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 forA) 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, psychomotorretardation 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 thebest 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 intobeating 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