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100 Item Comprehensive Exam II With Answers and Rationale

100 Item Comprehensive Exam II With Answers and Rationale

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Published by: koreana-hermosa-4165 on Nov 01, 2009
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1. In a child with suspected coarctation of the aorta, the nurse would expect tofindThe correct answer is D: Bounding pulses in the armsCoarctation of the aorta, a narrowing or constriction of the descending aorta,causes increased flow to the upper extremities (increased pressure and pulses)2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions byThe correct answer is C: Confine the percussion to the rib cage areaPercussion (clapping) should be only done in the area of the rib cage.3. A client was admitted to the psychiatric unit with major depression after asuicide attempt. In addition to feeling sad and hopeless, the nurse would assessforThe correct answer is C: Psychomotor retardation or agitationSomatic or physiologic symptoms of depression include: fatigue, psychomotorretardation or psychomotor agitation, chronic generalized or local pain, sleepdisturbances, disturbances in appetite, gastrointestinal complaints and impairedlibido.4. A victim of domestic violence states to the nurse, "If only I could change andbe how my companion wants me to be, I know things would be different." Whichwould be the best response by the nurse?The correct answer is D: "Batterers lose self-control because of their own internalreasons, not because of what their partner did or did not do."Only the perpetrator has the ability to stop the violence. A change in the victim’sbehavior will not cause the abuser to become nonviolent.5. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illnessis attributed to theThe correct answer is B: Yin, the negative force that represents darkness, cold,and emptiness. Chinese folk medicine proposes that health is regulated by theopposing forces of yin and yang. Yin is the negative female force characterized bydarkness, cold and emptiness. Excessive yin predisposes one to nervousness.6. A polydrug user has been in recovery for 8 months. The client has beganskipping breakfast and not eating regular dinners. The client has also startedfrequenting bars to "see old buddies." The nurse understands that the client’sbehavior is a warning sign to indicate that the client may beThe correct answer is A: headed for relapseIt takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it isimportant for clients to acknowledge that relapse is a possibility and to identifyearly signs of relapse.7. At the day treatment center a client diagnosed with Schizophrenia - ParanoidType sits alone alertly watching the activities of clients and staff. The client ishostile when approached and asserts that the doctor gives her medication tocontrol her mind. The client's behavior most likely indicates
The correct answer is B: Social isolation related to altered thought processesHostility and absence of involvement are data supporting a diagnosis of socialisolation. Her psychiatric diagnosis and her idea about the purpose of medicationsuggests altered thinking processes.8. A client is admitted with the diagnosis of meningitis. Which finding would thenurse expect in assessing this client?The correct answer is B: Flexion of the hip and knees with passive flexion of theneck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a positive Kernig’s sign—inability to extend the knee to more than 135degrees, without pain behind the knee, while the hip is flexed usually establishesthe diagnosis of meningitis.9. Post-procedure nursing interventions for electroconvulsive therapy includeThe correct answer is C: Remaining with client until orientedClient awakens post-procedure 20-30 minutes after treatment and appearsgroggy and confused. The nurse remains with the client until the client is orientedand able to engage in self care.10. The nurse is talking to parents about nutrition in school aged children. Whichof the following is theThe correct answer is C: ObesityMany factors contribute to the high rate of obesity in school aged children. Theseinclude heredity, sedentary lifestyle, social and cultural factors and poorknowledge of balanced nutrition.11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for severalmonths with fluphenazine (Prolixin). Which should be a focus of the firstassessment?A) Stressors in the homeThe correct answer is B: Medication complianceProlixin is an antipsychotic / neuroleptic medication useful in managing thesymptoms of Schizophrenia. Compliance with daily doses is a critical assessment.12. The nurse admits a client newly diagnosed with hypertension. What is thebest method for assessing the blood pressure?The correct answer is B: In both armsBlood pressure should be taken in both arms due to the fact that one subclavianartery may be stenosed, causing a false high in that arm.13. The nurse is caring for a client who has developed cardiac tamponade. Whichfinding would the nurse anticipate?The correct answer is C: Distended neck veinsIn cardiac tamponade, intrapericardial pressures rise to a point at which venousblood cannot flow into the heart. As a result, venous pressure rises and the neckveins become distended.14. At the geriatric day care program a client is crying and repeating "I want togo home. Call my daddy to come for me." The nurse should
The correct answer is C: Give the client simple information about what she will bedoing. The distressed disoriented client should be gently oriented to reduce fearand increase the sense of safety and security. Environmental changes provokestress and fear.15. When teaching adolescents about sexually transmitted diseases, what shouldthe nurse emphasize that is the most common infection?The correct answer is B: ChlamydiaChlamydia has the highest incidence of any sexually transmitted disease in thiscountry. Prevention is similar to safe sex practices taught to prevent any STD:use of a condom and spermicide for protection during intercourse.16. A 38 year-old female client is admitted to the hospital with an acuteexacerbation of asthma. This is her third admission for asthma in 7 months. Shedescribes how she doesn't really like having to use her medications all the time.Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?The correct answer is C: Lung remodeling and permanent changes in lungfunctionWhile an asthma attack is an acute event from which lung function essentiallyreturns to normal, chronic under-treated asthma can lead to lung remodeling andpermanent changes in lung function. Increased bronchial vascular permeabilityleads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leadingto airway obstruction. Changes in the extracellular matrix in the airway wall mayalso lead to airway obstruction. These long-term consequences should help you toreinforce the need for daily management of the disease whether or not thepatient "feels better".17. The mother of a 15 month-old child asks the nurse to explain her child's labresults and how they show her child has iron deficiency anemia. The nurse's bestresponse isThe correct answer is B: "Your child has less red blood cells that carry oxygen."The results of a complete blood count in clients with iron deficiency anemia willshow decreased red blood cell levels, low hemoglobin levels and microcytic,hypochromic red blood cells. A simple but clear explanation is appropriate.18. Privacy and confidentiality of all client information is legally protected. Inwhich of these situations would the nurse make an exception to this practice?The correct answer is B: When the client threatens self-harm and harm to others.Privacy and confidentiality of all client information is protected with the exceptionof the client who threatens self harm or endangering the public.19. At a well baby clinic the nurse is assigned to assess an 8 month-old child.Which of these developmental achievements would the nurse anticipate that thechild would be able to perform?The correct answer is C: Sit without supportThe age at which the normal child develops the ability to sit steadily withoutsupport is 8 months.20. First-time parents bring their 5 day-old infant to the pediatrician's officebecause they are extremely concerned about its breathing pattern. The nurse

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