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ANSWERS & RATIONALES-COMPRE 1-A Question 1. Which nursing diagnosis is applicable to all types of shock? 1.

Decreased cardiac output 2. Fluid volume deficit 3. Peripheral neurovascular dysfunction 4. Altered tissue perfusion Looking for answers(s !" #$planation! A is %&'())#'* because cardiac output is decreased primarily with cardiogenic shock+ , is %&'())#'* because fluid volume is affected primarily with hypovolemic shock+ ' is %&'())#'* because peripheral neurovascular problems occur with distributive types of shock- i+e+ neurogenic and vasogenic shock+ D is CORRECT be !use "e#!"$%ess o& t'e t()e o& s'o *+ t'e"e is )oo" )e"&usion !n$ tissue hypo$ia+ Question 2. What is the most important nursing diagnosis for a client with a newly diagnosed myocardial infarction? 1. %neffective breathing pattern 2. Activity intolerance 3. Altered tissue perfusion 4. Fluid volume e$cess Looking for answers(s !. #$planation! A is %&'())#'* because ineffective breathing pattern is not the primary concern/ however- if the heart fails- there may also be pulmonary congestion- and ultimately breathing will be affected+ , is %&'())#'* because this is not the primary problem/ however- activity intolerance may be a secondary concern+ ' is '())#'* because an 0% means there has been damage to the heart muscle/ as a result- the efficiency of the heart as a pump (and therefore the cardiac output may be affected- leading to inade1uate tissue perfusion+ D is %&'())#'* because this is not the initial problem/ however- compensatory sodium and water retention may increase the vascular volume- which could be e$cessive for this client+ Question 3. *he nurse should tell the client who is elderly that an important advantage of outpatient surgery- especially given the client2s age- would be! 1. 3reater satisfaction with the surgical e$perience 2. #arlier return to full4time work responsibilities 3. De "e!se$ e,)osu"e to 'os)it!% in&e tions 4. Less psychological stress than hospitali5ation Question 4. *he nurse can e$pect that a client admitted for a myocardial infarction will most likely develop which type of shock?

1. &eurogenic 2. 6asogenic 3. 7ypovolemic 4. C!"$io#eni Question -. *he nurse arrives at the site of an airplane crash and finds the following clients+ Which client should be checked first? *he client with! 1. 'losed fracture of the humerus 2. Full thickness (.rd and "th degree burns over the torso 3. Partial4thickness (8st degree on the face and neck 4. Laceration to the forehead- who is wandering among the wreckage asking for help Looking for answers(s !. #$planation! A is %&'())#'* because this client is not in immediate danger of respiratory or cardiac dysfunction+ , is %&'())#'* because- although this client is severely in9ured and will need intensive care- the client with a compromised airway should be checked first+ ' is '())#'* because clients with burns on the head- neck- and face may have inhalation in9ury which impairs respiratory function+ )emember the A,'s of 'P)! airway is first+ D is %&'())#'* because- although the possibility of a head in9ury e$ists- this client is awake and ambulatory at this time+ Question .. What is the priority in caring for an older adult? 1. *o provide a pain4free state 2. *o allow dependence if needed 3. *o maintain functional independence 4. *o provide home rehabilitation Looking for answers(s !. #$planation! A is %&'())#'* because a pain4free state may not be possible+ Pain management is important- but a complete lack of pain may be unattainable+ , is %&'())#'* because dependence is not the priority goal of care- although it is allowed when needed+ ' is '())#'* because the goal of care in the older adult is to achieve the optimal level of functioning for the client2s age+ D is %&'())#'* because the goal is optimal functioning/ rehabilitation may be the means of achieving that goal+ Question /. After surgical repair of an abdominal aortic aneurysm- what is the most important reason for the client to avoid sharp fle$ion of the hips? 1. *he peripheral pulses will be diminished 2. 6enous return will be impaired 3. Int"!-!b$o0in!% )"essu"e 1i%% be in "e!se$ 4. *hrombus formation in the leg may occur Question 2. What is the primary nursing diagnosis for the client in shock?

1. Fluid volume deficit 2. Altered tissue perfusion 3. 7igh risk for in9ury 4. %mpaired gas e$change Looking for answers(s !: #$planation! A is %&'())#'* because volume deficit is the problem for hypovolemic shock only+ , is '())#'* because all types of shock alter tissue perfusion+ ' is %&'())#'* because this diagnosis is too broad+ D is %&'())#'* because there is no problem at the gas e$change level/ rather- there is insufficient perfusion to the capillary bed+ '(D#;! A&- APP- <- Ph%- Physiological adaptation 0ed4;urg Question 3. Following a fall at home- what information would alert the nurse that the =>4 year4old client might be at risk for future falls? 1. A client lives alone in a single4story retirement apartment 2. T'e %ient #ets u) $u"in# t'e ni#'t to #o to t'e b!t'"oo0 3. *he client wears glasses following successful cataract surgery 4. *he client occasionally takes a *ylenol P0 to help sleep Question 14. *he nurse would know that the modified shock position is generally not used with which type of shock? 1. 7ypovolemic 2. 'ardiogenic 3. &eurogenic 4. Anaphylactic Looking for answers(s !: #$planation! A is %&'())#'* because- with this type of shock- an increase in venous return is desirable+ , is '())#'* because an increase in venous return may be contraindicated with cardiogenic shock- where the pump is failing- and cannot handle the circulating blood volume+ ' is %&'())#'* because- with this type of shock- an increase in venous return is desirable+ D is %&'())#'* because- with this type of shock- an increase in venous return is desirable+ Question 11. When caring for a client in shock- which position should the nurse implement? 1. 7ead lowered- legs elevated- keeping body straight 2. Legs elevated "? degrees- trunk hori5ontal 3. 7ead and trunk elevated .@ degrees- foot of bed lowered 4. ,ed flat- foot of bed raised on shock blocks Looking for answers(s !: #$planation! A is %&'())#'* because lowering the head and raising feet reduces

blood flow to the brain- and abdominal contents press on the diaphragm which impairs breathing+ , is '())#'* because the legs are elevated- but the head remains flat+ *his increases venous return- and does not impede pulmonary function+ ' is %&'())#'* because an elevated head will lower the blood pressure further+ D is %&'())#'* because placing the flat bed on shock blocks would have the same effect as lowering the head and raising the feet+ *his decreases cerebral blood flow- and puts pressure on the diaphragm from the abdominal contents+ Question 12. What is the greatest risk factor for developing a transient ischemic attack (*%A ? 1. ;edentary life4style 2. Family history of pulmonary embolism 3. 7istory of high blood pressure 4. (besity Looking for answers(s !. #$planation! A is %&'())#'* because inactivity is a risk factor for heart disease+ , is %&'())#'* because pulmonary embolism is not hereditary+ ' is '())#'* because high blood pressure would be associated with peripheral vascular or renal disease+ *%As are precursors to a stroke- which is often associated with a history of hypertension+ D is %&'())#'* because obesity is a risk factor for heart disease+ Question 13. What is the desired outcome for complete bedrest for a client with heart failure? 1. *emperature will be within normal limits 2. 7eart rate will be within normal limits 3. ,lood pressure will be within normal range 4. )espiratory rate will increase Looking for answers(s !: #$planation! A is %&'())#'* because bedrest does not directly affect the temperature+ *he metabolic rate is less during rest- so the temperature level should be normal as an indirect result+ , is '())#'* because the primary purpose of bedrest is to reduce the workload of the heart by reducing o$ygen consumption/ this would be assessed by the heart rate+ ' is %&'())#'* because this is not the best- most direct vital sign indicator of cardiac function+ %f the heart is working hard- the blood pressure will reflect the amount of resistance to blood flow+ D is %&'())#'* because this is not the best- most direct vital sign indicator of cardiac function+ %f the heart is not working effectively- the respiratory rate will increase in an attempt to provide more o$ygen+ Question 14. An elderly client has been placed in isolation because of tuberculosis+ Which action by the nurse would be helpful in preventing disorientation related to sensory deprivation?

1. Aeep the room lights on to provide visual stimulation+ 2. Put a clock on the bedside table for orientation+ 3. *ell the client about any procedures to be done+ 4. Provide a BWalkmanC and headset for listening to music+ Looking for answers(s !: #$planation! A is %&'())#'* because the constant lights would result in sensory overload+ *he lights should be turned on and off according to day and night cycles+ , is '())#'* because the best action is one that orients the client to time+ A calendar could also be hung in the room for further orientation+ ' is %&'())#'* because e$plaining procedures- while it is always important- will not keep the client oriented+ D is %&'())#'* because- even though music is a sensory stimulant- it will not orient the client- which is the intended goal+ Question 1-. %f cancer of the laryn$ is suspected- for which early sign or symptoms should the nurse assess? 1. 7oarseness 2. Dyspnea 3. Dysphagia 4. (ral lesions Looking for answers(s !8 #$planation! A is '())#'* because a change in voice 1uality- such as hoarsenesswill most likely be the first indication of a growth or tumor+ , is %&'())#'* because there will not be respiratory difficulty unless the tumor is obstructing the airway+ ' is %&'())#'* because- before the tumor would affect swallowing- there would have been an earlier symptom+ D is %&'())#'* because lesions would be found with oral cancer- not laryngeal cancer+ Question 1.. A woman in the second trimester of pregnancy has a history of rheumatic fever as a child+ For which potential problem should the nurse assess? 1. %ncreased blood pressure and urinary fre1uency 2. Proteinuria and increased serum creatinine 3. Ankle edema and weight gain 4. A murmur and complaint of increasing cough and sputum Looking for answers(s !" #$planation! A is %&'())#'* because the valvular incompetence might diminish cardiac output and renal perfusion+ Drine output would be less+ , is %&'())#'* because protein in the urine and a rising serum creatinine would indicate renal failure or insufficiency+ (6alvular incompetence would be treated before causing renal failure + ' is %&'())#'* because these signs are indicative of right4sided heart failure+ D is '())#'* because rheumatic fever often affects the mitral valve- resulting in valvular insufficiency or regurgitation+ *he increased preload and increased pulmonary vascular pressure will cause pulmonary congestion+

Question 1/. *he nurse reviews the history of a client with breast cancer+ Which factor should the nurse recogni5e as having placed the client at greater risk? 1. A family history of colon cancer 2. *aking birth control pills 3. 7aving breastfed her baby 4. A high fat diet Looking for answers(s !" #$planation! A is %&'())#'* because the risk increases with a family history of breast cancer in two close relatives- not colon cancer+ , is %&'())#'* because birth control pills are not associated with breast cancer+ ' is %&'())#'* because breastfeeding generally lessens the risk+ D is '())#'* because a high fat diet has been associated with an increased risk+ )educing the fat intake to :@E of dietary calories is the goal+ Question 12. Which finding would alert the nurse to a complication of the high osmolarity of *P& (hyperalimentation solution? 1. Development of ascites or third spacing of fluid 2. %ncreased blood pressure and pulse/ increased urine output 3. Decreased blood pressure and increased pulse/ decreased urine output 4. 7yperglycemia and hyperlipidemia Looking for answers(s !: #$planation! A is %&'())#'* because fluid moves into the vascular space+ With ascites- fluid moves out of the vascular space into the peritoneum+ , is '())#'* because the high glucose content causes fluid to shift from the interstitial and intracellular spaces into the intravascular space+ 'irculating volume increases/ vital signs and urine output will increase- indicating possible volume overload+ ' is %&'())#'* because the signs indicate volume depletion- not volume overload+ D is %&'())#'* because the osmolarity causes a shift of fluid+ *here is a risk of hyperglycemia- but not increased lipids (unless lipids are also being given + Question 13. Following an open repair of a compound fracture- the client suddenly complains of dyspnea- and is in obvious respiratory distress+ *he nurse should assess the client for which of the following? 1. Fat emboli 2. ;pontaneous pneumothora$ 3. Pneumonia 4. Atelectasis Looking for answers(s !8 #$planation! A is '())#'* because fractures- particularly of long bones or those with high marrow fat- increase the risk of fat being released into the circulation+ *he urine may appear BfattyC as a warning+ *he biggest concern is destruction of lung tissue leading to respiratory failure if the emboli lodge in the lung+ , is %&'())#'* because the nurse would not e$pect a pneumothora$ with a compound fracture (although the symptoms are similar + ' is %&'())#'* because pneumonia does not have a sudden onset+

D is %&'())#'* because atelectasis does not have a sudden onset+ Question 24. An >"4year4old client is admitted- diaphoretic and shivering- with a fever of 8@:+>FF of unknown origin+ *he nurse knows the client is at highest risk for which electrolyte imbalance? 1. 7yponatremia 2. 5()e" !% e0i! 3. 7ypokalemia 4. 7ypermagnesemia Question 21. What is the most appropriate nursing action for a client e$periencing nausea- vomiting and diarrhea associated with radiation therapy? 1. )ecord the intake and output accurately 2. 3ive an antiemetic before the treatment 3. (ffer a carbonated beverage before the treatment 4. (ffer soda crackers or dry toast before the treatment Looking for answers(s !: #$planation! A is %&'())#'* because the nursing action should be to prevent or minimi5e side effects/ recording the intake and output does nothing to lessen the effects+ , is '())#'* because an antiemetic before the treatment may prevent or minimi5e the side effects+ *he drug should be given 8 hour before the radiation+ ' is %&'())#'* because carbonated beverages may aggravate the symptoms+ %f oral fluids are takenthey should be uncarbonated- or Bflat+C D is %&'())#'* because the effects of radiation will not respond to dry toast or crackers+ (*hese may help with nausea from other causes- like pregnancy or motion sickness + Question 22. What initial nursing diagnosis is most important for the client in heart failure? 1. Activity intolerance 2. Fatigue 3. ;elf4care deficit 4. Altered tissue perfusion Looking for answers(s !" #$planation! A is %&'())#'* because- as a result of poor o$ygenation- the client will have activity intolerance+ ,ut initially- the client will be on bedrest anyway+ , is %&'())#'* because- as a result of poor o$ygenation- the client will have fatigue+ ,ut initially- the client will be on bedrest anyway+ ' is %&'())#'* because if treatment is ineffective- self4care problems will be a concern prior to discharge+ D is '())#'* because- regardless of the type of heart failure- the main problem is ineffective tissue perfusion+ Question 23. A correct e$planation given by the )& to the nursing student of the difference between primary (essential and secondary hypertension would include the fact that!

1. T'e !use o& )"i0!"( '()e"tension is un*no1n 2. *he ma9ority of clients have secondary hypertension 3. ;ystolic pressure is higher with secondary hypertension 4. Primary hypertension is due to pathological causes Question 24. %n assessing a client with right4side involvement from a transient ischemic attack (*%A - which symptom in the right arm should the nurse anticipate that this client would most likely e$perience? 1. 0uscle spasm 2. Weakness 3. ;welling 4. *remors Looking for answers(s !: #$planation! A is %&'())#'* because spasms are not seen with a *%A+ ;pasticity may occur following a stroke+ , is '())#'* because a *%A causes temporary weakness of the limb+ Without intervention- the client will likely have a cerebral vascular accident with the potential for permanent loss of neurological function+ ' is %&'())#'* because swelling or edema is not associated with a *%A+ D is %&'())#'* because tremors are not seen with a *%A+ Question 2-. *he nurse is completing a preoperative history on the client+ *he client is allergic to late$+ What other allergies might this client have? 1. %ndustrial solvents and perfume 2. Avocados and bananas 3. #c5ema 4. 'ats and dogs Looking for answers(s !: #$planation! A is %&'())#'* because allergies to industrial solvents and perfumes do not correlate with late$ allergies+ , is '())#'* because individuals with allergies to avocados- bananas- kiwischestnuts- ha5elnuts- tomatoes- potatoes- peaches- grapes- and apricots are at risk for being allergic to late$+ ' is %&'())#'* because ec5ema is a manifestation of an allergy- not an allergy itself+ D is %&'())#'* because allergies to cats and dogs do not correlate with late$ allergies+ Question 2.. Which nursing diagnosis is a priority on admission of a client with a '6A? 1. %mpaired physical mobility 2. ;elf4care deficit 3. Altered nutrition 4. Altered tissue perfusion Looking for answers(s !8 #$planation! A is '())#'* because the greatest concerns for the client following a '6A are complications of immobility- such as pneumonia+

, is %&'())#'* because this is not the initial priority- but will be a concern at the time of discharge+ ' is %&'())#'* because this is not the initial priority/ monitoring for dysphagia will be an ongoing assessment+ D is %&'())#'* because tissue perfusion would be altered if the client developed pneumonia/ moreover- the better nursing diagnoses would be ineffective breathing pattern or ineffective airway clearance+ Question 2/. Which response by the client would indicate a possible problem with altered self4concept following a mastectomy? 1. )efusing her tray at dinner 2. )e1uesting pain medication fre1uently 3. Asking for a robe when walking in the hall 4. 'oncern about what to wear home Looking for answers(s !" #$planation! A is %&'())#'* because lack of appetite would be more consistent with ineffective individual coping+ , is %&'())#'* because re1uesting fre1uent pain medication would indicate a problem with pain management+ ' is %&'())#'* because wearing a robe is normal for a hospitali5ed client+ D is '())#'* because e$pressed concern about appearance may indicate altered self4concept+ A representative from a support group such as )each for )ecovery may be contacted to talk to the client before discharge+ Question 22. A client is admitted because of dysrhythmia- and a pacemaker is being considered+ *he client is found unresponsive- and the heart rate is "@ beats per minute+ Which nursing action would be appropriate? 1. 'all a code- and start 'P) immediately 2. Assess the client for the cause of unresponsiveness 3. 3ive atropine %6 per order 4. Prepare the client for pacemaker insertion Looking for answers(s !. #$planation! A is %&'())#'* because 'P) is not done if a pulse is present+ , is %&'())#'* because the client needs immediate intervention to restore the heart rate to a normal level+ ' is '())#'* because atropine is the drug of choice for bradycardia+ *he drug will increase A6 conduction and the pulse rate+ D is %&'())#'* because the pacemaker insertion will likely be done after the client has been stabili5ed+ Question 23. *he nurse should assess for indications of impaired wound healing in the older adult because of which normal aging process? 1. Decreased inflammatory response 2. Decreased skin turgor 3. 'hange in skin p7 4. Loss of subcutaneous fat

Looking for answers(s !8 #$planation! A is '())#'* because the first phase of wound healing is inflammationwhich includes phagocytosis- a fundamental step for wound healing+ With aging- the inflammatory response is not as effective- which delays wound healing+ , is %&'())#'* because the amount of moisture in the skin does not affect wound healing- but contributes to breakdown+ ' is %&'())#'* because skin p7 may contribute to infection- but it is the diminished immune system that delays healing+ D is %&'())#'* because a loss of subcutaneous fat would actually improve healingsince fat is avascular+ '(D#;! A&- A&L- 8- 7P0- 7ealth promotion and maintenance 0ed4;urg Question 34. *he client is to receive :@@ mL of %6 fluids hourly because of pancreatitis+ What is the best e$planation for the high %6 fluid volume? 1. Dehydration has occurred from persistent vomiting 2. 7yperglycemia has caused an osmotic diuresis 3. Fluid has shifted into the retroperitoneal space 4. Pleural effusion of the left lung has reduced volume Looking for answers(s !. #$planation! A is %&'())#'* because even though persistent vomiting brought on by pain and decreased peristalsis may be present- the hypovolemia results from the effects of kinin+ , is %&'())#'* because even though some degree of islet involvement (glucose intolerance may be present- the hypovolemia is due to the effects of kinin+ ' is '())#'* because kinin is released with pancreatitis- causing peripheral vasodilation and increased vascular permeability- allowing fluid to shift into the retroperitoneal space- and thereby causing hypovolemia+ D is %&'())#'* because even though left lung pleural effusion is presenthypovolemia would not result from the presence of fluid in the pleural space+ Question 31. *he client tells the nurse she is upset about the alopecia which is going to occur from chemotherapy+ What is the best response by the nurse? 1. ;uggest a permanent- to give the hair body and prevent loss 2. *ell her to brush her hair vigorously to prevent loss 3. ;uggest she start wearing a wig before the hair is gone 4. Dse a medicated shampoo on the client- to prevent scalp irritation Looking for answers(s !. #$planation! A is %&'())#'* because a permanent will not prevent hair loss+ %t may actually destroy the hair and irritate the scalp- which may become infected+ , is %&'())#'* because the vigorous brushing will not prevent hair loss- and may traumati5e the scalp- which may become infected+ ' is '())#'* because wearing a wig before the hair is completely gone will make the change less noticeable to others+ 7ats or other head covering may also be worn+ D is %&'())#'* because the scalp will not be irritated with alopecia- but may become irritated by the shampoo+

Question 32. A client has a positive 'hvostek2s+ What electrolyte imbalance does this demonstrate? 1. 7ypoglycemia 2. 7yponatremia 3. 5()o !% e0i! 4. 7ypokalemia Question 33. Which response by the client indicates a lack of understanding about the warning signs of cancer? 1. BI '!6e '!$ t'is 0o%e &o" (e!"s+ so ! '!n#e is "e!%%( not'in# to 1o""( !bout.7 2. B%f this sore isn2t gone in a few weeks- %2ll call my doctor+C 3. B%2ve been having bloody vaginal drainage which % need to have checked+C 4. B%2ve made an appointment to have this lump in my breast checked+C Question 34. Assessment findings of a client with mitral valve regurgitation would most likely include which manifestation? 1. Dependent edema 2. 7epatomegaly 3. 7acking cough 4. &ail bed cyanosis Looking for answers(s !. #$planation! A is %&'())#'* because dependent edema would be seen in tricuspid insufficiency or right4sided heart failure- when the blood and increased preload would affect systemic circulation+ , is %&'())#'* because organ enlargement would be seen if the blood was backing up into the systemic circulation due to increased right4sided preload+ ' is '())#'* because regurgitation will increase preload and pulmonary vascular pressure+ *here will be pulmonary congestion- a cough- and dyspnea- if severe+ D is %&'())#'* because nail4bed cyanosis would be seen with poor peripheral circulation or as a late sign of hypo$ia+ Question 3-. Which assessment finding should the nurse determine to be consistent with dehydration? 1. *achycardia 2. Gugular vein distention 3. Warm- moist skin 4. Low urine specific gravity Looking for answers(s !8 #$planation! A is '())#'* because tachycardia would be seen with dehydration+ *he rapid heart rate would indicate a low circulation volume+ , is %&'())#'* because 9ugular vein distention would be inconsistent with dehydration+ G6D reflects heart failure and volume overload+ ' is %&'())#'* because dry- scaly skin would be seen with dehydration+ ;kin turgor is an indication of fluid status+ *he amount of water in the skin diminishes with age+

D is %&'())#'* because a high urine specific gravity would be consistent with dehydration+ *he urine would be concentrated- and the specific gravity would be highlikely above 8+@.@+ Question 3.. *he nurse e$pects edema formation with malnutrition- burns- and liver disease because in these conditions there is! 1. %ncreased aldosterone production 2. Decreased capillary osmotic pressure 3. %ncreased capillary osmotic pressure 4. Decreased systemic blood pressure Looking for answers(s !: #$planation! A is %&'())#'* because- in these conditions- there is no direct stimulation of the adrenals to increase the release of aldosterone+ (%ncreased aldosterone causes sodium and water retention/ if there is a decrease in circulating volume as a result of these conditions- aldosterone will be released as a compensatory response + , is '())#'* because all of these conditions have low blood albumin levels- which decreases the capillary osmotic pressure+ *he hydrostatic pressure is greater than the osmotic pressure- so fluid moves into the interstitial space- causing edema+ ' is %&'())#'* because the blood albumin level is decreased in these conditions/ it does not cause the capillary osmotic pressure to increase+ With the low albumin levelfluid moves into the interstitial space+ D is %&'())#'* because the primary problem with these conditions is not hypotension- but rather a loss of blood albumin- which controls the capillary osmotic pressure+ Question 3/. A client2s vital signs are as follows! ,PHI:J?@/ PH88:/ )4:@/ '6P4.+ 7ow do these assessment findings influence nursing intervention? 1. 3ive digo$in- as vital signs indicate heart failure 2. Anticipate the need for fluids- as hypovolemia may be present 3. Place the client in modified *rendelenburg immediately 4. 'ontinue to monitor vital signs- as no other action is needed Looking for answers(s !: #$planation! A is %&'())#'* because heart failure will show an elevated '6Pindicating inability to handle the circulating blood volume+ , is '())#'* because the vital signs are consistent with hypovolemia+ ' is %&'())#'* because fluids should be given first+ *he '6P will not increase with positioning- and it is the most significant value+ D is %&'())#'* because the vital signs are not normal- and nursing actions are needed+ Question 32. What urine assessment finding would be present in a client with diabetes insipidus? 1. Presence of white blood cells 2. %ncreased protein

3. Decreased urine p7 4. De "e!se$ s)e i&i #"!6it( Question 33. *he nurse directs the nursing assistant to provide mouth care to a client with stomatitis who is receiving chemotherapy+ What direction should the nurse give the nursing assistant? 1. )inse the client2s mouth with normal saline 2. )inse the client2s mouth with hydrogen pero$ide 3. 6igorously brush and floss the client2s teeth 4. Follow brushing with an alcohol4based mouthwash Looking for answers(s !8 #$planation! A is '())#'* because normal saline can effectively clean the client2s mouth and is not irritating to inflamed tissues+ A topical anesthetic such as viscous Kylocaine can also be used to reduce discomfort of stomatitis+ , is %&'())#'* because hydrogen pero$ide is inappropriate to use on inflamed tissue or open wounds/ it will cause tissue damage and discomfort+ ' is %&'())#'* because- while it is important to brush and floss the client2s teeth- this should be done gently- not vigorously+ D is %&'())#'* because an alcohol4based mouthwash will irritate oral tissues and cause the client more pain+ Question 44. *he nurse2s assessment of a client with complete heart block will most likely reveal a history of! 1. ;yncope 2. Ata$ia 3. %nsomnia 4. *achycardia Looking for answers(s !8 #$planation! A is '())#'* because syncope- or fainting- may occur when severe bradycardia decreases cerebral tissue perfusion+ , is %&'())#'* because ata$ia would be seen with neurological problems+ ' is %&'())#'* because the client is more likely to be fatigued+ D is %&'())#'* because with heart block- the ventricular rate is dangerously slow+ Question 41. *he nurse knows that the primary goal of treatment in all types of shock is to increase! 1. Tissue )e"&usion 2. ;ympathetic innervation 3. 'irculating volume 4. 'ardiac contractility Question 42. Following a mastectomy- which client response would indicate appropriate adaptation to a body image disturbance? 1. Does her dressing change 2. 7olds her children on her lap

3. Denies any pain 4. Plans to keep her follow4up appointment Looking for answers(s !8 #$planation! A is '())#'* because the client2s ability to look at- touch- and care for her incision- reflects the beginning of the client2s ad9ustment to the change in body image+ , is %&'())#'* because the loss of a breast usually does not interfere with the maternal role identity+ %t may affect her role identity as a wife+ ' is %&'())#'* because relief of pain- and pain management would not indicate how the client is adapting to the body image change+ D is %&'())#'* because keeping follow4up appointments does not indicate her acceptance of- or ability to deal with- a change in body image+ Question 43. A client receiving radiation therapy for treatment of multiple myeloma has developed moderate leukopenia+ What is the priority for nursing care? 1. (bserve for bleeding 2. Prevent infection 3. Promote acceptance of death 4. 'onserve energy Looking for answers(s !: #$planation! A is %&'())#'* because low platelets- thrombocytopenia- would lead to a bleeding risk+ , is '())#'* because leukopenia is a decrease in the white blood cells below the normal of ?@@@+ *he chance of infection increases with a low W,'+ ' is %&'())#'* because prevention of infection will prolong life+ #ven though multiple myeloma is a terminal condition- radiation and chemotherapy will e$tend the client2s life+ D is %&'())#'* because this is not the priority for nursing care+ 'onserving energy will also be important- as the client will likely be fatigued with radiation therapy+ Question 44. Which physical assessment finding would be characteristic of breast cancer? 1. Palpable- movable lump 2. Dull ache in affected breast 3. Dark- cyanotic areola 4. Di0)%in# o6e" %u0) Question 4-. Which nursing action is most important for the client e$periencing hyperthyroidism? 1. %ncrease oral fluid intake 2. 0aintain physical activity 3. 0aintain a cool environment 4. (rient the client to surroundings Looking for answers(s !. #$planation! A is %&'())#'* because fluids are not the main nutritional need+ *he

client may need to eat si$ full meals daily because of the e$cessive appetite and weight loss+ , is %&'())#'* because the client is e$periencing an accelerated metabolic rate- and needs rest- not e$ercise or increased environmental stimuli+ ' is '())#'* because the increased metabolic rate causes heat intolerance- so the client is most comfortable in a cool environment+ D is %&'())#'* because the client is not disoriented or confused+ Question 4.. Following a mastectomy for breast cancer- what is the best indication of the client2s ad9ustment to her altered body image? 1. Wanting to look at the incision 2. Putting on make4up and lipstick 3. *alking to friends about the surgery 4. Walking with her husband in the hall Looking for answers(s !8 #$planation! A is '())#'* because looking at the change in her body is the beginning step in acceptance+ , is %&'())#'* because the change has not been with her face+ Also- she may not normally wear significant make4up+ ' is %&'())#'* because there is no indication of what she is saying to her friends+ D is %&'())#'* because walking with a spouse does not indicate that there has been any acceptance of the body image change+ Question 4/. Following a femoral4popliteal bypass graft- which assessment finding in the client should the nurse report immediately? 1. Warm toes with some mottling 2. 7ourly urine output of =@ mL 3. Absent pedal pulse 4. ,lood pressure! 8@>J?> Looking for answers(s !. #$planation! A is %&'())#'* because this finding would be normal postoperatively+ , is %&'())#'* because this finding would be normal postoperatively+ ' is '())#'* because absence of a distal peripheral pulse may indicate graft obstruction or tearing+ D is %&'())#'* because this finding would be normal postoperatively+ Question 42. During health teaching- the nurse should counsel a client who is post40% that the position re1uiring the least amount of e$ertion when resuming se$ual activity is! 1. 'ardiac4client prone 2. ;ide4lying for both partners 3. Whatever position the client chooses 4. ;itting or standing with back supported Looking for answers(s !: #$planation! A is %&'())#'* because there would be e$cessive e$ertion by the client+ , is '())#'* because there are two positions that re1uire the least amount of e$ertion

for the cardiac client- supine and side4lying+ %n these positions- the amount of e$ertion is usually no greater than climbing a flight of stairs+ ' is %&'())#'* because there would be e$cessive e$ertion by the client+ D is %&'())#'* because there would be e$cessive e$ertion by the client+ Question 43. *he nurse would conclude the client is e$periencing left4sided heart failure when which of the following is observed? 1. Abdominal distention 2. Gugular venous distention 3. ;wollen ankles bilaterally 4. 'rackles on auscultation Looking for answers(s !" #$planation! A is %&'())#'* because abdominal distention is not an indication of left4 sided failure+ 'auses may be gas distention- ascites- or 3% bleeding+ , is %&'())#'* because G6D is a sign of right4sided heart failure+ ' is %&'())#'* because ankle or dependent edema is a sign of right4sided heart failure+ D is '())#'* because left4sided heart failure causes backward effects leading to pulmonary congestion+ *he pulmonary artery catheter reading would reflect an increase in the PAWP+ *he forward effects will be diminished cardiac output- and poor peripheral perfusion+ Question -4. Dpon discharge- a client with heart failure should be instructed to notify the 0D if which change occurs? 1. Weight increased by . lbs in one week 2. Pulse rate slows to <@H=@ beatsJmin 3. ,ody temperature drops to I=+>FF 4. Drinary output e$ceeds 8@@@ mL daily Looking for answers(s !8 #$planation! A is '())#'* because an increase in weight is likely due to fluid retention and should be reported+ Weight changes are an accurate reflection of fluid volume+ , is %&'())#'* because the slowing of the pulse could be a desired effect of digo$inan inotropic drug used to treat heart failure+ ' is %&'())#'* because a temperature of I=+>FF is not abnormal+ D is %&'())#'* because a urine output of greater than 8@@@ mL will likely be a desired effect of prescribed diuretics+

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