen
is strong enough ignores
the mother’s
question and therefore isn’t
appropriate.
Aspirin is contraindicated in
conditions
that may have bleeding, such
as trauma,
and for children or young
adults with
viral illnesses due to the
danger of
Reye’s syndrome. Stronger
medications
may not necessarily lead to
vomiting
but will sedate the client,
thereby
masking changes in his level of
consciousness.
71. Answer:
(A) Appropriate; lowering carbon
dioxide
(CO2) reduces intracranial
pressure
(ICP)
Rationale:
A normal Paco2 value is 35 to
45 mm Hg
CO2 has vasodilating
properties;
therefore, lowering Paco2
through
hyperventilation will lower ICP
caused by
dilated cerebral vessels.
Oxygenation
is evaluated through Pao2
and oxygen
saturation. Alveolar
hypoventilation
would be reflected in an
increased
Paco2.
72. Answer:
(B) A 33-year-old client with a
recent
diagnosis of Guillain-Barre
syndrome
Rationale:
Guillain-Barre syndrome is
characterized
by ascending paralysis and
potential
respiratory failure. The order of
client
assessment should follow client
priorities,
with disorder of airways,
breathing,
and then circulation. There’s no
information
to suggest the postmyocardial
infarction
client has an arrhythmia or
other
complication. There’s no evidence
to suggest
hemorrhage or perforation for
the
remaining clients as a priority of care.
73. Answer:
(C) Decreases inflammation
Rationale:
Then action of colchicines is to
decrease
inflammation by reducing the
migration
of leukocytes to synovial fluid.
Colchicine
doesn’t replace estrogen,
decrease
infection, or decrease bone
demineralization.
74. Answer:
(C) Osteoarthritis is the most
common form
of arthritis
Rationale:
Osteoarthritis is the most
common form
of arthritis and can be
extremely
debilitating. It can afflict people
of any age,
although most are elderly.
75. Answer:
(C) Myxedema coma
Rationale:
Myxedema coma, severe
hypothyroidism,
is a life-threatening
condition
that may develop if thyroid
replacement
medication isn't taken.
Exophthalmos,
protrusion of the eyeballs,
is seen
with hyperthyroidism. Thyroid
storm is
life-threatening but is caused by
severe
hyperthyroidism. Tibial myxedema,
peripheral
mucinous edema involving the
lower leg,
is associated with
hypothyroidism
but isn't life-threatening.
76. Answer:
(B) An irregular apical pulse
Rationale:
Because Cushing's syndrome
causes
aldosterone overproduction, which
increases
urinary potassium loss, the
disorder
may lead to hypokalemia.
Therefore,
the nurse should immediately
report
signs and symptoms of
hypokalemia,
such as an irregular apical
pulse, to
the physician. Edema is an
expected
finding because aldosterone
overproduction
causes sodium and fluid
retention.
Dry mucous membranes and
frequent
urination signal dehydration,
which isn't
associated with Cushing's
syndrome.
77. Answer:
(D) Below-normal urine
osmolality
level, above-normal serum
osmolality
level
Rationale:
In diabetes insipidus, excessive
polyuria
causes dilute urine, resulting in a
below-normal
urine osmolality level. At
the same
time, polyuria depletes the body
of water,
causing dehydration that leads
to an
above-normal serum osmolality
level. For
the same reasons, diabetes
insipidus
doesn't cause above-normal
urine
osmolality or below-normal serum
osmolality
levels.
78. Answer:
(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."
Rationale:
Inadequate fluid intake during
hyperglycemic
episodes often leads to
HHNS. By
recognizing the signs of
hyperglycemia
(polyuria, polydipsia, and
polyphagia)
and increasing fluid intake,
the client
may prevent HHNS. Drinking a
glass of
nondiet soda would be
appropriate
for hypoglycemia. A client
whose diabetes
is controlled with oral
antidiabetic
agents usually doesn't need
to monitor
blood glucose levels. A highcarbohydrate
diet would
exacerbate the
client's
condition, particularly if fluid
intake is
low.
79. Answer:
(D) Hyperparathyroidism
Rationale:
Hyperparathyroidism is most
common in
older women and is
characterized
by bone pain and weakness
from excess
parathyroid hormone (PTH).
Clients
also exhibit hypercaliuria-causing
polyuria.
While clients with diabetes
mellitus
and diabetes insipidus also have
polyuria,
they don't have bone pain and
increased
sleeping. Hypoparathyroidism is
characterized
by urinary frequency rather
than
polyuria.
80. Answer:
(C) "I'll take two-thirds of the
dose when I
wake up and one-third in the
late
afternoon."
Rationale:
Hydrocortisone, a
glucocorticoid,
should be administered
according
to a schedule that closely
reflects
the bodies own secretion of this
hormone;
therefore, two-thirds of the
dose of
hydrocortisone should be taken in
the morning
and one-third in the late
afternoon.
This dosage schedule reduces
adverse
effects.
81. Answer:
(C) High corticotropin and high
cortisol
levels
Rationale:
A corticotropin-secreting
pituitary
tumor would cause high
corticotropin
and high cortisol levels. A
high
corticotropin level with a low cortisol
level and a
low corticotropin level with a
low
cortisol level would be associated
with
hypocortisolism. Low corticotropin
and high
cortisol levels would be seen if
there was a
primary defect in the adrenal
glands.
82. Answer:
(D) Performing capillary glucose
testing
every 4 hours
Rationale:
The nurse should perform
capillary
glucose testing every 4 hours
because
excess cortisol may cause insulin
resistance,
placing the client at risk for
hyperglycemia.
Urine ketone testing isn't
indicated
because the client does secrete
insulin
and, therefore, isn't at risk for
ketosis.
Urine specific gravity isn't
indicated
because although fluid balance
can be
compromised, it usually isn't
dangerously
imbalanced. Temperature
regulation
may be affected by excess
cortisol and
isn't an accurate indicator of
infection.
83. Answer:
(C) onset to be at 2:30 p.m. and
its peak to
be at 4 p.m.
Rationale:
Regular insulin, which is a
short-acting
insulin, has an onset of 15 to
30 minutes
and a peak of 2 to 4 hours.
Because the
nurse gave the insulin at 2
p.m., the
expected onset would be from
2:15 p.m.
to 2:30 p.m. and the peak from
4 p.m. to 6
p.m.
84. Answer:
(A) No increase in the thyroidstimulating
hormone
(TSH) level after 30
minutes
during the TSH stimulation test
Rationale:
In the TSH test, failure of the
TSH level
to rise after 30 minutes confirms
hyperthyroidism.
A decreased TSH level
indicates a
pituitary deficiency of this
hormone.
Below-normal levels of T3 and
T4, as
detected by radioimmunoassay,
signal hypothyroidism.
A below-normal T4
level also
occurs in malnutrition and liver
disease and
may result from
administration
of phenytoin and certain
other
drugs.
85. Answer:
(B) "Rotate injection sites within
the same
anatomic region, not among
different
regions."
Rationale:
The nurse should instruct the
client to
rotate injection sites within the
same
anatomic region. Rotating sites
among
different regions may cause
excessive
day-to-day variations in the
blood
glucose level; also, insulin
absorption
differs from one region to the
next.
Insulin should be injected only into
healthy
tissue lacking large blood vessels,
nerves, or
scar tissue or other deviations.
Injecting
insulin into areas of hypertrophy
may delay
absorption. The client shouldn't
inject
insulin into areas of lipodystrophy
(such as
hypertrophy or atrophy); to
prevent
lipodystrophy, the client should
rotate
injection sites systematically.
Exercise
speeds drug absorption, so the
client
shouldn't inject insulin into sites
above muscles
that will be exercised
heavily.
86. Answer:
(D) Below-normal serum
potassium
level
Rationale:
A client with HHNS has an
overall
body deficit of potassium resulting
from
diuresis, which occurs secondary to
the
hyperosmolar, hyperglycemic state
caused by
the relative insulin deficiency.
An elevated
serum acetone level and
serum
ketone bodies are characteristic of
diabetic
ketoacidosis. Metabolic acidosis,
not serum
alkalosis, may occur in HHNS.
87. Answer:
(D) Maintaining room
temperature
in the low-normal range
Rationale:
Graves' disease causes signs
and
symptoms of hypermetabolism, such
as heat
intolerance, diaphoresis, excessive
thirst and
appetite, and weight loss. To
reduce heat
intolerance and diaphoresis,
the nurse
should keep the client's room
temperature
in the low-normal range. To
replace
fluids lost via diaphoresis, the
nurse
should encourage, not restrict,
intake of
oral fluids. Placing extra blankets
on the bed
of a client with heat
intolerance
would cause discomfort. To
provide
needed energy and calories, the
nurse
should encourage the client to eat
high-carbohydrate
foods.
88. Answer:
(A) Fracture of the distal radius
Rationale:
Colles' fracture is a fracture of
the distal
radius, such as from a fall on an
outstretched
hand. It's most common in
women.
Colles' fracture doesn't refer to a
fracture of
the olecranon, humerus, or
carpal
scaphoid.
89. Answer:
(B) Calcium and phosphorous
Rationale:
In osteoporosis, bones lose
calcium and
phosphate salts, becoming
porous,
brittle, and abnormally vulnerable
to
fracture. Sodium and potassium aren't
involved in
the development of
steoporosis.
90. Answer:
(A) Adult respiratory distress
syndrome
(ARDS)
Rationale:
Severe hypoxia after smoke
inhalation
is typically related to ARDS. The
other
conditions listed aren’t typically
associated
with smoke inhalation and
severe
hypoxia.
91. Answer:
(D) Fat embolism
Rationale:
Long bone fractures are
correlated
with fat emboli, which cause
shortness
of breath and hypoxia. It’s
unlikely
the client has developed asthma
or
bronchitis without a previous history.
He could
develop atelectasis but it
typically
doesn’t produce progressive
hypoxia.
92. Answer:
(D) Spontaneous pneumothorax
Rationale:
A spontaneous pneumothorax
occurs when
the client’s lung collapses,
causing an
acute decreased in the amount
of
functional lung used in oxygenation.
The sudden
collapse was the cause of his
chest pain
and shortness of breath. An
asthma
attack would show wheezing
breath
sounds, and bronchitis would have
rhonchi.
Pneumonia would have bronchial
breath
sounds over the area of
consolidation.
93. Answer:
(C) Pneumothorax
Rationale:
From the trauma the client
experienced,
it’s unlikely he has
bronchitis,
pneumonia, or TB; rhonchi
with
bronchitis, bronchial breath sounds
with TB
would be heard.
94. Answer:
(C) Serous fluids fills the space
and
consolidates the region
Rationale:
Serous fluid fills the space and
eventually
consolidates, preventing
extensive
mediastinal shift of the heart
and
remaining lung. Air can’t be left in the
space.
There’s no gel that can be placed in
the pleural
space. The tissue from the
other lung
can’t cross the mediastinum,
although a
temporary mediastinal shift
exits until the space is filled.
95. Answer:
(A) Alveolar damage in the
infracted
area
Rationale:
The infracted area produces
alveolar
damage that can lead to the
production
of bloody sputum, sometimes
in massive
amounts. Clot formation
usually
occurs in the legs. There’s a loss of
lung
parenchyma and subsequent scar
tissue
formation.
96. Answer:
(D) Respiratory alkalosis
Rationale:
A client with massive
pulmonary
embolism will have a large
region and
blow off large amount of
carbon
dioxide, which crosses the
unaffected
alveolar-capillary membrane
more
readily than does oxygen and results
in
respiratory alkalosis.
97. Answer:
(A) Air leak
Rationale:
Bubbling in the water seal
chamber of
a chest drainage system stems
from an air
leak. In pneumothorax an air
leak can
occur as air is pulled from the
pleural
space. Bubbling doesn’t normally
occur with
either adequate or inadequate
suction or
any preexisting bubbling in the
water seal
chamber.
98. Answer:
(B) 21
Rationale:
3000 x 10 divided by 24 x 60.
99. Answer:
(B) 2.4 ml
Rationale:
.05 mg/ 1 ml = .12mg/ x ml,
.05x = .12,
x = 2.4 ml.
100.
Answer: (D) “I should put on the stockings
before
getting out of bed in the morning.
Rationale:
Promote venous return by
applying external pressure on veins.
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