100 Item Comprehensive Exam II With Answers and Rationale

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100 item Comprehensive Exam II with Answers and Rationale

1. In a child with suspected coarctation of the aorta, the nurse would expect to findA) Strong pedal pulsesB) Diminishing cartoid pulsesC) Normal femoral pulses

D) Bounding pulses in the arms

The correct answer is D: Bounding pulses in the armsCoarctation of the aorta, a narrowing or constriction of the descending aorta, causesincreased flow to the upper extremities (increased pressure and pulses)2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of thefollowing actions by the nurse would be appropriate?A) Schedule the therapy thirty minutes after mealsB) Teach the child not to cough during the treatment

C) Confine the percussion to the rib cage area

D) Place the child in a prone position for the therapyThe 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 a suicideattempt. In addition to feeling sad and hopeless, the nurse would assess for A) Anxiety, unconscious anger, and hostilityB) Guilt, indecisiveness, poor self-concept

C) Psychomotor retardation or agitation

D) Meticulous attention to grooming and hygieneThe correct answer is C: Psychomotor retardation or agitationSomatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleepdisturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.4. A victim of domestic violence states to the nurse, "If only I could change and be howmy companion wants me to be, I know things would be different." Which would be the best response by the nurse?A) "The violence is temporarily caused by unusual circumstances; don’t stop hoping for achange."B) "Perhaps, if you understood the need to abuse, you could stop the violence."C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"

D) "Batterers lose self-control because of their own internal reasons,not because of what their partner did or did not do."

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’s

behavior will not cause the abuser to become nonviolent.5. A nurse is to present information about Chinese folk medicine to a group of studentnurses. Based on this cultural belief, the nurse would explain that illness is attributed totheA) Yang, the positive force that represents light, warmth, and fullness

B) Yin, the negative force that represents darkness, cold, and emptiness

C) Use of improper hot foods, herbs and plantsD) A failure to keep life in balance with nature and othersThe correct answer is B: Yin, the negative force that represents darkness, cold, andemptiness. Chinese folk medicine proposes that health is regulated by the opposing forcesof yin and yang. Yin is the negative female force characterized by darkness, cold andemptiness. Excessive yin predisposes one to nervousness.6. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to"see old buddies." The nurse understands that the client’s behavior is a warning sign toindicate that the client may be

A) headed for relapse

B) feeling hopelessC) approaching recoveryD) in need of increased socializationThe correct answer is A: headed for relapseIt takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sitsalone alertly watching the activities of clients and staff. The client is hostile whenapproached and asserts that the doctor gives her medication to control her mind. Theclient's behavior most likely indicatesA) Feelings of increasing anxiety related to paranoia

B) Social isolation related to altered thought processes

C) Sensory perceptual alteration related to withdrawal from environmentD) Impaired verbal communication related to impaired judgmentThe correct answer is B: Social isolation related to altered thought processesHostility and absence of involvement are data supporting a diagnosis of social isolation.Her psychiatric diagnosis and her idea about the purpose of medication suggests alteredthinking processes.8. A client is admitted with the diagnosis of meningitis. Which finding would the nurseexpect in assessing this client?A) Hyperextension of the neck with passive shoulder flexion

B) Flexion of the hip and knees with passive flexion of the neck

C) Flexion of the legs with rebound tenderness

D) Hyperflexion of the neck with rebound flexion of the legsThe correct answer is B: Flexion of the hip and knees with passive flexion of the neck. 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 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis.9. Post-procedure nursing interventions for electroconvulsive therapy includeA) Applying hard restraints if seizure occursB) Expecting client to sleep for 4 to 6 hours

C) Remaining with client until oriented

D) Expecting long-term memory lossThe correct answer is C: Remaining with client until orientedClient awakens post-procedure 20-30 minutes after treatment and appears groggy andconfused. The nurse remains with the client until the client is oriented and able to engagein self care.10. The nurse is talking to parents about nutrition in school aged children. Which of thefollowing is the most common nutritional disorder in this age group?A) BulimiaB) Anorexia

C) Obesity

D) MalnutritionThe correct answer is C: ObesityMany factors contribute to the high rate of obesity in school aged children. These includeheredity, sedentary lifestyle, social and cultural factors and poor knowledge of balancednutrition.11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unitfor schizophrenia. His symptoms have been managed for several months withfluphenazine (Prolixin). Which should be a focus of the first assessment?A) Stressors in the home

B) Medication compliance

C) Exposure to hot temperaturesD) Alcohol useThe correct answer is B: Medication complianceProlixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.12. The nurse admits a client newly diagnosed with hypertension. What is the bestmethod for assessing the blood pressure?A) Standing and sitting

B) In both arms

C) After exercising

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