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):4 Explanation: A is INCORRECT because cardiac output is decreased primarily with cardiogenic shock. B is INCORRECT because fluid volume is affected primarily with hypovolemic shock. C is INCORRECT because peripheral neurovascular problems occur with distributive types of shock, i.e. neurogenic and vasogenic shock. D is CORRECT because regardless of the type of shock, there is poor perfusion and tissue hypoxia. Question 2. What is the most important nursing diagnosis for a client with a newly diagnosed myocardial infarction? 1. Ineffective breathing pattern 2. Activity intolerance 3. Altered tissue perfusion 4. Fluid volume excess Looking for answers(s):3 Explanation: A is INCORRECT 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. B is INCORRECT because this is not the primary problem; however, activity intolerance may be a secondary concern. C is CORRECT because an MI 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 inadequate tissue perfusion. D is INCORRECT because this is not the initial problem; however, compensatory sodium and water retention may increase the vascular volume, which could be excessive for this client. Question 3. The nurse should tell the client who is elderly that an important advantage of outpatient surgery, especially given the clients age, would be: 1. Greater satisfaction with the surgical experience 2. Earlier return to full-time work responsibilities 3. Decreased exposure to hospital infections 4. Less psychological stress than hospitalization Question 4. The nurse can expect that a client admitted for a myocardial infarction will most likely develop which type of shock?

1. Neurogenic 2. Vasogenic 3. Hypovolemic 4. Cardiogenic Question 5. The nurse arrives at the site of an airplane crash and finds the following clients. Which client should be checked first? The client with: 1. Closed fracture of the humerus 2. Full thickness (3rd and 4th degree) burns over the torso 3. Partial-thickness (1st degree) on the face and neck 4. Laceration to the forehead, who is wandering among the wreckage asking for help Looking for answers(s):3 Explanation: A is INCORRECT because this client is not in immediate danger of respiratory or cardiac dysfunction. B is INCORRECT because, although this client is severely injured and will need intensive care, the client with a compromised airway should be checked first. C is CORRECT because clients with burns on the head, neck, and face may have inhalation injury which impairs respiratory function. Remember the ABCs of CPR: airway is first. D is INCORRECT because, although the possibility of a head injury exists, this client is awake and ambulatory at this time. Question 6. What is the priority in caring for an older adult? 1. To provide a pain-free state 2. To allow dependence if needed 3. To maintain functional independence 4. To provide home rehabilitation Looking for answers(s):3 Explanation: A is INCORRECT because a pain-free state may not be possible. Pain management is important, but a complete lack of pain may be unattainable. B is INCORRECT because dependence is not the priority goal of care, although it is allowed when needed. C is CORRECT because the goal of care in the older adult is to achieve the optimal level of functioning for the clients age. D is INCORRECT because the goal is optimal functioning; rehabilitation may be the means of achieving that goal. Question 7. After surgical repair of an abdominal aortic aneurysm, what is the most important reason for the client to avoid sharp flexion of the hips? 1. The peripheral pulses will be diminished 2. Venous return will be impaired 3. Intra-abdominal pressure will be increased 4. Thrombus formation in the leg may occur Question 8. What is the primary nursing diagnosis for the client in shock?

1. Fluid volume deficit 2. Altered tissue perfusion 3. High risk for injury 4. Impaired gas exchange Looking for answers(s):2 Explanation: A is INCORRECT because volume deficit is the problem for hypovolemic shock only. B is CORRECT because all types of shock alter tissue perfusion. C is INCORRECT because this diagnosis is too broad. D is INCORRECT because there is no problem at the gas exchange level; rather, there is insufficient perfusion to the capillary bed. CODES: AN, APP, 6, PhI, Physiological adaptation Med-Surg Question 9. Following a fall at home, what information would alert the nurse that the 78year-old client might be at risk for future falls? 1. A client lives alone in a single-story retirement apartment 2. The client gets up during the night to go to the bathroom 3. The client wears glasses following successful cataract surgery 4. The client occasionally takes a Tylenol PM to help sleep Question 10. The nurse would know that the modified shock position is generally not used with which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Neurogenic 4. Anaphylactic Looking for answers(s):2 Explanation: A is INCORRECT because, with this type of shock, an increase in venous return is desirable. B is CORRECT because an increase in venous return may be contraindicated with cardiogenic shock, where the pump is failing, and cannot handle the circulating blood volume. C is INCORRECT because, with this type of shock, an increase in venous return is desirable. D is INCORRECT 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. Head lowered, legs elevated, keeping body straight 2. Legs elevated 45 degrees, trunk horizontal 3. Head and trunk elevated 30 degrees, foot of bed lowered 4. Bed flat, foot of bed raised on shock blocks Looking for answers(s):2 Explanation: A is INCORRECT because lowering the head and raising feet reduces

blood flow to the brain, and abdominal contents press on the diaphragm which impairs breathing. B is CORRECT because the legs are elevated, but the head remains flat. This increases venous return, and does not impede pulmonary function. C is INCORRECT because an elevated head will lower the blood pressure further. D is INCORRECT because placing the flat bed on shock blocks would have the same effect as lowering the head and raising the feet. This 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 (TIA)? 1. Sedentary life-style 2. Family history of pulmonary embolism 3. History of high blood pressure 4. Obesity Looking for answers(s):3 Explanation: A is INCORRECT because inactivity is a risk factor for heart disease. B is INCORRECT because pulmonary embolism is not hereditary. C is CORRECT because high blood pressure would be associated with peripheral vascular or renal disease. TIAs are precursors to a stroke, which is often associated with a history of hypertension. D is INCORRECT 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. Temperature will be within normal limits 2. Heart rate will be within normal limits 3. Blood pressure will be within normal range 4. Respiratory rate will increase Looking for answers(s):2 Explanation: A is INCORRECT because bedrest does not directly affect the temperature. The metabolic rate is less during rest, so the temperature level should be normal as an indirect result. B is CORRECT because the primary purpose of bedrest is to reduce the workload of the heart by reducing oxygen consumption; this would be assessed by the heart rate. C is INCORRECT because this is not the best, most direct vital sign indicator of cardiac function. If the heart is working hard, the blood pressure will reflect the amount of resistance to blood flow. D is INCORRECT because this is not the best, most direct vital sign indicator of cardiac function. If the heart is not working effectively, the respiratory rate will increase in an attempt to provide more oxygen. 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. Keep the room lights on to provide visual stimulation. 2. Put a clock on the bedside table for orientation. 3. Tell the client about any procedures to be done. 4. Provide a Walkman and headset for listening to music. Looking for answers(s):2 Explanation: A is INCORRECT because the constant lights would result in sensory overload. The lights should be turned on and off according to day and night cycles. B is CORRECT because the best action is one that orients the client to time. A calendar could also be hung in the room for further orientation. C is INCORRECT because explaining procedures, while it is always important, will not keep the client oriented. D is INCORRECT because, even though music is a sensory stimulant, it will not orient the client, which is the intended goal. Question 15. If cancer of the larynx is suspected, for which early sign or symptoms should the nurse assess? 1. Hoarseness 2. Dyspnea 3. Dysphagia 4. Oral lesions Looking for answers(s):1 Explanation: A is CORRECT because a change in voice quality, such as hoarseness, will most likely be the first indication of a growth or tumor. B is INCORRECT because there will not be respiratory difficulty unless the tumor is obstructing the airway. C is INCORRECT because, before the tumor would affect swallowing, there would have been an earlier symptom. D is INCORRECT because lesions would be found with oral cancer, not laryngeal cancer. Question 16. 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. Increased blood pressure and urinary frequency 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):4 Explanation: A is INCORRECT because the valvular incompetence might diminish cardiac output and renal perfusion. Urine output would be less. B is INCORRECT because protein in the urine and a rising serum creatinine would indicate renal failure or insufficiency. (Valvular incompetence would be treated before causing renal failure). C is INCORRECT because these signs are indicative of right-sided heart failure. D is CORRECT because rheumatic fever often affects the mitral valve, resulting in valvular insufficiency or regurgitation. The increased preload and increased pulmonary vascular pressure will cause pulmonary congestion.

Question 17. The nurse reviews the history of a client with breast cancer. Which factor should the nurse recognize as having placed the client at greater risk? 1. A family history of colon cancer 2. Taking birth control pills 3. Having breastfed her baby 4. A high fat diet Looking for answers(s):4 Explanation: A is INCORRECT because the risk increases with a family history of breast cancer in two close relatives, not colon cancer. B is INCORRECT because birth control pills are not associated with breast cancer. C is INCORRECT because breastfeeding generally lessens the risk. D is CORRECT because a high fat diet has been associated with an increased risk. Reducing the fat intake to 20% of dietary calories is the goal. Question 18. Which finding would alert the nurse to a complication of the high osmolarity of TPN (hyperalimentation) solution? 1. Development of ascites or third spacing of fluid 2. Increased blood pressure and pulse; increased urine output 3. Decreased blood pressure and increased pulse; decreased urine output 4. Hyperglycemia and hyperlipidemia Looking for answers(s):2 Explanation: A is INCORRECT because fluid moves into the vascular space. With ascites, fluid moves out of the vascular space into the peritoneum. B is CORRECT because the high glucose content causes fluid to shift from the interstitial and intracellular spaces into the intravascular space. Circulating volume increases; vital signs and urine output will increase, indicating possible volume overload. C is INCORRECT because the signs indicate volume depletion, not volume overload. D is INCORRECT because the osmolarity causes a shift of fluid. There is a risk of hyperglycemia, but not increased lipids (unless lipids are also being given). Question 19. Following an open repair of a compound fracture, the client suddenly complains of dyspnea, and is in obvious respiratory distress. The nurse should assess the client for which of the following? 1. Fat emboli 2. Spontaneous pneumothorax 3. Pneumonia 4. Atelectasis Looking for answers(s):1 Explanation: A is CORRECT because fractures, particularly of long bones or those with high marrow fat, increase the risk of fat being released into the circulation. The urine may appear fatty as a warning. The biggest concern is destruction of lung tissue leading to respiratory failure if the emboli lodge in the lung. B is INCORRECT because the nurse would not expect a pneumothorax with a compound fracture (although the symptoms are similar). C is INCORRECT because pneumonia does not have a sudden onset.

D is INCORRECT because atelectasis does not have a sudden onset. Question 20. An 84-year-old client is admitted, diaphoretic and shivering, with a fever of 102.8F of unknown origin. The nurse knows the client is at highest risk for which electrolyte imbalance? 1. Hyponatremia 2. Hypercalcemia 3. Hypokalemia 4. Hypermagnesemia Question 21. What is the most appropriate nursing action for a client experiencing nausea, vomiting and diarrhea associated with radiation therapy? 1. Record the intake and output accurately 2. Give an antiemetic before the treatment 3. Offer a carbonated beverage before the treatment 4. Offer soda crackers or dry toast before the treatment Looking for answers(s):2 Explanation: A is INCORRECT because the nursing action should be to prevent or minimize side effects; recording the intake and output does nothing to lessen the effects. B is CORRECT because an antiemetic before the treatment may prevent or minimize the side effects. The drug should be given 1 hour before the radiation. C is INCORRECT because carbonated beverages may aggravate the symptoms. If oral fluids are taken, they should be uncarbonated, or flat. D is INCORRECT because the effects of radiation will not respond to dry toast or crackers. (These 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. Self-care deficit 4. Altered tissue perfusion Looking for answers(s):4 Explanation: A is INCORRECT because, as a result of poor oxygenation, the client will have activity intolerance. But initially, the client will be on bedrest anyway. B is INCORRECT because, as a result of poor oxygenation, the client will have fatigue. But initially, the client will be on bedrest anyway. C is INCORRECT because if treatment is ineffective, self-care problems will be a concern prior to discharge. D is CORRECT because, regardless of the type of heart failure, the main problem is ineffective tissue perfusion. Question 23. A correct explanation given by the RN to the nursing student of the difference between primary (essential) and secondary hypertension would include the fact that:

1. The cause of primary hypertension is unknown 2. The majority of clients have secondary hypertension 3. Systolic pressure is higher with secondary hypertension 4. Primary hypertension is due to pathological causes Question 24. In assessing a client with right-side involvement from a transient ischemic attack (TIA), which symptom in the right arm should the nurse anticipate that this client would most likely experience? 1. Muscle spasm 2. Weakness 3. Swelling 4. Tremors Looking for answers(s):2 Explanation: A is INCORRECT because spasms are not seen with a TIA. Spasticity may occur following a stroke. B is CORRECT because a TIA 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. C is INCORRECT because swelling or edema is not associated with a TIA. D is INCORRECT because tremors are not seen with a TIA. Question 25. The nurse is completing a preoperative history on the client. The client is allergic to latex. What other allergies might this client have? 1. Industrial solvents and perfume 2. Avocados and bananas 3. Eczema 4. Cats and dogs Looking for answers(s):2 Explanation: A is INCORRECT because allergies to industrial solvents and perfumes do not correlate with latex allergies. B is CORRECT because individuals with allergies to avocados, bananas, kiwis, chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots are at risk for being allergic to latex. C is INCORRECT because eczema is a manifestation of an allergy, not an allergy itself. D is INCORRECT because allergies to cats and dogs do not correlate with latex allergies. Question 26. Which nursing diagnosis is a priority on admission of a client with a CVA? 1. Impaired physical mobility 2. Self-care deficit 3. Altered nutrition 4. Altered tissue perfusion Looking for answers(s):1 Explanation: A is CORRECT because the greatest concerns for the client following a CVA are complications of immobility, such as pneumonia.

B is INCORRECT because this is not the initial priority, but will be a concern at the time of discharge. C is INCORRECT because this is not the initial priority; monitoring for dysphagia will be an ongoing assessment. D is INCORRECT 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 27. Which response by the client would indicate a possible problem with altered self-concept following a mastectomy? 1. Refusing her tray at dinner 2. Requesting pain medication frequently 3. Asking for a robe when walking in the hall 4. Concern about what to wear home Looking for answers(s):4 Explanation: A is INCORRECT because lack of appetite would be more consistent with ineffective individual coping. B is INCORRECT because requesting frequent pain medication would indicate a problem with pain management. C is INCORRECT because wearing a robe is normal for a hospitalized client. D is CORRECT because expressed concern about appearance may indicate altered self-concept. A representative from a support group such as Reach for Recovery may be contacted to talk to the client before discharge. Question 28. A client is admitted because of dysrhythmia, and a pacemaker is being considered. The client is found unresponsive, and the heart rate is 40 beats per minute. Which nursing action would be appropriate? 1. Call a code, and start CPR immediately 2. Assess the client for the cause of unresponsiveness 3. Give atropine IV per order 4. Prepare the client for pacemaker insertion Looking for answers(s):3 Explanation: A is INCORRECT because CPR is not done if a pulse is present. B is INCORRECT because the client needs immediate intervention to restore the heart rate to a normal level. C is CORRECT because atropine is the drug of choice for bradycardia. The drug will increase AV conduction and the pulse rate. D is INCORRECT because the pacemaker insertion will likely be done after the client has been stabilized. Question 29. The 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. Change in skin pH 4. Loss of subcutaneous fat

Looking for answers(s):1 Explanation: A is CORRECT because the first phase of wound healing is inflammation, which includes phagocytosis, a fundamental step for wound healing. With aging, the inflammatory response is not as effective, which delays wound healing. B is INCORRECT because the amount of moisture in the skin does not affect wound healing, but contributes to breakdown. C is INCORRECT because skin pH may contribute to infection, but it is the diminished immune system that delays healing. D is INCORRECT because a loss of subcutaneous fat would actually improve healing, since fat is avascular. CODES: AN, ANL, 1, HPM, Health promotion and maintenance Med-Surg Question 30. The client is to receive 200 mL of IV fluids hourly because of pancreatitis. What is the best explanation for the high IV fluid volume? 1. Dehydration has occurred from persistent vomiting 2. Hyperglycemia 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):3 Explanation: A is INCORRECT because even though persistent vomiting brought on by pain and decreased peristalsis may be present, the hypovolemia results from the effects of kinin. B is INCORRECT because even though some degree of islet involvement (glucose intolerance) may be present, the hypovolemia is due to the effects of kinin. C is CORRECT 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 INCORRECT because even though left lung pleural effusion is present, hypovolemia would not result from the presence of fluid in the pleural space. Question 31. The 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. Suggest a permanent, to give the hair body and prevent loss 2. Tell her to brush her hair vigorously to prevent loss 3. Suggest she start wearing a wig before the hair is gone 4. Use a medicated shampoo on the client, to prevent scalp irritation Looking for answers(s):3 Explanation: A is INCORRECT because a permanent will not prevent hair loss. It may actually destroy the hair and irritate the scalp, which may become infected. B is INCORRECT because the vigorous brushing will not prevent hair loss, and may traumatize the scalp, which may become infected. C is CORRECT because wearing a wig before the hair is completely gone will make the change less noticeable to others. Hats or other head covering may also be worn. D is INCORRECT because the scalp will not be irritated with alopecia, but may become irritated by the shampoo.

Question 32. A client has a positive Chvosteks. What electrolyte imbalance does this demonstrate? 1. Hypoglycemia 2. Hyponatremia 3. Hypocalcemia 4. Hypokalemia Question 33. Which response by the client indicates a lack of understanding about the warning signs of cancer? 1. I have had this mole for years, so a change is really nothing to worry about. 2. If this sore isnt gone in a few weeks, Ill call my doctor. 3. Ive been having bloody vaginal drainage which I need to have checked. 4. Ive made an appointment to have this lump in my breast checked. Question 34. Assessment findings of a client with mitral valve regurgitation would most likely include which manifestation? 1. Dependent edema 2. Hepatomegaly 3. Hacking cough 4. Nail bed cyanosis Looking for answers(s):3 Explanation: A is INCORRECT because dependent edema would be seen in tricuspid insufficiency or right-sided heart failure, when the blood and increased preload would affect systemic circulation. B is INCORRECT because organ enlargement would be seen if the blood was backing up into the systemic circulation due to increased right-sided preload. C is CORRECT because regurgitation will increase preload and pulmonary vascular pressure. There will be pulmonary congestion, a cough, and dyspnea, if severe. D is INCORRECT because nail-bed cyanosis would be seen with poor peripheral circulation or as a late sign of hypoxia. Question 35. Which assessment finding should the nurse determine to be consistent with dehydration? 1. Tachycardia 2. Jugular vein distention 3. Warm, moist skin 4. Low urine specific gravity Looking for answers(s):1 Explanation: A is CORRECT because tachycardia would be seen with dehydration. The rapid heart rate would indicate a low circulation volume. B is INCORRECT because jugular vein distention would be inconsistent with dehydration. JVD reflects heart failure and volume overload. C is INCORRECT because dry, scaly skin would be seen with dehydration. Skin turgor is an indication of fluid status. The amount of water in the skin diminishes with age.

D is INCORRECT because a high urine specific gravity would be consistent with dehydration. The urine would be concentrated, and the specific gravity would be high, likely above 1.030. Question 36. The nurse expects edema formation with malnutrition, burns, and liver disease because in these conditions there is: 1. Increased aldosterone production 2. Decreased capillary osmotic pressure 3. Increased capillary osmotic pressure 4. Decreased systemic blood pressure Looking for answers(s):2 Explanation: A is INCORRECT because, in these conditions, there is no direct stimulation of the adrenals to increase the release of aldosterone. (Increased 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). B is CORRECT because all of these conditions have low blood albumin levels, which decreases the capillary osmotic pressure. The hydrostatic pressure is greater than the osmotic pressure, so fluid moves into the interstitial space, causing edema. C is INCORRECT because the blood albumin level is decreased in these conditions; it does not cause the capillary osmotic pressure to increase. With the low albumin level, fluid moves into the interstitial space. D is INCORRECT because the primary problem with these conditions is not hypotension, but rather a loss of blood albumin, which controls the capillary osmotic pressure. Question 37. A clients vital signs are as follows: BP92/50; P112; R-20; CVP-3. How do these assessment findings influence nursing intervention? 1. Give digoxin, as vital signs indicate heart failure 2. Anticipate the need for fluids, as hypovolemia may be present 3. Place the client in modified Trendelenburg immediately 4. Continue to monitor vital signs, as no other action is needed Looking for answers(s):2 Explanation: A is INCORRECT because heart failure will show an elevated CVP, indicating inability to handle the circulating blood volume. B is CORRECT because the vital signs are consistent with hypovolemia. C is INCORRECT because fluids should be given first. The CVP will not increase with positioning, and it is the most significant value. D is INCORRECT because the vital signs are not normal, and nursing actions are needed. Question 38. What urine assessment finding would be present in a client with diabetes insipidus? 1. Presence of white blood cells 2. Increased protein

3. Decreased urine pH 4. Decreased specific gravity Question 39. The 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. Rinse the clients mouth with normal saline 2. Rinse the clients mouth with hydrogen peroxide 3. Vigorously brush and floss the clients teeth 4. Follow brushing with an alcohol-based mouthwash Looking for answers(s):1 Explanation: A is CORRECT because normal saline can effectively clean the clients mouth and is not irritating to inflamed tissues. A topical anesthetic such as viscous Xylocaine can also be used to reduce discomfort of stomatitis. B is INCORRECT because hydrogen peroxide is inappropriate to use on inflamed tissue or open wounds; it will cause tissue damage and discomfort. C is INCORRECT because, while it is important to brush and floss the clients teeth, this should be done gently, not vigorously. D is INCORRECT because an alcohol-based mouthwash will irritate oral tissues and cause the client more pain. Question 40. The nurses assessment of a client with complete heart block will most likely reveal a history of: 1. Syncope 2. Ataxia 3. Insomnia 4. Tachycardia Looking for answers(s):1 Explanation: A is CORRECT because syncope, or fainting, may occur when severe bradycardia decreases cerebral tissue perfusion. B is INCORRECT because ataxia would be seen with neurological problems. C is INCORRECT because the client is more likely to be fatigued. D is INCORRECT because with heart block, the ventricular rate is dangerously slow. Question 41. The nurse knows that the primary goal of treatment in all types of shock is to increase: 1. Tissue perfusion 2. Sympathetic innervation 3. Circulating volume 4. Cardiac contractility Question 42. Following a mastectomy, which client response would indicate appropriate adaptation to a body image disturbance? 1. Does her dressing change 2. Holds her children on her lap

3. Denies any pain 4. Plans to keep her follow-up appointment Looking for answers(s):1 Explanation: A is CORRECT because the clients ability to look at, touch, and care for her incision, reflects the beginning of the clients adjustment to the change in body image. B is INCORRECT because the loss of a breast usually does not interfere with the maternal role identity. It may affect her role identity as a wife. C is INCORRECT because relief of pain, and pain management would not indicate how the client is adapting to the body image change. D is INCORRECT because keeping follow-up 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. Observe for bleeding 2. Prevent infection 3. Promote acceptance of death 4. Conserve energy Looking for answers(s):2 Explanation: A is INCORRECT because low platelets, thrombocytopenia, would lead to a bleeding risk. B is CORRECT because leukopenia is a decrease in the white blood cells below the normal of 5000. The chance of infection increases with a low WBC. C is INCORRECT because prevention of infection will prolong life. Even though multiple myeloma is a terminal condition, radiation and chemotherapy will extend the clients life. D is INCORRECT because this is not the priority for nursing care. Conserving 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. Dimpling over lump Question 45. Which nursing action is most important for the client experiencing hyperthyroidism? 1. Increase oral fluid intake 2. Maintain physical activity 3. Maintain a cool environment 4. Orient the client to surroundings Looking for answers(s):3 Explanation: A is INCORRECT because fluids are not the main nutritional need. The

client may need to eat six full meals daily because of the excessive appetite and weight loss. B is INCORRECT because the client is experiencing an accelerated metabolic rate, and needs rest, not exercise or increased environmental stimuli. C is CORRECT because the increased metabolic rate causes heat intolerance, so the client is most comfortable in a cool environment. D is INCORRECT because the client is not disoriented or confused. Question 46. Following a mastectomy for breast cancer, what is the best indication of the clients adjustment to her altered body image? 1. Wanting to look at the incision 2. Putting on make-up and lipstick 3. Talking to friends about the surgery 4. Walking with her husband in the hall Looking for answers(s):1 Explanation: A is CORRECT because looking at the change in her body is the beginning step in acceptance. B is INCORRECT because the change has not been with her face. Also, she may not normally wear significant make-up. C is INCORRECT because there is no indication of what she is saying to her friends. D is INCORRECT because walking with a spouse does not indicate that there has been any acceptance of the body image change. Question 47. Following a femoral-popliteal bypass graft, which assessment finding in the client should the nurse report immediately? 1. Warm toes with some mottling 2. Hourly urine output of 70 mL 3. Absent pedal pulse 4. Blood pressure: 108/58 Looking for answers(s):3 Explanation: A is INCORRECT because this finding would be normal postoperatively. B is INCORRECT because this finding would be normal postoperatively. C is CORRECT because absence of a distal peripheral pulse may indicate graft obstruction or tearing. D is INCORRECT because this finding would be normal postoperatively. Question 48. During health teaching, the nurse should counsel a client who is post-MI that the position requiring the least amount of exertion when resuming sexual activity is: 1. Cardiac-client prone 2. Side-lying for both partners 3. Whatever position the client chooses 4. Sitting or standing with back supported Looking for answers(s):2 Explanation: A is INCORRECT because there would be excessive exertion by the client. B is CORRECT because there are two positions that require the least amount of exertion

for the cardiac client, supine and side-lying. In these positions, the amount of exertion is usually no greater than climbing a flight of stairs. C is INCORRECT because there would be excessive exertion by the client. D is INCORRECT because there would be excessive exertion by the client. Question 49. The nurse would conclude the client is experiencing left-sided heart failure when which of the following is observed? 1. Abdominal distention 2. Jugular venous distention 3. Swollen ankles bilaterally 4. Crackles on auscultation Looking for answers(s):4 Explanation: A is INCORRECT because abdominal distention is not an indication of leftsided failure. Causes may be gas distention, ascites, or GI bleeding. B is INCORRECT because JVD is a sign of right-sided heart failure. C is INCORRECT because ankle or dependent edema is a sign of right-sided heart failure. D is CORRECT because left-sided heart failure causes backward effects leading to pulmonary congestion. The pulmonary artery catheter reading would reflect an increase in the PAWP. The forward effects will be diminished cardiac output, and poor peripheral perfusion. Question 50. Upon discharge, a client with heart failure should be instructed to notify the MD if which change occurs? 1. Weight increased by 3 lbs in one week 2. Pulse rate slows to 6070 beats/min 3. Body temperature drops to 97.8F 4. Urinary output exceeds 1000 mL daily Looking for answers(s):1 Explanation: A is CORRECT because an increase in weight is likely due to fluid retention and should be reported. Weight changes are an accurate reflection of fluid volume. B is INCORRECT because the slowing of the pulse could be a desired effect of digoxin, an inotropic drug used to treat heart failure. C is INCORRECT because a temperature of 97.8F is not abnormal. D is INCORRECT because a urine output of greater than 1000 mL will likely be a desired effect of prescribed diuretics.