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Escuela de Nstra. Sra. de La SalettDE LA SALLE SUPERVISEDTapuac District, Dagupan CityFINAL EXAM IN CA II

COMPETENCY APPRAISAL II

I. Write the correct answer in your test booklet. (Write your answer in capital

letters only and NO ERASURES.)

1. An 8-year-old child is sent home by the school nurse with pediculosis. The child's father speaks with the nurse and is obviouslyupset and embarrassed. Which of the following statements by the mother would indicate to the nurse that he understands how hischild got pediculosis

A. !" brush her hair twice a day.!#. !$ould this result from sharing batting helmets at T-ball practice!$. !" make sure she shampoos her hair daily.!%. !We always use a dandruff-control shampoo.!

!. "& (ediculosis) or head lice) is commonly spread by the sharing of headwear) combs) and brushes. The adult lice can alsotravel from one person to another if contact is close. The adult lice lay eggs) or nits. These nits are !glued! to the hair andcannot be removed unless treated with special shampoo formulated for *ust this purpose. The hair is then combed with a fine-toothed comb to remove the nits. #ecause head lice spread so easily) a child is usually kept out of school until he or she istreated and found to be free of nits. 1 +airbrushing will not prevent pediculosis. , $leanliness does not prevent theacuisition of pediculosis. %andruff shampoos will not protect the child from head lice. /0 &2384

&. The nurse is teaching a group of women to perform breast self-e5amination. The nurse should e5plain that the purpose ofperforming the e5amination is to discover

A. cancerous lumps.#. areas of thickness or fullness.$. changes from previous self-e5aminations.

%. fibrocystic masses.

!#. Women are instructed to e5amine themselves to discover changes that have occurred in the breast. 6nly a physician candiagnose lumps that are cancerous) areas of thickness or fullness that signal the presence of a malignancy) or masses that arefibrocystic as opposed to malignant. /0 7&&4

,. A client has had a cerebrovascular accident /$A4. #ecause the $A affected the left side of the client's brain) the nurse shouldanticipate that the client would most likely e5perience

A. 95pressive aphasia.#. %ysle5ia.$. Apra5ia.

%. Agnosia.

!$. %1 #roca's area) which controls e5pressive speech) is located on the left side of the brain. Therefore) a client with acerebrovascular accident in this area is likely to e5hibit e5pressive or motor aphasia. & %ysle5ia) the inability of a person withnormal vision to interpret written language) is thought to be due to a central nervous system defect in the ability to organi:egraphic symbols. , Apra5ia is the inability to perform purposeful movements in the absence or loss of motor power) sensation)or coordination. Agnosia is the loss of comprehension of auditory) visual) or other sensations despite an intact sensorysphere. /0 ,&;74

. The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has

A. e5travasation.#. osteomalacia.$. petechiae.%. uremia.

!&. (etechiae are small hemorrhagic spots. 95travasation is the leakage of fluid in the interstitial space. 6steomalacia is thesoftening of bone tissue.

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%. !" can be certain my husband is not being inappropriate.!

!'. #/4 This statement by the patient may indicate that she suspects her husband of child abuse and does not trust him to be alonewith the child. The statement reuires further e5ploration. /14/&4and /,4. $o-sleeping) in which the parents allow the child tosleep with them) is a relatively common and accepted practice) especially among #lack) +ispanic and Asian families. 6thergroups that are adopting co-sleeping include single parents) whose need for company may encourage the practice> workingparents) who desire the closeness at night that was lost during the day and parents who have had an issue about sleep orseparation in their past. /0 ==84

6. A school-age child is admitted to the hospital with a diagnosis of acute lymphoblasticleukemia. The nurse formulates a nursing diagnosis of Risk for infection.Which of thefollowing is the most eective way for the nurse to reduce the childs risk of infection!A. "mplementing reverse isolation#. $aintaining standard precautions%. &e'uiring sta and visitors to wear masks(. )racticing thorough hand washing

A*+W,& (Acute lymphoblastic leukemia and its treatment cause immunosuppression.Thorough hand washing is the single most eective way to prevent infection in animmunosuppressed client. &everse isolation doesnt signicantly reduce the

incidence of infection in immunosuppressed clients/ furthermore0 isolation maycause psychological stress. +tandard precautions are intended mainly to protectcaregivers from contact with infectious matter0 not to reduce the clients risk ofinfection. +ta and others need not wear masks when visiting because mostinfections are transmitted by direct contact. "nstead of relying on masks and otherbarrier methods0 the nurse should keep persons with known infections out of theclients room.

. 2pon admission of a four-year-old child to rule out leukemia0 the parents ask the nursewhen they will know the diagnosis. The nurses response is based on the knowledgethat the results of which of the following conrms leukemia!

A. #one marrow aspiration#. %omplete blood count 3%#%4%. 5umbar puncture(. )eripheral blood smear

A*+W,& AA bone marrow aspiration or biopsy conrms the diagnosis and type of leukemiabased on an eamination of the actual cells.# Although a %#% may suggest leukemia 3such as normal0 elevated0 or decreasedW#% count with immature cells0 decreased %0 and decreased platelet count40 itdoes not conrm the diagnosis.% A lumbar puncture is performed to rule out spread of leukemia cells to the

central nervous system once the diagnosis has been established.( ,ven though the peripheral blood smear is used to note immature blood cells0 itis not the denitive diagnostic test.

7. The nurse analy8es the laboratory values of a child with leukemia who is receivingchemotherapy. The nurse notes that the platelet count is 9:0::: cells;

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@. A child with leukemia is to be sent home on a protocol that includes severalantineoplastics after an intrathecal administration of methotreate. #efore dischargethe nurse instructs the childs parents toA. 5imit contact with peers because they tend to have communicable diseases#. &eturn weekly for bone marrow aspiration to monitor eectiveness of therapy%. +chedule routine laboratory screening to evaluate response to the medication(. Withhold medications when nausea occurs to prevent additional episodes of

vomiting

A*+W,& %#lood tests indicate response to therapy/ if the W#% count drops severely0 therapymay be temporarily halted.A These children receive therapy for etended periods0 and prolonged isolationfrom their peers may lead to destructive social isolation.# This is a very painful procedure and is not done weekly.( *ausea commonly occurs with this therapy/ although antiemetic measures areinstituted0 the drug is not withdrawn.

1:. "n addition to systemic chemotherapy0 the nurse is aware that cranial radiation isdone on children with leukemia to

A. "mprove the 'uality of the childs life#. &educe the risk of systemic infection%. Avoid metastasis to the lymphatic system(. )revent central nervous system involvement

A*+W,& (%ranial radiation destroys leukemic cells in the brain because chemotherapeuticagents are poorly absorbed through the blood-brain barrier.A:This is not the primary reason for the treatment/ it is a curative measure.B:This is not the reason for cranial radiation.C:This is inaccurate/ leukemia is an abnormality of the bone marrow and lymphaticsystem.

11. A child with leukemia is complaining of nausea. A nurse suspects that the nauseais related to the chemotherapy. The nurse0 concerned about the childs nutritionalstatus0 most appropriately would oer which of the following during this episode ofnausea!A. The childs favorite foods#. %ool0 clear li'uids%. 5ow-protein foods(. 5ow-calorie foods

A*+W,& #When the child is nauseated0 oering cool0 clear li'uids is best because they aresoothing and better tolerated. ?ne should not oer favorite foods when the child isnauseated because foods eaten during times of nausea will be associated withbeing sick. +upportive nutritional measures also should include oral supplementswith high-protein and high- calorie foods.

19. The most common symptom associated with bladder cancer isA. )ainless hematuria.#. (ecreasing urine output.%. #urning on urination.(. re'uent infections.

A*+W,& A)ainless hematuria is the most common symptom associated with bladder cancer.#leeding from the lesions occurs fairly early in the disease process0 but bladdercancer is basically asymptomatic in early stages.# #ladder cancer is not related to renal function.% #urning on urination is associated with urinary tract infections.( #ladder cancer is not related to infection.

B

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1B. A client with carcinoma of the tonsils and enlarged lymph glands in the neck isreceiving chemotherapy following surgery. The nurse0 recogni8ing the eects oftherapy0 should check the clients laboratory reports0 especially theA. )latelet count#. &ed blood cell count%. White blood cell count(. Cematocrit and hemoglobin

A*+W,& %

Antineoplastic drugs depress bone marrow0 which causes leukopenia/ the clientmust be protected from infection0 which could cause death.A These may decrease as rapidly but complications can be limited with infusionsof platelets.# %s diminish slowly and can be easily replaced with a transfusion of packedcells.( %s diminish slowly and can be easily replaced with a transfusion of packedcells.

1=. A client who is to receive radiation therapy for cancer says to the nurse0 D$y familysaid " will get a radiation burn.D The best response by the nurse would be

A. D"t will be no worse than a sunburn.D#. DA locali8ed skin reaction usually occurs.D%. DCave they had eperience with this type of radiation!D(. D(aily application of an emollient will prevent the burn.D

A*+W,& #&adiodermatitis occurs B to 6 weeks after the start of treatment.A:The word burn should be avoided because it may increase aniety.% This response does not address the clients concern.( ,mollients are contraindicated/ they may alter the calculated -ray route andin>ure normal tissue.

1E. After a mastectomy for breast cancer0 the nurse teaches the client how to avoidthe development of lymphedema. Which of the following instructions would beincluded!A. Applying an elastic bandage to the aected etremity.#. 5imiting range-of-motion eercises in the shoulder and elbow.%. ,levating the aected arm on a pillow.(. Taking diuretics as necessary to decrease swelling.

A*+W,& %The client should be taught to elevate the aected arm on a pillow to promotevenous return and lymphatic drainage of the area.A Applying an elastic bandage is inappropriate because constriction of theetremity should be avoided.# &ange-of-motion eercising is not limited. &ather0 it is encouraged.( (iuretics are not used to control lymphedema.

17. The nurse is caring for a client who spontaneously aborted an 8-week-old fetus. The client is sobbing and moaning after thee5pulsion of the fetus. A priority goal for this client is that she'll

A. verbali:e her feelings related to the pregnancy loss.#. e5press decreased pain and increased comfort.$. discuss the causes of the spontaneous abortion.%. avoid se5ual intercourse for at least & days.

%$. %A pregnancy loss can precipitate the grieving process. erbali:ing her feelings about the pregnancy loss is important for theclient so that she may recover from the grief process. 95pressing decreased pain and increased comfort is important but not apriority at this time. %iscussing the causes of the spontaneous abortion isn't helpful at this time. The client should avoidinserting anything into the vagina for at least & weeks. /0 &24

13. Which of the following nursing diagnoses should the nurse use to best address the suicidal patient's feelings of despair

A. "neffective coping#. 0piritual distress$. An5iety%. %ysfunctional grieving

=

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%&. "/&4The nursing diagnosis of spiritual distress is appropriate for the suicidal client who is e5periencing a lack of hope for thefuture and a feeling of despair. /14"neffective coping may describe the individual's lack of problem-solving skills that led to thesuicidal ideation or intent) but is not related to feelings of despair. /,4An5iety may be appropriate to describe the suicidalclient's concerns regarding the future. "t may also be a response to a situational crisis. +owever) it does not best describe thefeelings of despair. /4%ysfunctional grieving resulting from a loss may contribute to the person feeling isolated and confusedand lead to the suicidal feelings. +owever) spiritual distress better describes the individual's feeling of despair /0 =224

18. Which of the following statements best e5plains the common observation that health care personnel avoid terminally ill people

A. The family members who are present can provide essential care.#. +ealth care personnel do not understand their own feelings about death and dying.$. The dying person reuires minimal physical care to be comfortable.%. To protect a person's right to die with dignity) it is best to avoid interrupting the client.

%'. "& +ealth care personnel may avoid the terminally ill client because they are uncomfortable about death and do not understandtheir own feelings about dying. 1 ?amily members should not be e5pected to assume responsibility for the client's care) butthey should be involved in the client's care to the e5tent they desire. , 0killed and knowledgeable nursing care is reuired tomake a dying person comfortable. "nterrupting the client does not necessarily interfere with the right to die with dignity. /0,;834

12. The nurse is assessing a client suffering from stress and an5iety. A common physiological response to stress and an5iety is

A. sedation.#. diarrhea.$. vertigo.%. urticaria.

%. "%iarrhea is a common physiological response to stress and an5iety. The other choices could also be related to stress andan5iety but they don't occur as commonly as diarrhea. /0 &,84

&;. A week ago) a tornado destroyed the client's home and seriously in*ured her husband. The client has been walking around thehospital in a da:e without any outward display of emotions. The client is being admitted to the stress unit with the diagnosis of

Acute 0tress %isorder. The client tells the nurse in a matter-of-fact manner that her husband is paraplegic) !but that's better thantotal paralysis.! Which protective mechanism is the client e5hibiting

A. 0uppression.#. ationali:ation.$. %enial.%. "ntellectuali:ation.

". # The client is e5hibiting intellectuali:ation) which is using logical e5planations without feelings or an affective component. 10uppression is the voluntary e5clusion from awareness of feelings) ideas) or situations that are an5iety provoking. &ationali:ation is an attempt to make or prove that one's feelings or behaviors are *ustifiable. , %enial is an unconsciousrefusal to admit an unacceptable idea or behavior. /0 &82&4

&1. Which of the following would be an effective rela5ation strategy for a school-age child to use during a painful procedure

A. +aving the child keep his eyes shut at all times#. +aving the child hold his breath and not allowing him to yell

$. +aving the child take a deep breath and then blow it out until told to stop%. #eing honest with the child and telling him the procedure will hurt a lot

"%. +aving the child take a deep breath and then blow it out is a form of distraction and will help the child cope better with theprocedure. A child may prefer to keep his eyes open during a procedure so he can see what is going on and can anticipatewhat is going to happen. +olding the breath isn't beneficial and could have adverse effects /such as di::iness or faintness4.

Allowing the child to yell during a procedure is another form of distraction. The nurse should prepare a child for a procedure byusing nonpain descriptors and not suggesting pain. ?or e5ample) the nurse might say) !0ometimes this feels like pushing orsticking) and sometimes it doesn't bother children at all.! /0 1=4

&&. A single) pregnant client) attending a crisis intervention group) has decided to go through with the pregnancy and keep the baby.@ow the crisis intervention nurse's primary responsibility is to

A. 0upport the client for making a wise decision#. 95plore other problems the client may be e5periencing$. ake an appointment for the client to see a physician for prenatal care%. (rovide information about other health resources where the client may receive additional assistance

"". #%!)!This is part of the general interaction with the client> it is not a specific primary responsibility. !)!This is not part of theimmediate goal during the crisis> the client may be encouraged to seek help later for other problems. !)!This is one of manyinstructions for which the client must take primary responsibility. !)!The crisis center nurse's main responsibility is to assist theclient in using the problem-solving process> the client will be helped in e5ploring alternative solutions to a situation and will begiven information regarding other agencies) facilities) and services. ! /0 &12&4

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&,. A =-year-old woman is brought to the mental health center by her family. 0he is e5periencing severe headaches) insomnia) and apoor appetite. 9ach time a uestion is asked) the patient provides a lengthy) detailed description of events. Which of the followingactions) if taken by the nurse) would be 60T appropriate

A. emind her of the time.#. Tell her not to worry.$. 0it and listen to her.%. Ask her to be brief.

".

B

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. # erbali:ing the desire to stop drinking alcohol is an initial outcome that acknowledges alcohol consumption as a problembehavior and leads to further participation in treatment. 1 %escribing adaptive methods to use instead of drinking alcohol toinduce sleep is an outcome to be reached later in the clientHIJs course of treatment. & erbali:ing the negative effects ofalcohol on the body is a therapeutic behavior but is not specific to helping the client sleep. , %escribing the dangerous effectsof using alcohol with antidepressant medication is a therapeutic behavior but is not specific to helping the client sleep. /0&2124

&2. The nurse is working in a community mental health center. A client with an A5is " diagnosis of An5iolytic Withdrawal is prescribedpra:epam /$entra54 in daily decreasing doses for , weeks. 0he has been taking $entra5 for , days. The client had been

dependent on dia:epam /alium4) which she had been taking daily for the past 8 months at a dose of 7; mg. The client states shefeels shaky) is having problems sleeping) and does not want to continue with $entra5. 0he asks the nurse if she can stop takingthe $entra5 now. The nurse's best response is

A. !Dou need to continue the $entra5 as prescribed to ensure a slow and safe withdrawal.!#. !#ecause your symptoms of withdrawal are minimal) you can take the $entra5 when you feel you need it.!$. !Dou can discontinue the $entra5 because the worse symptoms of withdrawal are over.!%. !" recommend one dose of $entra5 at bedtime to help you sleep.!

#. %1 The nurse instructs the client to continue taking pra:epam /$entra54 as prescribed to ensure a safe) slow taperingwithdrawal from dia:epam /alium4. & This reflects poor nursing *udgment as the client needs to follow the tapering scheduleto ensure a safe withdrawal from ben:odia:epine dependence. , This reflects poor nursing *udgment as the client needs tofollow the tapering schedule to ensure a safe withdrawal from ben:odia:epine dependence. This reflects poor nursing

*udgment as the client needs to follow the tapering schedule to ensure a safe withdrawal from ben:odia:epine dependence./0 &88&4

,;. The nurse is teaching a client about the disease concept of alcoholism. Which of the following client statements indicates that theclient understands the nurse's teaching

A. !@ow that " know " have this disease) it's up to me to decide if "'m going to take that drink.!#. !" can't help it if " drink. " have an illness.!$. !All of my relatives have problems with alcohol) but "' m not as bad as they are.!%. !y children won't be affected by my drinking because "'ve uit.!

!. %1 The development of alcoholism is influenced by biologic) sociocultural) and environmental factors. The biologic theories ofalcoholism clearly identify genetic factors as a ma*or influence on the development of alcoholism in some people. The diseaseconcept of alcoholism permits the individual with the disease to not feel guilty about causing the illness. +owever) theresponsibility of using alcohol is still up to the individual) who alone decides whether or not to take that drink of alcohol. & Thisstatement reflects using the disease of alcoholism as an e5cuse to drink and as a way to avoid responsibility for taking thatdrink. , This statement reflects ongoing denial about alcoholism. $hildren of alcoholic parents are more likely to becomealcoholics than are the children of nonalcoholic parents) even if raised in an alcohol-free environment. /0 &8724

,1. "n teaching a client about Alcoholics Anonymous) the nurse states that Alcoholics Anonymous has helped in the rehabilitation ofmany alcoholics) probably because many people find it easier to change their behavior when they

A. +ave the support of rehabilitated alcoholics.#. Know that rehabilitated alcoholics will sympathi:e with them.$. $an depend on rehabilitated alcoholics to help them identify personal problems related to alcoholism.%. eali:e that rehabilitated alcoholics will help them develop mechanisms to cope with their alcoholism.

$. %

1 embership in Alcoholics Anonymous is voluntary. "ts rehabilitated members are available to support alcoholics) and theunderstanding and influence of these rehabilitated members often helps alcoholics change their behavior. & The role ofrehabilitated members does not include sympathi:ing with others abusing alcohol. , The role of rehabilitated members doesnot include helping others abusing alcohol to identify personal problems. The role of rehabilitated members does not includehelping others abusing alcohol to develop defense mechanisms to cope with alcoholism. /0 &2&24

,&. The client in an outpatient alcohol treatment program states to the nurse) !Why do we need to talk about relapse " know "'ll neverdrink again.! Which of the following responses by the nurse is best

A. !Anyone can slip. elapse commonly occurs during the first few months after a treatment program.!#. !elapse prevention is important in follow-up care.!$. !"t's important to talk about relapse prevention because your recovery has only begun.!%. !"f you don't continue with follow-up care) you won't hear about relapse prevention.!

&. %

1 The client's statement !" know "'ll never drink again! reflects overconfidence) one of the symptoms of relapse. The nursereminds the client that anyone can slip) that anyone is vulnerable to start drinking again) and that relapse often occurs duringthe first few months after treatment. & This statement is true but is not complete information to give to the client. , Thisstatement is true but does not provide any useful rationale for understanding relapse. This statement is not helpful becauseit does not provide the client with any information about relapse. /0 &83&4

,,. The nursing care coordinator in the surgical intensive care unit notes that a number of clients do not seem to be responding tomeperidine /%emerol4 that has been administered for pain. Eater that evening the coordinator finds a staff nurse in the nurses'lounge do:ing. 6n being awakened the staff nurse appears somewhat uncoordinated and drugged with slurred speech. Thecoordinator should

A. Ask the other staff members whether they have noticed anything unusual#. Tell the staff nurse that everyone now knows who has been stealing the %emerol$. $all the nursing director and have the director present before confronting the staff nurse

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%. Arrange to secretly observe the staff nurse the ne5t time the staff nurse administers %emerol

'. $!)!This is unnecessary> as a professional the nurse has enough information to confront the other nurse. !)!This is anassumption that may result in an altercation> a witness should be present. !)!This is a serious charge) and confrontation shouldoccur in the presence of the supervisor. !)!This is not a professional approach> the nurse has a legal responsibility to intervene.! /0 &1,14

,. To give clients with long histories of alcohol abuse greater responsibility for self-control) the nurse should initially plan toA. Tell them about deto5ification programs#. $onfront them with their substance abuse

$. Assist them to identify and adopt more healthful coping patterns%. Administer their medications according to the prescribed schedule

. $!)!This would tell the client what to e5pect but would not instill responsibility for change. !)!This will increase guilt and placethe client on the defensive> it usually does not foster the development of a trusting relationship. !)!The client must learn todevelop and use more healthful coping mechanisms if drinking is to be stopped> the responsibility is with the client becausethe client must do the changing. !)!edications do not provide the motivation for change> this must come from within the client.! /0 &1,&4

,=. A client is admitted to the psychiatric unit with complaints of sleep disturbance) fatigue) feelings of uselessness) and inability toconcentrate. The client was let go from her place of employment last month owing to her inability to keep up with the demands ofher position. 6n the day after an interview during which the client talked at length and tearfully about feeling useless and old) shefailed to keep an appointment with the nurse. Which action would be best for the nurse to take

A. Assume that the client had a good reason for not coming and let her make the ne5t move.#. $onfront the client with her behavior and ask her to e5plain the reason for her absence.$. 0eek out the client at the end of the scheduled interview time and tell her she was missed today.%. Arrange for another session with the client later the same day and say nothing about her absence.

%. , The responsibility for maintaining a relationship with a client rests with the nurse. "f a client misses a scheduled interview)the nurse is assuming responsibility for the relationship by seeking her out at the end of the scheduled interview time andtelling her she was missed. 1 Without knowing the facts) the nurse makes an assumption by thinking that the client has goodreason for not keeping her appointment. The nurse is not assuming responsibility by waiting for the client to make the ne5tmove in this situation. & To confront the client with her absence and ask her to e5plain it is threatening and not therapeutic. To arrange another session with the client and to say nothing about the missed appointment does not keep to the terms of thenurseHILclient contract and offers little help to the client. /0 &3384

36. Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have!. Multiple stimuli

". #outine !ctivitiesC. Minimal decision ma$ing

D. %aried !ctivities

3&. To 'urther assess a client(s suicidal potential. Nurse )atrina should be especially alert to the clientexpression o'

!. *rustration + 'ear o' death

". !nger + resentmentC. !nxiety + loneliness

D. elplessness + hopelessness

3-. ! nursing care plan 'or a male client with bipolar disorder should include

!. /roviding a structured environment

". Designing activities that will re0uire the client to maintain contact with reality

C. 1ngaging the client in conversing about current a''airsD. Touching the client provide assurance

32. hen planning care 'or a 'emale client using ritualistic behavior, Nurse 4ina must recogni5e that the ritual!. elps the client 'ocus on the inability to deal with reality

". elps the client control the anxiety

C. s under the client(s conscious controlD. s used by the client primarily 'or secondary gains

7. ! 38 year old male graduate student, who has become increasingly withdrawn and neglect'ul o' his wor$and personal hygiene, is brought to the psychiatric hospital by his parents. !'ter detailed assessment, a

diagnosis o' schi5ophrenia is made. t is unli$ely that the client will demonstrate

!. 9ow sel' esteem

". Concrete thin$ingC. 1''ective sel' boundaries

D. ea$ ego

7

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:. ! 83 year old client has been admitted with a diagnosis o' schi5ophrenia says to the nurse ;

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2. Nurse Tina is caring 'or a client with depression who has not responded to antidepressant medication. Thenurse anticipates that what treatment procedure may be prescribed?

!. Neuroleptic medication

". hort term seclusionC. /sychosurgery

D. 1lectroconvulsive therapy

7. Mario is admitted to the emergency room with drug@included anxiety related to over ingestion o' prescribedantipsychotic medication. The most important piece o' in'ormation the nurse in charge should obtain initially is

the

!. 9ength o' time on the med.". Name o' the ingested medication + the amount ingested

C. #eason 'or the suicide attempt

D. Name o' the nearest relative + their phone number

36.B. Depression usually is both emotional + physical. ! simple daily routine is the best, least stress'ul and

least anxiety producing.

3&.D. The expression o' these 'eeling may indicate that this client is unable to continue the struggle o' li'e.

3-.A. tructure tends to decrease agitation and anxiety and to increase the client(s 'eeling o' security.

32.B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by

maintaining a set pattern o' action.

7.C. ! person with this disorder would not have ade0uate sel'@boundaries.

:.D. 9oose associations are thoughts that are presented without the logical connections usually necessary

'or the listening to interpret the message.

8.C. elping the client to develop 'eeling o' sel' worth would reduce the client(s need to use pathologic

de'enses.

3.B. Bpen ended 0uestions and silence are strategies used to encourage clients to discuss their problem in

descriptive manner.

.C. Clients who are withdrawn may be immobile and mute, and re0uire consistent, repeated interventions.

Communication with withdrawn clients re0uires much patience 'rom the nurse. The nurse 'acilitates

communication with the client by sitting in silence, as$ing open@ended 0uestion and pausing to provide

opportunities 'or the client to respond.

.D. hen hallucination is present, the nurse should rein'orce reality with the client.

6.A. /ersonal characteristics o' abuser include low sel'@esteem, immaturity, dependence, insecurity and

>ealousy.

&.D. ! short acting s$eletal muscle relaxant such as succinylcholine F!nectineG is administered during this

procedure to prevent in>uries during sei5ure.

-.C. #ecogni5ing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid

speci'ic stimulus.

2.D. 1lectroconvulsive therapy is an e''ective treatment 'or depression that has not responded to

medication.

1:

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7.B. n an emergency, lives saving 'acts are obtained 'irst. The name and the amount o' medication

ingested are o' outmost important in treating this potentially li'e threatening situation.

:. ! 'emale client who has had a myocardial in'arction as$s the nurse why she should not bear down orstrain to ensure having a bowel movement. The nurse incorporates in a response that this would trigger

!. %agus nerve stimulation, causing a decrease in heart rate and cardiac contractility.". %agus nerve stimulation, causing an increase in heart rate and cardiac contractility.

C. ympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility.

D. ympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility.

51. 1

"earing down as i' straining to have a bowel movement can stimulate a vagal re'lex. timulation o' the

vagus nerve causes a decrease in heart rate and cardiac contractility. The sympathetic nervous systemstimulation has the opposite e''ect. These two branches o' the autonomic nervous system oppose each

other to maintain homeostasis. F# 66--G

8. ! nurse is per'orming cardiopulmonary resuscitation FC/#G on an adult client. hen per'orming chest

compressions, the nurse understands that correct hand placement is located over the

!. 9ower third o' the sternum.

". Apper hal' o' the sternum.

C. Apper third o' the sternum.

D. 9ower hal' o' the sternum.

52. 4

Determine proper hand placement 'or chest compressions by locating the notch where the rib marginmeets the sternum and placing the middle 'inger on this notch and the index 'inger next to it. Then place

the heel o' the opposite hand on the lower hal' o' the sternum close to the index 'inger. #emove the 'irst

hand and place it on top o' the hand on the sternum, and begin chest compressions. This location is the

lower hal' o' the sternum. F# 6&3&G

3. ! client with cardiogenic shoc$ has a catheter multilumen pulmonary artery catheter placed. The nurse

would interpret that the client is most unstable i' which o' the 'ollowing cardiac output FCBG andpulmonary capillary wedge pressure F/C/G readings were obtained?

!. CB 9Hmin, /C/ low". CB 9Hmin, /C/ high

C. CB 3 9Hmin, /C/ high

D. CB 8 9Hmin, /C/ low

53. 3

The normal cardiac output is to - 9Hmin. ith cardiogenic shoc$ the cardiac output 'alls below normal

because o' 'ailure o' the heart as a pump. The pulmonary capillary wedge pressure, however, risesbecause it is a re'lection o' the le't ventricular end@diastolic pressure, which rises with pump 'ailure. F#

6&:G

. ! nurse is preparing to de'ibrillate a client in ventricular 'ibrillation. The nurse places that paddles on

the client(s chest and be'ore de'ibrillating the client assesses that

!. The client has received lidocaine hydrochloride FIylocaineG

". The rhythm is actually ventricular 'ibrillation.

C. The machine has been set to the ;synchroni5e= mode.D. The client has been intubated.

54. 2

Antil the de'ibrillator is attached and charged, the client is resuscitated by using cardiovascularresuscitation. Bnce the de'ibrillator has been attached, the electrocardiogram is chec$ed to veri'y that

the rhythm is ventricular 'ibrillation or pulseless ventricular tachycardia. 9eads also are chec$ed 'or any

loose connections. ! nitroglycerin patch, i' present, is removed. The client does not have to be intubatedto be de'ibrillated. 9idocaine may be given subse0uently but is not set to the synchronous mode because

there is no underlying rhythm with which to synchroni5e. F# 6&6&G11

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. ! client is admitted to the hospital with a suspected diagnosis o' myocardial in'arction. The nurse isreviewing the laboratory results per'ormed on the client. hich o' the 'ollowing laboratory results most

speci'ically would indicate the presence o' a myocardial in'arction?

!. ncreased creatinine $inase M".

". ncreased creatinine $inase MM

C. ncreased blood urea nitrogen.

D. Decreased white blood cell count.

55. 1

The creatinine $inase M" is speci'ic in determining the presence o' a myocardial in'arction. Thecreatinine $inase MM re'lects in>ury to s$eletal muscle. The white blood cell count will most li$ely

would be elevated in the client with a myocardial in'arction. The blood urea nitrogen is unrelated to this

disorder. F# 667-G

6. ! 'emale client is at ris$ 'or developing disseminated intravascular coagulation. The nurse is reviewing

the laboratory results and determines that the 'ibrinogen level is normal i' which o' the 'ollowing isnoted on the laboratory report?

!. :-7 mgHd9

". 77 mgHd9C. -7 mgHd9

D. 77 mgHd9

56. 2

The normal 'ibrinogen level is :-7 to 37 mgHd9 'or males and :27 to 87 mgHd9 'or 'emales. ! critical

value is one that is less than :77 mgHd9. ith disseminated intravascular coagulation the 'ibrinogenlevel drops because 'ibrinogen is used up in the clotting process. Bption 8 is the only option that

identi'ies a normal level 'or a 'emale client. F# 6&83G

&. ! client with myocardial in'arction has been trans'erred 'rom a coronary care unit to a general medical

unit with cardiac monitoring via telemetry. ! nurse plans to allow 'or which o' the 'ollowing client

activities?

!. trict bed rest 'or 8 hours a'ter trans'er

". "athroom privileges and sel'@care activities

C. Ansupervised hallway ambulation with distance under 877 'eetD. !d lib activities because the client is monitored

57. 2

Bn trans'er 'rom the coronary care unit, the client is allowed sel'@care activities and bathroomprivileges. upervised ambulation in the hall 'or brie' distances gradually increased F7, :77, 877 'eetG.

F# 6&3G

-. ! client recovering 'rom pulmonary edema is preparing 'or discharge. The nurse plans to teach the client

to do which o' the 'ollowing to manage or prevent recurrent symptoms a'ter discharge?

!. Ta$e a double dose o' the diuretic i' peripheral edema is noted.

". old the digoxin F9anoxinG i' slight respiratory distress occurs.

C. eigh sel' daily.D. leep with the head o' the bed 'lat.

58. 3

The client can best determine 'luid status at home by weighing daily. The client should report to the

physician increases o' 8 to 3 lb in a short time. The client should sleep with the head o' the bed elevated.

During recumbent sleep, 'luid Fwhich has seeped into the interstitium by day with the assistance o' the

e''ects o' gravityG is reabsorbed rapidly into the systemic circulation. leeping with the head o' bed 'latis there'ore avoided. The client does not modi'y medication dosages without consulting the physician.

F# 668G

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2. ! client receiving total parenteral nutrition has a history o' congestive heart 'ailure. The physician has

ordered 'urosemide F9asixG 7 mg /B daily to prevent 'luid overload. The nurse monitors whichlaboratory value to identi'y adverse e''ects 'rom this medication?

!. 4lucose". odium

C. /otassium

D. Magnesium

59. 3

*urosemide is a non@potassium@sparing diuretic, and insu''icient replacement o' potassium may lead to

hypo$alemia. !lthough the glucose, sodium, and magnesium levels may be monitored, these laboratoryvalues are not speci'ic to administering 'urosemide. F# 6682G

67. ! client is ta$ing spironolactone F!ldactoneG to control her hypertension. er serum potassium level is 6m10H9. *or this client, the nurseJs priority would be to assess her

!. neuromuscular 'unction.". bowel sounds.

C. respiratory rate.D. electrocardiogram F1C4G results.

60. 4

!lthough changes in all these 'indings are seen in hyper$alemia, 1C4 changes can indicate potentially

lethal arrhythmias such as ventricular 'ibrillation. t wouldnJt be appropriate to assess the clientJsneuromuscular 'unction, bowel sounds, or respiratory rate 'or e''ects o' hyper$alemia. F# 2G

61. A client admitted to the hospital with coronary artery disease complains ofdyspnea at rest. A nurse caring for the client uses which of the following items as thebest means to monitor respiratory status on an ongoing basis!

A. ?ygen Fow meter#. ?ygen saturation monitor%. Telemetry cardiac monitor(. Apnea monitor

218. 2

(yspnea in the cardiac client often is accompanied by hypoemia. Cypoemia canbe detected by an oygen saturation monitor0 especially if used continuously. Anoygen Fow meter is part of the setup needed to deliver oygen therapy. %ardiacmonitors detect dysrhythmias. An apnea monitor detects apnea episodes0 such as

when the client has stopped breathing brieFy. 3+& 66964

69. A client is admitted with pulmonary embolism and is to be treated withstreptokinase 3+treptase4. A nurse would report which of the following assessments tothe physician before initiating this therapy!

A. Adventitious breath sounds#. &espiratory rate of 97 breaths per minute%. Temperature of @@.=o orally(. #lood pressure of 1@7;11: mm Cg

219. 4

Thrombolytic therapy is contraindicated in a number of preeisting conditions inwhich there is a risk of uncontrolled bleeding0 similar to the case in anticoagulanttherapy. Thrombolytic therapy also is contraindicated in sever uncontrolledhypertension because of the risk of cerebral hemorrhage. Therefore the nursewould report the results of the blood pressure to the physician before initiatingtherapy. 3+& 67=4

1B

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6B. A client has developed atrial brillation with a ventricular rate of 1E: beats perminute. The nurse assesses the client for

A. Cypotension and di88iness.#. *ausea and vomiting.%. Cypertension and headache.(. lat neck veins.

220. 1The client with uncontrolled atrial brillation and a ventricular rate of more than1:: beats per minute is at risk for low cardiac output because of loss of atrial kick.The nurse assesses the client for palpitations0 chest pain or discomfort0hypotension0 pulse decit0 fatigue0 weakness0 di88iness0 syncope0 shortness ofbreath0 and distended neck veins. 3+& 66@4

6=. A clientGs electrocardiogram strip shows atrial and ventricular rates of :complees per minute. The )-& interval is :.16 second0 the H&+ comple measures:.:6 second0 and the )-) interval is slightly irregular. The nurse interprets this rhythmto be

A. +inus bradycardia.#. *ormal sinus rhythm.%. +inus tachycardia(. +inus arrhythmia.

221. 4

+inus arrhythmia has all the characteristics of normal sinus rhythm0 ecept anirregular )-) interval. This occurs because of phasic changes in the rate of ring ofthe sinoatrial node0 which may occur with vagal tone and with respiration. %ardiacoutput is not aected. 3+& 66EE4

6E. A nurse is assessing the blood pressure of a client diagnosed with primaryhypertension. The nurse ensures accurate measurement by avoiding which of thefollowing!

A. +eating the client with arm bared0 supported and at heart level#. $easuring the blood pressure after the client has been seated 'uietly for E minutes%. 2sing a cu with a rubber that encircles at least 7:I of the limb(. Taking the blood pressure within 1E minutes after nicotine or caeine ingestion

222. 4

#lood pressure should be taken with the client seated with the arm bared0positioned with support and at heart level. The client should sit with the legs onthe Foor0 feet uncrossed0 and not speak during the recording. The client should nothave smoked tobacco or taken in caeine in the B: minutes preceding themeasurement. The client should rest 'uietly for E minutes before the reading istaken. The cu bladder should encircle at least 7:I of the limb being measured.Jauges other than a mercury sphygmomanometer should be calibrated every 6months to ensure accuracy. inally0 two or more reading should be averaged. 3+&6@4

66. A new nursing graduate is caring for a client who is attached to a cardiac monitor.While assisting the client with bathing0 the nurse notes that the client suddenlydevelops ventricular tachycardia but remains alert and oriented and has a pulse.+elect all interventions that the nurse would take!

A. (ebrillate the client.#. Assess airway0 breathing0 and circulation.%. Administer a precordial thump.(. Administer oygen.,. ?btain an electrocardiogram.

1=

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. %ontact the physician.

223. 2+4+5+6

or a stable client with ventricular tachycardia0 the nurse assesses the client0administers oygen0 and conrms the rhythm via a 19-lead electrocardiogram. Thenurse contacts the physician0 who may prescribe an antidysrhythmic medication.With pulseless ventricular tachycardia0 the physician or specially trained nursemust debrillate the client immediately or initiate cardiopulmonary resuscitation

and debrillate the client as soon as possible. 3$& 66@:4

6. The nurse is teaching the mother of an infant with tetralogy of allot. The motherasks what to do when her infant becomes very blue and has trouble breathing aftercrying. The nurse should tell the mother

A. D5eave the infant alone until the crying stops.D#. D)ut the infant in the knee-chest position.D%. D?er the infant a bottle of formula.D(. DTake the infant for a ride in the car.D

224. 2

The infant is having a DtetD or blue spell0 which is an acute spell of hypoia andcyanosis. This occurs when the infants oygen re'uirements are greater than whatis supplied in the blood. Treatment involves placing the infant in the knee-chestposition to reduce venous return from the etremities because that blood isdesaturated. "t also increases systemic vascular resistance0 which causes moreblood to be shunted to the pulmonary artery. 5eaving the infant alone until thecrying stops will cause an increase in cyanosis. An infant who is crying and havingtrouble breathing shouldnt be oered a bottle because of the danger of aspiration.A ride in the car may 'uiet some infants0 but it would be inappropriate in thissituation. 3+& =:9@4

67. A client with myocardial infarction has been transferred from the coronary care unitto the general medical unit. The nurse encourages the client to do which of thefollowing activities immediately after transfer!

A. Ad lib activities because the client will be discharged soon.#. 2nsupervised hallway ambulation with distances up to 9:: feet%. #athroom privileges and self-care activities(. +trict bedrest for 9= hours after transfer.

225. 3

?n transfer from the coronary care unit 3%%24 to an intermediate care or generalmedical unit0 the client is allowed self-care activities and bathroom privileges.5imiting the client to bedrest is unnecessary and possibly harmful. The clientshould ambulate with supervision in the hall for brief distances0 with the distancesbeing increased gradually to E:0 1::0 and 9:: feet. 3+& 66B74

6@. A client with myocardial infarction is eperiencing new0 multiform prematureventricular contractions. Knowing that the client is allergic to lidocaine hydrochloride0the nurse plans to have which of the following medications available for immediateuse!

A. (igoin 35anoin4#. $etoprolol 35opressor4%. Lerapamil 3"soptin4(. )rocainamide 3)ronestyl4

226. 4

)rocainamide is an antidysrhythmic that may be used to treat ventriculardysrhythmias in clients who are allergic to lidocaine. (igoin is a cardiac glycoside/

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metoprolol is a M-adrenergic blocking agent/ and verapamil is a calcium channelblocking agent. 3+& 66E4

:. A home health nurse is visiting a client who has had a prosthetic valve stenosis.Which statement by the client reFects an understanding of specic postoperative carefollowing this surgery!

A. N" threw away my straight ra8or and bought an electronic ra8or.O

#. N" have to go to the bathroom fre'uently because of my medication.O%. N" need to count my pulse everyday.O(. N" have to do deep breathing eercises every 9 hours.O

227. 1

)rosthetic valves re'uire long-term anticoagulation therapy to prevent clots fromforming on the NforeignO tissue implanted in the clientGs body. Anticoagulationtherapy re'uires clients to avoid any trauma or potential means of bleeding0 suchas straight ra8ors. ?ptions #0 %0 and ( are not related specically to postoperativecare following prosthetic valve replacement. ?ption # relates to a client taking adiuretic. ?ption % relates to a client with a pacemaker. ?ption ( is necessary in the

immediate postoperative period. 3+& 66664

1. A nurse notes bilateral 9P edema in the lower etremities of a client withmyocardial infarction who was admitted 9 days ago. The nurse would plan to do whichof the following net!

A. &eview the intake and output records for the laity 9 days.#. %hange the time of diuretic administration from morning to evening.%. &e'uest a sodium restriction of 1 g;day from the physician.(. ?rder daily weights starting on the following morning.

228. 1

,dema0 the accumulation of ecess Fuid in the interstitial spaces0 can be measuredby intake greater than output and by a sudden increase in weight. (iuretics shouldbe given in the morning whenever possible to avoid nocturia. +trict sodiumrestrictions are reserved for clients with severe symptoms. 3+& 6==4

9. A child0 age =0 is admitted with a tentative diagnosis of congenital heart disease.When assessment reveals a bounding radial pulse coupled with a weak femoral pulse0the nurse suspects that the child has

A. patent ductus arteriosus.#. coarctation of the aorta.%. a ventricular septal defect.(. truncus arteriosus.

229. 2

%oarctation of the aorta causes signs of peripheral hypoperfusion0 such as a weakfemoral pulse and a bounding radial pulse. These signs are rare in patent ductusarteriosus0 ventricular septal defect0 and truncus arteriosus. 3+& =1194

B. A client is at risk for pulmonary embolism and is on anticoagulant therapy withwarfarin sodium 3%oumadin4. The clientGs prothrombin time is 9: seconds0 with acontrol of 11 seconds. The nurse assesses that this result is

A. The same as the clientGs own baseline level.#. 5ower than the needed therapeutic level.%. Within the therapeutic range.(. Cigher than the therapeutic range.

230. 3

The therapeutic range for prothrombin time is 1.E to 9 times control for clients at

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high risk for thrombus. #ased on the clientGs control value0 the therapeutic rangefor this individual would be 16.E to 99 seconds. Therefore the result is within thetherapeutic range. 3+& 6714

=. A client receiving total parenteral nutrition has a history of congestive heart failure.The physician has ordered furosemide 35asi4 =: mg )? daily to prevent Fuidoverload. The nurse monitors which laboratory value to identify adverse eects fromthis medication!

A. Jlucose#. +odium%. )otassium(. $agnesium

231. 3

urosemide is a non-potassium-sparing diuretic0 and insuQcient replacement ofpotassium may lead to hypokalemia. Although the glucose0 sodium0 andmagnesium levels may be monitored0 these laboratory values are not specic toadministering furosemide. 3+& 669@4

E. When a client has a myocardial infarction0 one of the ma>or manifestations is adecrease in the conductive energy provided to the heart. When assessing this clientthe nurse understands that the eisting action potential is in direct relationship to the

A. Ceart rate#. &efractory period%. )ulmonary pressure(. +trength of contraction

232. 4

(D0DThe heart rate is related to factors such as +A node function0 partial pressuresof oygen and carbon dioide0 and emotions. D0DThis is the period when the heart isat rest0 not when it is contracting. D0D)ulmonary pressure does not inFuence actionpotential/ it becomes elevated in the presence of left ventricular failure. D0DA directrelationship eists between the strength of cardiac contractions and the electricalconductions through the myocardium. D 3+& 1=B4

374 Adolescent poisonings are most likely to be caused by which factor

A4 improper storage of to5ic household substances

#4 inadeuate supervision$4 recreational drugs

%4 an overdose of a prescribed medication

Answer $

334 Which statement by the parents of an infant indicates they understand safety measures for their

baby

A4 !" can prop the baby's bottle when " am busy with the two-year-old.!

#4 !A crib with wide spaces between the slats is safest.!

$4 !Earge soft toys without little parts are best right now.!%4 !The car seat can fit in the front passenger seat.!

Answer $

384 A -year-old client has sensory deficits from nerve damage. Which of the following nursing

interventions would be appropriate for this client

A4 Teach on the ha:ards of using a heating pad for muscle spasms.

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#4 9ncourage the placement of grab bars in the bathroom.

$4 "nstruct on automobile safety.

%4 Assess for home fire e5tinguisher and smoke alarm.

Answer A

324 Which client is at risk for in*ury because of diminished ability to protect himself

A4 one who is deaf #4 one who is bored with his marriage$4 one who did not finish high school %4 one who works in a law firm

Answer A

8;4 Which factor reduces the risk of electrical ha:ards

A4 two-pronged electrical plugs #4 non-insulated wiring in the home

$4 three-pronged electrical plugs %4 using frayed cords cautiously

Answer $

814 A 3=-year-old client has been hospitali:ed because of a stroke. +e has left-sided weakness but is

permitted to ambulate with a walker. To ensure the client's safety when he is out of bed) the nurse

should

A4 apply a (osey restraint when he is in the chair.

#4 follow him with a wheelchair as he walks.

$4 restrict his activity to use of a wheelchair.

%4 see that he wears nonskid footwear.

Answer %

8&4 The daughter of an elderly confused female client reuests that her mother not be restrained.

What can the nurse do instead to ensure for this client's safety

A4 (ut the restraint under the client's gown so the daughter won't see it.

#4

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Answer #

87. A nurse employed in an emergency department is assigned to triage clients arriving to theemergency room for treatment on the evening shift. The nurse should assign highest priority to whichof the followingclients

A. A client complaining of muscle aches) a headache) and malaise#. A client who twisted her ankle when she fell while rollerblading$. A client with a minor laceration on the inde5 finger sustained while cutting an eggplant%. A client with chest pain who states that he *ust ate pi::a that was made with a very spicy sauce

1. #Rationale: "n an emergency department) triage involves brief clientassessment to classify clients according to their need for care andincludes establishing priorities of care. The type of illness or in*ury)the severity of the problem) and the resources available govern theprocess. $lients with trauma) chest pain) severe respiratory distress orcardiac arrest) limb amputation) acute neurological deficits) and thosewho have sustained chemical splashes to the eyes are classified asemergent and are the number 1 priority. $lients with conditions such as a simple fracture) asthmawithout respiratory distress) fever)hypertension) abdominal pain) or a renal stone have urgent needs andare classified as number & priority. $lients with conditions such as aminor laceration) sprain) or cold symptoms are classified as nonurgentand are the number , priority.

83. A mother calls a neighbor who is a nurse and tells the nurse that her ,-year-old child has *ustingested liuid furniture polish. The nurse would direct the mother immediately to

A. "nduce vomiting.

#. $all an ambulance.$. $all the (oison $ontrol $enter.$. #ring the child to the emergency department.

. Rationale: "f a poisoning occurs) the (oison $ontrol $enter shouldbe contacted immediately. omiting should not be induced if the victim is unconscious or if thesubstance ingested is a strongcorrosive or petroleum product. #ringing the child to the emergencydepartment or calling an ambulance would not be the initial actionbecause this would delay treatment. The (oison $ontrol $enter mayadvise the mother to bring the child to the emergency department

and) if this is the case) the mother should call an ambulance.

88. An emergency department nurse receives a telephone call and is informed that a tornado has hita local residential area and that numerous casualties have occurred. The victims will be brought tothe emergency room. The initial nursing action is which of the following

A. (repare the triage rooms.#. Activate the agency disaster plan.$. 6btain additional supplies from the central supply department.%. 6btain additional nursing staff to assist in treating the casualties.

=. " Rationale: "n an e5ternal disaster) many victims may be brought tothe emergency department for treatment. Although options 1) ,) and may be components of preparing for the casualties) the initialnursing action must be to activate the disaster plan.

82. A nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediatelyassists the client out of the room. The ne5t nursing action would be to

A. $all for help.#. 95tinguish the fire.

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$. Activate the fire alarm.%. $onfine the fire by closing the room door.

3. Rationale: The order of priority in the event of a fire is to rescue theclients who are in immediate danger. The ne5t step is to activate thefire alarm. The fire then is confined by closing all doors and) finally)the fire is e5tinguished.

2;. A nurse enters the nursing lounge and discovers that a chair is on fire. 0he activates the alarm)closes the lounge door) and obtains the fire e5tinguisher to e5tinguish the fire. The nurse pulls the pinon the fire e5tinguisher. The ne5t appropriate action for the use of the fire e5tinguisher is to

A. Aim at the base of the fire.#. 0uee:e the handle on the e5tinguisher.$. 0weep the fire from side to side with the e5tinguisher.%. 0weep the fire from top to bottom with the e5tinguisher.

8. % Rationale:A fire can be e5tinguished or by using a fire e5tinguisher.To use the e5tinguisher) pull the pin first. The nurse then aims at the

base of the fire. The e5tinguisher is suee:ed and the fire ise5tinguished by sweeping from side to side to coat the area evenly.

21. A nurse is preparing to initiate an intravenous line containing a high dose of potassium chlorideand plans to use an intravenous infusion pump. The nurse brings the pump to the bedside) preparesto plug the pump cord into the wall) and notes that no receptacle is available in the wall socket. Whichof the following is the appropriate nursing action

A. "nitiate the intravenous line without the use of a pump.#. $ontact the electrical maintenance department for assistance.$. (lug in the pump cord in the available plug above the room sink.%.

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%. if sutured bronchus opens) fluid could drain fromoperative area into good lung. /0 1&1,4

2=.The nursing diagnosis with the highest priority for a child with A"%0 would be

A. isk for in*ury#. isk for infection$. Alteration in growth and development%. Alteration in nutrition less than body reuirements

"'. "#!)!All children have a high risk for in*ury because of their curiosity) ine5perience) and lack of

*udgment. !)!$hildren with A"%0 have a dysfunction of the immune system /depressed orineffective T cells) # cells) and immunoglobulins4 and are susceptible to opportunisticinfections. !)!Although children with A"%0 are most likely small for their ages) altered growthand development are not as life threatening as an infection. !)!Although this can occur inchildren with A"%0) the prevention of infection is the priority. ! /0 12&=4

27.A client arrives in the emergency room with a bloody nose. The initial nursing action is to

A. (lace the client in supine position.

#. Apply an ice collar around the clientNs neck.$. Assist the client to a sitting position with the head tilted forward.%. "nstruct the client to swallow the blood until the bleeding can be controlled.

%$.

The initial action to treat the client with a bloody nose is to loosen clothing around the neck to prevent

pressure on the carotid artery. The nurse should assist the client to a sitting position with the head

tilted slightly forward) and pressure should be applied to the nares by pinching the nose toward the

septum for 1; minutes. "ce packs can be applied to the nose and forehead. "f these actions are not

successful in controlling the bleeding) an ice collar may be applied along with topical vasoconstrictive

medication. The physician may also prescribe packing of the nostrils. The client should be provided

with an emesis basis and should be instructed not to swallow blood to reduce the risk of nausea and

vomiting.

23.An emergency room nurse is assessing a client who sustained a blunt in*ury to the chest wall.Which of these signs would indicate the presence of a pneumothora5 in this client

A. A sucking sound at the site of in*ury.#. %iminished breath sounds.

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$. A low respiratory rate.%. The presence of a barrel chest.

%'". "

This client has sustained a blunt or a closed chest in*ury. #asic symptoms of a closed pneumothora5

are shortness of breath and chest pain. A larger pneumothora5 are shortness of breath and chest

pain. A larger pneumothora5 may cause tachypnea) cyanosis) diminished breath sounds) and

subcutaneous emphysema. +yperressonce also may occur on the affected side.

28.A nurse in the emergency room is caring for a client who was in a motor vehicle accident and ise5periencing hypovolemic shock. A pneumatic antishock garment is applied to the client for thetreatment of the shock. The client will be transferred to the intensive care unit. While awaitingclient transfer to the intensive care unit) the emergency room nurse performs which criticalassessment

A. onitoring hemoglobin and hematocrit levels#. onitoring vascular status of the lower e5tremities$. Assessing radial pulses

%. Assessing vascular status of the upper e5tremities

%'#. "

The pneumatic antishock garment may be useful to treat hypovolemic shock associated with

traumatic in*ury to provide circulatory assistance. The device is used only as a temporary measure

until definitive treatment is given because it can compromise blood flow to the lower half of the body.

The critical nursing assessment includes monitoring the vascular status of the lower e5tremities.

Although options A) $) and % may be components of the nursing assessment) these actions are not

the critical assessment reuired in the client with a pneumatic antishock garment.

22.The client is brought into the emergency room in ventricular fibrillation. The advanced cardiac lifesupport nurse prepares to defibrillate by placing conductive gel pads on which part of the chest

A. To the upper and lower half of the sternum#. To the right of the sternum *ust below the clavicle and left of the precordium$. To the right shoulder and in the back of the left shoulder%. (arallel between the umbilicus and the right nipple

"'. "

The advanced cardiac life support nurse would place one gel pad to the right of the sternum *ust

below the clavicle and the other gel pad to the left of the precordium. The nurse then would place theelectrode paddles over the pads. 6ptions A) $) and % identify incorrect positions.

1;;. A 1;-year-old with history of bronchial asthma triggered by e5posure to cold) smoke) and nutsis brought to the hospital's emergency room by his mother. Appearing restless and an5ious) thechild has a respiratory rate of ,7 breathsGminute and pulse rate of 17; bpm. Which of the followingfindings would be of greatestconcern to the nurse

A. "ncreased respiratory effort.#. oist) loose cough.$. Absence of whee:ing.

%. (rolonged e5piratory phase.

'#.

"ncreased respiratory effort would be suspected secondary to bronchospasm associated with asthma.

O %uring an asthma attack) the cough usually is dry and sounds tight due to mucus accumulation and

bronchoconstriction. O Knowing that this child is most likely e5periencing an asthmatic attack) the

nurse would e5pect to hear whee:ing and note some shortness of breath with a prolonged e5piratory

phase. +owever) of greatest concern would be the absence of whee:ing indicating that the child is

not moving air well through the lungs and is at risk for hypo5ia and possible respiratory failure. O99

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Typically during an asthmatic attack) the client would demonstrate a prolonged e5piratory phase

because of air trapping and the increased effort to move air through constricted bronchioles.

(repared by

0ir Eui