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21. A 21 year-old male has been seen in the 25. For a client newly diagnosed with radiation-
clinic for a thickening in his right testicle. The induced thrombocytopenia, the nurse should
physician ordered a human chorionic include which intervention in the plan of care?
gonadotropin (HCG) level. The nurse’s A. Administer aspirin if the temperature exceeds
explanation to the client should include the fact 38.8º C.
that: B. Inspect the skin for petechiae once every
A. The test will evaluate prostatic function. shift.
B. The test was ordered to identify the site of a C. Provide for frequent periods of rest.
possible infection. D. Place the client in strict isolation.
C. The test was ordered because clients who
have testicular cancer has elevated levels of ANS: B
HCG. Because thrombocytopenia impairs blood
D. The test was ordered to evaluate the clotting, the nurse should assess the client
testosterone level. regularly for signs of bleeding, such as
petechiae, purpura, epistaxis, and bleeding
ANS: C gums. The nurse should avoid administering
HCG is one of the tumor markers for testicular aspirin because it can increase the risk of
cancer. The HCG level won’t identify the site of bleeding. Frequent rest periods are indicated for
an infection or evaluate prostatic function or clients with anemia, not thrombocytopenia. Strict
testosterone level. isolation is indicated only for clients who have
highly contagious or virulent infections that are
22. A client is receiving captopril (Capoten) for spread by air or physical contact.
heart failure. The nurse should notify the
physician that the medication therapy is 26. A client is chronically short of breath and yet
ineffective if an assessment reveals: has normal lung ventilation, clear lungs, and an
A. A skin rash. arterial oxygen saturation (SaO2) 96% or better.
B. Peripheral edema. The client most likely has:
C. A dry cough. A. poor peripheral perfusion
D. Postural hypotension. B. a possible Hematologic problem
C. a psychosomatic disorder
ANS: B D. left-sided heart failure
Peripheral edema is a sign of fluid volume
overload and worsening heart failure. A skin ANS: B
rash, dry cough, and postural hypotension are SaO2 is the degree to which hemoglobin is
adverse reactions to captopril, but the don’t saturated with oxygen. It doesn’t indicate the
indicate that therapy isn’t effective. client’s overall Hgb adequacy. Thus, an
individual with a subnormal Hgb level could have
23. Which assessment finding indicates normal SaO2 and still be short of breath. In this
dehydration? case, the nurse could assume that the client has
A. Tenting of chest skin when pinched. a Hematologic problem. Poor peripheral
B. Rapid filling of hand veins. perfusion would cause subnormal SaO2. There
C. A pulse that isn’t easily obliterated. isn’t enough data to assume that the client’s
D. Neck vein distention problem is psychosomatic. If the problem were
left-sided heart failure, the client would exhibit
pulmonary crackles.
ANS: C
27. For a client in addisonian crisis, it would be Caffeine is a stimulant, which can exacerbate
very risky for a nurse to administer: palpitations and should be avoided by a client
A. potassium chloride with symptomatic mitral valve prolapse. High-
B. normal saline solution fluid intake helps maintain adequate preload and
C. hydrocortisone cardiac output. Aerobic exercise helps in
D. fludrocortisone increase cardiac output and decrease heart rate.
Protein-rich foods aren’t restricted but high-
ANS: A calorie foods are.
Addisonian crisis results in Hyperkalemia;
therefore, administering potassium chloride is 31. A client with a history of hypertension is
contraindicated. Because the client will be diagnosed with primary hyperaldosteronism.
hyponatremic, normal saline solution is This diagnosis indicates that the client’s
indicated. Hydrocortisone and fludrocortisone hypertension is caused by excessive hormone
are both useful in replacing deficient adrenal secretion from which organ?
cortex hormones. A. adrenal cortex
B. pancreas
28. The nurse is reviewing the laboratory report C. adrenal medulla
of a client who underwent a bone marrow D. parathyroid
biopsy. The finding that would most strongly
support a diagnosis of acute leukemia is the ANS: A
existence of a large number of immature: Excessive of aldosterone in the adrenal cortex is
A. lymphocytes responsible for the client’s hypertension. This
B. thrombocytes hormone acts on the renal tubule, where it
C. reticulocytes promotes reabsorption of sodium and excretion
D. leukocytes of potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
ANS: D metabolism. The adrenal medulla secretes the
Leukemia is manifested by an abnormal cathecolamines—epinephrine and
overpopulation of immature leukocytes in the norepinephrine. The parathyroids secrete
bone marrow. parathyroid hormone.
29. The nurse is performing wound care on a 32. A client has a medical history of rheumatic
foot ulcer in a client with type 1 diabetes fever, type 1 (insulin dependent) diabetes
mellitus. Which technique demonstrates surgical mellitus, hypertension, pernicious anemia, and
asepsis? appendectomy. She’s admitted to the hospital
A. Putting on sterile gloves then opening a and undergoes mitral valve replacement surgery.
container of sterile saline. After discharge, the client is scheduled for a
B. Cleaning the wound with a circular motion, tooth extraction. Which history finding is a major
moving from outer circles toward the center. risk factor for infective endocarditis?
C. Changing the sterile field after sterile water is A. appendectomy
spilled on it. B. pernicious anemia
D. Placing a sterile dressing ½” (1.3 cm) from C. diabetes mellitus
the edge of the sterile field. D. valve replacement
ANS: C ANS: D
A sterile field is considered contaminated when it A heart valve prosthesis, such as a mitral valve
becomes wet. Moisture can act as a wick, replacement, is a major risk factor for infective
allowing microorganisms to contaminate the endocarditis. Other risk factors include a history
field. The outside of containers, such as sterile of heart disease (especially mitral valve
saline bottles, aren’t sterile. The containers prolapse), chronic debilitating disease, IV drug
should be opened before sterile gloves are put abuse, and immunosuppression. Although
on and the solution poured over the sterile diabetes mellitus may predispose a person to
dressings placed in a sterile basin. Wounds cardiovascular disease, it isn’t a major risk factor
should be cleaned from the most contaminated for infective endocarditis, nor is an
area to the least contaminated area—for appendectomy or pernicious anemia.
example, from the center outward. The outer
inch of a sterile field shouldn’t be considered 33. A 62 yr-old client diagnosed with
sterile. pyelonephritis and possible septicemia has had
five urinary tract infections over the past two
30. A client with a forceful, pounding heartbeat is years. She’s fatigued from lack of sleep; urinates
diagnosed with mitral valve prolapse. This client frequently, even during the night; and has lost
should avoid which of the following? weight recently. Test reveal the following: sodium
A. high volumes of fluid intake level 152 mEq/L, osmolarity 340 mOsm/L,
B. aerobic exercise programs glucose level 125 mg/dl, and potassium level 3.8
C. caffeine-containing products mEq/L. which of the following nursing diagnoses
D. foods rich in protein is most appropriate for this client?
A. Deficient fluid volume related to inability to heartbeat. An electrocardiogram shows a heart
conserve water rate of 110 beats/minute (sinus tachycardia) with
B. Imbalanced nutrition: less than body frequent premature ventricular contractions.
requirements related to hypermetabolic state Shortly after admission, the client has ventricular
C. Deficient fluid volume related to osmotic tachycardia and becomes unresponsive. After
diuresis induced by hypernatremia successful resuscitation, the client is taken to
D. Imbalanced nutrition: less than body the intensive care unit. Which nursing diagnosis
requirements related to catabolic effects of is appropriate at this time?
insulin deficiency A. Deficient knowledge related to interventions
used to treat acute illness
ANS: A B. Impaired physical mobility related to complete
The client has signs and symptoms of diabetes bed rest
insipidus, probably caused by the failure of her C. Social isolation related to restricted visiting
renal tubules to respond to antidiuretic hormone hours in the intensive care unit
as a consequence of pyelonephritis. The D. Anxiety related to the threat of death
hypernatremia is secondary to her water loss.
Imbalanced nutrition related to hypermetabolic ANS: D
state or catabolic effect of insulin deficiency is an Anxiety related to the threat of death is an
inappropriate nursing diagnosis for the client. appropriate nursing diagnosis because the
client’s anxiety can adversely affect hear rate
34. A 20 yr-old woman has just been diagnosed and rhythm by stimulating the autonomic
with Crohn’s disease. She has lost 10 lb (4.5 kg) nervous system. Also, because the client
and has cramps and occasional diarrhea. The required resuscitation, the threat of death is a
nurse should include which of the following real and immediate concern. Unless anxiety is
when doing a nutritional assessment? dealt with first, the client’s emotional state will
A. Let the client eat as desired during the impede learning. Client teaching should be
hospitalization. limited to clear concise explanations that reduce
B. Weight the client daily. anxiety and promote cooperation. An anxious
C. Ask the client to list what she eats during a client has difficulty learning, so the deficient
typical day. knowledge would continue despite attempts t
D. Place the client on I & O status and draw teaching. Impaired physical mobility and social
blood for electrolyte levels. isolation are necessitated by the client’s critical
condition; therefore, they aren’t considered
ANS: C problems warranting nursing diagnoses.
When performing a nutritional assessment, one
of the first things the nurse should do is to 37. A client is admitted to the health care facility
assess what the client typically eats. The client with active tuberculosis. The nurse should
shouldn’t be permitted to eat as desired. include which intervention in the plan of care?
Weighing the client daily, placing her on I & O A. Putting on a mask when entering the client’s
status, and drawing blood to determine room.
electrolyte level aren’t part of a nutritional B. Instructing the client to wear a mask at all
assessment. times
C. Wearing a gown and gloves when providing
35. When instructions should be included in the direct care
discharge teaching plan for a client after D. Keeping the door to the client’s room open to
thyroidectomy for Grave’s disease? observe the client
A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP). ANS: A
C. Be sure to get regulate follow-up care. Because tuberculosis is transmitted by droplet
D. Be sure to exercise to improve cardiovascular nuclei from the respiratory tract, the nurse
fitness. should put on a mask when entering the client’s
room. Having the client wear a mask at all the
Regular follow-up care for the client with Grave’s times would hinder sputum expectoration and
disease is critical because most cases make the mask moist from respirations. If no
eventually result in hypothyroidism. Annual contact with the client’s blood or body fluids is
thyroid-stimulating hormone tests and the anticipated, the nurse need not wear a gown or
client’s ability to recognize signs and symptoms gloves when providing direct care. A client with
of thyroid dysfunction will help detect thyroid tuberculosis should be in a room with laminar air
abnormalities early. Intake and output is flow, and the door should be closed at all times.
important for clients with fluid and electrolyte
imbalances but not thyroid disorders. DDAVP is 38. The nurse is caring for a client who
used to treat diabetes insipidus. While exercise underwent a subtotal gastrectomy 24 hours
to improve cardiovascular fitness is important, earlier. The client has a nasogastric (NG) tube.
for this client the importance of regular follow-up The nurse should:
is most critical. A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of
36. A client comes to the emergency department nausea.
with chest pain, dyspnea, and an irregular C. Irrigate the NG tube gently with normal saline
solution. the lower airways. Whit standard procedures the
D. Reposition the NG tube if pulled out. other choices wouldn’t be at high risk.
71. A client is admitted to the hospital following a 74. The nurse is providing home care
burn injury to the left hand and arm. The client’s instructions to a client who has recently had a
burn is described as white and leathery with no skin graft. Which instruction is most important for
blisters. Which degree of severity is this burn? the client to remember?
A. first-degree burn A. Use cosmetic camouflage techniques.
B. second-degree burn B. Protect the graft from direct sunlight.
C. third-degree burn C. Continue physical therapy.
D. fourth-degree burn D. Apply lubricating lotion to the graft site.
ANS: C ANS: B
Third-degree burn may appear white, red, or To avoid burning and sloughing, the client must
black and are dry and leathery with no blisters. protect the graft from sunlight. The other three
There may be little pain because nerve endings interventions are all helpful to the client and his
have been destroyed. First-degree burns are recovery but are less important.
superficial and involve the epidermis only. There
is local pain and redness but no blistering. 75. a 28 yr-old female nurse is seen in the
Second-degree burn appear red and moist with employee health department for mild itching and
blister formation and are painful. Fourth-degree rash of both hands. Which of the following could
burns involve underlying muscle and bone be causing this reaction?
tissue. A. possible medication allergies
B. current life stressors she may be
72. The nurse is caring for client with a new experiencing
donor site that was harvested to treat a new C. chemicals she may be using and use of latex
burn. The nurse position the client to: gloves
A. allow ventilation of the site D. recent changes made in laundry detergent or
B. make the site dependent bath soap.
C. avoid pressure on the site
D. keep the site fully covered ANS: C
Because the itching and rash are localized, an
ANS: C environmental cause in the workplace should be
A universal concern I the care of donor sites for suspected. With the advent of universal
burn care is to keep the site away from sources precautions, many nurses are experiencing
of pressure. Ventilation of the site and keeping allergies to latex gloves. Allergies to
the site fully covered are practices in some medications, laundry detergents, or bath soaps
institutions but aren’t hallmarks of donor site or a dermatologic reaction to stress usually elicit
care. Placing the site in a position of a more generalized or widespread rash.
dependence isn’t a justified aspect of donor site
care. 76. The nurse assesses a client with urticaria.
The nurse understands that urticaria is another
73. a 45-yr-old auto mechanic comes to the name for:
physician’s office because an exacerbation of A. hives
his psoriasis is making it difficult to work. He tells B. a toxin
the nurse that his finger joints are stiff and sore C. a tubercle
in the morning. The nurse should respond by: D. a virus
A. Inquiring further about this problem because
psoriatic arthritis can accompany psoriasis ANS: A
vulgaris Hives and urticaria are two names for the same
B. Suggesting he take aspirin for relief because skin lesion. Toxin is a poison. A tubercle is a tiny
it’s probably early rheumatoid arthritis round nodule produced by the tuberculosis
C. Validating his complaint but assuming it’s an bacillus. A virus is an infectious parasite.
adverse effect of his vocation
D. Asking him if he has been diagnosed or 77. A client with psoriasis visits the dermatology
treated for carpal tunnel syndrome clinic. When inspecting the affected areas, the
nurse expects to see which type of secondary
ANS: A lesion?
Anyone with psoriasis vulgaris who reports joint A. scale
pain should be evaluated for psoriaic arthritis. B. crust
Approximately 15% to 20% of individuals with C. ulcer
psoriasis will also develop psoriatic arthritis, D. scar
which can be painful and cause deformity. It
would be incorrect to assume that his pain is ANS: A
caused by early rheumatoid arthritis or his A scale is the characteristic secondary lesion
vocation without asking more questions or occurring in psoriasis. Although crusts, ulcers,
performing diagnostic studies. Carpal tunnel and scars also are secondary lesions in skin
disorders, they don’t accompany psoriasis. A. The wound should remain moist form the
dressing.
78. The nurse is caring for a bedridden, elderly B. The wet-to-dry dressing should be tightly
adult. To prevent pressure ulcers, which packed into the wound.
intervention should the nurse include in the plan C. The dressing should be allowed to dry out
of care? before removal.
A. Turn and reposition the client a minimum of D. A plastic sheet-type dressing should cover the
every 8 hours. wet dressing.
B. Vigorously massage lotion into bony
prominences. ANS: A
C. Post a turning schedule at the client’s A wet-to-dry saline dressing should always keep
bedside. the wound moist. Tight packing or dry packing
D. Slide the client, rather than lifting when can cause tissue damage and pain. A dry gauze
turning. —not a plastic-sheet-type dressing—should
cover the wet dressing.
ANS: C
A turning schedule with a signing sheet will help 82. While in skilled nursing facility, a client
ensure that the client gets turned and thus, help contracted scabies, which is diagnosed the day
prevent pressure ulcers. Turning should occur after discharge. The client is living at her
every 1-2 hours—not every 8 hours—for clients daughter’s home with six other persons. During
who are in bed for prolonged periods. The nurse her visit to the clinic, she asks a staff nurse,
should apply lotion to keep the skin moist but “What should my family do?” the most accurate
should avoid vigorous massage, which could response from the nurse is:
damage capillaries. When moving the client, the A. “All family members will need to be treated.”
nurse should lift rather than slide the client to B. “If someone develops symptoms, tell him to
void shearing. see a physician right away.”
C. “Just be careful not to share linens and
79. Following a full-thickeness (3rd degree) burn towels with family members.”
of his left arm, a client is treated with artificial D. “After you’re treated, family members won’t
skin. The client understands postoperative care be at risk for contracting scabies.”
of the artificial skin when he states that during
the first 7 days after the procedure, he’ll restrict: ANS: A
A. range of motion When someone in a group of persons sharing a
B. protein intake home contracts scabies, each individual in the
C. going outdoors same home needs prompt treatment whether
D. fluid ingestion he’s symptomatic or not. Towels and linens
should be washed in hot water. Scabies can be
ANS: A transmitted from one person to another before
To prevent disruption of the artificial skin’s symptoms develop
adherence to the wound bed, the client should
restrict range of motion of the involved limb. 83. In an industrial accident, client who weighs
Protein intake and fluid intake are important for 155 lb (70.3 kg) sustained full-thickness burns
healing and regeneration and shouldn’t be over 40% of his body. He’s in the burn unit
restricted. Going outdoors is acceptable as long receiving fluid resuscitation. Which observation
as the left arm is protected from direct sunlight. shows that the fluid resuscitation is benefiting
the client?
80. A client received burns to his entire back and A. A urine output consistently above 100
left arm. Using the Rule of Nines, the nurse can ml/hour.
calculate that he has sustained burns on what B. A weight gain of 4 lb (1.8 kg) in 24 hours.
percentage of his body? C. Body temperature readings all within normal
A. 9% limits
B. 18% D. An electrocardiogram (ECG) showing no
C. 27% arrhythmias.
D. 36%
ANS: A
ANS: C In a client with burns, the goal of fluid
According to the Rule of Nines, the posterior and resuscitation is to maintain a mean arterial blood
anterior trunk, and legs each make up 18% of pressure that provides adequate perfusion of
the total body surface. The head, neck, and vital structures. If the kidneys are adequately
arms each make up 9% of total body durface, perfused, they will produce an acceptable urine
and the perineum makes up 1%. In this case, output of at least 0.5 ml/kg/hour. Thus, the
the client received burns to his back (18%) and expected urine output of a 155-lb client is 35
one arm (9%), totaling 27%. ml/hour, and a urine output consistently above
100 ml/hour is more than adequate. Weight gain
81. The nurse is providing care for a client who from fluid resuscitation isn’t a goal. In fact, a 4 lb
has a sacral pressure ulcer with wet-to-dry weight gain in 24 hours suggests third spacing.
dressing. Which guideline is appropriate for a Body temperature readings and ECG
wet-to-dry dressing? interpretations may demonstrate secondary
benefits of fluid resuscitation but aren’t primary the bladder of a client with urine retention.
indicators.
87.The nurse is caring for a client who is to
84. The nurse is reviewing the laboratory results undergo a lumbar puncture to assess for the
of a client with rheumatoid arthritis. Which of the presence of blood in the cerebrospinal fluid
following laboratory results should the nurse (CSF) and to measure CSF pressure. Which
expect to find? result would indicate n abnormality?
A. Increased platelet count A. The presence of glucose in the CSF.
B. Elevated erythrocyte sedimentation rate B. A pressure of 70 to 200 mm H2O
(ESR) C. The presence of red blood cells (RBCs) in the
C. Electrolyte imbalance first specimen tube
D. Altered blood urea nitrogen (BUN) and D. A pressure of 00 to 250 mmH2O
creatinine levels
ANS: D
ANS: B The normal pressure is 70 to 200 mm H2O are
The ESR test is performed to detect considered abnormal. The presence of glucose
inflammatory processes in the body. It’s a is an expected finding in CSF, and RBCs
nonspecific test, so the health care professional typically occur in the first specimen tube from
must view results in conjunction with physical the trauma caused by the procedure.
signs and symptoms. Platelet count,
electrolytes, BUN, and creatinine levels aren’t 88. The nurse is administering eyedrops to a
usually affected by the inflammatory process. client with glaucoma. To achieve maximum
absorption, the nurse should instill the eyedrop
85. Which nursing diagnosis takes the highest into the:
priority for a client with Parkinson’s crisis? A. conjunctival sac
A. Imbalanced nutrition: less than body B. pupil
requirements C. sclera
B. Ineffective airway clearance D. vitreous humor
C. Impaired urinary elimination
D. Risk for injury ANS: A
The nurse should instill the eyedrop into the
ANS: B conjunctival sac where absorption can best take
In Parkinson’s crisis, dopamine-related place. The pupil permits light to enter the eye.
symptoms are severely exacerbated, virtually The sclera maintains the eye’s shape and size.
immobilizing the client. A client who is confined The vitreous humor maintains the retina’s
to bed during a crisis is at risk for aspiration and placement and the shape of the eye.
pneumonia. Also, excessive drooling increases
the risk of airway obstruction. Because of these 89. A 52 yr-old married man with two adolescent
concerns, ineffective airway clearance is the children is beginning rehabilitation following a
priority diagnosis for this client. Although cerebrovascular accident. As the nurse is
imbalanced nutrition:less than body planning the client’s care, the nurse should
requirements, impaired urinary elimination and recognize that his condition will affect:
risk for injury also are appropriate diagnoses for A. only himself
this client, they aren’t immediately life- B. only his wife and children
threatening and thus are less urgent. C. him and his entire family
D. no one, if he has complete recovery
86. A client with a spinal cord injury and
subsequent urine retention receives intermittent ANS: CAccording to family theory, any change in
catheterization every 4 hours. The average a family member, such as illness, produces role
catheterized urine volume has been 550 ml. The changes in all family members and affects the
nurse should plan to: entire family, even if the client eventually
A. Increase the frequency of the recovers completely.
catheterizations.
B. Insert an indwelling urinary catheter 90. Which action should take the highest priority
C. Place the client on fluid restrictions when caring for a client with hemiparesis caused
D. Use a condom catheter instead of an invasive by a cerebrovascular accident (CVA)?
one. A. Perform passive range-of-motion (ROM)
exercises.
ANS: A B. Place the client on the affected side.
As a rule of practice, if intermittent C. Use hand rolls or pillows for support.
catheterization for urine retention typically yields D. Apply antiembolism stockings
500 ml or more, the frequency of catheterization
should be increased. Indwelling catheterization ANS: B
is less preferred because of the risk of urinary To help prevent airway obstruction and reduce
tract infection and the loss of bladder tone. Fluid the risk of aspiration, the nurse should position a
restrictions aren’t indicated for this case; the client with hemiparesis on the affected side.
problem isn’t overhydration, rather it’s urine Although performing ROM exercises, providing
retention. A condom catheter doesn’t help empty pillows for support, and applying antiembolism
stockings can be appropriate for a client with ANS: BThe third cranial nerve (oculomotor) is
CVA, the first concern is to maintain a patent responsible for pupil constriction. When there is
airway. damage to the nerve, the pupils remain dilated
and don’t respond to light. Glaucoma, lumbar
91. The nurse is formulating a teaching plan for spine injury, and Bell’s palsy won’t affect pupil
a client who has just experienced a transient constriction.
ischemic attack (TIA). Which fact should the
nurse include in the teaching plan? 95. A 70 yr-old client with a diagnosis of left-
A. TIA symptoms may last 24 to 48 hours. sided cerebrovascular accident is admitted to
B. Most clients have residual effects after having the facility. To prevent the development of diffuse
a TIA. osteoporosis, which of the following objectives is
C. TIA may be a warning that the client may most appropriate?
have cerebrovascular accident (CVA) A. Maintaining protein levels.
D. The most common symptom of TIA is the B. Maintaining vitamin levels.
inability to speak. C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises
ANS: C
TIA may be a warning that the client will ANS: C
experience a CVA, or stroke, in the near future. When the mechanical stressors of weight
TIA aymptoms last no longer than 24 hours and bearing are absent, diffuse osteoporosis can
clients usually have complete recovery after TIA. occur. Therefore, if the client does weight-beari
The most common symptom of TIA is sudden, ng exercises, disuse complications can be
painless loss of vision lasting up to 24 hours. prevented. Maintaining protein and vitamins
levels is important, but neither will prevent
92. The nurse has just completed teaching about osteoporosis. ROM exercises will help prevent
postoperative activity to a client who is going to muscle atrophy and contractures.
have a cataract surgery. The nurse knows the
teaching has been effective if the client: 96. A client is admitted with a diagnosis of
A. coughs and deep breathes postoperatively meningitis caused by Neisseria meningitides.
B. ties his own shoes The nurse should institute which type of isolation
C. asks his wife to pick up his shirt from the floor precautions?
after he drops it. A. Contact precautions
D. States that he doesn’t need to wear an B. Droplet precautions
eyepatch or guard to bed C. Airborne precautions
D. Standard precautions
ANS: C
Bending to pick up something from the floor ANS: B
would increase intraocular pressure, as would This client requires droplet precautions because
bending to tie his shoes. The client needs to the organism can be transmitted through
wear eye protection to bed to prevent accidental airborne droplets when the client coughs,
injury during sleep. sneezes, or doesn’t cover his mouth. Airborne
precautions would be instituted for a client
93. The least serious form of brain trauma, infected with tuberculosis. Standard precautions
characterized by a brief loss of consciousness would be instituted for a client when contact with
and period of confusion, is called: body substances is likely. Contact precautions
A. contusion would be instituted for a client infected with an
B. concussion organism that is transmitted through skin-to-skin
C. coup contact.
D. contrecoup
97. A young man was running along an ocean
ANS: B pier, tripped on an elevated area of the decking,
Concussions are considered minor with no and struck his head on the pier railing. According
structural signs of injury. A contusion is bruising to his friends, “He was unconscious briefly and
of the brain tissue with small hemorrhages in the then became alert and behaved as though
tissue. Coup and contrecoup are type of injuries nothing had happened.” Shortly afterward, he
in which the damaged area on the brain forms began complaining of a headache and asked to
directly below that site of impact (coup) or at the be taken to the emergency department. If the
site opposite the injury (contrecoup) due to client’s intracranial pressure (ICP) is increasing,
movement of the brain within the skull. the nurse would expect to observe which of the
following signs first?
94. When the nurse performs a neurologic A. pupillary asymmetry
assessment on Anne Jones, her pupils are B. irregular breathing pattern
dilated and don’t respond to light. C. involuntary posturing
A. glaucoma D. declining level of consciousness
B. damage to the third cranial nerve
C. damage to the lumbar spine ANS: D
D. Bell’s palsy With a brain injury such as an epidural
hematoma (a diagnosis that is most likely based
on this client’s symptoms), the initial sign of risk of neck injury or airway obstruction. Side-
increasing ICP is a change in the level of lying isn’t specifically a therapeutic treatment for
consciousness. As neurologic deterioration increased ICP.
progresses, manifestations involving pupillary
symmetry, breathing patterns, and posturing will 101. In a comatose client, hearing is the last
occur. sense to be lost. Therefore, the nurse should
always:
98. Emergency medical technicians transport a A. talk loudly in case the client can hear
28 yr-old iron worker to the emergency B. speak softly before touching the client
department. They tell the nurse, “He fell from a C. tell others in the room not to talk to the client
two-story building. He has a large contusion on D. tell family members that the client probably
his left chest and a hematoma in the left parietal can’t hear
area. He has compound fracture of his left femur
and he’s comatose. We intubated him and he’s ANS: B
maintaining an arterial oxygen saturation of 92% Many clients have reported being able to hear
by pulse oximeter with a manual-resuscitation when being in a comatose state. Therefore, the
bag.” Which intervention by the nurse has the nurse should converse as if the client was alert
highest priority? and oriented. Talking loudly is only appropriate if
A. Assessing the left leg the client is hard of hearing, and family members
B. Assessing the pupils should be encouraged to talk with the client
C. Placing the client in Trendelenburg’s position unless contraindicated.
D. Assessing the level of consciousness
102. When a client experiences loss of vibratory
ANS: A sense on examination, this indicates:
In the scenario, airway and breathing are A. injury to the cranial nerves
established so the nurse’s next priority should be B. injury to the peripheral nerves
circulation. With a compound fracture of the C. intact cranial nerves
femur, there is a high risk of profuse bleeding; D. intact peripheral nerves
therefore, the nurse should assess the site.
Neurologic assessment is a secondary concern ANS: B
to airway, breathing and circulation. The nurse Appropriate perception of vibration indicates
doesn’t have enough data to warrant putting the intact dorsal column tracts and peripheral
client in Trendelenburg’s position. nerves. If there’s a loss of vibratory sense, an
injury to the peripheral nerves is probable.
99. Alzheimer’s disease is the secondary
diagnosis of a client admitted with myocardial
infarction. Which nursing intervention should
appear on this client’s plan of care?
A. Perform activities of daily living for the client
to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as
possible.
ANS: C
Establishing and maintaining a routine is
essential to decreasing extraneous stimuli. The
client should participate in daily care as much as
possible. Attempting to reason with such clients
isn’t successful, because they can’t participate in
abstract thinking.
ANS: B
For clients with increased intracranial pressure
(ICP), the head of the bed is elevated to
promote venous outflow. Trendelenburg’s
position is contraindicated because it can raise
ICP. Flat or neutral positioning is indicated when
elevating the head of the bed would increase the