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Published by Linda Kuglarz

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Published by: Linda Kuglarz on Oct 14, 2008
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PN Comprehensive Review CD Questions 301-400
{COMP: No Equations/Formulas; No <AQ> questions}301. A nursing student is assisting in caring for a client with a lung tumor who will behaving a pneumonectomy. The nursing instructor reviews the postoperative plan of caredeveloped by the student and suggests deleting which of the following from the plan?1. Monitoring the closed chest tube drainage system2. Encouraging coughing and deep breathing exercises3. Checking the surgical dressing for drainage4. Avoiding complete lateral positioningAnswer: 1Rationale: Closed chest drainage is not usually used following pneumonectomy. Theserous fluid that accumulates in the empty thoracic cavity eventually consolidates. Theconsolidation prevents shifts of the mediastinum, heart, and remaining lung. Completelateral positioning is avoided because the mediastinum is no longer held in place on bothsides by lung tissue and extreme turning may cause mediastinal shift and compression of the remaining lung. Options 2 and 3 are general postoperative measures.Test-Taking Strategy: Use the process of elimination and note the key words
. These words indicate a false response question and that you need to select theincorrect intervention. Eliminate options 2 and 3 first because they are general postoperative measures. From the remaining options, focus on the surgical procedure andthe effects of the surgical procedure to direct you to the correct option. If you haddifficulty with this question, review postoperative care of this surgical procedure.Level of Cognitive Ability: AnalysisClient Needs: Physiological IntegrityIntegrated Process: Teaching/LearningContent Area: Adult Health/OncologyReference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003).
Medical-surgical nursing: Health and illness perspectives
(7th ed.). St. Louis: Mosby, p.558.302. A nurse is monitoring a client with a diagnosis of cancer for signs and symptomsrelated to vena cava syndrome. The nurse understands that which of the following is anearly sign of this oncological emergency?1. Periorbital edema2. Confusion3. Mental status changes4. DisorientationAnswer: 1Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morningand include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiencesedema of the hands and arms. Mental status changes are late signs.Test-Taking Strategy: Use the process of elimination and note the key word
. Note
the similarity between options 2, 3, and 4 and eliminate these options. If you areunfamiliar with vena cava syndrome, review this oncological emergency.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/OncologyReference: Christensen, B., & Kockrow, E. (2003).
 Adult health nursing 
(4th ed.). St.Louis: Mosby, p. 291.303. A client arrives in the emergency room in a crisis state. The client demonstratessigns of profound anxiety and is unable to focus on anything but the object of the crisisand the impact on self. The initial data collection would focus on:1. The object of the crisis2. The presence of support systems3. The physical condition of the client4. The client’s coping mechanismsAnswer: 3Rationale: The initial nursing assessment of a client in a crisis state is to determine the physical condition of the client, the potential for self-harm, and the potential for harm toothers. Once this has been determined and appropriate interventions have been initiated,the nurse would then proceed to care for the client.Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Physiological needstake priority over other needs. Option 3 is the only option that addresses a physiologicalneed. Review care to the client in crisis if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Mental HealthReference: Morrison-Valfre, M. (2005).
 Foundations of mental health care
(3rd ed.). St.Louis: Mosby, p. 198.304. A nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide?1. The client is disorganized2. The client is impulsive3. The client has a history of suicide attempts4. The client has an immediate plan for a suicide attemptAnswer: 4Rationale: The client presents a lethality potential if the client appears disorganized andimpulsive. Clients at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse and those with a personal or family history of suicideattempts, depression, alcoholism, or psychotic episodes. Having a suicide plan, however, particularly if the method is immediate and available, makes the client very high risk.Test-Taking Strategy: Use the process of elimination. Noting the key words
a very highrisk 
should easily direct you to option 4. Also, note the key words
immediate plan
in the
correct option. Review the risk factors associated with suicide if you had difficulty withthis question.Level of Cognitive Ability: AnalysisClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Mental HealthReference: Morrison-Valfre, M. (2005).
 Foundations of mental health care
(3rd ed.). St.Louis: Mosby, p. 287.305. A nurse has been closely observing a client that has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating.Which of the following nursing interventions is least helpful for this client at this time?1. Acknowledge the client’s behavior 2. Maintain a safe distance from the client3. Assist the client to an area that is quiet4. Initiate confinement measuresAnswer: 4Rationale: During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance,acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. It is not appropriate during this period to initiate confinement measures.Initiating confinement measures is most appropriate during the crisis period.Test-Taking Strategy: Note the key words
least helpful 
. These words indicate a falseresponse question and that you need to select the least helpful intervention. Noting theword “confinement” in option 4 will direct you to this option. Review these interventionsif you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthReference: Morrison-Valfre, M. (2005).
 Foundations of mental health care
(3rd ed.). St.Louis: Mosby, p. 116.306. A nursing assistant is assigned to work with a nurse to care for a client who was atrisk for suicide. Which of these statements made by the nursing assistant indicates to thenurse that the nursing assistant understands suicide?1. “When a person talks about making suicide threats, the only thing the person wants isattention from family and friends.”2. “Discussing suicide with a client is not harmful.”3. “Depressed clients are the only persons who commit suicide.”4. “Those clients who talk about suicide never do it.”Answer: 2Rationale: An open discussion of suicide will not encourage a client to make a decisionto commit suicide, and will, in fact, often help to prevent it. Such a discussion offers thehealth care personnel the opportunity to assess the reality of suicide for the client andtake necessary precautions to keep the client safe. Options 1, 3, and 4 are incorrect.

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