TEST III - Care of Clients with Physiologic and Psychosocial Alterations part 2
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."
51. A
37-year-old client with uterine cancer asks the
nurse,
"Which is the most common type of
cancer in
women?" The nurse replies that it's
breast
cancer. Which type of cancer causes the
most deaths
in women?
a. Breast
cancer
b. Lung
cancer
c. Brain
cancer
d. Colon
and rectal cancer
52. Antonio
with lung cancer develops Horner's
syndrome
when the tumor invades the ribs and
affects the
sympathetic nerve ganglia. When
assessing
for signs and symptoms of this
syndrome,
the nurse should note:
a. miosis,
partial eyelid ptosis, and
anhidrosis
on the affected side of the
face.
b. chest pain,
dyspnea, cough, weight loss,
and fever.
c. arm and
shoulder pain and atrophy of
arm and
hand muscles, both on the
affected
side.
d. hoarseness and dysphagia.
53. Vic
asks the nurse what PSA is. The nurse should
reply that
it stands for:
a.
prostate-specific antigen, which is used
to screen
for prostate cancer.
b. protein
serum antigen, which is used to
determine
protein levels.
c.
pneumococcal strep antigen, which is a
bacteria
that causes pneumonia.
d.
Papanicolaou-specific antigen, which is
used to screen
for cervical cancer.
54. What is
the most important postoperative
instruction
that nurse Kate must give a client
who has
just returned from the operating room
after
receiving a subarachnoid block?
a.
"Avoid drinking liquids until the gag
reflex
returns."
b.
"Avoid eating milk products for 24
hours."
c.
"Notify a nurse if you experience blood
in your
urine."
d.
"Remain supine for the time specified by
the physician."
55. A male
client suspected of having colorectal
cancer will
require which diagnostic study to
confirm the
diagnosis?
a. Stool
Hematest
b.
Carcinoembryonic antigen (CEA)
c.
Sigmoidoscopy
d.
Abdominal computed tomography (CT)
scan
56. During
a breast examination, which finding most
strongly
suggests that the Luz has breast cancer?
a. Slight asymmetry
of the breasts.
b. A fixed
nodular mass with dimpling of
the
overlying skin
c. Bloody
discharge from the nipple
d. Multiple
firm, round, freely movable
masses that
change with the menstrual
cycle
57. A
female client with cancer is being evaluated
for
possible metastasis. Which of the following is
one of the
most common metastasis sites for
cancer
cells?
a. Liver
b. Colon
c.
Reproductive tract
d. White
blood cells (WBCs)
58. Nurse
Mandy is preparing a client for magnetic
resonance
imaging (MRI) to confirm or rule out a
spinal cord
lesion. During the MRI scan, which of
the
following would pose a threat to the client?
a. The
client lies still.
b. The
client asks questions.
c. The
client hears thumping sounds.
d. The client
wears a watch and wedding
band.
59. Nurse
Cecile is teaching a female client about
preventing
osteoporosis. Which of the following
teaching
points is correct?
a.
Obtaining an X-ray of the bones every 3
years is
recommended to detect bone
loss.
b. To avoid
fractures, the client should
avoid
strenuous exercise.
c. The
recommended daily allowance of
calcium may
be found in a wide variety
of foods.
d.
Obtaining the recommended daily
allowance
of calcium requires taking a
calcium
supplement.
60. Before
Jacob undergoes arthroscopy, the nurse
reviews the
assessment findings for
contraindications
for this procedure. Which
finding is
a contraindication?
a. Joint
pain
b. Joint
deformity
c. Joint
flexion of less than 50%
d. Joint stiffness
61. Mr. Rodriguez
is admitted with severe pain in
the knees.
Which form of arthritis is
characterized
by urate deposits and joint pain,
usually in
the feet and legs, and occurs primarily
in men over
age 30?
a. Septic
arthritis
b.
Traumatic arthritis
c.
Intermittent arthritis
d. Gouty
arthritis
62. A
heparin infusion at 1,500 unit/hour is ordered
for a
64-year-old client with stroke in evolution.
The
infusion contains 25,000 units of heparin in
500 ml of
saline solution. How many milliliters
per hour
should be given?
a. 15
ml/hour
b. 30
ml/hour
c. 45
ml/hour
d. 50 ml/hour
63. A
76-year-old male client had a thromboembolic
right
stroke; his left arm is swollen. Which of the
following
conditions may cause swelling after a
stroke?
a. Elbow
contracture secondary to
spasticity
b. Loss of
muscle contraction decreasing
venous
return
c. Deep
vein thrombosis (DVT) due to
immobility
of the ipsilateral side
d.
Hypoalbuminemia due to protein
escaping
from an inflamed glomerulus
64.
Heberden’s nodes are a common sign of
osteoarthritis.
Which of the following statement
is correct
about this deformity?
a. It
appears only in men
b. It
appears on the distal interphalangeal
joint
c. It
appears on the proximal
interphalangeal
joint
d. It
appears on the dorsolateral aspect of
the interphalangeal
joint.
65. Which
of the following statements explains the
main
difference between rheumatoid arthritis
and
osteoarthritis?
a.
Osteoarthritis is gender-specific,
rheumatoid
arthritis isn’t
b.
Osteoarthritis is a localized disease
rheumatoid
arthritis is systemic
c.
Osteoarthritis is a systemic disease,
rheumatoid
arthritis is localized
d.
Osteoarthritis has dislocations and
subluxations,
rheumatoid arthritis
doesn’t
66. Mrs.
Cruz uses a cane for assistance in walking.
Which of
the following statements is true about
a cane or
other assistive devices?
a. A walker
is a better choice than a cane.
b. The cane
should be used on the affected
side
c. The cane
should be used on the
unaffected
side
d. A client
with osteoarthritis should be
encouraged
to ambulate without the
cane
67. A male
client with type 1 diabetes is scheduled
to receive
30 U of 70/30 insulin. There is no
70/30
insulin available. As a substitution, the
nurse may
give the client:
a. 9 U
regular insulin and 21 U neutral
protamine
Hagedorn (NPH).
b. 21 U
regular insulin and 9 U NPH.
c. 10 U
regular insulin and 20 U NPH.
d. 20 U
regular insulin and 10 U NPH.
68. Nurse
Len should expect to administer which
medication
to a client with gout?
a. aspirin
b. furosemide
(Lasix)
c.
colchicines
d. calcium
gluconate (Kalcinate)
69. Mr.
Domingo with a history of hypertension is
diagnosed
with primary hyperaldosteronism.
This
diagnosis indicates that the client's
hypertension
is caused by excessive hormone
secretion
from which of the following glands?
a. Adrenal
cortex
b. Pancreas
c. Adrenal
medulla
d.
Parathyroid
70. For a
diabetic male client with a foot ulcer, the
doctor
orders bed rest, a wet-to-dry dressing
change
every shift, and blood glucose
monitoring
before meals and bedtime. Why are
wet-to-dry
dressings used for this client?
a. They
contain exudate and provide a
moist wound
environment.
b. They
protect the wound from
mechanical
trauma and promote
healing.
c. They
debride the wound and promote
healing by
secondary intention.
d. They
prevent the entrance of
microorganisms
and minimize wound
discomfort.
71. Nurse
Zeny is caring for a client in acute
addisonian
crisis. Which laboratory data would
the nurse
expect to find?
a.
Hyperkalemia
b. Reduced
blood urea nitrogen (BUN)
c.
Hypernatremia
d.
Hyperglycemia
72. A
client is admitted for treatment of the
syndrome of
inappropriate antidiuretic hormone
(SIADH).
Which nursing intervention is
appropriate?
a. Infusing
I.V. fluids rapidly as ordered
b.
Encouraging increased oral intake
c.
Restricting fluids
d.
Administering glucose-containing I.V.
fluids as ordered
73. A
female client tells nurse Nikki that she has
been
working hard for the last 3 months to
control her
type 2 diabetes mellitus with diet
and
exercise. To determine the effectiveness of
the
client's efforts, the nurse should check:
a. urine
glucose level.
b. fasting
blood glucose level.
c. serum
fructosamine level.
d.
glycosylated hemoglobin level.
74. Nurse
Trinity administered neutral protamine
Hagedorn
(NPH) insulin to a diabetic client at 7
a.m. At
what time would the nurse expect the
client to
be most at risk for a hypoglycemic
reaction?
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
75. The
adrenal cortex is responsible for producing
which
substances?
a.
Glucocorticoids and androgens
b.
Catecholamines and epinephrine
c.
Mineralocorticoids and catecholamines
d.
Norepinephrine and epinephrine
76. On the
third day after a partial thyroidectomy,
Proserfina
exhibits muscle twitching and
hyperirritability
of the nervous system. When
questioned,
the client reports numbness and
tingling of
the mouth and fingertips. Suspecting
a
life-threatening electrolyte disturbance, the
nurse
notifies the surgeon immediately. Which
electrolyte
disturbance most commonly follows
thyroid
surgery?
a.
Hypocalcemia
b.
Hyponatremia
c.
Hyperkalemia
d.
Hypermagnesemia
77. Which
laboratory test value is elevated in clients
who smoke
and can't be used as a general
indicator
of cancer?
a. Acid
phosphatase level
b. Serum
calcitonin level
c. Alkaline
phosphatase level
d.
Carcinoembryonic antigen level
78. Francis
with anemia has been admitted to the
medical-surgical
unit. Which assessment findings
are
characteristic of iron-deficiency anemia?
a. Nights
sweats, weight loss, and diarrhea
b. Dyspnea,
tachycardia, and pallor
c. Nausea,
vomiting, and anorexia
d. Itching,
rash, and jaundice
79. In
teaching a female client who is HIV-positive
about
pregnancy, the nurse would know more
teaching is
necessary when the client says:
a. The baby
can get the virus from my
placenta."
b.
"I'm planning on starting on birth control
pills."
c.
"Not everyone who has the virus gives
birth to a
baby who has the virus."
d.
"I'll need to have a C-section if I become
pregnant and have a baby."
80. When
preparing Judy with acquired
immunodeficiency
syndrome (AIDS) for
discharge
to the home, the nurse should be sure
to include
which instruction?
a.
"Put on disposable gloves before
bathing."
b.
"Sterilize all plates and utensils in boiling
water."
c.
"Avoid sharing such articles as
toothbrushes
and razors."
d.
"Avoid eating foods from serving dishes
shared by
other family members."
81. Nurse
Marie is caring for a 32-year-old client
admitted
with pernicious anemia. Which set of
findings
should the nurse expect when assessing
the client?
a. Pallor,
bradycardia, and reduced pulse
pressure
b. Pallor,
tachycardia, and a sore tongue
c. Sore
tongue, dyspnea, and weight gain
d. Angina,
double vision, and anorexia
82. After
receiving a dose of penicillin, a client
develops
dyspnea and hypotension. Nurse
Celestina
suspects the client is experiencing
anaphylactic
shock. What should the nurse do
first?
a. Page an
anesthesiologist immediately
and prepare
to intubate the client.
b.
Administer epinephrine, as prescribed,
and prepare
to intubate the client if
necessary.
c.
Administer the antidote for penicillin, as
prescribed,
and continue to monitor the
client's
vital signs.
d. Insert
an indwelling urinary catheter and
begin to
infuse I.V. fluids as ordered.
83. Mr.
Marquez with rheumatoid arthritis is about
to begin
aspirin therapy to reduce inflammation.
When
teaching the client about aspirin, the
nurse
discusses adverse reactions to prolonged
aspirin
therapy. These include:
a. weight
gain.
b. fine
motor tremors.
c.
respiratory acidosis.
d.
bilateral hearing loss.
84. A
23-year-old client is diagnosed with human
immunodeficiency
virus (HIV). After recovering
from the
initial shock of the diagnosis, the client
expresses a
desire to learn as much as possible
about HIV
and acquired immunodeficiency
syndrome
(AIDS). When teaching the client
about the
immune system, the nurse states that
adaptive
immunity is provided by which type of
white blood
cell?
a.
Neutrophil
b. Basophil
c. Monocyte
d.
Lymphocyte
85. In an
individual with Sjögren's syndrome, nursing
care should
focus on:
a. moisture
replacement.
b.
electrolyte balance.
c.
nutritional supplementation.
d. arrhythmia management.
86. During
chemotherapy for lymphocytic leukemia,
Mathew
develops abdominal pain, fever, and
"horse
barn" smelling diarrhea. It would be most
important
for the nurse to advise the physician
to order:
a.
enzyme-linked immunosuppressant
assay
(ELISA) test.
b.
electrolyte panel and hemogram.
c. stool
for Clostridium difficile test.
d. flat
plate X-ray of the abdomen.
87. A male
client seeks medical evaluation for
fatigue,
night sweats, and a 20-lb weight loss in 6
weeks. To
confirm that the client has been
infected
with the human immunodeficiency virus
(HIV), the
nurse expects the physician to order:
a.
E-rosette immunofluorescence.
b.
quantification of T-lymphocytes.
c.
enzyme-linked immunosorbent assay
(ELISA).
d. Western
blot test with ELISA.
88. A
complete blood count is commonly performed
before a
Joe goes into surgery. What does this
test seek
to identify?
a.
Potential hepatic dysfunction indicated
by
decreased blood urea nitrogen (BUN)
and
creatinine levels
b. Low
levels of urine constituents normally
excreted in
the urine
c.
Abnormally low hematocrit (HCT) and
hemoglobin
(Hb) levels
d.
Electrolyte imbalance that could affect
the blood's ability to coagulate properly
89. While
monitoring a client for the development
of
disseminated intravascular coagulation (DIC),
the nurse should
take note of what assessment
parameters?
a. Platelet
count, prothrombin time, and
partial
thromboplastin time
b. Platelet
count, blood glucose levels, and
white blood
cell (WBC) count
c. Thrombin
time, calcium levels, and
potassium
levels
d. Fibrinogen
level, WBC, and platelet
count
90. When
taking a dietary history from a newly
admitted
female client, Nurse Len should
remember
that which of the following foods is a
common
allergen?
a. Bread
b. Carrots
c. Orange
d.
Strawberries
91. Nurse
John is caring for clients in the outpatient
clinic.
Which of the following phone calls should
the nurse
return first?
a. A client
with hepatitis A who states, “My
arms and
legs are itching.”
b. A client
with cast on the right leg who
states, “I
have a funny feeling in my right
leg.”
c. A client
with osteomyelitis of the spine
who states,
“I am so nauseous that I
can’t eat.”
d. A client
with rheumatoid arthritis who
states, “I
am having trouble sleeping.”
92. Nurse
Sarah is caring for clients on the surgical
floor and has
just received report from the
previous
shift. Which of the following clients
should the
nurse see first?
a. A
35-year-old admitted three hours ago
with a
gunshot wound; 1.5 cm area of
dark
drainage noted on the dressing.
b. A
43-year-old who had a mastectomy
two days
ago; 23 ml of serosanguinous
fluid noted
in the Jackson-Pratt drain.
c. A
59-year-old with a collapsed lung due
to an
accident; no drainage noted in the
previous
eight hours.
d. A
62-year-old who had an abdominalperineal
resection
three days ago; client
complaints
of chills.
93. Nurse
Eve is caring for a client who had a
thyroidectomy
12 hours ago for treatment of
Grave’s
disease. The nurse would be most
concerned
if which of the following was
observed?
a. Blood
pressure 138/82, respirations 16,
oral
temperature 99 degrees Fahrenheit.
b. The
client supports his head and neck
when
turning his head to the right.
c. The
client spontaneously flexes his wrist
when the
blood pressure is obtained.
d. The
client is drowsy and complains of
sore
throat.
94. Julius
is admitted with complaints of severe pain
in the
lower right quadrant of the abdomen. To
assist with
pain relief, the nurse should take
which of
the following actions?
a.
Encourage the client to change positions
frequently
in bed.
b.
Administer Demerol 50 mg IM q 4 hours
and PRN.
c. Apply
warmth to the abdomen with a
heating
pad.
d. Use
comfort measures and pillows to
position
the client.
95. Nurse
Tina prepares a client for peritoneal
dialysis.
Which of the following actions should
the nurse
take first?
a. Assess
for a bruit and a thrill.
b. Warm the
dialysate solution.
c. Position
the client on the left side.
d. Insert a
Foley catheter
96. Nurse
Jannah teaches an elderly client with
right-sided
weakness how to use cane. Which of
the
following behaviors, if demonstrated by the
client to
the nurse, indicates that the teaching
was
effective?
a. The
client holds the cane with his right
hand, moves
the can forward followed
by the
right leg, and then moves the left
leg.
b. The
client holds the cane with his right
hand, moves
the cane forward followed
by his left
leg, and then moves the right
leg.
c. The
client holds the cane with his left
hand, moves
the cane forward followed
by the
right leg, and then moves the left
leg.
d. The
client holds the cane with his left
hand, moves
the cane forward followed
by his left
leg, and then moves the right
leg.
97. An
elderly client is admitted to the nursing home
setting.
The client is occasionally confused and
her gait is
often unsteady. Which of the
following
actions, if taken by the nurse, is most
appropriate?
a. Ask the
woman’s family to provide
personal
items such as photos or
mementos.
b. Select a
room with a bed by the door so
the woman
can look down the hall.
c. Suggest
the woman eat her meals in the
room with
her roommate.
d.
Encourage the woman to ambulate in
the halls
twice a day.
98. Nurse
Evangeline teaches an elderly client how
to use a
standard aluminum walker. Which of
the
following behaviors, if demonstrated by the
client,
indicates that the nurse’s teaching was
effective?
a. The
client slowly pushes the walker
forward 12
inches, then takes small
steps
forward while leaning on the
walker.
b. The
client lifts the walker, moves it
forward 10
inches, and then takes
several
small steps forward.
c. The
client supports his weight on the
walker
while advancing it forward, then
takes small
steps while balancing on the
walker.
d. The
client slides the walker 18 inches
forward,
then takes small steps while
holding
onto the walker for balance.
99. Nurse
Deric is supervising a group of elderly
clients in
a residential home setting. The nurse
knows that
the elderly are at greater risk of
developing
sensory deprivation for what reason?
a.
Increased sensitivity to the side effects
of
medications.
b.
Decreased visual, auditory, and
gustatory
abilities.
c.
Isolation from their families and familiar
surroundings.
d. Decrease
musculoskeletal function and
mobility.
100. A male
client with emphysema becomes
restless
and confused. What step should
nurse
Jasmine take next?
a.
Encourage the client to perform pursed
lip
breathing.
b. Check
the client’s temperature.
c. Assess
the client’s potassium level.
d. Increase the client’s oxygen flow
rate.
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