John J.

Teodoro PTRP, RN

1. A home care nurse is preparing to visit a client with a diagnosis of Menieres disease. The nurse reviews the physicians orders and expects to note that which of the following dietary measures will be prescribed? A. low fiber diet with decreased fluids B. low sodium diet and fluid restriction C. low carbohydrate diet and elimination of red meats . low fat with restriction of citrus fruits !. A nurse is assigned to care for a client who has "ust undergone eye surgery. The nurse plans to instruct the client that which of the following activities is permitted in the postoperative period? A. reading B. watching television C. bending over . lifting ob"ects #. A nurse is instilling an otic solution into an adult clients left ear. The nurse avoids doing which of the following as part of this procedure? A. warming the solution to room temperature $. placing the client in a side lying position with the ear facing up C. pulling the auricle bac%ward and upward D. placing the tip of the dropper on the edge of the ear canal &. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the clients? A. wound healing usually ta%es 1! wee%s $. expected the vision will be permanently impaired

C. a shield or eye patch should e worn to protect the eye . the sutures are removed after 1 wee% '. (hich assessment findings provide the best evidence that a client with acute angle) closure glaucoma is responding to drug therapy? A. swelling of the eyelids decreases $. redness of the sclera is reduced C. eye pain is reduced or eliminated . peripheral vision is diminished *. At the time of retinal detachment+ a client most li%ely describes which symptoms? !. a seeing flashes of light $. being unable to see light C. feeling discomfort in light . seeing poorly in daylight ,. The most important health teaching the nurse can provide to the client with con"unctivitis is toA. eat a well balanced+ nutritious diet $. wear sunglasses in bright light C. cease sharing towels and washcloths . avoid products containing aspirin .. (hen the nurse prepares the client or the myringotomy+ the best explanation as to the purpose for the procedures is that it willA. prevent permanent hearing loss B. provide a pathway for drainage C. aid in administering medications . maintain motion of the ear bones

/. A nurse is reviewing the record of the client with a disorder involving the inner ear. (hich of the following would the nurse expect to see documented as an assessment finding in this client? A. severe hearing loss $. complaints of severe pain in the affected ear C. complaints of burning in the ear D. complaints of tinnitus 10. A client with a conduction hearing loss as%s the nurse how a hearing aid improves hearing. The nurse most accurately informs the client that a hearing aid!. amplifies sound heard $. ma%es sounds sharper and clearer C. produces more distinct+ crisp+ speech . eliminates garbled bac%ground sounds 11. (hich nursing action is best for controlling the clients nosebleed? A. have the client lay down slowly and swallow fre1uently $. have the client lay down and breathe through his mouth C. have the client lean forward and apply direct pressure . have the client lean forward and clench his teeth 2ituation- $en"ie '/ years old male was admitted to the hospital complaining of nausea+ vomiting+ weight loss of !0 lbs+ constipation and diarrhea. A diagnosis of carcinoma of the colon was made. 1!. A sigmoidoscopy was performed as a diagnostic measures. (hat position $en"ie should assume for hi examination? !. "nee#chest $. 2ims

C. 3owlers . Trendelenburg 1#. As part of the preparation of the client for sigmoidoscopy the nurse shouldA. explain to $en"ie that he will swallow a chal%)li%e substance $. administer a cathartic the night before C. withhold fluids and foods on the day of examination D. administer cleansing enema in the morning of the e$amination 1&. The doctor performed a colostomy+ post operative nursing care include!. "eeping the s"in around the opening clean and dry $. limiting visitors C. withholding . limiting fluid inta%e 1'. uring the irrigation of the colostomy+ $en"ie complains of abdominal cramps+ the nurse shouldA. discontinue the irrigation B. clamp the catheter for a few minutes C. advance the catheter about one inch . add color water 1*. 4f colostomy irrigation is done+ the height of the irrigator can must be how many inches above the stoma? A. 1&)1. inches B. %&#'( inches C. !0)!& inches . 10)1& inches

1,. (hich of the following gastrointestinal condition is %nown to predispose to Cancer of the colon? A. hemorrhoids $. intussusception C. islated colonic polyps . pyloric stenosis 2ituation- Mr. 5 was brought to the 67 complaining of pain located in the upper abdomen hematemesis and melena. iagnosis is peptic ulcer. 1.. A fre1uent discomfort experience by Mr. 5 due to his peptic ulcer isA. diarrhea $. vomiting C. eructation . nausea 1/. (hich of this diagnostic measure is not indicated for Mr. 5? A. x)ray of the abdomen B. patient)s history C. gastrointestinal series . gastric analysis !0. The purpose of dietary treatment of Mr. 5 is to!. neutrali*e the free +C, in the stomach $. delay gastric emptying C. prevent constipation . delay surgery !1. Antacids are administered to Mr. 5 to-

A. tran1uili8e the intestine $. decrease gastric motility C. lower the acidity of gastric secretion . aid in digestion !!. 4t is thought that emotional stress contribute to ulcer formation through!. e$cessive stimulation of the parasympathetic nervous system $. increased activity of the sympathetic nervous system C. disturbance o cerebral cortex appetite control . decrease of pituitary function !#. The tissue change most characteristics of peptic ulcer isA. a soft mass of the necrotic tissue with bleeding $. an erosion of the mucosa covered with thic% exudates C. a sharp e$cavation of tissue mem rane with a clean ase . an elevated fibrous tissue membrane with soft margins !&. The stool 9uiac test was ordered to detect the presence ofA. hydrochloric acid B. occult lood C. inflammatory cells . undigested food !'. 4n addition to its antacids effects+ aluminum hydroxide gel is locallyA. analgesic B. astringent C. irritating

. depressant !*. 4ntervention that would help control his bleeding!. gastric lavage using iced cold normal saline solution $. gastric using warm normal saline solution C. application of tourni1uet . insertion of :9T !,. 2ince she has :9T the appropriate nursing action isA. render sponge bath $. provide laxative at bedtime C. administer enema once a day D. provide oral hygiene -$ a day !.. ;e underwent total gastrectomy+ dumping syndrome may occur and the least symptoms he may experience would be!. feeling of soreness $. wea%ness C. feeling of fullness . diaphoresis !/. To prevent dumping syndrome the following includes your nursing care exceptA. serve dry meals B. allow him to wal" for a while after eating C. instruct him to lie down after eating . giving of fluids after meals must be avoided #0. <our operative nursing assessment after surgeryA. note and report excessive bleeding only

B. assess for e$cessive secretions from the operative site C. ensure that the :9 tube is detached from suction apparatus . chec% the drainage from the :9 tube everyday #1. (hat is the involvement of her total gastrectomy? A. removal of the stomach only B. removal of the stomach with anastomosis of the esophagus to the .e.unum C. removal of the ovary and fallopian tube . removal of the stomach with anastomosis of the duodenal to "e"unum #!. A nurse is giving instructions to the client with peptic ulcer disease about symptom management. The nurse tells the client to!. eat slowly and chew food thoroughly $. eat large meals to absorb gastric acid C. limit the inta%e of water . use acetylsalicylic acid =aspirin> to relieve gastric pain ##. A client has been given a prescription for ?ropantheline =?robanthine> as ad"unctive treatment for peptic ulcer disease. The nurse tells the client to ta%e this medicationA. with antacids B. -( minutes efore meals C. with meals . "ust after meals 2ituation- @im was %nown to be alcoholic for 1' yrs. ;e was admitted in the hospital after having vomited a large 1uantity of bright red blood with some coffee ground appearance. #&. The most probable cause of @ims cirrhosis isA. malnutrition

$. bacterial inflammation of liver cells C. alcoholism . obstruction of ma"or bile ducts #'. (hich of the following vitamins are stored by the normal liver? A. vit. A+ vit. $ and vit. C $. vit. A+ vit. $+ vit. C+ and vit. C. vit ! and vit B . vit. A and vit. C #*. The nurse should %now how that pathophysiology predispose him to!. varicose veins $. splenic rupture C. inguinal hernia . umbilical hernia #,. @ims portal hypertension is the result ofA. contraction of vascular muscles response to psychological stress $. compression of the liver substance due to emotional stress C. acceleration of portal blood flow secondary to severe anemia D. twisting and constriction of intralo ular and interlo ular lood vessels #.. @im is scheduled for a liver biopsy. (hat instructions regarding respiration is essential for the nurse to give him prior to the biopsyA. exhale forcefully and to hold his breath for a few seconds $. hold his breath when the needle has reached the liver site C. ta"e several deep reaths and to hold his reath while needle is eing introduced . flat with one pillow under his head

#/. (hich position in bed would be best for @im immediately after he has the needle biopsy of the liver? !. on his right side, with a small pillow under the costal margin $. anyway that he is comfortable C. semi)3owlers with his %nees flexed . flat with one pillow under his head &0. A $la%emore)2engsta%en tube is inserted to prevent bleeding from esophageal varices. The nurse responsibility in this instance would be to!. alternate inflate and deflate the esophageal alloon $. ma%e certain that the desired degree of pressure is constantly maintained C. deflate both balloons periodically . encourage @im to swallow fre1uently while tube is 4 place &1. A physician orders the deflation of the esophageal balloon of a 2engsta%en) $al%emore tube in a client. The nurse prepares for the procedure %nowing that the deflation of the esophageal balloon places. The client is at ris% forA. increased ascites $. esophageal necrosis C. recurrent hemorrhage from the esophageal varices . gastritis &!. 3oods usually omitted from diet of @im with cirrhosis of liver areA. whole grain cereals $. mil% products C. cereal products D. rich gravies and sauces &#. Clay colored stool are caused by-

A. improper utili8ation of vitamin @ by the body B. the a sence of ile salt in the feces C. the absence of bile pigments in the urine . rich gravies and sauces &&. @im develop ascites+ this is caused byA. pulmonary failure B. portal o struction C. capillary obstruction . arterial obstruction &'. 2ymptoms indicating progression into hepatic coma include1. flapping tremor !. nystagmus #. fruity odor breath &. fetid breath A. ! and & C. ! and # B. % and / . 1 and #

&*. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and has difficulty breathing. A nurse performs which intervention as a priority measure to assist the client with breathing? A. auscultates the lung fields every & hours $. repositions side to side every ! hours C. encourages deep breathing exercises every ! hours D. elevates the head of the ed 0( degrees 2ituation- @arla is confine with a diagnosis of chronic cholecystitis.

&,. After thorough examination your findings would beA. high red blood cell counts and fever $. leu%ocyte count is low and high fever C. leu"ocyte count high and pyre$ia . leu%ocytosis and abdominal pain that radiates to the groin &.. The surgical intervention indicated for @arla isA. choledochostomy $. cholecystostomy C. cholecystotomy D. cholecystectomy &/. 3ollowing exploration of the common duct is a T)tube inserted. The rationale for this is toA. facilitate healing of the operative site $. offer a route to post operative cholecystectomy C. provide sufficient drainage to promote healing D. ensure ade1uate ile drainage during duct healing '0. Apon admission her doctor ordered for cholecystoghram in AM. The preparations of this procedure beginsA. in early am B. with evening meal C. at bedtime . upon admission '1. The ingestion of fatty food usually precipitates rubies episodes of the upper abdominal pain becauseB A. fat in the stomach increases the rate of peristaltic movements

B. fat in the duodenal contents initiate the reaction that cause gall ladder contraction C. fatty foods are li%ely to generate gas . fatty foods contain higher amount of cholesterol than do proteins '!. @arla is having pruritus of the extremities. (hich of the following nursing measures might be most helpful in relieving her discomfort. A. rubbing the s%in with potassium permanganate 10-1000 solution B. athing in wea" sodium icar onate solution C. dusting with liberal amount of talcum powder . rubbing the s%in with alcohol '#. @arla is experiencing severe biliary colic. The drug of choice during attac% isA. ponstan B. Demerol C. atropine sulfate . morphine sulfate '&. A T)tube was inserted into the common bile duct. ;er nursing care of the T)tube is!. empty and measure the ile drainage every / hours $. report 2TAT for any bile seen in the drainage system C. secure it very well . irrigate the T)tube with sterile normal saline every & hours ''. A client with diverticulitis has "ust been advanced from a li1uid diet to solids. The nurse encourages the client to eat foods that are!. low residue $. high residue C. moderate in fat

. high roughage '*. A client has "ust undergone an upper gastrointestinal =94> series. The nurse provides which of the following upon the clients return to the unit as an important part of routine post procedure care? A. increased fluids $. bland diet C. :?C status D. la$ative ',. A nurse is administering continuous tube feedings to the client. The nurse ta%es which of the following actions as party of routine care for this client? !. chec"s the residual every /hours $. changes the feeding bag and tubing every 1! hours C. pours additional feeding into bag when !' ml are left . holds the feeding if greater than !00 ml are aspirated '.. A nurse is monitoring drainage from a nasogastric =:9> tube in a client who had a gastric resection. :o drainage has been noted during the past & hours and the client complains of severe nausea. The most appropriate nursing action would be toA. reposition the tube $. irrigate the tube C. notify the physician . medicate for nausea '/. A nurse is performing a health history on a client with chronic pancreatitis. The nurse expects to most li%ely note which of the following when obtaining information regarding the clients health history? A. abdominal pain relieved with food or antacids $. exposure to occupational chemicals C. weight gain

D. use of alcohol *0. A home care nurse visits a client with bowel cancer who recently received a course of chemotherapy. The client has developed stomatitis. The nurse avoids telling the client to!. drin" foods and li1uids that are cold $. eat foods without spices C. maintain a diet of soft foods . drin% "uices that are not citrus *1. A nurse is caring for a client with is receiving total parenteral nutrition =T?:>. The nurse plans which nursing intervention to prevent infection? !. using strict aseptic techni1ue for intravenous site dressing changes $. monitoring serum blood urea nitrogen =$A:> daily C. weighing the client daily . encouraging increased fluid inta%e *!. A nurse is caring for a client with possible cholelithiasis who is being prepared for a cholangiogram. The nurse teaches the client about the procedure. (hich client statement indicates that the client understands the purpose of this procedure? !. 2they are going to loo" at my gall ladder and ducts.3 $. Dthis procedure will drain my gallbladderE C. Dmy gallbladder will be irritatedE . Dthey will put medication in my gallbladderE *#. A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which of the following factors is most li%ely responsible for the anemia? A. decrease inta%e of dietary iron $. intestinal malabsorption C. lood loss

. intestinal hoo%worm *&. A clients nasogastric =:9> feeding tube has become clogged. The nurses first action is toA. flush the tube with warm water B. aspirate the tu e C. flush the carbonated li1uids+ such as cola . 7eplace the tube *'. (hen the client as% the nurse why he must ta%e the neomycin sulfate =Mycifradin>+ the most accurate explanation in this case is that the drug is given toA. treat any current infection he may have B. suppress the growth of intestinal acteria C. prevent the onset of postoperative diarrhea . reduce the number of bacteria near the incision **. 4f the client is typical of others with appendicitis the nurse can expect that when the clients abdomen is palpated midway between the umbilicus and right iliac crest+ the client will!. e$perienced more pain when pressure is released $. lac% any sensation of pain or pressure on palpation C. have extreme discomfort with the slightest pressure . will feel referred pain in the opposite 1uadrant *,. (hich factor most probably contributed to the development of the clients hemorrhoids? A. the client ta%es a daily stool softener $. the client has a history of ulcerative colitis C. the client is fre1uently constipated . the client wor%s as a computer programmer

*.. (hen the client describes her discomfort to the nurse she is most li%ely to indicate that the pain she experiences becomes worse!. shortly after eating $. especially on an empty stomach C. following periods of activities . before rising in the morning */. (hen the nurse empties the drainage in the 5ac%son ?ratt bulb reservoir. (hich nursing action is essential for reestablishing the negative pressure within this drainage device? !. the nurse compresses the ul reservoir and closes the drainage valve $. the nurse opens the drainage valve+ allowing the bulb to fill with air C. the nurse fill the bulb reservoir with sterile normal saline . the nurse secures the bulb reservoir to the s%in near the wound ,0. (hen the client as%s the nurse how she ac1uired hepatitis A+ the best answer is that a common route of hepatitis. A transmission is from!. fecal contamination $. insect carries C. infected blood . wound drainage ,1. 4t is essential that the nurse inform the client with hepatitis $ that for the remainder of his lifetime he must avoidA. sexual activity B. donating lood C. excessive caffeine . foreign travel ,!. (hich nursing action is appropriate prior to assisting with the paracentesis?

!. the nurse as"s the client to void $. the nurse withholds food and water C. the nurse cleanses the clients abdomen with $etadine . the nurse obtains a suction machine from storage room ,#. (hich statements provides the best evidence that a client with colostomy is ad"usting to the change in body image? A. the client wears loose)fitting garments $. the client ta%es a shower each day C. the client empties the appliance . the client avoids foods that form gas ,&. A previously health client comes to the emergency department complaining of severe nausea and vomiting hours after eating in a restaurant. (hich assessment 1uestion best determines if a food borne pathogen is the cause of the clients syndrome? !. 2what food did you eat43 $. Ddid you ta%e something for you nausea?E C. Ddid your food loo% spoiled?E . Dhave you ever had food poisoning?E ,'. A nurse is caring for a client with peptic ulcer. 4n assessing the client for gastrointestinal perforation =94>+ the nurse monitors forA. increase bowel sounds B. sudden, severe a dominal pain C. positive 9uaiac test . slow+ strong pulse ,*. (hich assessment is most important for the nurse to ma%e before advancing a client from li1uid to solid food? A. increase bowel sounds

$. appetite C. presence of bowel sounds D. chewing a ility ,,. (hat method would a nurse use to most accurately assess the effectiveness of a weight loss diet for an obese client? !. daily weights $. serum protein levels C. daily caloric counts . daily inta%e and output ,.. A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. (hich findings would the nurse expect to note on assessment of the client? A. absence of any and symptoms B. pain, itching and vaginal discharge C. proteinuria+ hematuria+ edema and hypertension . costovertebral angle pain ,/. A nurse is caring for a client who is hospitali8ed with acute systemic lupus erythematosus =2F6>. The nurse monitors the client %nowing that which of the following clinical manifestation is not associated with this disease? A. fever $. muscular aches and pains C. butterfly rash on the face D. radycardia .0. A male being seen in the ambulatory care clinic has a history of being treated for syphilis infection. The nurse interprets that the client has been reinfected if which of the following characteristics is noted in a penile lesion? A. multiple vesicles+ with some that have ruptured

$. popular areas and erythema C. cauliflower)li%e appearance D. induration and a sence of pain .1. A nurse is preparing a poster for a booth at a health care to promote primary prevention of cervical cancer. The nurse includes which of the following recommendations on the poster? A. perform monthly breast self)examination =$26> $. use oral contraceptives as a preferred method of birth control C. use a commercial douches on a daily basis D. see" treatment promptly for infections of the cervi$ .!. A nurse is caring for a client who has "ust had a mastectomy. The nurse assists the client in doing which of the following exercises during the first !& hours following surgery? !. el ow fle$ion and e$tension $. shoulder abduction and external rotation C. pendulum arm swing . hand wall climbing .#. Tretinoin =7etin)A> is prescribed for a client with acne. The client calls the clinic nurse and says that the s%in has become very red and is beginning to pee. (hich of the following nursing statements to the client would be most appropriate? A. Dcome to the clinic immediatelyE $. Ddiscontinue the medicationE C. Dnotify the physicianE D. this is a normal occurrence with the use of medication3 2ituation- Fu8 1/ years old single is scheduled for mastectomy of the right breast .&. $ased on the health history and other assessment data+ Fu8s nursing diagnosis includes the following except-

A. potential sexual dysfunction $. body image disturbance C. pain related to anesthesia . self)care deficit related to immobility of arm on the operative side .'. The following are her possible post operative complication except!. hematoma $. lymphedema C. neurovascular deficits . infection .*. Fu8 complains of pain ! hours after receiving her medication of Meperidine ;CF '0 mg 4M ordered every & hours for the first !& hours only. <ou shouldA. tell Fu8 to wait for ! hours more $. give the medicine 2TAT C. give fractional dose of Meperidine ;CF D. use nursing measure to relieve pain .,. <ou informed her that the most common breast tumor occurring in young women isA. fibrocystic $. papilloma C. gynecomastia D. fi roadenoma ... (hich of these wor%)up is not related to her surgery? A. C$C B. 5rinalysis C. $.T.

. C.T. ./. 7ationale for moderately elevating post operative affected arm is to!. prevent lymphedema $. reduce pain C. $.T. . C.T. /0. (hich of these maybe used to her post operatively? A. pleural drainage B. hemovac C. prevent infection . improve coping ability /1. (hich of the following is not a post operative complication A. bronchopneumonia $. pneumonia C. atelectasis D. decu itus ulcer /!. Allowing her to do deep breathing exercise every ! hours would preventA. bronchopneumonia B. atelectasis C. bronchitis . pneumonia /#. A client has a left mastectomy with axillary lymph node dissection. The nurse determines that client understands post operative restrictions and arm care if the client states to-

A. use a straight ra8or to shave under the arms $. allow blood pressures to be ta%en only on the left arm C. carry a handbag and heavy ob"ects on the left arm D. use gloves when wor"ing in the garden /&. A nurse has provided instructions to a client who is receiving external radiation therapy. (hich of the following if started by the client would indicate a need for further instructions regarding self)care related to the radiation therapy? A. D4 need to avoid exposure to sunlight?E $. D4 need to wash my s%in with a mild soap and pat dryE C. 26 need to apply pressure to the irritated area to prevent leeding3 . D4 need to eat a high)protein dietE /'. A nurse is teaching a client about the modifiable ris% factors that can reduce the ris% for colorectal cancer. The nurse places highest priority on discussing which of the following ris% factors with this client? A. personal history of ulcerative colitis or gastrointestinal =94> polyps $. distant relative with colorectal cancer C. age over #0 years D. high#fat, low fi er diet 2ituation- 3e+ a !1)year)old fourth year physical therapy student has been diagnosed with peptic ulcer. The personal and family history shows that she has difficulty coping with the demands of the course and her mother is being treated for peptic ulcer to/*. A relevant diagnosis the nurse identifies is one of the followingA. defensive coping $. self)esteem disturbance

C. sensory)perceptual alteration D. ineffective individual coping /,. Typical personality traits of a person with peptic ulcerA. submissive and dependent B. competitive and aggressive C. self)sacrificing and dependent . perfectionist and assertive /.. Cne of the nursing intervention is to teach 3eA. relaxation techni1ue $. behavior modification C. stress management techni1ue . desensiti8ation techni1ue //. The following are psycho)physiological reactions exceptA. migraine B. constipation C. bronchial asthma . peptic ulcer 100. The defense mechanism usually used by patient with peptic ulcer is!. denial $. reaction formation C. pro"ection . sublimation

1. The home health nurse is visiting the client who has had a prosthetic valve replacement for severe mitral valve stenosis. (hich statement by the client reflects an understanding of specific postoperative care for this surgery? !. 26 threw away my straight ra*or and rought an electric ra*or.3 $. D4 have to go to the bathroom several times at nightE C. D4 count my pulse everydayE . D4 still do my deep breathing exerciseE !. A client has been diagnosed with thromboangitis obliterans. The nurse is considering measures to help the client cope up with lifestyle changes needed to control the disease process. The nurse plans to refer the client to aA. medical social wor%er $. dietician C. smo"ing cessation program . pain management clinic #. The nurse is implementing a plan of care for a client with deep pain thrombosis of the right leg. (hich of the following interventions does the nurse avoid when delivering care to this client? A. elevation of the right leg B. am ulation in the hall twice per shift C. application of moist heat to the right leg . administration of acetaminophen =Tylenol> &. The client was hospitali8ed ' days ago have developed left calf tenderness and have a positive ;omans sign. The nurse assigned to this client next assess to this client next assesses the client forA. coolness and pallor of the affected limb $. diminished distal peripheral pulses C. increased calf circumference

. bilateral edema '. The nurse is monitoring a client with leu%emia who is receiving oxorubicin =Adriamycin> by 4G infusion. (hich of the following assessment findings indicate toxicity of the medication? A. 6levated $A: C. 7C8 changes $. elevated creatinine . a red coloration of the urine

*. A &')year)old male returned to his room an hour ago following a bronchoscopy. ;e is re1uesting for some water. The nurse mustA. %eep the client :?C until n order is written $. chec% the vital signs first C. chec" the gag and swallowing refle$ . encourage coughing and deep breathing ,. A &')year)old client is receiving heparin sodium for a pulmonary embolus. The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy. A. within normal range $. one to 1.' times the control value C. two to '.9 times the control value . three times the control value .. A client is ta%ing (afarin =coumadin> following the placement of an artificial mitral valve. The nurse instructs this client to avoid ta%ing the following commonly used drugA. Maalox plus $. sudafed C. Tylenol cold and flu medication

D. aspirin

/. A client with insulin dependent diabetes mellitus =4 M> is being discharged. The nurse %nows that the client has understood essential teaching when the following statement is heard!. 26 need to cut my nails straight across3

$. D4 cant ma%e any substitutions in my dietE C. Dmy insulin should be given into my armsE . D4 should eat less before exercisingE 10. A client is on chemotherapy for acute myelogenous leu%emia. The nurse assesses the following laboratory test dailyA. complete blood count C. prothrom in time $. electrolyte studies . $A: and creatinine

11. A client has developed depression of the bone marrow from antineoplastic drugs. The nurse states the nursing diagnosis of highest priority asA. fluid volume deficit C. ineffective thermoregulation

$. ;igh ris% for aspiration D. high ris" for infection 1!. 7adioactive iodine is being used to treat a client with cancer of the thyroid gland. The nurse %nows that the client has understood teaching about the treatment when the following statement is heardA. Donly my thyroid gland will be radioactiveE $. D4 need not be concerned about radioactivityE C. Dmy whole body will be radioactiveE D. 2my ody fluids will e radioactive for a short time3 1#. A clients T?: is * hours behind schedule. The nurse wouldA. run the fluid at rate to ma%e up the lost time. $. report the situation to the physician C. run the 4G at the prescribed site D. chec" the lood glucose level 1&. A &')year)old client is in acute congestive heart failure. The nurse and client establish a goal of highest priority as!. rest mentally as well as physically

$. learn stress management C. train for a less demanding "ob . prevent complications of immobility 1'. A client diagnosed with 4 M becomes irritable and confusedB the s%in is cool and clammy and the pulse rate is 110. The first action of the nurse would be to!. give a half#cup of orange .uice $. chec% the serum glucose C. administer regular insulin . call the physician 1*. A client with 4 M is recovering from @A. 4nformation of the serum level of the following substance will be very important to the nurseA. sodium C. potassium $. calcium . magnesium

1,. A 1,)year)old clients mother has been recently diagnosed with pulmonary tuberculosis. The nurse would expect the doctor to order which of the following tests initially? !. the mantou$ C. a sputum culture $. an H)ray . gram stain of the sputum

1.. The nurse in"ects 0.1 ml. of purified protein derivative =?? > intradermally into the inner aspect of the forearm of a client. This nurse will interpret the reaction to this test as positive when the following is seenA. redness greater than 'mm. $. swelling greater than ,mm. C. induration greater than %(mm. . exudates covering more than 1!mm

1/. A !/)year)old has been ta%ing ?rednisone *0 mg. daily for an inflammatory condition for the past * months. The physician "ust wrote an order to discontinue the medication. The nurse shouldA. stop the medication as ordered $. continue the medication until physician is available C. call the physician and 1uestion the order D. hold the medication until the physician is availa le !0. A '' year old has a chest tube connected to a ?leur 6vac system to remove blood from the pleural cavity. (hile turning the client the nurse remembers to!. "eep the Pleur 7vac elow the level of the wound $. 7emove the suction from the ?leur vac C. Clamp the tubing connected to the ?leur 6vac . drain the sterile water from the ?leur 6vac !1. A client on anti)neoplastic therapy has a platelet count of !0+000Icu.mm. An appropriate intervention for the nurse to use would beA. administering Git. @ 4M $. massaging in"ection sites to avoid absorption C. encouraging the use of firm toothbrushes and vigorous flossing D. avoiding rectal temperatures and other rectal procedures !!. A nurse assumes responsibility for the care of the client at , A.M. :?; insulin is ordered for ,-#0 A.M. $efore giving the insulin+ the nurse chec%s to see if the client will eat that day and for theA. signs and symptoms of hypoglycemia $. previous sites of in"ection C. serum glucagons level D. serum glucose level

!#. A nurse is teaching a client to observe for signs of hypoxia. The nurse explains that cyanosis is not reliable indicator of the amount that tissues are receiving because the blue color is caused by!. reduced hemoglo in $. a low partial pressure of oxygen in the blood C. inability of oxygen to enter the cell . increased p; of the blood !&. A client has A7 2. The lowest fraction of inspired oxygen possible for optimi8ing gas exchange is used. The nurse explains to the family that the reason for this precaution is toA. avoid respiratory depression B. prevent o$ygen to$icity C. increase lung compliance . promote production of surfactant !'. A client who is recovering from a myocardial infarction demonstrates that touching has been effective with the statementsA. Dif my chest pain lasts for more than ' minutes+ 4 should get myself to the emergency roomE $. D4 "ust need to avoid salty foods and not add salt to my foodE C. 26 need to avoid constipation and all activities that have caused me chest pain in the past3 . D4 need to get to the drugstore to get some medicine for my coldE !*. A client is admitted to the hospital complaining of nervousness+ heat intolerance and muscle wea%ness. ;er pulse rate is 11. and she has exopthalmos. An essential part of her assessment will be!. palpation of the thyroid gland $. evaluation of fluid and electrolyte balance C. evaluation of deep tendon reflexes

. use of the 9lasgow Coma 2cale !,. A client is scheduled for thyroidectomy. The nurse explains that ?TA or an iodine preparation is given prior to surgery in order toA. increase the si8e of the thyroid gland $. render the parathyroid glands visible C. induce a euthyroid state in the ody . 2eparate the thyroid from the laryngeal nerve !.. A client is being evaluated for the possibility of 9raves disease. The nurse teaches that the best laboratory test for evaluating whether a client has hypothyroidism or hyperthyroidism is the serum level of!. thyro$ine :T/; C. T2; . epinephrine

$. triiodothyroinine =T#>

!/. A client is ta%ing Fevothyroxine =synthroid> for hypothyroidism. The nurse teaches the client to!. monitor the pulse regularly $. restrict sodium in the diet C. ta%e the drug with meals . measure urinary output #0. A client with :4 M is admitted to the hospital. The client is confused and has dry mucus membranes and poor s%in turgor. The serum sodium is 1&/B the blood pressure /0I*0 mm;gB the pulse is 11.B and the serum glucose &*' mgIdl. The nurse anticipates that insulin and the following will be neededA. a potassium drip C. intravenous fluids . calcium gluconate

$. sodium bicarbonate

#1. A nurse is teaching a diabetic client how to attain the optimal level of health. (hen assessing for other ris% factors stro%e and heart attac%+ this nurse loo%s forA. hypervolemia C. proteinuria

$. hypo%alemia

D. hypertension

#!. A nurse stops at the sight of a motor vehicle accident to find a young woman slumped over the wheel. 2he is breathing with a regular rhythm at a rate of !!B ventilation efforts normal. ;er pulse rate is 110. The nurses next action would beA. chec% the level of consciousness $. immobili8e the spine C. call the rescue s1uad D. chec" for leeding ##. A ',)year)old client is being prepared for discharge following a myocardial infarction. The nurse %nows that her teaching has been understood when she hearsA. D4 guess my sex life is overE $. Ddepression is bad for me. 4 must stay happy and optimisticE C. 2 the est way to "now the amount of e$ercise 6 should ta"e is to watch my pulse3 . Dthe in"ured area will be replaced with a new heart tissueE #&. A client with 4 M has "ust been admitted to the 67 after hitting a telephone pole with her car. $ystanders said she acted as if she has been drin%ing. ;er temperature is #,.& degrees Celsius+ pulse .0+ resp. && and deep. 2he complained of headache and acted confused. A fruity odor was noted on her breath. ;er A$9 report readJ p;J ,.#!+ pCC!J #*+ and bicarbonateJ 1.. The nurse prepared for the treatment of!. meta olic acidosis $. metabolic al%alosis C. respiratory acidosis . respiratory al%alosis

#'. A client with peptic ulcer is ta%ing Maalox+ Amoxicillin and 3amotidine. The nurse teaches the client to ta%e the MaaloxA. 1)! hours before meals C. K hour before meals $. with meals D. %#' hours after meals

#*. A client with varicose veins tells the nurse+ D4 am afraid they will burst while 4 am wal%ing.E (hich response by the nurse would be the $62T?

A. Dthe only way to prevent rupture is to have surgeryE $. Dyou must find another "ob+ one that re1uires less wal%ingE C. Dif that happens+ you could bleed to deathE D. 2rupture of varicose veins rarely occur3 #,. A client as%s why is it important to chec% the pupils. The nurse replies that changes in the pupils are a reflection of how well the following area of the nervous system is functioningA. spinal cord B. rain stem C. midbrain . cerebellum

#.. A #!)year)old client is being evaluated in the clinic today for possible Addisons disease. The nurse %nows that the most common cause of the disease is attributed to!. autoimmune response C. disseminated tuberculosis $. blastomycosis . diabetes mellitus

#/. The nurse %nows that the recommended diet for a client with Addisons disease includesA. 1 mg. :a B. - gms. Na C. low fat+ low cholesterol . high potassium+ high cholesterol

&0. A #*)year)old client with a history of Cushings disease is being seen in the 67 for complaints of anorexia+ vomiting+ wea%ness and muscle cramps for the past !& hours. The nurse recogni8es that these clinical findings are a result ofA. hypernatremia $. hypoglycemia C. hyperglycemia D. hypo"alemia

&1. (hen teaching a patient about home care related to outpatient corticosteroid therapy+ the nurse emphasi8es that side effects of corticosteroid therapy includeA. hyperglycemia and weight loss $. hyponatremia and hypotension C. hypoglycemia and gastric ulcers

D. hyperglycemia and weight gain &!. Additional teaming to a newly diagnosed diabetic client related to the effects of regular insulin is necessary when the client as%s+ Dif 4 ta%e my regular insulin at . A.M.+ when might 4 experience signs of low blood sugar reaction? A. .-#0 am B. %% am C. 1-#0 pm . & pm &#. The nurse recogni8es which of the following as signs of early hypoxia? A. bradycardia+ hypotension+ facial flushing $. confusion+ bradycardia+ headache C. hypotension+ tachypnea+ lethargy D. restlessness, yawning, tachycardia &&. A *.)year)old client has a new colostomy and is being treated today at the clinic for diarrhea. (hen discussing diet with the client+ the nurse explains to him that the one food that caused this problem wasA. cabbage B. eggs C. tapioca . fried chic%en

&'. The nurse is caring for a client with folic acid deficiency. The nurse recalls that one of the most fre1uent causes of folic acid deficiency isA. poor nutritional inta%e due to alcoholism B. lac" of a sorption of the intrinsic factor C. a diet that consists of vegetables only and no meat . a complicated pregnancy during the second trimester &*. (hen planning care for a patient who is pancytopenic+ the ma"or goal should be!. prevent hemorrhage and infection

$. administering an oral iron preparation C. preventing fatigue and fluid overload . encouraging consumption of a neutropenic diet &,. when explaining different effects of chemotherapy to students+ the nurse correctly identifies which group of chemotherapy drugs that does not affect :A synthesis to %ill tumor cells? !. hormones C. antimetabolites . al%ylating agents

$. vinca al%alosis

&.. The nurse evaluates the clients ability to self)monitor blood glucose level at home. (hat information $62T indicates the average degree of diabetes control during the past ! to & months? !. serum glycosylated hemoglo in $. postprandial blood glucose level C. a written record of daily blood glucose levels . a written record of daily double voided urine glucose levels &/. (hich of the findings would the nurse most li%ely note during an Addisonian crisis? A. serum potassium of # m61IF+ $?J1'.I,! mm;g B. serum potassium of 9.& m71<,, BP=0'</& mm+g C. serum sodium of 1'0 m61IF+ $?J 1'.I,! . serum sodium of 1#' m61IF+ $?J*!I&. '0. ?ropanolol =4nderal> is commonly prescribed for clients with hyperthyroidism toA. bloc% formation of the thyroid hormone $. decrease the vascularity of the thyroid gland C. inhibit peripheral conversion of T& and T# D. decrease CN> stimulation

'1. The client with cancer is receiving chemotherapy and develops thrombocytopenia. (hich goal should be given the highest priority in the :C?? A. ambulation tree times a day $. monitoring temperature C. monitoring hemoglo in and hematocrit . monitoring for pathologic fractures '!. The nurse assesses the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse determines that this occurrenceA. is common B. is characteristic of thrush infection C. indicates that oral hygiene need to be improved . suggests that the client is anemic '#. The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the ($C count is normal if which of the following results is present? A. #+000 to .+000Icu.mm. B. /,((( to ?,(((<cu.mm. C. ,+000 to 1'+000Icu.mm. . !+000 to '+000Icu. Mm. '&. The client suspected of having an abdominal tumor is scheduled for a CT scan with dye in"ection. (hich of the following is an accurate description of the scan? A. the test maybe painful B. the dye in.ected may cause a warm, flushing, sensation C. fluids will be restricted following the test . the test ta%es approximately ! hours

''. The client is diagnosed as having a bowel tumor. 2everal diagnostic test are prescribed. (hich of the following test will confirm the diagnosis of the malignancy? A. M74 C. abdominal ultrasound D. iopsy of the tumor

$. CT scan

'*. The oncology nurse is preparing to administer chemotherapy to the client with ;odg%ins disease. A multiagent medication regimen %nown as MC?? is prescribed. The medications included in the therapy areA. belomycin+ oncovin+ vincristine+ prednisone $. adrimycin+ vincristine+ oncovin+ prednisone C. adriamycin+ cytoxan+ prednisone+ oncovin D. procar a*ine, mechlorethemine, oncovin, prednisone ',. The nurse is analy8ing the laboratory results of a client with leu%emia who received a regimen of chemotherapy. (hich of the following laboratory values does the nurse note specifically as a result of massive cell destruction that occurred from chemotherapy? A. anemia C. decrease platelets

$. decreased ($C D. increased uric acid level '.. The client is receiving external radiation to the nec% for cancer of the larynx. The MC2T li%ely side effect to be expected isA. constipation $. dyspnea C. sore throat . diarrhea

'/. The nurse is providing instructions to the client receiving external radiation therapy. (hich of the following is :CT a component of the instructions? A. avoid exposure to sunlight $. wash the s%in with a mild soap and pat dry C. apply pressure on the irritated area to prevent leeding . eat a high protein diet

*0. The nurse teaches s%in care to the client receiving external radiation therapy. (hich of the following statements+ if made by the client indicates the need for further instruction? A. D4 will handle the area gentlyE $. D4 will avoid the use of deodorantsE C. 26 will limit sun e$posure to % hour daily3 . D4 will wear loose fitting clothingE *1. The nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10+000Icu.mm. $ased on this laboratory value+ the priority nursing assessment is which of the following? !. assess level of consciousness $. assess temperature C. assess bowel sounds . assess s%in turgor *!. The client is admitted to the hospital with a diagnosis of suspected ;odg%ins disease. (hich of the following assessment signs would the nurse MC2T li%ely to note in the client? A. wea%ness $. fatigue C. weight gain D. enlarged lymph nodes

*#. The client with leu%emia is receiving $usulfan =myleran>. Allopurinol =Lyloprim> is prescribed for the client. The purpose of Allopurinol =Lyloprim> is toA. preventgouty arthritis C. prevent hyperuricemia $. prevent stomatitis . prevent diarrhea

*&. A gastrectomy is performed on a client with gastyric cancer. 4n the immediate postoperative period+ the nurse notes bloody drainage from the :9T. (hich of the ff. is the MC2T appropriate nursing intervention? A. notify the physician C. continue to monitor the drainage . irrigate the :9T

$. measure abdominal girth

*'. The nurse is reviewing the history of a client with bladder cancer. The MC2T common symptom of this type of cancer is which of the following? A. fre1uency of urination C. hematuria $. urgency of urination . dysuria

**. The nurse is assessing the stoma of a client following a ureterostomy. (hich of the following does the nurse expect to note? A. a pale stoma $. a dry stoma C. a red and moist stoma . a dar%)colored stoma

*,. The nurse is caring for a client following a radical mastectomy. (hich of the following nursing interventions would assist in preventing lymphedema of the affected arm? A. placing cool compress on the affected arm B. elevating the affected arm on pillow elow the heart level C. maintaining an 4G site below the antecubital area of the affected side . avoiding arm exercises in the immediate post)operative period *.. The nurse is teaching $26 to a client who had a hysterectomy. The MC2T appropriate instruction regarding $26 should be performed is!. @ to %( days after menstruation $. "ust before menses begin C. at ovulation time . at a specific day of the month and on the same day every month thereafter */. The nurse is instructing the client+ $en how to perform testicular self) examination. (hich instruction is correct? A. examine testicles when lying down B. the est time for the e$amination is after a shower C. gently feel the testicle with one finger to feel for a growth

. testicular examination should be done at least every * months ,0. The nurse is instructing a group of female about $26. The nurse instructs the clients to perform the examinationA. at the onset of menstruation B. one wee" after menstruation egins C. every month during ovulation . wee%ly at the same time of the day ,1. The client has undergone esophagogastroduodenoscopy =69 >. The nurse places highest priority on which of the following items as apart of the clients care plan? !. assessing for the return of the gag refle$ $. giving warm gargle for sore throat C. monitoring temperature . monitoring complaints of heartburn ,!. The client being seen in a physicians office has "ust been schedule for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test? !. removal all metal and .ewelry efore the test $. eat regular supper and brea%fast C. continue to ta%e all oral medication as scheduled . monitor own bowel movement pattern for constipation ,#. The client is diagnosed with bleed and the bleeding has been controlled antacid are prescribed to be administered every hour. The nurse should plan on maintaining an approximately gastric p; ofA. # $. / C. 0 . 1'

,&. The nurse is caring for a client following a $illroth 44 ?rocedure. Cn review of the post)operative orders+ which of the following+ if prescribed+ does the nurse 1uestion and verify?

!. irrigating the N8 tu e $. coughing and deep breathing exercises C. leg exercises . early ambulation ,'. A client who has a peptic ulcer is schedule for a vagotomy. The client as%s about the purpose of this procedure. The $62T nursing response is which of the following? A. Ddecreases food absorption in the stomachE $. Dheal the gastric mucosaE C. Dhalts stress reactionE D. 2reduces the stimulus to acid secretion3 ,*. The nurse ins monitoring a client for the early signs and symptoms of dumping syndrome. (hich of the following syndrome indicate this occurrence? A. abdominal cramping and pain B. radycardia and indigestion C. sweating and pallor . double vision and chest pain ,,. The nurse is caring for a hospitali8ed patient with a diagnosis of ulcerative colitis. (hen assessing the client+ which finding+ if noted+ would the nurse report to the physician? !. loody diarrhea $. hypotension C. hemoglobin level of 1! mgIdl

. rebound tenderness

,.. The nurse is providing discharge instruction to a client following gastrectomy which of the following measures will the nurse instruct the client to the following assist in preventing dumping syndrome? A. eat high carbonated food B. limit the fluid ta"ing with food

C. ambulate following a meal . sit in a high)fowlers position during meals ,/. The nurse is caring for a client post)operatively following the creation of a colostomy. (hich of the ff. nursing diagnosis does the nurse include in the plan of care? A. altered nutritionB more than body re1uirements B. ody image distur ance C. fear related to poor diagnosis . sexual dysnfunction .0. The nurse is reviewing the record of the client with Crohns disease. (hich of the following stool characteristic does the nurse expect to note in this client? A. bloody stool B. diarrhea C. constipation alternating with diarrhea . stool constantly oo8ing from the rectum .1. The client with cirrhosis has ascites and a fluid volume excess. (hich measure will the nurse include in the plan of care for this client? A. increase the amount of sodium in diet B. restrict the amount of fluids consumed C. encourage ambulation fre1uently . administer magnesium antacids .!. The client with ascites is schedule for a paracentesis. The nurse is assisting the physician in performing the procedure. (hich of the following positions will the nurse assist the client to assume for this procedure? A. supine C. right side lying D. upright

$. left side lying

.#. An ultrasound of the gallbladder is schedule for the client with a suspect diagnosis of cholecystitis. The nurse explain to the client that this test!. re1uires the client to lie still for short intervals $. re1uires that the client be :?C C. re1uires the administration of oral tables . is uncomfortable .&. The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. (hich of the following interventions is of highest priority in the preoperative teaching plan? !. teaching coughing and deep reathing e$ercises $. teaching leg exercises C. instructions regarding fluid restrictions . fre1uent need to wor% overtime on short notice .'. A client with peptic ulcer states that stress fre1uently causes exacerbation of the disease. The nurse interprets that which of the following items mentioned by the client is most li%ely responsible for the exacerbations? A. sleeping . hours a night $. eating ' to * small meals per day C. ability to wor% at home periodically D. fre1uent need to wor" overtime on short notice .*. The client with peptic ulcer disease needs dietary modification to reduce episode of epigastric pain. The nurse plans to teach the client that which of the following items+ which the client en"oys+ does not need to be limited or eliminated with this disease? A. wine C. coffee . fresh fruit

B. a"ed chic"en

.,. The medication history of a client with peptic ulcer disease reveals intermittent use of the following medications. The nurse teaches the client to avoid which of these medications altogether because of the irritating effects on the lining of the 94 tract?

A. =?rilosec> B. i uprofen :Aotrin; C. sucralfate =Carafate> . :i8atidine =Axid> ... The nurse instructs the ileostomy client to do which of the following as part of essential care of the stoma? !. cleanse the peristomal s"in meticulously $. ta%e in high)fiber foods such as nuts C. massage the area below the stoma . limit fluid inta%e to prevent diarrhea ./. The client who has undergone creation of a colostomy has a nursing diagnosis of $ody 4mage disturbance. The nurse evaluates that he client is ma%ing the most significant progress toward identified goals if the clientA. watches the nurse empty the ostomy bag B. loo"s at the ostomy site C. reads the ostomy product literature . practices cutting the ostomy appliance /0. The client with a new colostomy is concerned about odor from stool in the ostomy drainage bag. The nurse should teach the client to include which of the following foods in the diet to reduce odor? !. yogurt $. broccoli C. cucumbers . eggs

/1. The nurse is giving dietary instruction for the client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first & to * wee%s postoperatively? A. high protein C. low calorie

$. high carbohydrates D. low residue

/!. The nurse has given instructions to the client with an ileostomy about foods to eat to thic%en the stool. The nurse evaluates that the client did not fully understand the instructions if the client stated that eating which of the following foods ma%es the stool less watery? A. pasta C. bran B. oiled rice . low)fat cheese

/#. The client has "ust had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperatively period for which of the following most fre1uent complications of this type of surgery? A. intestinal obstruction B. fluid and electrolyte im alance C. malabsorption of fat . folate deficiency /&. The client with acute pancreatitis is experiencing severe pain from the disorder. The nurse teaches the client to avoid which of the following positions that could aggravate the pain? A. sitting up B. lying flat C. leaning forward . flexing the left leg

/'. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse evaluates that the client understands the instructions given if the client stated that which of the following food items is acceptable in the diet? !. a"ed scrod C. fried chic%en $. sauces and gravies . fresh whipped cream

/*. The nurse assesses the client experiencing an acute episode of cholecystitis for pain that is located in the rightA. upper 1uadrant and radiates to the left scapula and shoulder B. upper 1uadrant and radiates to the right scapula and shoulder C. lower 1uadrant and radiates to the umbilicus

. lower 1uadrant and radiates to the bac% /,. The client is beginning to show signs of hepatic encephalopathy. The nurse plans a dietary consult to limit the amount of which of the following ingredients in the clients diet? A. fat C. protein . minerals

$. carbohydrates

/.. The client with Crohns disease has an order to begin ta%ing antispasmodic medication. The nurse should time the medication so that each dose is ta%en!. -( minutes efore meals $. during meals C. *0 minutes after meals . upon arising and at bedtime //. The client with ulcerative colitis is diagnosed with mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets? A. high)fat with mil% $. high)protein without mil% C. low#roughage without mil" . low)roughage with mil% 100. 4t has been determined that the client with hepatitis has contracted the infection from contaminated food. (hat type of hepatitis is this client most li%ely experiencing? !. hepatitis ! $. hepatitis $ C. hepatitis C . hepatitis 2ituation- The head nurse of an eye and ear clinic is ordering nursing students.

1. :ormal visual acuity as measured with a 2nellen eye chart is !0I!0. (hat does a visual acuity of !0I#0 indicate? ! at '( feet, an individual can only read letters large enough to e read at -( feet $. at #0 feet+ an individual can read letters large enough to be read at !0 feet C. an individual can read !0 out of #0 total letters on the chart . an individual can read #0 out of '0 total letters on the chart at !0 feet !. amage to the visual area of the occipital love of cerebrum+ on the left side+ would produce what type of visual loss? A. left eye only $. right eye only C. medial half of the right eye and lateral half of the left eye . medial half of the left eye and lateral half of the right eye #. An anterior chamber of the eye refers to all the space in what area? A. anterior to the retina $. between the iris and the cornea C. etween the lens and the cornea . between the lens and the iris &. (hat condition results when rays of light are focused in front of the retina? !. myopia $. hyperopia C. presbyopia . emmetropia '. As the person grows older+ the lens losses its elasticity+ causing which %ind of farsightedness? A. emmetropia

B. pres yopia C. diplopia . myopia *. 4f a person has a foreign ob"ect of un%nown material that is not readily seen in one eye+ what would the first action be? A. irrigate the eye with a boric acid solution $. examine the lower eyelid and then the upper eyelid C. irrigate the eye with opious amounts of water D. shield the eye from pressure, and see" medical help ,. A sudden loss of an area of vision+ as if a curtain were being drawn+ is a principal symptom of? !. retinal detachment $. glaucoma C. cataracts . %eratitis .. ?ostoperative care following stapedectomy would not include which of the following !. out of ed as desired $. no moisture in the affected ear C. avoid snee8ing . no bending over or lifting /. imenhydrinate = ramamine> is given after a stapedectomy A. to accelerate the auditory process $. to dull the pain experienced with the semicircular canal is disturbed C. to minimi*e the sensations of e1uili rium distur ances and im alance

. to prevent an increase tendency toward nausea 10. A client with Menieres syndrome is extremely uncomfortable because of which of these? A. severe earache $. many perceptual difficulties C. vertigo and resultant nausea . facial paralysis 11. (hat is the cataract of the eyes? A. opacity of the cornea $. clouding of the a1ueous humor C. opacity of the lens . papilledema 1!. Treating a cataract primarily involves which of the following? A. instillation of miotics $. installation of mydriatics C. removal of the lens . enucleation 1#. ?reoperative instruction will not need to include A. type of surgery $. how to use the call bell C. how to prevent paralytic illeus . how to prevent respiratory infetins 1&. 4n preparing to teach patient about ad"ustment to cataract lenses+ the nurse needs to %now that the lenses will.

!. magnify o .ects y one#third# with central vision $. magnify ob"ects by one)third with peripheral vision C. reduce ob"ects by one)third with central vision . reduce ob"ects by one)third with peripheral vision 1'. 4n the immediate postoperative period the one action that is contraindicated for patient compared with clients after most other operations is which of the following? !. coughing $. turning on the unoperative side C. measures to control nausea and vomiting . eating after nausea passes 1*. 4mmediate nursing care following cataract extraction is directed primarily toward preventing A. Atelectasis $. infection of the cornea C. hemorrhage . prolapse of the iris 1,. The patient is confused during her first night after eye surgery. (hat would the nurse do? A. tell her to stay in bed $. apply restraints to %eep her in bed C. e$plain why she cannot get out of ed, "eep side rails up, and chec" her fre1uently . sedate her 1.. ischarge teaching would probably not need to include !. staying in a dar"ened room as much as possi le

$. avoiding alcoholic drin%s+B limiting the use of tea and coffee C. using no eye washes or drops unless they were prescribed by the physician . avoiding being excessively sedentary 1/. ?atient also needs to be instructed to limit. A. sewing $. watching TG C. wal%ing D. weeding her garden 2ituation- Fea visit her ophthalmologist and receives a mydriatic drug in order to facilitate the examination. After returning home+ she experiences severe pain+ nausea and vomiting+ and blurred vision. uring a visit to the emergency room+ a diagnosis of acute glaucoma is made. !0. Feas glaucoma has been caused by the dilation of the pupil. !. loc"age of he outflow of a1ueous humor y the dilation of the pupil $. bloc%age of the outflow of a1ueous humor by the constriction of the pupil C. increase intraocular pressure resulting from the increased production of a1ueous humor . decrease intraocular pressure resulting from decrease production of a1ueous humor !1. 4ntraocular pressure is measured clinically by tonometer. (hat tonometer reading would be indicative of glaucoma? A. pressure of 10 mm;g $. pressure of 1' mm;g C. pressure of !0 mm;g D. pressure of '9 mm+g

!!. (hich cranial nerve transmits visual impulses? A. 4 =olfactory> B. 66 :optic; C. 444 =oculomotor> . 4G =abducens> !#. Antreated or uncontrolled glaucoma damages the optic nerve. Three of the following signs and symptoms result from optic nerve atrophyB which one does not? A. colored halos around lights $. severe pain in the eye C. dilated and fixed pupils D. opacity of the lens !&. 9laucoma is conservatively managed with miotic eye drops. Mydriatic eye drops are contraindicated for glaucoma. (hich of the following drugs is a mydriatic? A. neostigmine $. pilocarpine C. physostigmatine D. atropine !'. 9laucoma may re1uire surgical treatment. ?reoperatively+ the client would be taught to expect which of the following postoperatively? A. cough and deep)breathing 1h. B. turn only to the unaffected side C. medication for severe eye pain . restriction of fluids for the first !& hours 2ituation- 7oy+ a '')year)old man+ is admitted to the hospital with wide)angle glaucoma !*. (hat was the symptom that probably brought 7oy to the ophthalmologist initially?

!. decreasing vision $. extreme pain in eye C. redness and tearing of the eye . seeing colored flashes of light !,. The teaching plan for 7oy would include which of the following? A. reduce fluid inta%e B. add e$tra lighting in the home C. wear dar% glassesIduring the day . avoid exercise !.. Miotics are used in the treatment of glaucoma. (hat is an example of a commonly used miotic? A. atropine B. pilocarpine C. aceta8olamide = iamox> . scopolamine !/. (hat is the rationale for using miotics in the treatment of glaucoma? A. they decrease the rate of a1ueous humor production B. pupil constriction increases outflow of a1ueous humor C. increased pupil si8e relaxes the ciliary muscles . the blood flow to the con"unctiva is increased #0. (hen instilling eye drops for a client with glaucoma+ what procedure would the nurse follow? !. place the medication in the middle of the lower lid, and put pressure on the lacrimal duct after instillation. $. 4nstill the drug to the outer angle of the eye+ have client tilt head bac%

C. instill the drug at the innermost angleB wipe with cotton away from inner aspect . instill medication in middle eye+ have client blin% for better absorption #1. Carbonic anhydrase inhibitors are sometimes used in the treatment of glaucoma because they!. depress secretion of a a1ueous humor $. dilate the pupil C. paraly8e the power of accommodation . increase the power of accommodation #!. Teaching a client with glaucoma will not include which of the following? !. vision can e restored only if the client remains under a physician)s care $. avoid stimulant =eg.+ caffeine> C. ta%e all medications conscientiously . prevent constipation and avid heavy lifting and emotional excitement ##. 9laucoma is a progressive disease that can lead to blindness. 4t can be managed if diagnosed early. ?reventive health teaching would best include which of the points? A. early surgical action may be necessary B. all clients over /( years of age should have an annual tonometry e$am C. the use of contract lances in older clients is not advisable . clients should see% early treatment for eye infections #&. A client with progressive glaucoma may be experiencing sensory deprivation. (hich of the following actions would best minimi8e this problem? A. spea% in a louder voice $. ensure that a sedative is ordered C. orient the client to time+ place+ and person D. use touch fre1uently when providing care

2ituation- ')9ary is seen in the emergency room with the diagnosis of epitaxis. #'. 4t is unli%ely that 9arys history will include A. minor trauma to the nose $. a deviated septum C. acute sinusitis D. hypotension #*. (hich of the following medications would be used with in order to promote vasoconstriction and control bleeding? !. epinephrine $. lidocaine C. pilovarpine . cylospentolate #,. (hich of the following positions would be most desirable for 9ary? A. trendelenburgs to control shoc% B. a sitting position, unless he is hypotensive C. side)lying+ to prevent aspiration . prone+ to prevent aspiration #.. The physician decides to insert nasal pac%ing. Cf the following nursing actions+ which would have the highest priority? A. encourage 9ary to breath through his mouth+ because he may feel panic%y after the insertion. $. advice 9ary to expectorate the blood in the nasopharynx gently and not to swallow it C. periodically chec" the position of the nasal pac"ing, ecause airway o struction can occur if the pac"ing accidentally slip out of place . ta%e rectal temperature+ because he must rely on mouth breathing and would be unable to %eep his mouth closed on the thermometer.

#/. After bleeding has been controlled+ 9ary ta%en to surgery to correct a deviated nasal septum. (hich of the following is li%ely complication of this surgery? A. loss of the ability to smell B. ina ility to reath through the nose C. infection . hemorrhage &0. Apon his discharge+ the nurse instructs 9ary on the use of vasoconstrictive nose drops and cautions him to avoid too fre1uent+ and excessive use to these drugs+ which of the following provides the best rationale for this caution !. ! re ound effect occurs in which stuffness worsens after each successive dose $. cocaine+ a fre1uent ingredient in nose drops+ may lead to psychological addiction C. these medications may be absorbed systematically+ causing severe hypotension . persistent vasoconstriction of the nasal mucosa can lead to alterations in the olfactory nerve 2ituation- $rix had redial and nec% surgery for cancer of the larynx. &1. $rix has tracheostomy. (hen suctioning and suctioning through laryngectomy tube. (hen doing these two procedures at the same time+ the nurse would not do which of the ffA. Ase sterile techni1ue $. turn head to right to suction left bronchus C. suction for no longer then 10 to 1' seconds D. o serve for tachycardia &!. $rix re1uires both nasopharyngeal suctioning and suctioning through laryngectomy tube. (hen doing these two procedures at the same time+ the nurse would not do which of the ffA. use a sterile suction setup B. suction the nose first, then the laryngectomy tu e

C. suction the laryngectomy tube first+ then the nose . lubricate the catheter with saline &#. A nasogastric tube is used to provide $rix with fluids and nutrient for approximately 10 days+ for which of the following reasons? A. to prevent pain while swallowing B. to prevent contamination of the suture line C. to decrease need for swallowing . to prevent need for holding head up to ear &&. $rixs children are concerned about their own ris% of developing cancer. All but one of the following are facts that describe malignant neoplasia and must be considered by the nurse in her responses. (hich one is correct? A. family factors may influence an individuals susceptibility to neoplasia B. long#term use of corticosteroids enhances the ody)s defense C. 2exual differences influence an individuals susceptibility to specific neoplasm . living in industriali8ed areas increase an individuals susceptibility to a malignant neoplasm &'. (hen would $rix best begin speech rehabilitation? A. when he leaves the hospital B. when the esophageal suture line is healed C. three months after surgery . when he regains all his strength &*. The nurse is complaining the initial morning assessment on the client. (hich physical examination techni1ue would be used first when assessing the abdomen? !. inspection $. light palpation C. auscultation

. percussion &,. The client has orders for a nasogastric =:9> tube insertion. uring the procedure+ instruction that will assist in insertion would be!. instruct the client to tilt his head ac" for insertion into the nostril, then fle$ his nec" for final insertion $. after insertion into the nostril+ instruct the client to extend his nec% C. introduce the tube with the clients head tilted bac%+ then instruct him to %eep his head upright for final insertion . instruct the client to hold his chin down+ then bac% for insertion of the tube &.. The most important pathophysiologic factor contributing to the formation of esophageal varices isA. decreased prothrombin formation $. decreased albumin formation by the liver C. portal hypertension . increased central venous pressure &/. The nurse analy8es the results of the blood chemistry tests done on a client with acute pancreatitis. (hich of the following results would the nurse expect to find? A. low glucose $. low al%aline phosphatase C. elevated amylase . elevated creatinine '0. A client being treated for esophageal varices has a 2engsta%en)$la%emore tube inserted to control the bleeding. The most important assessment is for the nurse toA. chec% that a hemostat is at the bedside $. monitor 4G fluids for the shift C. regularly assess respiratory status

. chec% that the balloon is deflated on a regular basis '1. A female client complains of gnawing midepigastric pain for a few hours after meals. At times+ when the pain is severe+ vomiting occurs. 2pecific tests are indicated to rule outA. cancer of the stomach B. peptic ulcer disease C. chronic gastritis . pylorospasm '!. (hen a client has peptic ulcer disease+ the nurse would expect a priority intervention to beA. assisting in inserting a Miller)Abbott tube $. assisting in inserting an atrial pressure line C. inserting a nasogastric tu e . inserting an 4G '#. A &0)year)old male client has been hospitali8ed with peptic ulcer disease. ;e is being treated with a histamine receptor antagonists =cimetidine>+ antacids+ and diet. The nurse doing discharge planning will teach him that the action of cimetidine is toA. reduce gastric acid output $. protect the ulcer surface C. inhi it the production of hydrochloric acid :+Cl; . inhibit vagal nerve stimulation '&. The nurse is admitting a client with Crohns disease who is scheduled for intestinal surgery. (hich surgical procedure would the nurse anticipate for the treatment of this conditionA. ileostomy with total colectomy $. sigmoid colostomy with mucous fistula C. intestinal resection with end#to#end anastomosis

. colonoscopy with biopsy and polypectomy ''. A client who has "ust returned home following ileostomy surgery will need a diet that is supplemented!. potassium $. vitamin $1! C. sodium . fiber '*. A client scheduled for colostomy surgery. An appropriate preoperative diet will includepreoperative diet will includeA. broiled chic%en+ ba%ed potato+ and wheat bread $. ground hamburger+ rice+ and salad C. roiled fish, rice, s1uash, and tea . stea%+ mashed potatoes+ raw carrots+ and celery ',. As the nurse is completing evening care for a client+ he observes that the client is upset+ 1uiet+ and withdrawn. The nurse %nows that the client is scheduled for diagnostic tests the following day. An important assessment 1uestion to as% the client isA. Dwould you li%e to go to the dayroom to watch TG?E $. Dare you prepared for the test tomorrow?E C. 2have you tal"ed with anyone a out the test tomorrow43 . Dhave you as%ed your physician to give you a sleeping pill tonight?E '.. 3ollowing abdominal surgery+ a client complaining of Dgas painsE will have a rectal tube inserted. The client should be positioned on hisA. left side+ recumbent B. left side, sims C. right side+ semi)fowlers

. left side+ semi)3owlers '/. (hich of the following statements is most correct regarding colostomy irrigations? A. the solution temperature should be 100 deg. 3 B. %((( ml is the usual amount of solution for the irrigation C. the solution container should be placed 10 inches above the stoma . the irrigation cone is inserted in an upward direction in relation to the stoma *0. The nurse is teaching a client with a new colostomy how to apply an appliance to a colostomy. ;ow much s%in should remain exposed between the stoma and the ring of the appliance? !. %<& inch $. K inch C. M inch . 1 inch *1. 3ollowing a liver biopsy+ the highest priority assessment of the clients condition is to chec% forA. pulmonary edema $. uneven respiratory pattern C. hemorrhage . pain *!. A client has a bile duct obstruction and is "aundiced. (hich intervention will be most effective in controlling the itching associated with his "aundice? A. %eep the clients nails clean and short $. maintain the clients room temperature at ,! to ,' deg. 3 C. provide tepid water for athing . use alcohol for bac% rubs

*#. (hen a client is in liver failure+ which of the following behavioral changes is the most important assessment to report? A. shortness of breath B. lethargy C. fatigue . nausea *&. A client with a history of cholecystitis is now being admitted to the hospital for possible surgical intervention. The orders include :?C+ 4G therapy+ and bed rest. 4n addition to assessing for nausea+ vomiting and anorexia+ the nurse should observe for painA. in the right lower 1uadrant $. after ingesting food C. radiating to the left shoulder D. in the upper 1uadrant *'. The nurse ta%ing a nursing history from a newly admitted client learns that he has a enver shunt. This suggest that he has a history ofA. hydrocephalus $. renal failure C. peripheral occlusive disease D. cirrhosis **. A female client had a laparoscopic cholecystectomy this morning. 2he is now complaining of right shoulder pain. The nurse would explain to the client this symptom is!. common following this operation $. expected after general anesthesia C. unusual and will be reported to the surgeon . indicative of a need to use the incentive spirometer

*,. 3or a client with the diagnosis of acute pancreatitis+ the nurse would plan for which critical component of his care? A. testing for ;omans sign B. measuring the a dominal girth C. performing a glucometer test . straining the urine *.. After removing a fecal impaction+ the client complains of feeling lightheaded and the pulse rate is &&. The priority intervention isA. monitoring vital signs B. place in shoc" position C. call the physician . begin C?7 */. ?eritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular space into the peritoneal cavity. 4f this occurs+ the nurse would evaluate forA. decreased serum albumin $. abdominal pain C. oliguria . peritonitis ,0. The assessment finding should be reported immediately should it develop in the client with acute pancreatitis isA. nausea and vomiting $. abdominal pain C. decreased bowel sounds D. shortness of reath

,1. 3ollowing brain surgery+ the client suddenly exhibits polyuria and begins voiding 1' to !0 FIday. 2pecific gravity of the urine is 1.00*. The nurse will recogni8e these symptoms as the possible development of!. dia etes insipidus $. diabetes+ type 1 C. diabetes+ type ! . Addisons disease ,!. A person with a diagnosis of adult iabetes+ type !+ should understand the symptoms of a hyperglycemic reaction. The nurse will %now this client understands if she says these symptoms areA. thirst+ polyuria and decreased appetite B. flushed chee"s, acetone reath, and increased thirst C. nausea+ vomiting and diarrhea . weight gain+ normal breath and thirst ,#. The non)insulin dependent diabetic who is obese is best controlled by weight loss because obesityA. reduces the number of insulin receptors $. causes pancreatic islet cell exhaustion C. reduces insulin inding t receptor sites . reduces pancreatic insulin production ,&. A nursing assessment for initial signs of hypoglycemia will include!. Pallor, lurred vision, wea"ness, ehavioral changes $. fre1uent urination+ flushed face+ pleural friction rub C. abdominal pain+ diminished deep tendon reflexes+ double vision . wea%ness+ lassitude+ irregular pulse+ dilated pupils

,'. (hich of the following nursing diagnosis would be most appropriate for the client with decreased thyroid functionA. alteration in growth and development related to increased growth hormone production $. alteration in thought processes related to decreased neurologic function C. fluid volume deficit related to polyuria . hypothermia related to decreased metabolic rate ,*. The 7: should assess for which of the following clinical manifestations in the client with Cushings syndrome? A. hypertension+ diaphoresis+ nausea and vomiting $. tetany+ irritability+ dry s%in and sei8ures C. une$plained weight gain, energy loss, and cold intolerance . water retention+ moon face+ hirsutism and purple striae ,,. The client hyperparathyroidism should have extremities handled gently because!. decreased calcium one deposits can lead to pathologic fractures $. edema causes stretched tissue to tear easily C. hypertension can lead to stro%e with residual paralysis . polyuria leads to dry s%in and mucous membrane that can brea%down ,.. (hich of the following priority nursing implementation for a client with a tumor of the posterior lobe of the pituitary gland who has had a urine output of # F in the last hour with a specific gravity of 1.00!? A. measure and record vital signs each shift $. turn client every ! hours to prevent s%in brea%down C. administer Pitressin Tannate as ordered . maintain a dar% and 1uiet room ,/. A client has a diagnosis of diabetes. ;is physician has ordered short and long acting insulin. (hen administering two type of insulin+ the nurse would-

A. withdraw the long acting insulin into the syringe before the short acting insulin B. withdraw the short acting insulin into the syringe efore the long acting insulin C. draw up in two separate syringes+ then combine in one syringe . withdraw long acting insulin+ in"ect air into regular insulin+ and withdraw insulin .0. Certain physiological changes will result from the treatment for myxedem. The symptoms that may indicate adverse changes in the body that the nurse should observe for areA. increased respiratory excursion B. increased the fre1uency of rest periods C. initiate postural drainage . continue with routine nursing care .1. A client with myxedema has been in the hospital for # days. The nursing assessment reveals the following clinical manifestations- respiratory rate .Imin+ diminished breath sounds in the right lower lobe+ crac%les in the left lower lobe. The most appropriate nursing intervention is to!. increased the use of RBA, turning, deep reathing e$ercises $. increased the fre1uency of rest periods C. initiate postural drainage . continue with routine nursing care .!. 4n an individual with the diagnosis of hyperparathyroidism+ the nurse will assess for which primary symptomA. fatigue+ muscular wea%ness $. cardiac arrhytmias C. tetany . constipation

.#. The nurse explains to a client who has "ust received the diagnosis of type ! non) insulin dependent diabetes mellitus =:4 M> that sulfonylureas+ one group of oral hypoglycemic agents+ as act by!. stimulating the pancreas to produce or release insulin $. ma%ing the insulin that is produce more available for use C. lowering the blood sugar by facilitating the upta%e and utili8ation of glucose . altering both fat and protein metabolism .&. A client has been admitted to the hospital with a tentative diagnosis of adrenocortical hyperfucntion. 4n assessing the client+ an observable sign the nurse would chart isA. butterfly rash on the face B. moon face C. positive Chvoste%s sign . bloated extremities .'. The nurse is teaching a diabetic client to monitor glucose using a glucometer. The nurse will %now the client is competent in performing her finger)stic% to obtain blood when sheA. uses a ball of a finger as the puncture site B. uses the side of fingertip as the puncture site C. avoid using the fingers of her dominant hand as puncture sites . avoid using the thumbs as puncture sites .*. A client is scheduled for a voiding cystogram. (hich nursing intervention would be essential to carry put several hours before the test? A. maintain :?C status $. medicating with urinary antiseptics C. administering owel preparations . forcing fluids

.,. A retention catheter for a male client is correctly taped if it is!. on the lower a domen $. on the umbilicus C. under the thigh . on the inner thigh ... A client with a diagnosis of gout will beta%ing colchicines and allopurinol $4 to prevent recurrence. The most common early sign of colchicines toxicity that the nurse assess for isA. blurred vision $. anorexia C. diarrhea . fever ./. A clients laboratory results have been returned and the creatinine level is , mgIdl. This finding would lead the nurse to place the highest priority on assessingA. temperature B. inta"e andoutput C. capillary refill . pupillary reflex /0. After the lungs+ the %idneys wor% to maintain body p;. The best explanation of how the %idneys accomplish regulation of p; is that theyA. secrete hydrogen ions and sodium $. secrete ammonia C. e$change hydrogen and sodium in the "idney tu ules . decrease sodium ions+ hold on to the hydrogen ions+ and then secrete sodium bicarbonate /1. Conditions %nown to predispose to renal calculi formation include-

A. ?olyuria B. dehydration, immo ility C. glycosuria . presence of an indwelling 3oley catheter /!. the most appropriate nursing intervention+ based on physicians orders+ for treating metabolic acidosis is toA. replace potassium ions immediately to prevent hypo%alemia $. administer oral sodium bicarbonate to act as a buffer C. administer 6C cathecholamines :,evophed; to prevent hypertension . administer fluids to prevent dehydration /#. 4G is attached to a controller to maintain the flow rate. 4f the alarm sounds on the controller!. ensure that drip cham er is full $. assess that height of 4G container is at least #0 inches above venipuncture site C. ensure that the drop sensor is properly placed on the drip chamber . evaluate the needle and 4G tubing to determine if they are patent and positioned appropriately /&. A ,*)year)old woman who has been in good health develops urinary incontinence over a period of several days and is admitted to the hospital for a diagnostic wor%up. The nurse would assess the client for other indicators ofA. renal failure B. urinary tract infection C. fluid volume excess . dementia /'. A *0)year)old male clients physician schedules a prostatectomy and orders a straight urinary drainage system to be inserted preoperatively. 3or the system to be effective+ the nurse would-

A. coil the tubing above the level of the bladder $. position the collection bag above the level of the bladder C. chec" that the collection ag is vented and distensi le . determine that the tubing is less that # feet in length /*. uring a retention catheter insertion or bladder irrigation+ the nurse must use!. sterile e1uipment and wear sterile gloves $. clean e1uipment and maintain surgical asepsis C. sterile e1uipment and maintain medical asepsis . clean e1uipment and techni1ue /,. The physician has ordered a !& hours urine specimen. After explaining the procedure to the client+ the nurse collects the first specimen. This specimen. This specimen is the!. discarded, then collection egins $. saved as part of the !& hours collection C. tested+ then discarded . placed in a separate container and later added to collection /.. The most common cause of bladder infection in the client with a retention catheter is contaminationA. due to insertion techni1ue $. at the time of the catheter removal C. of the urethralI catheter interface D. of the internal lumen of the catheter //. A client in acute renal failure receive an 4G infusion of 10 percent dextrose in water with !0 units of regular insulin. The nurse understands that the rational for this therapy is toA. correct the hyperglycemia that occurs with acute renal failure

B. facilitate the intracellular movement of potassium C. provide calories to prevent tissue catabolism and a8otemia . force potassium into cells to prevent arrhythmias 100. A client with chronic renal failure is on continuous ambulatory peritoneal dialysis =CA? >. (hich nursing diagnosis should have the highest priority? A. powerlessness B. high ris" for infection C. altered nutrition- less than body re1uirements . high ris% for fluid volume deficit !A#C!R7 Review !cademy for Nurses 7oom #01 #rd 3loor ? N 5 Fim $ldg. Tiano $rothers @alambaguhan 2ts.+ Cagayan de Cro City Tel. No. :(&&''; @'%#&(9 N,7 D7C7AB7R '((9 A7D6C!, >5R86C!, N5R>6N8 6C 2ituation- 5ohn Fee is an 1.)year old high school student who suffered an in"ury to his cervical spine in a football game. 1. 4n directing emergency care until the ambulance arrives+ it is most important that the school nurse A. place a small ma%eshift pillow under his head $. chec% to see if he can move all of his extremities C. "eep him flat and immo ili*ed in a natural position . cover him with a blan%et !. A primary goal of nursing care when 5ohn is brought into the emergency room will be A. prevention of spinal shoc%

B. maintenance of respiration C. maintenance of orientation provision for pain relief 2ituation- Crutchfield tongs are used to apply traction to realign the spinal cord. #. A nursing measure for "ohn while he is in cervical traction should be to !. massage the ac" of his head $. position him from side to side C. remove the weights at least once a shift . encourage involvement in his own care 2ituation- 5ohn is found to have a temperature of #*OC =/*..O3>. &. The most appropriate initial nursing measure for 5ohn in response to his hypothermia would be to !. cover him with additional lan"ets $. place a hot)water bottle at his feet C. chec% for signs of shoc% . notify his physician 2ituation- 5ohn has a tracheostomy performed and is on assisted ventilation. '. The alarm on the ventilator sounds. The initial response by the nurse should be to 1uic%ly A. notify the respiratory therapist B. chec" all connections from the respirator C. notify the respiratory therapist to come immediately . use a self)inflating bag to ventilate 5ohn *. (hen suctioning 5ohn+ the nurse should

!. ensure that he is a le to ta"e a reath etween insertions of the catheter $. suction him for at least #0 seconds with each catheter insertion C. apply suction and gently rotate the catheter while inserting it into the bronchial bifurcation . use clean techni1ue during the suction procedure ,. 5ohn suddenly becomes diaphoretic+ his blood pressure rises to 1/0I110+ and he complains of a headache. The nurse should assess the patient for signs of A. increased intracranial pressure $. spinal meningitis C. pulmonary congestion D. fecal impaction .. Apon admission 5ohn had a complete loss of motor ability. (ithin &. hours he is noted to be having muscle spasms. ;is family becomes very excited when they notice these movements. (hich of the following choices would be the most appropriate response by the nurse? !. at this stage, muscle spasms are e$pected, ut it is too soon to evaluate the e$tent of the in.ury or its permanent effects $. 4 can understand your excitement. These movements are a good sign that he is ma%ing progress C. these movements are an indication that he is trying to move and that his will is very strong . these movements are reflex activities that indicate that his spinal cord is intact 2ituation- Mar% 7ichards has a compound fracture of the temporal bone. /. The nurse notices bleeding from the orifice of the ear. (hich of the following actions by the nurse can be safely used to determine if the drainage contains cerebrospinal fluid =C23>? The nurse should A. swab the orifice of the ear with sterile applicator and send the specimen to the laboratory

B. lot the drainage with a sterile gau*e pad and loo" for a clear halo or ring around the spot of lood C. gently suction the ear an send the specimen to the laboratory . test the C23 with a Tes)Tape and get a negative reading for sugar 10. The nursing care plans states DCbserve for early signs of increased intracranial pressure =44?>.E 6arly symptoms of 44? include A. widening pulse pressure and dilated pupils $. rising blood pressure and bradycardia C. elevated temperature and decerebrate posturing D. nausea, vomiting, and restlessness 11. uring the initial period after a head in"ury+ nursing intervention for Mr. 7ichards should include A. pac%ing the ear with cotton balls to stop bleeding B. awa"ening the patient every ' hours to determine his level of consciousness C. placing the patient in Trendelenburgs position . forcing fluids to restore hydration 1!. $efore discharge+ a computeri8ed axial tomogram will be performed to rule out any intracranial or extracranial bleeding. Mr. 7ichards should be told that !. the procedure is noninvasive and he will not feel any pain $. he will experience a burning sensation as the dye is being in"ected C. the procedure is done in the operating room under anesthesia . local anesthetic is used before in"ecting air into the ventricles of the brain via the spinal canal 2ituation- Tonnie Miccio is a &#)year old divorced man who has been rushed to the emergency room with an acute gouty arthritis. 1#. (hile admitting Mr. Miccio to the hospital+ the nurse should recogni8e those factors that can precipitate an acute attac%. They include

A. excessive smo%ing B. large alcohol inta"e C. emotional stress . improper rest 1&. A serum uric acid level is performed by the hospital laboratory. 4n acute gout+ the uric acid level is approximately A. 1.0 mgI100 ml $. !.1 mgI100 ml C. *.' mgI100 ml D. %( mg<%(( ml 1'. Colchicine is the standard drug used to treat acute gout- The physician orders colchicines+ 1.0 mg every ! hours. After receiving the third dose+ the patient complains of nausea+ vomiting+ and diarrhea. The nurse should recogni8e that this is A. a transient side effect and give the next dose B. a sign of to$icity and withhold the medication C. an allergic response to the drug and notify the physician . a psychogenic response to the severe pain 1*. The expected outcome for colchicine is to A. reduce uric acid levels B. relieve .oint pain and inflammation C. increase blood flow to the %idney . detoxify purines in the liver 1,. uring the night+ Mr. Miccio complains of severe pain in his toe and as%s the nurse for ! aspirin tablets. The nurse should A. give the patient the ! aspirin tablets

$. elevate the foot on a pillow C. notify the physician . offer the patient a cup of tea 1.. 2ome physicians prescribe an al%ali)ash diet to enhance the effect of the medications. (hich of the following foods are allowed? A. liver+ shellfish+ and fats $. cranberries+ cheese+ and whole grain cereals C. mil", vegeta les, and most fruits . eggs+ mil%+ prunes+ and plums 1/. After the acute attac% subsides+ the physician orders allopurinol =Lyloprim>+ #00 mgIday. The expected outcome for this drug is to !. lower the plasma and urinary uric acid level $. reduce inflammation of the affected "oints C. produce diuresis . relieve pain !0. A teaching program for Mr. Miccio should include A. emphasi8ing that aspirin is contraindicated in patients ta%ing allopurinol $. restricting fluid inta%e to 1+000 mlIday C. e$plaining that acute gouty attac"s often occur during initiation of allopurinol therapy . stating that a low)purine diet should be followed while ta%ing allopurinol !1. About ! months after ta%ing the allopurinol+ Mr. Miccio develops a s%in rash. The nurse should A. recogni8e this as a minor side effect that will subside $. as% the patient if he has been ta%ing any aspirin while ta%ing the allopurinol

C. recogni*e this is an indication to discontinue the drug . be aware that concomitant use of colchicines with allopurinol causes this reaction !!. Cne day+ 5ennifer as%s her roommate+ 6rin+ how her scoliosis was first recogni8ed. 6rin replies+ DThe school health nurse told me that there may be a problem after all the girls in my class were as%ed to stand erect while she examined our bac%s.E The nurse suspected scoliosis when she observed that 6rins shoulder on one side was elevated and her A. head appeared aligned to the opposite side $. leg on the same side appeared shorter C. hip on the opposite side appeared prominent . arm on the same side appeared longer !#. (hen 6rins scoliosis was diagnosed after x)ray examination of her spine+ she was fitted with a Milwau%ee brace. 6rin as%s the nurse when it could be removed each day. (hich of the following would be the best response? A. only when you are lying flat+ either resting or sleeping B. for % hour a day when you athe, shower, or go swimming C. only for special occasions+ such as a party . for # hours a day- one in the morning+ one in the afternoon+ and one in the evening 2ituation- 6rins admission to the hospital for spinal fusion was necessary because hr scoliosis did not respond to the Milwau%ee brace. !&. ?reoperative preparation for 6rin includes explaining that for ! wee%s after surgery she will be positioned A. on either side or prone $. sitting upright C. flat and will e logrolled . on her bac%

!'. (hen 6rin is told that after surgery she will wear a body cast for about 1 year+ she begins to sob. 2he tells the nurse she will loo% li%e a football player+ not a girl. (hich of the following is the best response the nurse can ma%e? A. the people who really care about you wont even notice your cast $. it only will be for a year. <oure mature enough to wait C. "ust ignore any comments that people ma%e D. a pretty hairstyle and some loose peasant louses will "eep you loo"ing feminine !*. After surgery+ the nurse applies slight pressure to 6rins toes and as%s 6rin is he can feel her foot being touched. 6rin replies+ D:o+ 4 dont feel anything.E The nurse should then A. wait 1 hour and supply pressure again $. record 6rins expected response C. as% 6rin if her toes feel cold D. report 7rin)s response to the surgeon 2ituation- Girginia @ is a !') year old woman who wor%s as a lifeguard at the local beach. Cn her way to wor% she is in an automobile accident and is rushed to the hospital by ambulance. A diagnosis of complete transaction of the spinal cord at the third lumbar =F#> level is made. !,. (hile assess Ms. @ for neurologic function+ the nurse can expect she will be unable to A. shrug her shoulders $. tighten her abdominal muscles C. bend her elbow D. straighten her legs !.. Fong)term goals for Ms. @ include developing s%ills in A. performing wheelchair ambulation $. activating an electric wheelchair

C. wal"ing with leg races and crutches . wal%ing without aids !/. observing for symptoms of which of the following is the priority of care for Ms. @ in the acute stages of complete transaction of the lumbar cord? !. spinal shoc" $. respiratory insufficiency C. autonomic hyperreflexia . hypertensive crisis #0. To prevent the complication of urinary tract infections+ which of the following measures should be included in the nursing care plan? !. encouraging e$tra fluid inta"e $. offering at least two servings of citrus fruit "uice per day C. telling the patient to avoid fruit "uices such as plum+ prune+ and cranberry . notifying the dietician to include a container of mil% at all meals 2ituation- 5im+ a 1,)year old senior in high school+ has sustained a simple fracture of the mandible after falling from his motorbi%e. #1. Apon admission to the emergency room+ which of the following choices should the nurse expect to observe? A. bleeding in the external auditory canal $. dropped prominence of the chee% on the affected side C. edema of the eyes and chee%s D. teeth unevenly lined up 2ituation- An open reduction with wiring of the lower "aw to the upper "aw has been done by the surgeon. #!. 4n anticipating the postoperative needs o the patient+ which of the following actions has the priority for 5im?

A. placing paper and pencil at the bedside $. providing a tracheostomy set for tracheostomy care C. taping a wire cutter to the head of the ed . inserting a gau8e wic% in the inside of the chee% ##. (hile teaching 5im mouth care the nurse should A. show him how to use moistened gau8e sponges to clean his mouth and tongue B. demonstrate how an oral irrigation can e performed y inserting the catheter along the inside of the mouth etween the teeth and the chee" C. explain to him that mouth care should not be done until the wires are removed . tell him to use an astringent mouthwash to remove all the debris

Mrs. Marian ; is a '0)year old woman who has a spinal cord lesion at the fourth thoracic =T&> vertebra. #&. (hen there are lesions above T& and T*+ the patient may experience autonomic hyperreflexia. This condition can be prevented by !. avoiding ladder distention $. changing the patients position hourly C. wearing supportive elastic hose . doing a neurologic chec% #'. Mrs. ; complains of severe headache and is extremely anxious. The nurse chec%s her blood pressure and finds it is !10I110. The nurse should then !. chec" the patency of the urinary catheter $. apply ice pac%s to her head C. place the patient in a flat position . sit with the patient until the symptoms subside

2ituation- orothy C+ 7:+ age #'+ is at wor%. After moving a particularly heavy patient+ she suddenly develops severe pain in the lumbosacral area that radiates down her right leg. The preliminary diagnosis is rupture of an intervertebral dis%. #*. ?roper body mechanics may have prevented this in"ury to Ms. C. 4f she had adhered to the correct method of turning a patient from the supine position to the left side+ she would have crossed the patients right arm over chest+ and crossed the right leg over the left leg. Then+ while standing with her feet A. together at the patients right side+ she would gently turn the patient by pushing at the shoulder and sacral areas $. apart at the right side of the bed+ she would turn the patient by gently pushing at the shoulder and center of the bac% C. apart at the left side of the bed+ she would gently roll the patient toward her while %eeping her legs straight D. apart at the left side of the ed, she would gently roll the patient toward her while fle$ing her "nees #,. 4nstructions for Ms. Cs recuperation at home should include the use of a bed board+ firm mattress+ and rest in which of the following positions? A. completely flat in bed B. head elevated on a pillow, and "nees and feet elevated with pillows C. head elevated with several pillows+ and her legs flat . ;ead elevated with several pillows+ and several pillows under her %nees #.. Ms. C should be reminded that if she is turning on her side+ it is best if she A. grasps a chair leg by the side of the bed+ and slowly pulls herself over+ flexing the uppermost %nee $. %eeps her legs extended while crossing them to the side to which she is turning+ and then uses her arms to help turn the upper portion of her body C. crosses her arms, fle$es the uppermost "nee toward the side to which she is turning, and then rolls over

. crosses her arms+ crosses her legs while they are extended to the side toward which she is turning+ and then rolls over #/. The physician gives Ms. C a prescription for methocarbamol =7obaxin>. $ecause of her nursing bac%ground+ Ms. C will %now that the mediation is having the desired effects if which of the following occurs? A. 2he feels drowsy+ and is sleeping more $. she has a feeling of euphoria C. there is a decrease in muscle spasms . there is an increase in the %nee)"er% reflex 2ituation- After a wee% of bed rest at home+ Ms. Cs condition remains about the same. 2he is admitted to the hospital for further treatment and diagnostic tests. &0. ?henylbuta8one =$uta8olidin> is ordered for Ms. C. ?lanning for the administration of this medication should include directions to !. administer it immediately efore or after eating $. avoid administering it with dairy products C. administer it at least ! hours after eating . administer it at specific time intervals+ without regard to meals &1. 4n addition to the order for phenylbuta8one+ Ms. C is placed on bed rest and in pelvic traction. To diminish adverse responses to this treatment+ the nurse should re1uest an order for A. acetylsalicylic acid =aspirin> $. diphenoxylate hydrochloride =Fomotil> C. prochlorpea8ine =Compa8ine> D. dioctyl sodium sulosuccinate :Colace; &!. A myelogram is performed on Mrs. C with a water)soluble contrast medium. Care after this procedure should include

A. limiting fluid inta%e and elevating the head of the bed to 1' to #0 degrees $. not allowing anything by mouth and %eeping the bed flat C. encouraging fluid inta%e and %eeping the bed flat D. encouraging fluid inta"e and raising the head of the ed to %9 to -( degrees &#. Ms. C has a laminectomy. ?ostoperatively+ she complains that the pain is no different now than it was before surgery. The nurse should !. administer analgesics as ordered, and e$plain that the pain is to e e$pected ecause of the edema that results from the surgery $. administer the analgesics as ordered+ but re1uest that the physician chec% the patient immediately C. withhold the analgesic and notify the physician . administer the analgesics as ordered+ and tell Ms. C it will give her relief shortly &&. 7ehabilitation will be facilitated if Ms. C is encouraged to do which of the following? A. sleep in prone position $. sit up for at least part of he day C. perform a dominal#strengthening e$ercise . perform full trun% range)of)motion exercises 2ituation- Martha 2 is a !,)year old patient who has experienced increasing generali8ed stiffness+ especially in the morning+ fatigue+ general malaise+ and swelling and pain in the finger "oints. 2he has a tentative diagnosis of rheumatoid arthritis. &'. Apon admission+ Mrs. 2 is noted to have a rectal temperature of #,.,OC =100O3>. A white blood count is ordered+ and the report comes bac% at .+'00ImmP. The nurse should recogni8e this as being consistent with rheumatoid arthritis because it is !. within normal limits $. evidence of leu%openia C. only slightly elevated . indicative of a generali8ed infectious process

&*. (hich of the following blood)analysis tests would be consistent with diagnosis of rheumatoid arthritis? A. an elevated erythrocyte sedimentation rate and negative C)reactive protein B. an elevated erythrocyte sedimentation rate and positive C#reactive protein C. a low erythrocyte sedimentation rate and negative C)reactive protein . a low erythrocyte sedimentation rate and positive C)reactive protein &,. The primary goal of nursing care for Mrs. 2 during this initial acute phase of rheumatoid arthritis should be to !. prevent deformity and reduce inflammation $. prevent the spread of the inflammation to other "oints C. provide for comfort and relief of pain . assist her to accept the fact that rheumatoid arthritis is a log)term illness &.. uring hospitali8ation+ the nurse should explain to Mrs. 2amuel that analgesics of choice would be A. codeine B. acetylsalicylic acid :aspirin; C. acetaminophen =Tylenol> . proppoxyphene hydrochloride = arvon> &/. uring the acute phase of Mrs. 2s illness+ which of the following measures would be the most appropriate? A. fre1uent periods of active exercises B. fre1uent periods of ed rest C. rest for he affected "oints only . encouragement to perform activities of daily living independently '0. The nurse understands that the main nursing goal in helping Mrs. 2 adapt to her chronic illness and plan is to

A. provide the care she is unable to give herself B. provide guidance so that she will not repress her illness C. plan for social contacts so that she will not feel alone . arrange for her after)care with the home health aide '1. Mrs. 2 is given instructions for using paraffin for her hands. The nurse should include the fact that the dips will be most effective if they are performed !. efore e$ercising her hands $. after exercising her hands C. instead of exercising her fingers . while exercising her fingers '!. (henever Mrs. 2 feels pain from her arthritis+ she tells the nurse she feels not only the pain but that her Dwhole body feels threatened.E (hich response by the nurse is the most therapeutic? A. 4 will have someone stay with you so you wont harm yourself B. 6 will teach you some rela$ing e$ercises so you won)t e so tense C. you must have some medication to help you gain control . arthritic pain will lessen if you try to grin and bear it '#. (hen Mrs. 2 is discharged+ she is instructed to ta%e aspirin at home. 4t is important that she be told to ta%e the drug !. on a regular asis throughout the day $. only when other measures are not effective C. upon arising and again at bedtime . between meals to promote its absorption '&. (hen Mrs. 2 is discharged+ the nursing staff refers her to a nurse therapist who will assist her in dealing with the anxiety over her arthritis and the changes it has made in her life. The nursing team recogni8es that the role of the nurse therapist is to

A. wor% in con"unction with a psychiatrist B. provide individual nursing psychotherapy C. lead groups in therapy for those with similar problems . give family nursing psychotherapy 2ituation- Twenty years after Mrs. 2 was first diagnosed with rheumatoid arthritis+ she is admitted for a right total hip replacement. 2he has experienced severe right hip pain that has not responded to treatment for several years+ and has had increasing difficulty moving about because of damage to the right hip "oint. ''. ?reoperative teaching for Mrs. 2 should include !. isometric e$ercises of the 1uadriceps and gluteal muscles $. instructions on the necessity for %eeping the right leg perfectly straight after surgery C. the need to flex the involved hip postoperatively to maintain mobility . the avoidance of aspirin for & days prior to surgery '*. (hich of the following should the nurse consider to be most significant if noted when chec%ing Mrs. 2 # days postoperatively? A. pain in the operative site $. swelling of the operative sites C. pain and tenderness in the calf . orthostatic hypotension ',. The physical therapist orders exercises of Mrs. 2s right hip+ %nee+ and foot to gradually increase range of motion to the right hip. The nurse can best assist Mrs. 2 by !. administering an analgesic efore the e$ercises $. stopping the exercises if Mrs. 2 experiences pain C. performing the exercises for Mrs. 2 . observing Mrs. 2s ability to perform the exercises

'.. Mrs. 2 should be instructed to avoid !. adduction of her right leg $. abduction of hr right leg C. bearing any weight on her right leg . the prone position in bed '/. The nurse and Mrs. 2 plan for her rehabilitation. Mrs. 2 as%s the nurse+ D(hat do 4 have to do in therapy?E (hich reply by the nurse most accurately describes the tas% of the patient in rehabilitation? To A. follow the instructions of the rehabilitation team $. regain some function that was lost C. prevent further loss of your ability to function D. learn to deal realistically with your disa ility *0. (hen the rehabilitation therapist tells Mrs. 2 that the outcome of her therapy depends on Dthe ability of the nursing staffE as well as on her motivation+ Mrs. 2 1uestions the nurse on the meaning of this phrase. The nurse should reply that Dthe nurses role in rehabilitation is to A. ma%e the patient as comfortable as possible $. follow the directions of the rehabilitation therapist C. supervise the patients therapy appointments and exercise program D. assist the patient in esta lishing therapy priorities and goals *1. Mrs. 2 as%s the nurse if her new "oint will function normally. The nurse can best answer this by saying that A. the new "oint will be stronger than the old one $. the new "oint wont function as well as a normal "oint+ but it will be better than the arthritic "oint C. the new .oint will function almost as well as a normal .oint, particularly if you perform your e$ercise faithfully

. the doctor will be able to assess your limitations in * wee%s and then explain them to you 2ituation- Mr. Fee is a !0)year)old patient who sustains a compound fracture of the right shaft of the femur and a simple fracture of the ulna in a motorcycle accident. *!. (hile serving as a member of a first aid s1uad+ Mary G+ 7:+ reaches the scene of the motorcycle accident and administers emergency treatment+ which includes the application of a splint. 4t is important that the splint A. be applied while the limb is in good alignment B. e applied to the lim in the position in which it is found C. extend from the fracture site downward . extend from the fracture site upward *#. (hile Mr. Fee is being transported in the ambulance to the hospital+ he should be positioned with the affected limbs !. elevated $. in a flat position C. lower than his heart . slightly abducted *&. (hile ta%ing a history from the patient+ the nurse determines that his last booster in"ection for tetanus immuni8ation was ' years ago. The nurse should recogni8e that this information is important because it means that he should receive A. a full tetanus immuni8ation program $. nothing+ because he is sufficiently immuni8ed against tetanus C. an additional ooster in.ection . human tetanus immune globulin 2ituation- Mr. Fee is ta%en to the operating room and the wound caused by the fracture of the femur is cleansed and debrided. The fracture is then reduced+ and a 2teinmann pin for

s%eletal traction is inserted. A closed reduction of the ulna is performed+ and a cast is applied. *'. The most important nursing measure in the immediate postoperative period will be A. encouragement of isometric exercises $. cleansing of the area around the 2teinmann pin C. careful o servation of vital signs . massage of pressure areas **. After Mr. Fee returns to his room+ he complains of pain in his right arm. The initial action of the nurse should be to A. administer analgesics as ordered B. chec" his fingers C. notify his physician immediately . pad the edges of the cast *,. To maintain proper alignment and immobili8ation of the femur+ the physician has ordered s%eletal traction with a Thomas splint. (hile caring for Mr. Fee+ the nurse should explain to him that he A. cannot turn or sit up $. cannot turn but can sit up C. can turn but cannot sit up D. can turn and can sit up *.. 4n dealing with the weights that are applying the traction+ the nurse should !. allow them to hang freely in place $. hold them up if the patient is shifting position in bed C. remove them if the patient is being moved up in bed . lighten them for short periods if the patient complains of pain

*/. Mr. Fee has a Thomas %nee splint in place. 4n addition to the usual measures for a patient in traction+ it will be important that the nurse observe !. the groin area for pressure $. for constipation C. his s%in for sings of decubiti . for signs of hypostatic pneumonia ,0. 4f Mr. Fee should show an increase in blood pressure and signs of confusion and increased restlessness+ the nurse should suspect A. a concussion $. impending shoc% C. fat em oli . anxiety ,1. $ecause of the nature of Mr. Fees wound and the insertion of a 2teinmann pin+ it is especially important that the nurse observe for !. a foul odor $. foot drop C. pulmonary congestion . fecal impaction ,!. Mr. Fee develops an acute locali8ed osteomyelitis. ;e is placed on intravenous antibiotic therapy. The wound is incised and drained+ and neomycin irrigations are ordered four times a day. 4t is important that these irrigations be performed !. with strict aseptic techni1ues $. with a warm solution C. for at least ' minutes . at e1ual time intervals

2ituation- Maria Alfredo is a #0)year old married woman who has systemic lupus erythematosus =2F6>. ,#. (hile doing as nursing history on Mrs. Alfredo+ the nurse should recogni8e that the most common initial symptoms of 2F6 are A. petechiae in the s%in+ nosebleeds+ and pallor $. hematuria+ increased blood pressure+ and edema C. tachycardia+ tremors+ and loss of weight D. painful muscles and .oints, stiffness, and inflammation of .oints ,&. Mrs. Afredo is instituted on long)term prednisone therapy. ;er daily maintenance dose is ' mgIday. 4n the instructions to Mrs. Alfredo+ the nurse should emphasi8e that A. once the symptoms of 2F6 subside+ the medication will be discontinued gradually $. a weight gain ! pounds per wee% should be reported to the physician C. the maintenance dose will e the lowest dose that controls symptoms . if adrenal atrophy occurs+ adrenocorticotropic hormone =ACT;> will have to be prescribed ,'. Mrs. Alfredo 1uestions the nurse about family planning and birth control. (hich of the following choices should the nurse include in her answer? !. oral contraceptives can precipitate an acute e$acer ation of your condition $. 4ntrauterine devices are the recommended brithcontrol measures C. there are no contraindications for pregnancy+ as long as the disease is being treated . studies indicate that the corticosteroids produce fetal damage ,*. The nursing care plan states+ DCbserve for signs of 7aynauds phenomenon.E The nurse should recogni8e that this phenomenon A. occurs as a side effect of prednisone B. is aggravated y smo"ing C. is relieved by application of cold compresses to the hands

. is the priority care ,,. Although many abnormal laboratory findings are found in 2F6+ there is no one specific diagnostic test. The test that is positive in over /' percent of all patients with 2F6 is the blood test for A. the lupus erythematosus =F6> factor $. the rheumatoid factor C. antinuclear anti odies :!N!; . C)reactive protein =C7?> ,.. The teaching program for Mrs. Alfredo planned by the nurse should include emphasis on which of the following? A. once the symptoms are controlled+ the corticosteroids will be discontinued $. if hair loss occurs+ it is irreversible C. overe$posure to the sun can produce an e$acer ation of symptoms . a low)potassium+ low)protein diet is recommended ,/. Mrs. Alfredo tells the nurse that she has had blac%+ tarry stools. The nurse should A. reassure the patient that this is a minor side effect of prednisone $. tell the patient that if she ta%es the prednisone with mil%+ blac%+ tarry stools will be avoided C. tell the patient that she will as% the physician to prescribe aluminum hydroxide D. notify the physician ecause lac", tarry stools can e an indication of leeding peptic ulcer .0. Mrs. Alfredo calls the physicians office and complains that she has chills+ a fever+ and a cough. The nurse should A. advise that she remain in bed+ drin% extra fluids+ and ta%e aspirin every & hours $. recommended that she increase her dose of prednisone until her temperature is normal C. recommended that she come to the office to e e$amined y the physician

. tell Mrs. Alfredo to call for an appointment when she is feeling better 2ituation- 4rene ? is being treated in the emergency room for an acute attac% of Menieres syndrome .1. The nurse should recogni8e that the triad of symptoms associated with Menieres syndrome is A. nystagmus+ arthralgia+ and vertigo $. nausea+ vomiting+ and arthralgia C. syncope+ headache+ and hearing loss D. hearing loss, vertigo, and tinnitus .!. ?atient teaching for Mrs. ? includes helping her to recogni8e that A. Menieres syndrome is psychogenic and is brought on by stress B. most patients can e successfully treated with a low#salt diet and diuretics C. acute infection can precipitate an attac% . a labyrinthectomy is the preferred treatment for relieving symptoms and restoring hearing .#. :ursing intervention during an acute attac% includes A. encouraging the patient to wal% $. placing the patient in a semi)3owlers position C. +aving the patient lie flat . placing the patient in Trendelenburgs position 2ituation- Mrs. C+ #0 years old+ has symptoms of diplopia+ fatigue+ slight vertigo+ and a lac% of coordination. After a neurological wor%)up she is diagnosed as having multiple sclerosis. .&. The main goal of nursing care for Mrs. C during the acute phase of the disease should be to !. promotes rest

$. prevent constipation C. maintain normal functioning . encourage activities of daily living .'. Mrs. C is note d to be having mood swings. 4n deciding what approach to use with her+ the nursing staff should recogni8e that this A. is probably the result of an underlying mental disorder $. indicates that Mrs. C is having difficulty accepting her diagnosis C. may e a result of pathology and involvement of the lim ic system in the disease . indicates that Mrs. Cs intellectual capacity has been compromised .*. Mrs. C 1uestions the nurse concerning the usual course of multiple sclerosis. (hich would be the best reply by the nurse? A. each individual is very differentB we cannot tell what will happen $. 4 %now you are worried+ but it is too soon to predict what will happen C. usually, acute episodes li"e this are followed y remissions, which may last a long time . the future will ta%e care of itselfB lets concentrate on the present .,. As Mrs. Cs condition improves+ it is most important that she be given guidance in A. developing a program of exercise B. learning to handle stressful situations C. see%ing vocational rehabilitation . limiting her activities to those that are absolutely necessary 2ituation- $arbara is a !#)year)old woman who lives with her mother+ sister+ and brother in a private residence. 2he is attending the neurological out)patient clinic for the first time. ;er health history includes two grand mal sei8ures.I A diagnosis of idiopathic epilepsy has been made. The physician has ordered an electroencephalogram =669> and phenytoin sodium = ilantin>+ #00 mgIday

... (hile doing a nursing history on $arbara+ the nurse should recogni8e that A. persons with idiopathic epilepsy have a lower intelligence level B. grand mal sei*ures do not cause mental deterioration C. a common characteristic of idiopathic epilepsy is committing acts of violence . idiopathic epilepsy is a form of mental illness ./. To prepare $arbara for 669+ the nurse should explain that A. during the test she will experience small electric shoc%s that feels li%e pin pric%s $. the test measures mental status as well as electrical brain waves C. during the hyperventilation portion of the test, she may e$perience di**iness . she will be unconscious during the test /0. ;ealth teaching for $arbara includes ensuring that she understands that !. proper prophylactic medication can control the incidence of sei*ures $. moderate use of alcohol is permitted C. forcing fluids helps to reduce the incidence of sei8ures . the incidence of sei8ures is related to hyperglycemia /1. uring a follow)up clinic visit+ $arbara tells the nurse that her urine has had a reddish)brown color. The nurse should !. reassure Bara ara that this is a harmless side effect of phenytoin sodium :Dilantin; $. tell $arbara that this is a sign of hepatic toxicity C. recommend that $arbara go to the laboratory for a serum ilantin concentration test . notify the physician that $arbara has hematuria /!. A long)term goal for $arbara is to minimi8e the gingival hyperplasia associated with ilantin therapy. The nurse should recogni8e that

A. another anticonvulsant will be prescribed if it occurs $. the physician will reduce the dosage at the first sign of hyperplasia C. a regular plan of good oral hygiene is essential . vitamin C should be ta%en daily with the ilantin /#. $arbaras serum concentration level ilantin is 1' QgIml. The nurse should recogni8e this as !. a desired therapeutic serum level $. below the desired therapeutic level C. above the recommended serum level . a toxic serum level /&. 3amily members should be instructed about caring $arbara during a grand mal sei8ure. 4mmediate care during a sei8ure should include A. restraining $arbaras arms and legs $. forcing the mouth open to insert an airway C. giving orange "uice before the clonic stage begins D. turning Bar ara)s head to the side /'. The nurse explains to $arbara that safety precautions can be ta%en by those who have warning symptoms before the sei8ure. =These symptoms are not part of the sei8ure+ as the aura is.> (hat warning symptoms should the nurse tell $arbara to be aware of? !. +ot and cold sensations, gastrointestinal pro lems, an$iety, and mood changes $. Muscle twitching+ lapse of consciousness+ anxiety+ and gastrointestinal problems C. tingling in a local region+ anxiety+ and lapse of consciousness . increased tonicity of muscles and autonomic behavior /*. The nurse should tell $arbaras family that after a sei8ure she will be in a confused state and will need some supervision. 4t is most important for the caring one to be calm because the confused state of the epileptic is considered to be

A. Cne mood swings and a feeling of general inade1uacy and fatigue that result in a decrease of interest B. an adaptive period, when one slowly learns to cope with the devastating insults to one)s psychological and physical integrity C. a gross impairment in social and intellectual functioning with crude+ tactless+ and impulsive behavior . a helpless state+ with intellectual deterioration+ difficulty in communication+ and regression to the infantile state /,. $arbara as%s the nurse if it is true that there is an Depileptic personality.E (hich of the following choices would be the nurses best responseI A. the person must be aware that anxiety over anticipation of a sei8ure may cause personality problems $. :o+ deviation in personality is caused by restrictions imposed by society C. <es+ one may learn to induce sei8ures as a way of getting attention from others D. the person may ta"e on a sic" role if mismanaged at home or in the community 2ituation- Ms. 7+ a #')year old woman+ has myasthenia gravis. 2he has been referred to the neurology clinic by her physician. /.. (hile doing a nursing history on Ms. 7+ the nurse should expect her to complain of which of the following symptoms? A. passive tremors+ cogwheel rigidity+ and drooling $. spastic wea%ness of the limbs+ intention tremors+ and incontinence C. diplopia, ptosis, and fatigue . nystagmus+ ataxia+ and tinnitus //. 4n preparing a teaching plan for Ms. 7+ the nurse should emphasi8e that

A. the anticholinesterase medications cause fewer side effects when ta%en on an empty stomach $. physical activity should be planned for the late afternoon early evening C. a mem er of the family should e taught how to use suction for emergency use . edrophonium chloride =Tensilon> is the drug of choice in the treatment of myasthenia gravis 100. 7espiratory distress is common in people with myasthenic crisis? Mar%ed improvement of respirations occurs after the administration of intravenous A. dia8epam =Galium> $. hydrocortisone C. atropine sulfate D. edrophonium chloride :Tensilon; 101. The medication used to treat cholinergic crisis !. atropine sulfate $. neostigmine =?rostigmin> C. aminophylline . hydrocortisone 10!. The physician has prescribed pyridostigmine =Mestinon>+ 1.0 mgIday. Ms. 7 tells the nurse that each time she ta%es the medication she feels nauseated. The nurse should tell Ms. 7 to A. crush the tablet before ta%ing it B. ta"e the ta let with food or mil" C. ta%e the tablet on an empty stomach . not to ta%e the medication until she notifies the physician Mr. 9o+ who has had ?ar%insosns disease for & years+ visits his wife daily during her hospital stay. ;is illness is being treated with levodopa =F)dopa>.

10#. (hen Mr. 9o visits his wife+ he is observed to be wal%ing rather slowly. The nurse should recogni8e that Mr. 9o is A. exhibiting a long)range side effect of F)dopa B. e$hi iting a symptom that is characteristic of stage 66 Par"inson)s disease C. beginning to experience atrophy of the cerebral cortex and cellular changes . probably doing this on purpose as a way of 10&. The nurse can help him to be more comfortable by !. discussing this pro lem and how he handles it, and discussing hygiene measures with him $. opening the windows and providing as much ventilation as possible while he is visiting C. suggesting that he is probably dressing too warmly for the hospital environment . explaining that this is a side effect of his medication+ and encouraging increased inta%e of fluids 2ituation- Mr. go has a sudden exacerbation of symptoms. ;e develops tachycardia+ a respiratory rate of &0+ and appears extremely anxious. ;e is hospitali8ed with a diagnosis of par%insonian crisis. 10'. ?lanning for Mr. 9os care should include measures to !. provide a 1uiet, restful environment $. maintain "oint range of motion C. decrease social isolation . improve his nutritional status 10*. Mr. 9o responds to treatment+ and his condition gradually improves. ;owever+ he complains that he feels di88y whenever he tries to stand up from a lying position. The nurse should A. explain that this is "ust part of his illness $. tell him that his doctor will be notified of this symptom

C. encourage him to change his position slowly . discuss his feelings about his wifes hospitali8ation 10,. Mr. 9o has problems in dressing himself as a result of tremors+ but he refuses all assistance. (hich of the following is the best initial action by the nurse in response to this complaint? A. tell him he needs assistance+ and gradually help him B. give him more time and encouragement to dress himself C. suggest that for the present he wear only the hospital gown . listen to his refusal+ but give him assistance as needed 10.. Mr. 9o discusses his wor% as an accountant with the nurse. ;e states that he his glad that he will be able to continue wor%ing. An appropriate initial response would be based on the nurses recognition that he !. should e encouraged to e active $. should be cautioned against overfatigue C. is being unrealistic about his future . needs to recogni8e that his situation is uni1ue 10/. Mr. 9o tells the nurse that someone told him that people with ?ar%insons disease develop early senility. 4n response+ the nurse should explain that !. Par"inson)s disease progresses very slowly over a period of years, and it is only in the late stages that any mental changes might ta"e place $. his information is false+ because ?ar%insons disease does not cause any changes in the individuals intellectual capacities C. he does not have to worry about senility because he is responding so well to treatment . although ?ar%insons disease does cause mental confusion+ this condition is clinically different from senility