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1. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours.

For which of the following would the nurse be alert? a. Endometritis b. Endometriosis c. Salpingitis d. Pelvic thrombophlebitis 2. A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? a. The ultrasound will help to locate the placenta b. The ultrasound identifies blood flow through the umbilical cord c. The test will determine where to insert the needle d. The ultrasound locates a pool of amniotic fluid 3. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy? a. Calcium gluconate b. Protamine sulfate c. Methylegonovine (Methergine) d. Nitrofurantoin (macrodantin) 4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? a. Turn the neonate every 6 hours b. Encourage the mother to discontinue breast-feeding c. Notify the physician if the skin becomes bronze in color d. Check the vital signs every 2 to 4 hours 5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? a. Back b. Abdomen c. Fundus d. Perineum 6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: a. Nausea and vomiting can be decreased if I eat a few crackers before arising b. If I start to leak colostrum, I should cleanse my nipples with soap and water c. If I have a vaginal discharge, I should wear nylon underwear d. Leg cramps can be alleviated if I put an ice pack on the area

7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartal psychological adaptation that the client would be in would be termed which of the following? a. Taking in b. Letting go c. Taking hold d. Resolution 8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? a. Activity limited to bed rest b. Platelet infusion c. Immediate cesarean delivery d. Labor induction with oxytocin 9. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? a. Feeding the neonate a maximum of 5 minutes per side on the first day b. Wearing a supportive brassiere with nipple shields c. Breast-feeding the neonate at frequent intervals d. Decreasing fluid intake for the first 24 to 48 hours 10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? a. Startle reflex b. Babinski reflex c. Grasping reflex d. Tonic neck reflex 11. A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: a. Tailor sitting b. Leg lifting c. Shoulder circling d. Squatting exercises 12. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? a. Notify the neonates pediatrician immediately b. Check the diaper and circumcision again in 30 minutes c. Secure the diaper tightly to apply pressure on the site d. Apply gently pressure to the site with a sterile gauze pad 13. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with abruption placenta? a. Excessive vaginal bleeding

b. Rigid, boardlike abdomen c. Titanic uterine contractions d. Premature rupture of membranes 14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurses most appropriate action? a. Note the fetal heart rate patterns b. Notify the physician immediately c. Administer oxygen at 6 liters by mask d. Have the client pant-blow during the contractions 15. A client tells the nurse, I think my baby likes to hear me talk to him. When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? a. High-pitched speech with tonal variations b. Low-pitched speech with a sameness of tone c. Cooing sounds rather than words d. Repeated stimulation with loud sounds 16. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? a. Active phase b. Latent phase c. Expulsive phase d. Transitional phase 17. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond? a. Yes, it produces no adverse effect. b. No, it can initiate premature uterine contractions. c. No, it can promote sodium retention. d. No, it can lead to increased absorption of fat-soluble vitamins. 18. A patient in her 14 week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient? a. Knowledge deficit b. Fluid volume deficit c. Anticipatory grieving d. Pain 19. Immediately after a delivery, the nurse-midwife assesses the neonates head for signs of molding. Which factors determine the type of molding? a. Fetal body flexion or extension b. Maternal age, body frame, and weight c. Maternal and paternal ethnic backgrounds d. Maternal parity and gravidity
th

20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? a. The membranes must rupture b. The fetus must be at 0 station c. The cervix must be dilated fully d. The patient must receive anesthesia 21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense: a. Around the pelvic girdle b. Around the pelvic girdle and in the upper arms c. Around the pelvic girdle and at the perineum d. At the perineum 22. A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the patients risk for: a. Endometriosis b. Female hypogonadism c. Premenstrual syndrome d. Tubal or ectopic pregnancy 23. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? a. Proteinuria, headaches, vaginal bleeding b. Headaches, double vision, vaginal bleeding c. Proteinuria, headaches, double vision d. Proteinuria, double vision, uterine contractions 24. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patients fluid intake and output closely during oxytocin administration? a. Oxytoxin causes water intoxication b. Oxytocin causes excessive thirst c. Oxytoxin is toxic to the kidneys d. Oxytoxin has a diuretic effect 25. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? a. Low room humidity b. Cold weight scale c. Cools incubator walls d. Cool room temperature 26. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? a. Decreased peristalsis b. Increase heart rate c. Dry mucous membranes d. Nausea and Vomiting

27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? a. Active phase b. Complete phase c. Latent phase d. Transitional phase 28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: a. Apply warm compresses to her nipples just before feedings b. Lubricate her nipples with expressed milk before feeding c. Dry her nipples with a soft towel after feedings d. Apply soap directly to her nipples, and then rinse 29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? a. Between 10 and 12 weeks gestation b. Between 16 and 20 weeks gestation c. Between 21 and 23 weeks gestation d. Between 24 and 26 weeks gestation 30. Normal lochial findings in the first 24 hours post-delivery include: a. Bright red blood b. Large clots or tissue fragments c. A foul odor d. The complete absence of lochia 1. Answer A. Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes. 2. Answer B. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. 3. Answer B. Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications cause by heparin overdose. 4. Answer D. While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. 5. Answer D. A bilateral pudental block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudental block anesthesia is adequate for episiotomy and its repair.

6. Answer A. Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. 7. Answer C. Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills. 8. Answer A. Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the clients bleeding. 9. Answer C. Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonates and mothers needs. 10. Answer A. The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months. 11. Answer A. Tailor sitting is an excellent exercise that helps to strengthen the clients b ack muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. 12. Answer D. If bleeding occurs after circumcision, the nurse should first apply gently pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. 13. Answer B. The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. 14. Answer B. The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation, unless cephalopelvic disproportion exists. 15. Answer A. Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than about 55 decibels. 16. Answer D. The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active phase extends form 4 to 7 cm; it is moderate for the patient. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta. 17. Answer B. Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not

known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased. 18. Answer B. If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis. 19. Answer A. Fetal attitudethe overall degree of body flexion or extensiondetermines the type of molding in the head a neonate. Molding is not influence by maternal age, body frame, weight, parity, or gravidity or by maternal and paternal ethnic backgrounds. 20. Answer A. Internal EFM can be applied only after the patients membranes have ruptures, when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. although the patient may receive anesthesia, it is not required before application of an internal EFM device. 21. Answer A.During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum. Upper arm pain is not common during ant stage of labor. 22. Answer D. Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome are not associated with progestin-only oral contraceptives. 23. Answer C. A patient with pregnancy-induced hypertension complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions are not associated with pregnancy-induces hypertension. 24. Answer A. The nurse should monitor fluid intake and output because prolonged oxytoxin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results form the work of labor and limited oral fluid intakenot oxytoxin. Oxytoxin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect. 25. Answer C. Common source of radiant heat loss includes cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss. 26. Answer D. Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase. 27. Answer D. The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 to 6 hours; it

is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions. 28. Answer B. Measures that help relieve nipple soreness in a breast-feeding patient include lubrication the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples. 29. Answer B. A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. 30. Answer A. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.

Pediatric
1. Nurse Nelli performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without

calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds he still isnt breathing and has no pulse. The nurse should then: a. b. c. d. 2. a. b. c. d. 3. resume CPR beginning with breaths declare her efforts futile resume CPR beginning with chest compressions call for assistance An infant, 6 weeks old, is brought to the clinic for a well-baby visit. To assess the fontanels, Supine Prone In the left lateral position Seated upright An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During

how should nurse Oliver position the infant?

physical assessment, nurse Jasmine measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant? a. b. c. d. Lying on the back Lying on the abdomen Sitting in an infant seat Sitting in high Fowlers position

4. a. b. c. d. 5. a. b. c. d. 6. a. b. c. d. 7.

How should nurse Amy position an infant when administering an oral medication? Seated in a high chair Restrained flat in the crib Held on the nurses lap Held in the bottle-feeding position A 3-month-old infant just had a cleft lip and palette repair. To prevent trauma to the operative Give the baby a pacifier to help soothe him Lie the baby in the prone position Place the infants arms in soft elbow restraints Avoid touching the suture line, even to clean A baby James has just had surgery to repair his cleft lip. Which nursing intervention is the Clean the suture line carefully with a sterile solution after every feeding Lay the infant on his abdomen to help drain fluids from his mouth Allow the infant to cry to promote lung reexpansion Give the baby a pacifier to suck for comfort An infant undergoes surgery to remove a myelomeningocele. To detect increased intracranial

site, nurse Aljon should do which of the following?

most important during the immediate postoperative period?

pressure (ICP) as early as possible, nurse Amanda should stay alert for which postoperative finding? a. b. c. d. 8. a. b. c. d. 9. a. b. c. d. 10. a. b. c. d. 11. Decreased urine output Increased heart rate Bulging fontanels Sunken eyeballs When performing cardiopulmonary resuscitation on a 7-month-old, which location would Carotid artery Femoral artery Brachial artery Radial artery Nurse Ted is administering I.V. fluids to an infant. Infants receiving I.V. therapy are Hypotension fluid overload cardiac arrhythmias pulmonary emboli Nurse Rose is caring for a neonate with congenital clubfoot. The child has a cast to correct The cast will be removed in 6 weeks A new cast is needed every 1 to 2 weeks A short leg cast is applied when the baby is ready to walk The cast will be removed when the baby begins to crawl Parents bring their infant to the clinic, seeking treatment for vomiting anddiarrhea that has

nurse Sally use to evaluate the presence of a pulse?

particularly vulnerable to:

the defect. Before discharge, what should the nurse tell the parents?

lasted for 2 days. On assessment, nurse Ernie detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? a. b. c. d. 12. a. b. c. d. 13. a. b. c. d. 14. a. b. c. d. 15. a. b. c. d. 16. a. b. c. d. 17. a. b. c. d. 18. A sunken fontanel Decreased pulse rate Increased blood pressure Low urine specific gravity When developing a postoperative plan of care for an infant scheduled for cleft lip repair, Comforting the child as quickly as possible Maintaining the child in a prone position Restraining the childs arms at all times, using elbow restraints Avoiding disturbing any crusts that form on the suture line Nurse Dave is conducting an examination of a 6-month-old baby. During the examination, Babinskis Startle Moros Dance If an infants I.V. access site is in an extremity, nurse Kate should: use a padded board to secure the extremity restrain all four extremities restrain the extremity to the beds side rail allow the extremity to be loose Nurse Wayne is aware that which finding would be least suggestive of necrotizing Hepatomegaly Distended abdomen Gastric retention Blood in the stool A 2-month-old baby hasnt received any immunizations. Which immunizations should nurse Measles, mumps, rubella (MMR); diphtheria, tetanus, pertussis (DTP); and Hepatitis B Polio (IPV), DTP, MMR Varicella, Haemophilus influenzae type b (HIB), IPV, and DTP HIB, DTP, HepB; and IPV Dr. Smith suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing Avoiding suctioning unless cyanosis occurs Elevating the neonates head and giving nothing by mouth Elevating the neonates head for 1 hour after feedings Giving the neonate only glucose water for the first 24 hours When caring for children who are sick, who have sustained traumas, or who are suffering

nurse Elaine should assign highest priority to which intervention?

the nurse should be able to elicit which reflex?

enterocolitis (NEC) in an infant?

Jess prepare to administer? (HepB)

intervention is most appropriate for this child?

from nutritional inadequacies, nurse Ron should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate? a. b. c. d. 19. a. b. c. d. 20. a. b. c. d. 21. Neonates: 10.6 to 16.5 g/dl 3 months: 10.6 to 16.5 g/dl 3 years: 9.4 to 15.5 g/dl 10 years: 10.7 to 15.5 g/dl When caring for a 12-month-old infant with dehydration and metabolic acidosis, nurse May A reduced white blood cell (WBC) count A decreased platelet count Shallow respirations Tachypnea Nurse Jake is aware that most oral pediatric medications are administered: with the nighttime formula hour after meals on an empty stomach with meals A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine

expects to see which of the following?

checkup. Nurse Aimee weighs the infant, the grandmother asks, Shouldnt the baby start eating solid food? My kids started on cereal when they were 2 weeks old. Which response by the nurse would be appropriate? a. b. c. d. 22. a. b. c. d. 23. a. b. c. d. 24. a. b. c. d. The baby is gaining weight and doing well. There is no need for solid food yet. Things have changed a lot since your children were born. Weve found that babies cant digest solid food properly until theyre 3 or 4 months old. Weve learned that introducing solid food early leads to eating disorders later in life. Sudden infant death syndrome (SIDS) is one of the most common causes of death in 1 to 2 years 1 week to 1 year, peaking at 2 to 4 months 6 months to 1 year, peaking at 10 months 6 to 8 weeks An infant is hospitalized for treatment of inorganic failure to thrive. Nurse Faith is aware that Encouraging the infant to hold a bottle Keeping the infant on bed rest to conserve energy Rotating caregivers to provide more stimulation Maintaining a consistent, structured environment Nurse Lei is aware that one of the following is an early sign of heart failure in an infant with Tachypnea Tachycardia Poor weight gain Pulmonary edema

infants. At what age is the diagnosis of SIDS most likely?

the nursing action is most appropriate for this child?

a congenital heart defect?

25.

An 8-month-old is admitted to the pediatric unit following a fall from his high chair. The child

is awake, alert, and crying. Nurse Fatima should know that a brain injury is more severe in children because of: a. b. c. d. increased myelination intracranial hypotension cerebral hyperemia a slightly thicker cranium

1. Answer: D. After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldnt be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions. 2. Answer: D. For the most accurate results, the nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense. When the infant is in a recumbent position, the fontanel is less flat than it is normally, creating the false impression that intracranial pressure is increased. 3. Answer: C. Because the infants assessment findings suggest that respiratory distress is developing, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion; an infant seat maintains this position. Placing an infant flat on the back or abdomen or in high Fowlers position could increase respiratory distress by preventing maximal chest expansion. 4. Answer: D. The nurse should hold an infant in the bottle-feeding position when administering an oral medication: place the childs inner arm behind the back, support the head in the crook of the elbow, and hold the childs free hand with the hand of the supporting arm. An infant cant sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap doesnt prevent spilling the medication with either hand. 5. Answer: C. Soft restraints from the upper arm to the wrist prevent the infant from touching his lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers, suction catheters, and small spoons shouldnt be placed in a babys mouth after cleft palette repair. A baby in a prone position may rub his face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can widen the scar. 6. Answer: A. To avoid an infection that could adversely affect the cosmetic outcome of the repair, the suture line must be cleaned very gently with a sterile solution after each feeding. Laying an infant on his abdomen after a cleft lip repair will put pressure on the suture line, causing damage. The infant can be positioned on his side to drain saliva without affecting the suture line. Crying puts tension on the suture line and should be avoided by anticipating the

babys needs, such as holding and cuddling him. Hard objects, such as pacifiers, should be kept away from the suture line because they can cause damage. 7. Answer: C. Because an infants fontanels remain open, the skull may expand in response to increased ICP. Therefore, bulging fontanels are a cardinal sign of increased ICP in an infant. Decreased urine output and sunken eyeballs indicate dehydration, not increased ICP. With increased ICP, the heart rate decreases. 8. Answer: C. The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heart beat. 9. Answer: B. Infants, small children, and children with compromised cardiopulmonary status receiving I.V. therapy are particularly vulnerable to fluid overload. To prevent fluid overload, the nurse should use a volume-control set and an infusion pump or syringe and place no more than 2 hours worth of I.V. fluid in the volume-control set at a time. Hypotension, cardiac arrhythmias, and pulmonary emboli arent problems associated with I.V. therapy in infants. 10. Answer: B. Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isnt left on for 6 weeks because of the rapid rate of the infants growth. By the tim e a baby is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until hes 1 year old. 11. Answer: A. In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity. 12. Answer: A. After surgery to repair a cleft lip, the primary goal of nursing care is to maintain integrity of the operative site. Crying causes tension on the suture line, so comforting the child as quickly as possible is the highest nursing priority. Parents may help by cuddling and comforting the child. The prone position is contraindicated after surgery because rubbing on the sheet may disturb the suture line. Elbow restraints may cause agitation; if used to prevent the child from disturbing the suture line, they must be removed, one at a time, every 2 to 4 hours so that the child can exercise and the nurse can assess for skin irritation. Crusts forming on the suture line contribute to scarring and must be cleaned carefully. 13. Answer: A. Babinskis reflex may be present the entire first year of life. The startle reflex disappears around 4 months of age; the Moro reflex, by 3 or 4 months of age; and the dance reflex, after the 3rd or 4th week. 14. Answer: A. A padded board is adequate to secure the extremity. Restraining all four extremities can be harmful and uncomfortable for the child. Restraining the extremity to the beds side rail limits the childs movement; the child may bang against the rail and ca use injury. Allowing the extremity to be loose increases the risk that the I.V will infiltrate or be dislodged by the infant.

15. Answer: A. Hepatomegaly is most commonly observed in neonatal sepsis, not NEC. A distended abdomen, gastric retention, and blood in the stool are all signs of NEC and should be monitored closely in infants who are at risk. 16.Answer: D. The current immunizations recommended for a 2-month-old who hasnt received any immunizations are HIB, DTP, HepB, and IPV. The first immunizations for MMR and varicella are recommended when a child is 12 months old. 17. Answer: B. Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonates head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status. 18. Answer: A. To sustain them until active erythropoiesis begins, neonates have Hb concentrations higher than those of older children. The normal value of Hb for neonates is 18 to 27 g/dl. Disease as well as such nonpathologic conditions as age, sex, altitude, and the degree of fluid retention or dehydration can affect Hb values. The values for a 3-month-old, a 3-year-old, and a 10-year-old are correct as stated above. 19.Answer: D. The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. Altered WBC and platelet counts arent specific signs of metabolic imbalance. 20.Answer: C. Most oral pediatric medications are administered on an empty stomach. They arent usually administered with milk or formula because these can affect gastric pH and alter drug absorption. Because a childs meals usually contain milk or a milk product, the nurse wouldnt administer the drugs with meals or even hour after meals. 21.Answer: C. Infants younger than 3 or 4 months lack the enzymes needed to digest complex carbohydrates. Option A doesnt address the grandmothers question directly. Option B is a clich that may block further communication with the grandmother. Option D is incorrect because no evidence suggests that introducing solid food early causes eating disorders. 22.Answer: B. SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months. 23.Answer: D. The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care. 24.Answer: B. The earliest sign of heart failure in infants is tachycardia (sleeping heart rate greater than 160 beats/minute) as a direct result of sympathetic stimulation. Tachypnea (respiratory rate greater than 60 breaths/minute in infants) occurs in response to decreased lung compliance. Poor weight gain is a result of the increased energy demands to the heart and

breathing efforts. Pulmonary edema occurs as the left ventricle fails and blood volume and pressure increase in the left atrium, pulmonary veins, and lungs. 25.Answer: C. Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension not hypotension places the child at greater risk for secondary brain injury. A childs cranium is thinner and more pliable, causing the child to receive a more severe injury.

Medsurg

1. Which of the following arteries primarily feeds the anterior wall of the heart? a. Circumflex artery b. Internal mammary artery c. Left anterior descending artery d. Right coronary artery The left anterior descending artery is the primary source of blood for the anterior wall of the heart. The circumflex artery supplies the lateral wall, the internal mammary artery supplies the mammary, and the right coronary artery supplies the inferior wall of the heart. 2. When do coronary arteries primarily receive blood flow? a. During inspiration b. During diastole c. During expiration d. During systole Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing

patterns are irrelevant to blood flow 3. Which of the following illnesses is the leading cause of death in the US? a. Cancer b. Coronary artery disease c. Liver failure d. Renal failure Coronary artery disease accounts for over 50% of all deaths in the US. Cancer accounts for approximately 20%. Liver failure and renal failure account for less than 10% of all deaths in the US. 4. Which of the following conditions most commonly results in CAD? a. Atherosclerosis b. DM c. MI d. Renal failure Atherosclerosis, or plaque formation, is the leading cause of CAD. DM is a risk factor for CAD but isn't the most common cause. Renal failure doesn't cause CAD, but the two conditions are related. Myocardial infarction is commonly a result of CAD. 5. Atherosclerosis impedes coronary blood flow by which of the following mechanisms? a. Plaques obstruct the vein b. Plaques obstruct the artery c. Blood clots form outside the vessel wall d. Hardened vessels dilate to allow the blood to flow through Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atherosclerosis is a direct result of plaque formation in the artery. Hardened vessels can't dilate properly and, therefore, constrict blood flow. 6. Which of the following risk factors for coronary artery disease cannot be corrected? a. Cigarette smoking b. DM c. Heredity

d. HPN Because "heredity" refers to our genetic makeup, it can't be changed. Cigarette smoking cessation is a lifestyle change that involves behavior modification. Diabetes mellitus is a risk factor that can be controlled with diet, exercise, and medication. Altering one's diet, exercise, and medication can correct hypertension. 7. Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease? a. 100 mg/dl b. 150 mg/dl c. 175 mg/dl d. 200 mg/dl Cholesterol levels above 200 mg/dl are considered excessive. They require dietary restriction and perhaps medication. Exercise also helps reduce cholesterol levels. The other levels listed are all below the nationally accepted levels for cholesterol and carry a lesser risk for CAD. 8. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease? a. Decrease anxiety b. Enhance myocardial oxygenation c. Administer sublignual nitroglycerin d. Educate the client about his symptoms Enhancing mocardial oxygenation is always the first priority when a client exhibits signs and symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. Sublingual nitorglycerin is administered to treat acute angina, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, nether are priorities when a client is compromised.

Image Via:medical-assistant.net 9. Medical treatment of coronary artery disease includes which of the following procedures? a. Cardiac catheterization b. Coronary artery bypass surgery c. Oral medication administration d. Percutaneous transluminal coronary angioplasty Oral medication administration is a noninvasive, medical treatment for coronary arterydisease. Cardiac catheterization isn't a treatment but a diagnostic tool. Coronary arterybypass surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments. 10. Prolonged occlusion of the right coronary artery produces an infarction in which of he following areas of the heart? a. Anterior b. Apical c. Inferior d. Lateral The right coronary artery supplies the right ventricle, or the inferior portion of the heart. Therefore, prolonged occlusion could produce an infarction in that area. The rightcoronary artery doesn't supply the anterior portion ( left ventricle ), lateral portion ( some of the left ventricle and the left atrium ), or the apical portion ( left ventricle ) of the heart. 11. Which of the following is the most common symptom of myocardial infarction? a. Chest pain b. Dyspnea

c. Edema d. Palpitations The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after an MI. Palpitations may result from reduced cardiac output, producing arrhythmias. 12. Which of the following landmarks is the corect one for obtaining an apical pulse? a. Left intercostal space, midaxillary line b. Left fifth intercostal space, midclavicular line c. Left second intercostal space, midclavicular line d. Left seventh intercostal space, midclavicular line The correct landmark for obtaining an apical pulse is the left intercostal space in the midclavicular line. This is the point of maximum impulse and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where the pulmonic sounds are auscultated. Normally, heart sounds aren't heard in the midaxillary line or the seventh intercostal space in the midclavicular line. 13. Which of the following systems is the most likely origin of pain the client describes as knifelike chest pain that increases in intensity with inspiration? a. Cardiac b. Gastrointestinal c. Musculoskeletal d. Pulmonary Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only increase with movement. Cardiac and GI pains don't change with respiration. 14. A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this? a. Aortic b. Mitral c. Pulmonic d. Tricuspid Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricuspid valve abnormalities are

heard at the third and fourth intercostal spaces along the sternal border. 15. Which of the following blood tests is most indicative of cardiac damage? a. Lactate dehydrogenase b. Complete blood count c. Troponin I d. Creatine kinase Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren't detectable in people without cardiac injury. Lactate dehydrogenase is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levles may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury. 16. What is the primary reason for administering morphine to a client with myocardial infarction? a. To sedate the client b. To decrease the client's pain c. To decrease the client's anxiety d. To decrease oxygen demand on the client's heart Morphine is administered because it decreases myocardial oxygen demand. Morphinewill also decrease pain and anxiety while causing sedation, but isn't primarily given for those reasons. 17. Which of the followng conditions is most commonly responsible for myocardial infarction? a. Aneurysm b. Heart failure c. Coronary artery thrombosis d. Renal failure Coronary artery thrombosis causes occlusion of the artery, leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn't cause an MI. Renal failure can be associated with MI but isn't a direct cause. Heart failure is usually the result of an MI. 18. What supplemental medication is most frequently ordered in conjuction with furosemide (Lasix)? a. Chloride b. Digoxin

c. Potassium d. Sodium Supplemental potassium is given with furosemide because of the potassium loss that occurs as a result of this diuretic. Chloride and sodium arent loss during diuresis. Digoxin acts to increase contractility but isnt given routinely with furosemide. 19. After myocardial infarction, serum glucose levels and free fatty acids are both increase. What type of physiologic changes are these? a. Electrophysiologic b. Hematologic c. Mechanical d. Metabolic Both glucose and fatty acids are metabolites whose levels increase after a myocardial infarction. Mechanical changes are those that affect the pumping action of the heart, and electro physiologic changes affect conduction. Hematologic changes would affect the blood. 20. Which of the following complications is indicated by a third heart sound (S3)? a. Ventricular dilation b. Systemic hypertension c. Aortic valve malfunction d. Increased atrial contractions Rapid filling of the ventricles causes vasodilation that is auscultated as S3. Increased atrial contraction or systemic hypertension can result is a fourth heart sound. Aortic valve malfunction is heard as a murmur. 21. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? a. Left-sided heart failure b. Pulmonic valve malfunction c. Right-sided heart failure d. Tricuspid valve malfunction The left ventricle is responsible for the most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesnt function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.

22. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? a. Cardiac catheterization b. Cardiac enzymes c. Echocardiogram d. Electrocardiogram The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but cant determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the study may not be performed immediately. 23. What is the first intervention for a client experiencing myocardial infarction? a. Administer morphine b. Administer oxygen c. Administer sublingual nitroglycerin d. Obtain an electrocardiogram Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and sublingual nitroglycerin are also used to treat MI, but theyre more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI. 24. What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying? a. "Tell me about your feeling right now." b. "When the doctor arrives, everything will be fine." c. "This is a bad situation, but you'll feel better soon." d. "Please be assured we're doing everything we can to make you feel better." Validation of the clients feelings is the most appropriate response. It gives the client a feeling of comfort and safety. The other three responses give the client false hope. No one can determine if a client experiencing MI will feel or get better and therefore, these responses are inappropriate. 25. Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?

a. Beta-adrenergic blockers b. Calcium channel blockers c. Narcotics d. Nitrates Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing the workload of the heart and decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decreased anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload). 26. What is the most common complication of a myocardial infarction? a. Cardiogenic shock b. Heart failure c. Arrhythmias d. Pericarditis Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common complication of an MI. cardiogenic shock, another complication of MI, is defined as the end stage of left ventricular dysfunction. The condition occurs in approximately 15% of clients with MI. Because the pumping function of the heart is compromised by an MI, heart failure is the second most common complication. Pericarditis most commonly results from a bacterial of viral infection but may occur after MI. 27. With which of the following disorders is jugular vein distention most prominent? a. Abdominal aortic aneurysm b. Heart failure c. Myocardial infarction d. Pneumothorax Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. Jugular vein distention isnt a symptom of abdominal aortic aneurysm or pneumothorax. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI doesnt cause jugular vein distention. 28. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? a. High-fowler's

b. Raised 10 degrees c. Raised 30 degrees d. Supine position Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 and 30 degrees. Inclined pressure cant be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowlers position, the veins would be barely discernible above the clavicle. 29. Which of the following parameters should be checked before administering digoxin? a. Apical pulse b. Blood pressure c. Radial pulse d. Respiratory rate An apical pulse is essential or accurately assessing the clients heart rate before administering digoxin. The apical pulse is the most accurate point in the body. Blood pressure is usually only affected if the heart rate is too low, in which case the nurse would withhold digoxin. The radial pulse can be affected by cardiac and vascular disease and therefore, wont always accurately depict the heart rate. Digoxin has no effect on respiratory function. 30. Toxicity from which of the following medications may cause a client to see a green halo around lights? a. Digoxin b. Furosemide c. Metoprolol d. Enalapril One of the most common signs of digoxin toxicity is the visual disturbance known as the green halo sign. The other medications arent associated with such an effect. 31. Which ofthe following symptoms is most commonly associated with left-sided heart failure? a. Crackles b. Arrhythmias c. Hepatic engorgement d. Hypotension Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are

caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both right and left-sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system. 32. In which of the following disorders would the nurse expect to assess sacral eddema in bedridden client? a. DM b. Pulmonary emboli c. Renal failure d. Right-sided heart failure The most accurate area on the body to assed dependent edema in a bedridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure. Diabetes mellitus, pulmonary emboli, and renal disease arent directly linked to sacral edema. 33. Which of the following symptoms might a client with right-sided heart failure exhibit? a. Adequate urine output b. Polyuria c. Oliguria d. Polydipsia Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria. Adequate urine output, polyuria, and polydipsia arent associated with right-sided heart failure. 34. Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? a. Beta-adrenergic blockers b. Calcium channel blockers c. Diuretics d. Inotropic agents Inotropic agents are administered to increase the force of the hearts contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart. 35. Stimulation of the sympathetic nervous system produces which of the following responses?

a. Bradycardia b. Tachycardia c. Hypotension d. Decreased myocardial contractility Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. The other symptoms listed are related to the parasympathetic nervous system, which is responsible for slowing the heart rate. 36. Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? a. Angina pectoris b. Cardiomyopathy c. Left-sided heart failure d. Right-sided heart failure Weight gain, nausea, and a decrease in urine output are secondary effects of rightsided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesnt cause weight gain, nausea, or a decrease in urine output. 37. What is the most common cause of abdominal aortic aneurysm? a. Atherosclerosis b. DM c. HPN d. Syphilis Atherosclerosis accounts for 75% of all abdominal aortic aneurysms. Plaques build up on the wall of the vessel and weaken it, causing an aneurysm. Although the other conditions are related to the development of an aneurysm, none is a direct cause. 38. In which of the following areas is an abdominal aortic aneurysm most commonly located? a. Distal to the iliac arteries b. Distal to the renal arteries c. Adjacent to the aortic branch d. Proximal to the renal arteries The portion of the aorta distal to the renal arteries is more prone to an aneurysm because the vessel isnt surrounded by stable structures, unlike the proximal portion of the aorta. Distal to the iliac arteries, the vessel is again surrounded by stable vasculature, making this an uncommon site for an aneurysm. There is no area

adjacent to the aortic arch, which bends into the thoracic (descending) aorta. 39. A pulsating abdominal mass usually indicates which of the following conditions? a. Abdominal aortic aneurysm b. Enlarged spleen c. Gastic distention d. Gastritis The presence of a pulsating mass in the abdomen is an abnormal finding, usually indicating an outpouching in a weakened vessel, as in abdominal aortic aneurysm. The finding, however, can be normal on a thin person. Neither an enlarged spleen, gastritis, nor gastic distention cause pulsation. 40. What is the most common symptom in a client with abdominal aortic aneurysm? a. Abdominal pain b. Diaphoresis c. Headache d. Upper back pain Abdominal pain in a client with an abdominal aortic aneurysm results from the disruption of normal circulation in the abdominal region. Lower back pain, not upper, is a common symptom, usually signifying expansion and impending rupture of the aneurysm. Headache and diaphoresis arent associated with abdominal aortic aneurysm. 41. Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? a. Abdominal pain b. Absent pedal pulses c. Angina d. Lower back pain Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdominal cavity, and the pain is referred to the lower back. Abdominal pain is most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Angina is associated with atherosclerosis of the coronary arteries. 42. What is the definitive test used to diagnose an abdominal aortic aneurysm? a. Abdominal X-ray b. Arteriogram c. CT scan

d. Ultrasound An arteriogram accurately and directly depicts the vasculature; therefore, it clearly delineates the vessels and any abnormalities. An abdominal aneurysm would only be visible on an X-ray if it were calcified. CT scan and ultrasound dont give a direct view of the vessels and dont yield as accurate a diagnosis as the arteriogram. 43. Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client? a. HPN b. Aneurysm rupture c. Cardiac arrythmias d. Diminished pedal pulses Rupture of the aneurysm is a life-threatening emergency and is of the greatest concern for the nurse caring for this type of client. Hypertension should be avoided and controlled because it can cause the weakened vessel to rupture. Diminished pedal pulses, a sign of poor circulation to the lower extremities, are associated with an aneurysm but isnt life threatening. Cardiac arrhythmias arent directly linked to an aneurysm. 44. Which of the following blood vessel layers may be damaged in a client with an aneurysm? a. Externa b. Interna c. Media d. Interna and Media The factor common to all types of aneurysms is a damaged media. The media has more smooth muscle and less elastic fibers, so its more capable of vasoconstriction and vasodilation. The interna and externa are generally no damaged in an aneurysm. 45. When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated? a. Right upper quadrant b. Directly over the umbilicus c. Middle lower abdomen to the left of the midline d. Midline lower abdomen to the right of the midline The aorta lies directly left of the umbilicus; therefore, any other region is inappropriate for palpation. 46. Which of the following conditions is linked to more than 50% of clients with

abdominal aortic aneurysms? a. DM b. HPN c. PVD d. Syphilis Continuous pressure on the vessel walls from hypertension causes the walls to weaken and an aneurysm to occur. Atherosclerotic changes can occur with peripheral vascular diseases and are linked to aneurysms, but the link isnt as strong as it is with hypertension. Only 1% of clients with syphilis experience an aneurysm. Diabetes mellitus doesnt have direct link to aneurysm. 47. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client? a. Bruit b. Crackles c. Dullness d. Friction rubs A bruit, a vascular sound resembling heart murmur, suggests partial arterial occlusion. Crackles are indicative of fluid in the lungs. Dullness is heard over solid organs, such as the liver. Friction rubs indicate inflammation of the peritoneal surface. 48. Which of the following groups of symptoms indicated a ruptured abdominal aneurysm? a. Lower back pain, increased BP, decreased RBC, increased WBC b. Severe lower back pain, decreased BP, decreased RBC, increased WBC c. Severe lower back pain, decreased BP, decreased RBC, decreased WBC d. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it cant 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 wouldnt increase. For the same reason, the RBC count is decreased not increase. The WBC count increases as cells migrate to the site of injury. 49. Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area? a. Hernia b. Stage 1 pressure ulcer c. Retroperitoneal rupture at the repair site d. Rapid expansion of the aneurysm Blood collects in the retroperitoneal space and is exhibited as a hematoma in the

perineal area. This rupture is most commonly caused by leakage at the repair site. A hernia doesnt cause vascular disturbances, nor does a pressure ulcer. Because no bleeding occurs with rapid expansion of the aneurysm, a hematoma wont form. 50. Which hereditary disease is most closely linked to aneurysm? a. Cystic fibrosis b. Lupus erythematosus c. Marfan's syndrome d. Myocardial infarction Marfans syndrome results in the degeneration of the elastic fibers of the aortic media. Therefore, clients with the syndrome are more likely to develop an aortic aneurysm. Although cystic fibrosis is hereditary, it hasnt been linked to aneurysms. Lupus erythematosus isnt hereditary. Myocardial infarction is neither hereditary nor a disease. 51. Which of the following treatments is the definitive one for a ruptured aneurysm? a. Antihypertensive medication administration b. Aortogram c. Beta-adrenergic blocker administration d. Surgical intervention When the vessel ruptures, surgery is the only intervention that can repair it. Administration of antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm. 52. Which of the following heart muscle diseases is unrelated to other cardiovascular disease? a. Cardiomyopathy b. Coronary artery disease c. Myocardial infarction d. Pericardial Effusion Cardiomyopathy isnt usually related to an underlying heart disease such as atherosclerosis. The etiology in most cases is unknown. Coronary artery disease and myocardial infarction are directly related to atherosclerosis. Pericardial effusion is the escape of fluid into the pericardial sac, a condition associated with pericarditis and advanced heart failure. 53. Which of the following types of cardiomyopathy can be associated with childbirth? a. Dilated

b. Hypertrophic c. Myocarditis d. Restrictive Although the cause isnt entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy of the first few months after birth. The condition may result from a preexisting cardiomyopathy not apparent prior to pregnancy. Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a strong familial tendency. Myocarditis isnt specifically associated with childbirth. Restrictive cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually myocardial. 54. Septal involvement occurs in which type of cardiomyopathy? a. Congestive b. Dilated c. Hypertrophic d. Restrictive In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum not the ventricle chambers is apparent. This abnormality isnt seen in other types of cardiomyopathy. 55. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? a. Heart failure b. DM c. MI d. Pericardial effusion Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. Myocardial infarction results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with percarditis. Diabetes mellitus is unrelated to cardiomyopathy. 56. What is the term used to describe an enlargement of the heart muscle? a. Cardiomegaly b. Cardiomyopathy c. Myocarditis d. Pericarditis Cardiomegaly denotes an enlarged heart muscle. Cardiomyopathy is a heart muscle disease of unknown origin. Myocarditis refers to inflammation of heart muscle.

Pericarditis is an inflammation of the pericardium, the sac surrounding the heart. 57. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? a. Pericarditis b. Hypertension c. Obliterative d. Restricitive These are the classic symptoms of heart failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances and a flushed face. Myocardial infarction causes heart failure but isnt related to these symptoms. 58. Which of the following types of cardiomyopathy does not affect cardiac output? a. Dilated b. Hypertrophic c. Restrictive d. Obliterative Cardiac output isnt affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Dilated cardiomyopathy, and restrictive cardomyopathy all decrease cardiac output. 59. Which of the following cardiac conditions does a fourth heart sound (S4) indicate? a. Dilated aorta b. Normally functioning heart c. Decreased myocardial contractility d. Failure of the ventricle to eject all the blood during systole An S4 occurs as a result of increased resistance to ventricular filling adterl atrial contraction. This increased resistance is related to decrease compliance of the ventricle. A dilated aorta doesnt cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An s4 isnt heard in a normally functioning heart. 60. Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? a. Antihypertensive b. Beta-adrenergic blockers c. Calcium channel blockers d. Nitrates By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of

cardiomyopathy. Antihypertensives arent usually indicated because they would decrease cardiac output in clients who are often already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-adrenergic blockers; however, they arent as effective as beta-adrenergic blockers and cause increase hypotension. Nitrates arent used because of their dilating effects, which would further compromise the myocardium.