Silvestri1001-1100 | Angina Pectoris | Diabetes Mellitus

PN~Comp~Review~CD~1001-1101 -1 PN Comprehensive Review CD~Questions 1001-1100 {COMP: No equations/formulas; No <AQ> questions} 1001.

A nurse is developing a plan of care for a postpartum client and includes interventions that will promote parent-infant bonding. Which of the following will the nurse include in the plan of care? 1. Encourage the parents to allow the infant to sleep in the parental bed 2. Encourage the mother to allow the nursing staff to care for the infant while hospitalized and until discharged 3. Encourage the mother to hold the infant when the infant cries 4. Use a low-pitched voice to speak to the infant Answer: 3 Rationale: Holding the infant close and allowing the infant to feel the mother’s warmth initiates a positive experience for the mother and consoles the infant. The use of a highpitched voice and participating in infant care are additional methods of promoting parental-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. Additionally, the danger of suffocation of the infant exists if the infant is allowed to sleep between the parents. Test-Taking Strategy: Use the process of elimination and focus on the issue—promoting parental-infant bonding. Note the relationship of the issue and option 3. If you had difficulty with this question, review strategies that will promote bonding between the parents and the infant. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 648. 1002. A postpartum nurse has provided discharge instructions to a postpartum client who delivered a healthy newborn infant. Which statement by the client indicates an understanding of the discharge instructions? 1. “If I have uterine cramping while breast-feeding, I should contact my physician.” 2. “If I notice any pain, redness, or swelling in my breasts, I should contact my physician.” 3. “If I experience any sweating during the night, I should call my physician.” 4. “If I experience any serosanguineous vaginal drainage in a week, I should contact my physician.” Answer: 2 Rationale: Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the physician. Options 1, 3, and 4 are normal changes that occur in the postpartum period. Test-Taking Strategy: Note the key words indicates an understanding. Use the process of elimination, noting the words pain, redness, and swelling in the correct option. These are signs of infection and should direct you to select option 2. If you had difficulty with

PN~Comp~Review~CD~1001-1101 -2 this question, review normal physiological occurrences in the postpartum period. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 234-235. 1003. A client arrives to the postpartum unit following delivery of the newborn infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which of the following nursing actions is appropriate? 1. Cover the client with a warm blanket 2. Contact the physician 3. Massage the fundus 4. Place the client in Trendelenburg’s position Answer: 1 Rationale: In the postpartum period, a woman may commonly experience a shaking and uncontrollable chill immediately after birth. The exact cause of this occurrence is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The best nursing action is to provide a warm blanket to the client and a warm drink if this is not contraindicated. It is not necessary to contact the physician. Massaging the fundus and placing the client in Trendelenburg’s position have no effect on the client’s condition. Test-Taking Strategy: Use the process of elimination and knowledge of the normal physiological occurrences of the immediate postpartum period to direct you to option 1. If you are unfamiliar with these normal physiological occurrences, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 201. 1004. A nurse is collecting data on a postpartum client and performs which of the following interventions when checking for thrombophlebitis? 1. Asks the client to ambulate and checks for the presence of pain 2. Sharply dorsiflexes the foot 3. Palpates for pedal pulses 4. Checks for the presence of vaginal hematoma Answer: 2 Rationale: Homans’ sign is pain in the calf when the foot is sharply dorsiflexed. This is a possible sign of thrombophlebitis, a potential complication in the postpartum period. Options 1, 3, and 4 do not determine the presence of thrombophlebitis. Test-Taking Strategy: Use the process of elimination and focus on the issue— thrombophlebitis. Note the relationship between the anatomy and physiology of thrombophlebitis and the correct option. If you had difficulty with this question, review

PN~Comp~Review~CD~1001-1101 -3 this data collection technique. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 291. 1005. A postpartum nurse has provided information to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client states that it will: 1. Numb the tissue 2. Stimulate a bowel movement 3. Reduce the edema and swelling 4. Promote healing and provide comfort Answer: 4 Rationale: Warm, moist heat is used 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to reduce edema and numb the tissue. Promoting a bowel movement is best achieved by ambulation. Test-Taking Strategy: Focus on the issue of the question—the purpose of a sitz bath. Use the process of elimination and recall the effects of warm, moist heat to direct you to option 4. If you had difficulty with this question, review the purpose of a sitz bath following vaginal delivery. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 205. 1006. A nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse determines that the client understands the procedure for checking blood glucose levels when the client states to do which of the following? 1. “I should check my blood glucose level every day at 5 PM.” 2. “I should check my blood glucose level before each meal and at bedtime.” 3. “I should check my blood glucose level 2 hours after each meal.” 4. “I should check my blood glucose level 1 hour after each meal.” Answer: 2 Rationale: The most effective and accurate measure for testing blood glucose is to test the level before each meal and at bedtime. Checking the level after the meal will provide an inaccurate assessment of diabetic control. Checking the level once daily will not provide enough data related to controlling the diabetes mellitus. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar. Next eliminate option 1, knowing that once daily is not an

PN~Comp~Review~CD~1001-1101 -4 effective measure for monitoring diabetic control. If you had difficulty with this question, review blood glucose monitoring in the client with diabetes mellitus. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1284. 1007. A nurse is providing dietary instructions to a client newly diagnosed with diabetes mellitus regarding measures to control the diabetes. The nurse instructs the client that it is best to: 1. Eat meals at approximately the same time each day 2. Adjust mealtimes depending on blood glucose levels 3. Avoid being concerned about the time of meals as long as snacks are taken on time 4. Vary mealtimes if insulin is not administered at the same time every day Answer: 1 Rationale: Mealtimes must be approximately the same time each day to maintain a stable blood glucose level. The client should not be instructed that mealtimes are varied depending on blood glucose levels or insulin administration. Mealtimes should not be adjusted based on blood glucose levels or snacks. Test-Taking Strategy: Use the process of elimination and eliminate options 2 and 4 because they are similar. From the remaining options, recalling that mealtimes should be consistently planned will assist in directing you to option 1. Review nutrition and the client with diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1261. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1281. 1008. A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the insulin injection, the insulin seems to leak through the skin. The nurse can most appropriately determine the problem by asking the client which of the following? 1. “Are you using a 1-inch needle to give the injection?” 2. “Are you placing an air bubble in the syringe prior to injection?” 3. “Are you aspirating before you inject the insulin?” 4. “Are you rotating the injection site?” Answer: 4 Rationale: The client should be instructed that insulin injection sites should be rotated within one anatomical area before moving to another. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. Options 1, 2, and 3 are not associated with the condition (skin leakage of insulin) presented in the question.

PN~Comp~Review~CD~1001-1101 -5 Test-Taking Strategy: Focus on the issue—skin leakage of insulin—and use the process of elimination to answer the question. Eliminate options 1, 2, and 3 because they are not associated with the issue. If you had difficulty with this question, review the procedure for insulin injection and the complications that can occur. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 910. 1009. A nurse is providing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The physician has prescribed a mixture of NPH and regular insulin. The nurse should instruct the client that the first step is to: 1. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin 2. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin 3. Draw up the correct dosage of regular insulin into the syringe 4. Draw up the correct dosage of NPH insulin into the syringe Answer: 1 Rationale: The initial step in preparing an injection of insulin that is a mixture of NPH and regular is to inject air into the NPH bottle equal to the amount of insulin prescribed. The client is instructed to next inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin should then be withdrawn followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer-acting form. Test-Taking Strategy: Use the process of elimination. Knowing that regular insulin is drawn up before NPH insulin will assist in eliminating option 4. Next, noting the key words first step and visualizing this procedure will direct you to option 1. If you had difficulty with this question, review the procedure for mixing NPH and regular insulin. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 481. 1010. A nurse is reviewing the orders of a client with a diagnosis of diabetes mellitus who was admitted to the hospital because of an infected foot ulcer. The nurse expects to note which of the following in the physician’s orders? 1. A decreased amount of NPH daily insulin 2. An increased amount of NPH daily insulin 3. An increased calorie diet 4. A decreased calorie diet Answer: 2 Rationale: Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose

PN~Comp~Review~CD~1001-1101 -6 levels. When the client is under stress, such as when an infection exists, the client will require an increase in the dose of insulin to facilitate the transport of excess glucose into the cells. The client does not necessarily need an adjustment in the daily diet. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question. Noting that the client has an infected foot ulcer will indicate that a stressor is present. Recalling that a stressor increases the client’s need for insulin will direct you to option 2. If you had difficulty with this question, review the relationship between infection and the need for insulin in the client with diabetes mellitus. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1281. 1011. A nurse is assisting in preparing a plan of care for a client with diabetes mellitus and plans to instruct the client regarding the symptoms of hypoglycemia. Which symptoms will the nurse prepare to list on the instruction sheet that will be given to the client? 1. Elevated pulse; lethargy; warm, dry skin 2. Elevated pulse; shakiness; cool, clammy skin 3. Decreased pulse; lethargy; warm, dry skin 4. Decreased pulse; confusion; increased urine output Answer: 2 Rationale: Symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin. Options 1, 3, and 4 are not symptoms of hypoglycemia. Test-Taking Strategy: Use the process of elimination and focus on the issue— hypoglycemia. Recalling that the client will experience cool, clammy skin will assist in directing you to option 2. If you had difficulty with this question, review the signs of hypoglycemia. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 921. 1012. A clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client’s apical pulse and places the stethoscope in which of the following positions? 1. At the midline of the chest just below the xiphoid process 2. At the midclavicular line at the fifth left intercostal space 3. At the midaxillary line on the left side of the chest 4. Midsternum equal with the nipple line Answer: 2 Rationale: The heart is located in the mediastinum. Its apex or distal end points to the

PN~Comp~Review~CD~1001-1101 -7 left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart’s apex. Test-Taking Strategy: Use the process of elimination and knowledge regarding the anatomical position of the heart to assist in directing you to option 2. If you had difficulty with this question, review the data collection technique for taking the apical pulse rate. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 338-339. 1013. A nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which of the following? 1. Oxygen assists in calming the client 2. Oxygen prevents the development of any thrombus formation 3. Oxygen dilates the blood vessels, supplying more nutrients to the heart muscle 4. The pain associated with the angina occurs because of the decreased oxygen supply to the heart cells Answer: 4 Rationale: The pain associated with angina is derived from ischemic myocardial cells. The pain is often associated with activity that places more oxygen demand on heart muscle. Supplemental oxygen helps to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client. Test-Taking Strategy: Focus on the issue of the question—the action of oxygen. Eliminate option 1 because it does not address the physiological necessity of oxygen. Eliminate options 2 and 3 because oxygen does not prevent clot formation or cause vessel dilation. Review the pathophysiology associated with angina if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 303. 1014. A nurse is assisting in performing an arterial blood gas analysis on a client. The nurse prepares to initiate which of the following after the blood gas is drawn? 1. Cover the site with 4x4 gauze 2. Apply warm packs to the site 3. Perform range of motion to the fingers 4. Apply pressure to the site

PN~Comp~Review~CD~1001-1101 -8 Answer: 4 Rationale: Pressure should be applied to the site following an arterial blood gas draw. The pressure in the artery is higher than in the veins. It is therefore necessary to apply pressure to the punctured artery to control bleeding. Placing gauze may protect the site but will not control bleeding. Heat causes vasodilation and increases bleeding to the site. Exercise will increase circulation to the area. Test-Taking Strategy: Use the process of elimination. Noting the key word arterial in the question will assist in directing you to the option that addresses applying pressure to the site. If you had difficulty with this question, review postprocedure care for arterial blood gas. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 249. 1015. A nurse is assisting to perform Romberg’s test on a client being seen in the clinic. The nurse performs this test to determine: 1. The client’s ability to ambulate 2. The ability of the vestibular apparatus in the inner ear to maintain standing balance 3. The intactness of the retinal structure of the eye 4. The intactness of the tympanic membrane Answer: 2 Rationale: Romberg’s test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. Romberg’s test also assesses intactness of the cerebellum and proprioception. This test does not assess the items noted in options 1, 3, or 4. Test-Taking Strategy: Focus on the issue—Romberg’s test. Remember, Romberg’s test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. If you are unfamiliar with the purpose of this test, review this assessment technique and its purpose. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 685. 1016. A nurse is assisting to perform an otoscopic examination on an adolescent who was hit in the ear with a basketball while playing in a game. A perforated eardrum is suspected. Which of the following does the nurse expect to note documented in the findings if the eardrum is perforated? 1. A colony of black dots on the eardrum 2. Dense white patches on the eardrum 3. A red, bulging eardrum 4. A round or oval darkened area on the eardrum

PN~Comp~Review~CD~1001-1101 -9 Answer: 4 Rationale: A round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red, bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection. Test-Taking Strategy: Focus on the issue—that the eardrum is perforated. Remember, a round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. If you had difficulty with this question, review the findings that are noted in this type of trauma. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1982. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 435. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 706. 1017. A nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check: 1. The client’s ability to hear low-pitched sounds 2. The client’s ability to hear high-pitched sounds 3. Central vision 4. Peripheral vision Answer: 4 Rationale: The confrontation test is a gross measure of peripheral vision. It compares the person’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focus on the issue—a confrontation test. Remember, the confrontation test is a gross measure of peripheral vision. If you are unfamiliar with this test, review its purpose. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 424. 1018. A nurse in a health care clinic is preparing to test the client for accommodation. Initially, the nurse asks the client to: 1. Focus on a distant object 2. Close one eye and read letters on a chart 3. Raise one finger when the sound is heard 4. Focus on a close object

PN~Comp~Review~CD~1001-1101 -10 Answer: 1 Rationale: The nurse tests for accommodation by asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 inches from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes. Test-Taking Strategy: Use the process of elimination and knowledge regarding the procedure for testing for accommodation. Focusing on the word “accommodation” will assist in eliminating options 2 and 3. From the remaining options, note the key word initially in the stem of the question to direct you to option 1. Review this data collection technique if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed.). Philadelphia: W.B. Saunders, p. 314. 1019. A client is diagnosed with stage 1 of Lyme disease. The nurse checks the client for the hallmark characteristic of this stage. Which of the following findings does the nurse expect to note? 1. Signs of neurological disorders 2. Enlarged and inflamed joints 3. Arthralgia 4. Skin rash Answer: 4 Rationale: The hallmark of stage 1 is the development of a skin rash that occurs within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull’s-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage 1, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar. From the remaining options, select the least serious characteristic because the issue of the question relates to stage 1. Expect neurological disorders to occur with progression of the disease. If you had difficulty with this question, review the stages of Lyme disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 204. 1020. A client has been diagnosed with Lyme disease, stage 2. The nurse understands that which of the following findings is most indicative of this stage? 1. Erythematous rash

PN~Comp~Review~CD~1001-1101 -11 2. Cardiac conduction deficits 3. Arthralgia 4. Joint enlargements Answer: 2 Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The most serious problems include cardiac conduction deficits and neurological disorders such as Bell’s palsy and paralysis. Arthralgia and joint enlargements are noted in stage 3. A rash appears in stage 1. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar. Knowledge that a rash appears initially following the tick bite will assist in eliminating option 1. If you had difficulty with this question, review the clinical manifestations associated with each stage of Lyme disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 202. 1021. A nurse reads the chart of a client who was seen by the physician and notes that the physician has documented that the client has Lyme disease, stage 3. Which of the following clinical manifestations does the nurse expect to note in the client? 1. A generalized skin rash 2. A cardiac dysrhythmia 3. Complaints of joint pain 4. Paralysis in the extremity where the tick bite occurred Answer: 3 Rationale: Stage 3 develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage 2. A rash occurs in stage 1. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme disease. Test-Taking Strategy: Use the process of elimination. Remember that a rash occurs in stage 1, cardiac and neurological disorders in stage 2, and joint involvement in stage 3. If you had difficulty with this question, review the clinical manifestations associated with Lyme disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 204. 1022. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. Which of the following nursing actions

PN~Comp~Review~CD~1001-1101 -12 is most appropriate? 1. Refer the client for a blood test immediately 2. Inform the client that the tick is needed to perform a test 3. Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable 4. Ask the client about the size and color of the tick Answer: 3 Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed prior to 4 to 6 weeks following the tick bite. Options 1, 2, and 4 are inaccurate. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first. “Immediately” should indicate that this is potentially an incorrect option. Next eliminate options 2 and 4 because they are similar and because the tick is not needed to perform the test. If you had difficulty with this question, review the method of diagnosing Lyme disease. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 204. 1023. A client suspected of having stage 1 Lyme disease is seen in the health care clinic and is told that the Lyme disease test is positive. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which of the following will be part of the treatment plan? 1. No treatment unless symptoms develop 2. A 3- to 4-week course of oral antibiotic therapy 3. Treatment with intravenous (IV) penicillin G 4. Ultraviolet light therapy Answer: 2 Rationale: A 3- to 4-week course of oral antibiotic therapy is recommended during stage 1. Later stages of Lyme disease may require therapy with intravenous antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease. Test-Taking Strategy: Use the process of elimination. Note that the question states stage 1. Eliminate option 3 because IV antibiotics are not administered in this stage. Eliminate option 4 because this is not a component of the treatment for Lyme disease. Waiting for symptoms to develop is an incorrect option. Review the treatment associated with Lyme disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 204.

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1024. A client is admitted to the hospital with a diagnosis of suspected myocardial infarction. The nurse is reviewing the laboratory results performed on the client. Which of the following results most specifically indicates the presence of a myocardial infarction (MI)? 1. Increased creatine kinase (CK) MB 2. Increased creatine kinase (CK) MM 3. Increased blood urea nitrogen (BUN) 4. Decreased white blood cell (WBC) count Answer: 1 Rationale: The CK-MB is most specific in determining the presence of a myocardial infarction. The CK-MM reflects injury to skeletal muscle. The WBC count is most likely elevated in the client with a myocardial infarction. The BUN is unrelated to this disorder. Test-Taking Strategy: Use the process of elimination and focus on the diagnosis, MI. Recalling that an increased CK-MB level indicates myocardial damage will direct you to option 1. If you are unfamiliar with the laboratory tests used to confirm an MI, review these diagnostic tests. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 581. 1025. A licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the physician. Following administration of the morphine sulfate, the LPN plans to monitor: 1. Mental status 2. Respirations and blood pressure 3. Urinary output 4. Temperature and blood pressure Answer: 2 Rationale: Morphine sulfate is a narcotic analgesic that may be administered to relieve pain in a client with MI. Although monitoring mental status is a component of the nurse’s assessment, it is not the priority following administration of morphine sulfate. The nurse should monitor the client’s respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature is also not associated with the use of this medication. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. This will direct you to option 2. If you are unfamiliar with the side effects associated with the administration of morphine sulfate and the priority nursing interventions, review this content.

PN~Comp~Review~CD~1001-1101 -14 Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 583-584. 1026. A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client calls the nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The chest pain is unrelieved by the nitroglycerin. The next nursing action is which of the following? 1. Administer another nitroglycerin tablet 2. Increase the flow rate of the oxygen 3. Contact the physician 4. Call the client’s family Answer: 1 Rationale: One nitroglycerin tablet is administered every 5 minutes times 3 for chest pain as long as the client maintains a systolic blood pressure of 100 mm Hg or more. Increasing the flow rate of the oxygen may be prescribed by the physician, but is not the next nursing action. If three nitroglycerin tablets do not relieve the client’s chest pain, the physician should be notified. It is premature to call the client’s family. Test-Taking Strategy: Note the key word next in the stem of the question. Recalling that the nurse should administer nitroglycerin times 3 to relieve chest pain will assist in directing you to option 1. If you had difficulty with this question or are unfamiliar with the administration of nitroglycerin, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 308-309. 1027. A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit following the procedure. The nurse provides instructions to the client regarding the procedure and home care measures. Which of the following statements by the client indicates an understanding of the instructions? 1. “I am so relieved that I can eat anything that I want to now.” 2. “I need to cut down on cigarette smoking.” 3. “I am so relieved that my heart is repaired.” 4. “I need to adhere to my dietary restrictions.” Answer: 4 Rationale: Following angioplasty, the client needs to be instructed of the specific dietary restrictions that must be followed. Following the recommended dietary and lifestyle changes assists to prevent further atherosclerosis. Abrupt closure of the artery can occur if the recommended dietary and lifestyle changes are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart. Test-Taking Strategy: Note the key words indicates an understanding in the stem of the

PN~Comp~Review~CD~1001-1101 -15 question. Use the process of elimination and knowledge regarding this procedure to assist in answering the question. Additionally, use of general health care principles will assist in directing you to option 4. If you had difficulty with this question, review client teaching points following angioplasty. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1640. 1028. A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The nurse is assisting the client in completing the diet menu. Which of the following beverages does the nurse instruct the client to select from the menu? 1. Coffee 2. Tea 3. Lemonade 4. Cola Answer: 3 Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI. Test-Taking Strategy: Use the process of elimination. Note the similarity between options 1, 2, and 4. These beverages all contain caffeine. Lemonade is the only beverage listed that does not contain caffeine. If you are unfamiliar with the dietary measures appropriate for the client with MI, or are unfamiliar with the food items that contain caffeine, review this content. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1727. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 315. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 807. 1029. A nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse prepares a plan of care for the client and avoids including which of the following in the plan? 1. Allow the client sufficient time to eat 2. Provide a full liquid diet for ease in swallowing 3. Provide oral hygiene after each meal

PN~Comp~Review~CD~1001-1101 -16 4. Maintain a suction machine at the bedside Answer: 2 Rationale: The client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suction should be available for clients who experience dysphagia and are at risk for aspiration. Test-Taking Strategy: Note the key words severely dysphagic and avoids in the question. Use the process of elimination, recalling that liquids are most difficult to swallow in the client with dysphagia. If you had difficulty with this question, review care to the client with ALS. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 402. 1030. A nurse is reviewing the record of a client seen in the health care clinic and notes that the physician has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder does the nurse expect to note in the record? 1. Muscle wasting 2. Mild clumsiness 3. Altered mentation 4. Diminished gag reflex Answer: 2 Rationale: The initial symptom of ALS is a mild clumsiness usually in the distal portion of one extremity. The client may complain of tripping and may drag one leg when the lower extremities are involved. Mentation and intellectual function are usually normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations. Test-Taking Strategy: Note the key word initial in the stem of the question. Focusing on the key word will assist in eliminating options 1, 3, and 4. If you are unfamiliar with the initial manifestations associated with ALS, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 401-402. 1031. A nurse in the neurological unit is assisting in caring for a client with a supratentorial lesion. The nurse monitors which of the following as the most critical index of central nervous system (CNS) dysfunction? 1. Blood pressure 2. Level of consciousness 3. Temperature

PN~Comp~Review~CD~1001-1101 -17 4. Ability to speak Answer: 2 Rationale: Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction. Test-Taking Strategy: Note the key words most critical in the stem of the question. Focusing on the issue of the question—a neurological problem—will assist in directing you to option 2. Also, option 2 is the most global option. If you had difficulty with this question, review the components of neurological assessment. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 607. 1032. A nurse is caring for a client following a craniotomy. The nurse monitors the client for signs of increased intracranial pressure (ICP). Which of the following if noted in the client indicates an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. A widened pulse pressure 4. Sluggish pupils Answer: 1 Rationale: Early manifestations of increased ICP are subtle and may often be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later clinical manifestations of increased ICP include decreasing levels of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and sluggish and dilating pupils appear in the later stages. Test-Taking Strategy: Note the key word early in the stem of the question. Recalling that the earliest indicator of increased ICP is a change in the level of consciousness will direct you to option 1. If you had difficulty with this question, review the early signs of increased ICP. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 616. 1033. Acetazolamide (Diamox) is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that its primary action is to:

PN~Comp~Review~CD~1001-1101 -18 1. Decrease cerebrospinal fluid production 2. Maintain an adequate blood pressure for cerebral perfusion 3. Prevent hyperthermia 4. Prevent hypertension Answer: 1 Rationale: Diamox is a carbonic anhydrase inhibitor. It is used in the client with, or at risk for, increased intracranial pressure to decrease cerebrospinal fluid production. Options 2, 3, and 4 are not actions of this medication. Test-Taking Strategy: Focus on the diagnosis presented in the question and the key word primary in the stem of the question. Note the relationship between “supratentorial” in the question and “cerebrospinal” in the correct option. If you had difficulty with this question, review the action of this medication. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 9. 1034. A nurse is documenting in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1. Sudden loss of consciousness 2. Brief flexion of the extremities 3. Violent extension spasm of the entire body 4. Body stiffening Answer: 3 Rationale: The clonic phase of a seizure is characterized by violent extension spasm of the entire body interrupted by muscular relaxation and accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. There is excessive salivation resulting in frothing from the mouth, the tongue may be bitten, the client sweats profusely, and the pulse rate is rapid. The clonic jerking subsides by slowing in frequency and losing strength over a period of 30 seconds. Options 1, 2, and 4 identify the tonic phase of a seizure. Test-Taking Strategy: Focus on the issue of the question—the clonic phase of a seizure. Use the process of elimination, recalling that spasm of the body occurs in this phase. If you are unfamiliar with the characteristics of this type of a seizure, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 623. 1035. A nurse is preparing for admission of a client with a diagnosis of seizures. Full seizure precautions are prescribed. The nurse obtains items to be placed at the client’s

PN~Comp~Review~CD~1001-1101 -19 bedside, knowing that which item is not needed? 1. Suction machine 2. Oxygen 3. Padding for the side rails 4. Padded tongue blade Answer: 4 Rationale: Full seizure precautions include providing bed rest for the client in a bed with padded side rails in a raised position, having a suction machine at the bedside, and having diazepam (Valium) or lorazepam (Ativan) available in addition to oxygen. Objects such as tongue blades are not necessary and should never be placed in the client’s mouth during a seizure. Test-Taking Strategy: Note the key words not needed in the question. This word indicates a false response question and that you need to select the incorrect item. Use the process of elimination, recalling that objects should not be placed in the client’s mouth during a seizure. This concept will direct you to option 4. If you had difficulty with this question, review nursing care for a client on full seizure precautions. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 624. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 387. 1036. A nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer’s disease. The nurse assists in developing a plan of care, knowing that which of the following is a characteristic of early Alzheimer’s disease? 1. Confusion is common 2. Forgetfulness interferes with the daily routine 3. The client may wander 4. The client may be easily frustrated Answer: 2 Rationale: In early Alzheimer’s disease, forgetfulness begins to interfere with daily routines. The client has difficulty concentrating and difficulty learning new material. Options 1, 3, and 4 are characteristic of dementia that occurs late as the disease progresses. Test-Taking Strategy: Note the key word early. Focus on the diagnosis and the characteristics associated with this disease to direct you to option 2. If you are unfamiliar with Alzheimer’s disease and the associated characteristics, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 633.

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1037. A clinic nurse is reviewing a record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride (Eldepryl). The nurse suspects that the client has which of the following disorders? 1. Coronary artery disease 2. Diabetes mellitus 3. Alzheimer’s disease 4. Parkinson’s disease Answer: 4 Rationale: Selegiline hydrochloride is an antiparkinsonian medication. The medication increases dopaminergic action, assisting in the reduction of tremor, akinesia, and the rigidity of parkinsonism. This medication is not used to treat coronary artery disease, diabetes mellitus, or Alzheimer’s disease. Test-Taking Strategy: Knowledge regarding the action and use of selegiline hydrochloride is required to answer this question. Remember, selegiline hydrochloride is an antiparkinsonian medication. If you had difficulty with this question or are unfamiliar with this medication, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 963. 1038. A nurse is reviewing the record of a client with a suspected diagnosis of Huntington’s disease. The nurse expects to note documentation of which of the following early symptoms of this disease? 1. Balance and coordination problems 2. Difficulty swallowing 3. Aphasia 4. Agnosia Answer: 1 Rationale: Early symptoms of Huntington’s disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, and altered speech and handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur. Test-Taking Strategy: Note the key word early. Recalling the pathophysiology of Huntington’s disease and that alteration in balance and coordination occur will direct you to option 1. If you are unfamiliar with this disorder or the associated manifestations, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 636-637.

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1039. A nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs of meningitis include which of the following? 1. Severe headache, fever, and changes in the level of consciousness 2. Nausea, delirium, and fever 3. Photophobia, fever, and confusion 4. Severe headache and back pain Answer: 1 Rationale: The classic signs of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia may also be a prominent early symptom and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs. Test-Taking Strategy: Note the key words classic signs in the stem of the question. Options 2 and 3 can be eliminated first, knowing that severe headache occurs. From the remaining options, focus on the name of the disorder, meningitis, to help you recall that fever is associated with this disorder. If you had difficulty with this question or are unfamiliar with the classic signs of meningitis, review this content. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 546. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 158. 1040. An emergency department nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse tells the client that diagnostic tests will be performed. The nurse informs the client that the diagnostic test used to confirm the diagnosis is which of the following? 1. White blood cell (WBC) count 2. Lumbar puncture 3. Blood culture 4. Measurement of serum electrolytes Answer: 2 Rationale: Meningitis is an acute or chronic inflammation of the meninges and the cerebrospinal fluid. The key diagnostic test used in meningitis is the lumbar puncture. A WBC count and serum electrolytes may also be performed but will not confirm the diagnosis. Blood cultures are not normally prescribed. Test-Taking Strategy: Note the key word confirm in the stem of the question. This will assist in eliminating options 1 and 4. From the remaining options, recalling that meningitis is an inflammation of the meningeal area will direct you to option 2. If you had difficulty with this question or are unfamiliar with the physiology associated with meningitis, review this content.

PN~Comp~Review~CD~1001-1101 -22 Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 546. 1041. A nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which of the following findings is not indicative of a bacterial infection? 1. A cerebrospinal fluid (CSF) pressure of 250 mm H2O 2. A protein level of 20 mg/dl 3. Increased white blood cell count 4. Increased glucose level Answer: 4 Rationale: If a bacterial infection of cerebrospinal fluid is present, test results will indicate a cloudy appearance to the CSF, a pressure greater than 200 mm H2O, a protein level greater than 15 mg/dl, an increased white blood cell count, and a reduced glucose level. Test-Taking Strategy: Use the process of elimination and note the key words not indicative in the stem of the question. These words indicate a false response question and that you need to select the incorrect finding. Focusing on the issue—bacterial infection— and recalling the components of normal CSF will direct you to option 4. If you had difficulty with this question or are unfamiliar with the findings associated with bacterial meningitis, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 546. 1042. A nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. The nurse expects to note that which of the following diagnostic tests will be prescribed to confirm this diagnosis? 1. Lumbar puncture 2. Brain biopsy 3. Electroencephalogram (EEG) 4. Computed tomography (CT) scan Answer: 2 Rationale: The diagnosis of herpes simplex encephalitis can be made by brain biopsy and is rarely made from the culture of cerebrospinal fluid obtained from a lumbar puncture. The EEG is abnormal in many cases with temporal lobe abnormalities, but it will not confirm the diagnosis. The CT scan is normal up to the first 5 days, with low-density lesions in the temporal lobe noted later. Test-Taking Strategy: Use the process of elimination. Note the key word confirm in the

PN~Comp~Review~CD~1001-1101 -23 stem of the question. Read each option carefully, remembering that from the options provided a biopsy is the only test that will confirm the diagnosis. If you had difficulty with this question or are unfamiliar with herpes simplex encephalitis, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 287. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 646. 1043. A nurse is caring for a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which of the following questions? 1. “Are you having normal bowel movements?” 2. “Are you getting up at night to urinate?” 3. “Are you having muscle spasms?” 4. “Are you consistently fatigued?” Answer: 2 Rationale: Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control; decreased urinary frequency, incontinence, and nocturia; and improved urinary control. Options 1, 3, and 4 are unrelated to the use of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that this medication is used to treat bladder dysfunction will direct you to option 2. If you are unfamiliar with this medication and its use, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 813. 1044. A nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. The client arrives to the nursing unit, and the nurse is reviewing the physician’s documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1. Altered level of consciousness 2. Multifocal seizures 3. Abrupt onset of fever and headache 4. Development of muscle weakness Answer: 4 Rationale: A hallmark clinical manifestation of Guillain-Barré syndrome is muscle weakness that develops rapidly. The client does not have symptoms such as a fever or

PN~Comp~Review~CD~1001-1101 -24 headache. Cerebral function, level of consciousness, and pupillary responses are normal. Seizures are not normally associated with this disorder. Test-Taking Strategy: Use the process of elimination and focus on the diagnosis— Guillain-Barré syndrome. Recalling that muscle weakness occurs in this disorder will direct you to option 4. If you are unfamiliar with the manifestations associated with Guillain-Barré syndrome, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 645. 1045. A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which of the following in the plan? 1. Avoid administering pain medication to prevent respiratory depression 2. Monitor the chest tube drainage 3. Maintain intravenous infusion of lactated Ringer’s solution 4. Restrict visitors for 24 hours postoperatively Answer: 2 Rationale: A thymectomy may be performed to improve the condition in clients with myasthenia gravis. The procedure is performed by a median sternotomy or a transcervical approach. Postoperatively, the client will have a chest tube in the mediastinum. Pain medication is administered as needed, but the client is monitored closely for respiratory depression. Lactated Ringer's intravenous solutions are usually avoided because they can increase weakness. There is no reason to restrict visitors. Test-Taking Strategy: Note the key words median sternotomy approach in the question. This should provide you with a clue that the client will have a chest tube in place following this procedure. If you are unfamiliar with the postoperative care following thymectomy, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 635. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 403. 1046. A nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. Based on these findings the nurse interprets that the client: 1. Had a very mild stroke 2. Most likely suffered a transient ischemic attack 3. May likely have perceptual and spatial disabilities

PN~Comp~Review~CD~1001-1101 -25 4. May have difficulty with language abilities only Answer: 3 Rationale: The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often result in interpretations that the client is less disabled than is the case. However, impulsive actions and confusion in carrying out activities may be very much a problem for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because of the word “only.” From the remaining options, recalling that perceptual and spatial disabilities occur in the client with a right hemispheric stroke will direct you to option 3. Review the clinical manifestations associated with a right and left hemispheric stroke if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 639. 1047. A nurse is preparing to care for a client with a diagnosis of cerebrovascular accident (CVA). The nurse notes in the client’s record that the client has anosognosia. The nurse plans care knowing that the client will: 1. Have difficulties speaking 2. Neglect the affected side 3. Have difficulty swallowing 4. Be fatigued Answer: 2 Rationale: In anosognosia, the client neglects the affected side of the body. The client may neglect the affected side (often creating a safety hazard as a result of potential injuries) or state that the involved arm or leg belongs to someone else. Options 1, 3, and 4 are not associated with anosognosia. Test-Taking Strategy: Knowledge of the definition of anosognosia and the associated manifestations is required to answer this question. Remember, in anosognosia the client neglects the affected side of the body. Review this manifestation of CVA if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Mosby’s medical, nursing, & allied health dictionary 2002. (6th ed.). St. Louis: Mosby, p. 103. 1048. A nurse is preparing a plan of care for a client with a cerebrovascular accident (CVA) who has global aphasia. The nurse incorporates communication strategies in the

PN~Comp~Review~CD~1001-1101 -26 plan of care, knowing that the client’s speech will be: 1. Intact 2. Associated with poor comprehension 3. Characterized by literal paraphasia 4. Rambling Answer: 2 Rationale: Global aphasia is a condition in which a person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and the speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke’s aphasia may exhibit a rambling type of speech. Test-Taking Strategy: Knowledge of the characteristics associated with global aphasia is required to answer this question. Remember, global aphasia is a condition in which a person has few language skills as a result of extensive damage to the left hemisphere. If you are unfamiliar with these characteristics, review this type of aphasia that can occur in a client with a CVA. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 608. 1049. A nurse is caring for a client with a diagnosis of cerebral vascular accident (CVA) with anosognosia. To meet the needs of the client with this deficit, the nurse plans activities that will: 1. Increase the client’s awareness of the affected side 2. Encourage communication 3. Promote adequate bowel elimination 4. Provide a consistent daily routine Answer: 1 Rationale: In anosognosia, the client neglects the affected side of the body. The nurse should plan care activities that force the client to look at the affected arm or leg, and activities that will increase the client’s awareness of the affected side. Options 2, 3, and 4 are not associated with this deficit. Test-Taking Strategy: Focus on the issue of the question. Recall that in anosognosia the client neglects the affected side of the body. This will direct you to option 1. If you are unfamiliar with this type of deficit that occurs in CVA, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 642. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment

PN~Comp~Review~CD~1001-1101 -27 and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1484. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1369. 1050. A nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. The initial nursing action is to: 1. Place the client in the prone position 2. Elevate the head of the bed 3. Digitally examine the rectum 4. Check the client’s blood pressure Answer: 2 Rationale: Autonomic dysreflexia is a serious complication that can occur in the spinal cord injury client. Once the syndrome is identified, the nurse elevates the head of the client’s bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client’s blood pressure, but the initial action is to elevate the head of the bed. The client should not be placed in the prone position. Test-Taking Strategy: Use the process of elimination. Note the key word initial in the stem of the question. Noting that both options 1 and 2 identify a client position may assist in eliminating options 3 and 4. If you are unfamiliar with this serious complication and the nursing interventions required if this complication occurs, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 446. 1051. Prescriptive eyeglasses are prescribed for a client with bilateral aphakia, and the nurse teaches the client about the glasses. Which statement by the client indicates the need for further instructions? 1. “My peripheral vision will not be distorted.” 2. “My central vision will be corrected.” 3. “It may be difficult to judge distances.” 4. “Approximately 30% of my central vision will be magnified.” Answer: 1 Rationale: Aphakia is the absence of the eye’s lens and is corrected by prescriptive glasses, contact lenses, or an intraocular lens implanted surgically. Although glasses can be used for this disorder, they have several disadvantages. With the use of glasses, only central vision is corrected and peripheral vision is distorted. There is an approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted. It is difficult for the client to judge distances, such as when driving a car. Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that peripheral vision is distorted with the use of glasses will assist

PN~Comp~Review~CD~1001-1101 -28 in answering the question correctly. If you had difficulty with this question or are unfamiliar with the advantages and disadvantages of prescriptive glasses, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 440441. 1052. A nurse has provided instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further instructions? 1. “I cannot eat or drink anything for 24 hours before the surgery.” 2. “I will have a patch on my eye after surgery.” 3. “A sedative will be given to help me relax for surgery.” 4. “I need to wash my face on the morning of surgery.” Answer: 1 Rationale: The client scheduled for cataract surgery should be instructed that oral intake may be restricted for 6 to 12 hours preoperatively. It is not necessary that the client remain NPO for 24 hours prior to surgery. Options 2, 3, and 4 are correct instructions regarding care related to cataract surgery. Test-Taking Strategy: Note the key words need for further instructions in the stem of the question. These words indicate a false response question and that you need to select the incorrect client statement. Noting the time frame of 24 hours in option 1 will assist in directing you to this option. If you had difficulty with this question, review preoperative instructions for the client scheduled for cataract surgery. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 450. 1053. A nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. The nurse prepares to position the client: 1. On the right side 2. Supine on the left side 3. On the left side with the head of the bed elevated 4. On the right side with the head of the bed elevated Answer: 3 Rationale: Following cataract extraction, the client should be positioned comfortably with the head of the bed elevated on the nonoperative side. The client should not be placed on the operative side because this position will promote swelling and edema in the operative area. A supine position will also promote edema and swelling. Test-Taking Strategy: Use the process of elimination. Recalling the principles related to trauma and swelling and that the client should not be placed on the operative side

PN~Comp~Review~CD~1001-1101 -29 following cataract surgery will assist in directing you to option 3. If you had difficulty with this question or are unfamiliar with the care of the client in the postoperative period following cataract extraction, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 571. 1054. A client who sustained an eye injury arrives at the emergency department. The initial nursing action is to: 1. Flush the eye with sterile saline solution 2. Obtain a history regarding the cause of the injury 3. Place an ice pack on the eye 4. Instill an antibiotic solution Answer: 2 Rationale: In the event of an eye injury, the initial nursing action is to determine the cause of the injury and when and how the injury occurred. Treatment depends on the cause of the injury. Test-Taking Strategy: Note the key word initial. Use the nursing process, remembering that data collection is the first step. The nurse would not perform treatment without determining the cause of the injury. If you had difficulty with this question, review care to the client with an eye injury. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 445. 1055. A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which of the following nursing actions is appropriate? 1. Apply pressure to the eye 2. Irrigate the eye 3. Cover the eye with cold sterile saline gauze 4. Send the client to x-ray for a skull series Answer: 3 Rationale: The appropriate nursing action following blunt trauma injury to the eye is to cover the eye with sterile gauze saturated with cold sterile saline. The nurse should avoid applying pressure and should allow the eye to bleed. The eye should not be irrigated without a physician’s order. Skull series are prescribed by the physician. Test-Taking Strategy: Focus on the situation presented in the question. Note that the client sustained trauma to the eye and that the eye is bleeding. Recalling that pressure should not be placed on this sort of injury because of the risk of intraocular pressure

PN~Comp~Review~CD~1001-1101 -30 will assist in eliminating option 1. Option 4 can be eliminated next because a physician’s order is required. From the remaining options, select option 3 because of the word “cold” in this option. If you had difficulty with this question, review care to the client with a blunt injury to the eye. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 445. 1056. A client arrives in the emergency department following an eye injury from a chemical solution. Which the following is the initial nursing action? 1. Test the eye pH with litmus paper 2. Obtain a medical history from the client 3. Cover the eye with sterile saline solution and contact the physician 4. Place a pressure dressing on the eye until the physician arrives Answer: 1 Rationale: If a client sustained a chemical injury to the eye, the client’s head should be tilted to the side of the affected eye and irrigated thoroughly. The pH of the eye should be tested with litmus paper before, during, and after irrigation. The physician should be notified. A pressure dressing is not placed on the eye in this type of injury. Covering the eye with sterile saline solution is not an appropriate action and would delay necessary and immediate treatment. A medical history would be obtained once initial treatment is initiated. Test-Taking Strategy: Note the key word initial. Focus on the type of injury described in the question to assist in the process of elimination. Noting the key word chemical will assist in directing you to option 1 as the initial treatment. If you had difficulty with this question, review care to the client who sustained a chemical injury to the eye. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 445. 1057. A nurse is reviewing the preoperative orders of a client scheduled for keratoplasty. Which of the following orders if noted in the client’s chart would the nurse question? 1. Cut the client’s eyelashes 2. Obtain a culture and sensitivity of the conjunctivae 3. Administer medication prescribed to dilate the pupil 4. Administer prescribed antibiotic eye medication Answer: 3 Rationale: In the preoperative period, the physician may prescribe medications such as 2% pilocarpine to constrict the pupil before keratoplasty. The nurse would question an order that indicated dilation of the pupil. Preoperative preparation may include obtaining

PN~Comp~Review~CD~1001-1101 -31 a culture and sensitivity with conjunctival swabs, instilling antibiotic eye medication, and cutting the eyelashes. Test-Taking Strategy: Use the process of elimination. Recalling that keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor will assist in directing you to option 3. If you are unfamiliar with this procedure and the preoperative care, review this content. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 582. 1058. A nurse has provided instructions to a client following right keratoplasty. Which statement by the client indicates a need for further instruction? 1. “I need to wear an eye shield at bedtime.” 2. “I need to faithfully apply antibiotic medication.” 3. “I need to report to the clinic in 1 week to have the sutures removed.” 4. “I should lie on my left side to sleep.” Answer: 3 Rationale: Following keratoplasty, sutures are usually left in place for as long as 6 months. The client is instructed not to lie on the operative side and should avoid sudden head movement. The client is instructed to instill antibiotic medication because infection is a dreaded complication of this procedure. An eye shield should be worn during sleep for about 2 months postoperatively. Test-Taking Strategy: Note the key words a need for further instruction in the question. These words indicate a false response question and that you need to select the incorrect client statement. Using general principles related to postoperative teaching following eye surgery will assist in eliminating options 1, 2 and 4. If you had difficulty with this question, review postoperative care following keratoplasty. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 583. 1059. A nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which of the following is the appropriate initial action? 1. Notify the registered nurse 2. Document the finding 3. Reinforce the dressing 4. Mark the site and continue to monitor Answer: 1 Rationale: Following enucleation if the nurse notes any staining or bleeding on the

PN~Comp~Review~CD~1001-1101 -32 surgical dressing, the registered nurse is notified and then contacts the physician immediately. Options 2, 3, and 4 are not appropriate initial nursing actions. Test-Taking Strategy: Note the key words initial action and focus on the issue— bloody staining following enucleation. Recall that following this procedure, if any bleeding is noted the registered nurse needs to be notified. If you are unfamiliar with the care of the client following enucleation, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 582. 1060. A client reports to the health care clinic because of recent right eye discomfort. The physician diagnoses chalazion of the right eye. The nurse provides instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? 1. “I should apply cold packs to my eye.” 2. “I should apply warm packs to my eye.” 3. “I should irrigate my eye with cool water daily.” 4. “I should use separate washcloths and towels to prevent spreading the infection to others.” Answer: 2 Rationale: A chalazion is a cyst and results from blockage of sebaceous material in a meibomian gland. Application of warm compresses over the affected eyelid three to four times per day is a common treatment in the early stages. The condition is not contagious, and it is not necessary for the client to use separate washcloths and towels. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are similar. Recalling that this condition is not contagious will assist in directing you to option 2 from the remaining options. If you had difficulty with this question or are unfamiliar with this disorder, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 567. 1061. A nurse is providing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions? 1. “I need to apply cool compresses to the eye for 15 minutes four times daily.” 2. “I should press on the eye when I apply the warm compresses.” 3. “When the eyelid turns white I should try to squeeze the sty.” 4. “I should apply antibiotic ointment as prescribed.” Answer: 4

PN~Comp~Review~CD~1001-1101 -33 Rationale: Therapeutic management of a hordeolum includes application of warm compresses for 15 minutes four times daily and instillation of antibiotic ointment to combat infectious organisms. The client is told not to press on or squeeze the sty because such pressure could force infectious material into the venous system of the eyelids and face, which can transmit infection to the brain. Test-Taking Strategy: Focus on the key words indicates an understanding of the instructions. General principles related to care of the eye will assist in eliminating options 2 and 3. Recalling that the client should use warm rather than cool compresses with this condition will direct you to option 4. If you had difficulty with this question or are unfamiliar with care to the client with a hordeolum, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 567. 1062. A nurse is assisting the physician in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse notes the presence of nystagmus. The nurse should document the findings of this test as: 1. Normal 2. Abnormal 3. Inconclusive 4. Indicating eighth cranial nerve dysfunction Answer: 1 Rationale: The caloric test is useful in testing the function of the eighth cranial nerve. Warmer water or cooler than body temperature water is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Eliminate options 2 and 4 first because they are similar. From the remaining options, use knowledge regarding the interpretation of the test results to assist in directing you to option 1. If you had difficulty with this question or are unfamiliar with this test, review this diagnostic procedure. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2056. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1079-1080. 1063. A nurse is assisting the physician in performing a caloric test on a client. Following instillation of warm water into ear, the client complains of vertigo. The nurse documents the findings of this test as: 1. Indicating eighth cranial nerve dysfunction

PN~Comp~Review~CD~1001-1101 -34 2. Abnormal 3. Inconclusive 4. Normal Answer: 4 Rationale: The caloric test is useful in testing the function of the eighth cranial nerve. Warmer water or cooler than body temperature water is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Eliminate options 1 and 2 first because they are similar. From the remaining options, use knowledge regarding the interpretation of the test results to assist in directing you to option 4. If you had difficulty with this question or are unfamiliar with this test, review this diagnostic procedure. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2056. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1079-1080. 1064. A nurse is assisting the physician in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse would document the findings of this test as: 1. Normal 2. Requiring a repeat test 3. Inconclusive 4. Indicating dysfunction of the eighth cranial nerve Answer: 4 Rationale: The caloric test is useful in testing the function of the eighth cranial nerve. Warmer water or cooler than body temperature water is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. No nystagmus indicates dysfunction of the eighth cranial nerve. Test-Taking Strategy: Eliminate options 2 and 3 first because they are similar. From the remaining options, use knowledge regarding the interpretation of the test results to assist in directing you to option 4. If you had difficulty with this question or are unfamiliar with this test, review this diagnostic procedure. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2056. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 436.

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1065. A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test? 1. An otoscope 2. An ophthalmoscope 3. A tongue blade 4. An emesis basin Answer: 1 Rationale: A caloric test is contraindicated in a client with a perforated tympanic membrane (air may be used as a substitute), or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine if the ear canals contain cerumen, which must be removed before the test. An ophthalmoscope, tongue blade, and emesis basin are not essential items. Test-Taking Strategy: Note the key words essential and preparation for in the stem of the question. Recalling that this test should not be performed if a perforated eardrum is present will assist in directing you to option 1. If you had difficulty with this question or are unfamiliar with preparation for the calorie test, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Ear Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 1320, 1322. 1066. A nursing instructor asks a student about cochlear implants. The student understands that which of the following clients is not a candidate for this surgical procedure? 1. A client who became deaf before learning to speak 2. A client with bilateral profound hearing loss 3. A client who communicates primarily by speech 4. A client who received no benefit from conventional hearing aids Answer: 1 Rationale: Adults who were born deaf or became deaf before learning to speak are usually not candidates for this type of surgery. Criteria for a cochlear implant are a client with bilateral profound hearing loss, a client who communicates primarily by speech, a client who receives no benefit from conventional hearing aids, a client who shows evidence of strong family and social support, and a client who has realistic expectations of the outcome of the implant. Test-Taking Strategy: Use the process of elimination, noting the key words is not a candidate. Recalling the purpose of this procedure will direct you to option 1. If you are unfamiliar with this procedure and those clients who may be candidates, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity

PN~Comp~Review~CD~1001-1101 -36 Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1081, 1083. 1067. A nurse is observing a nursing assistant communicating with a client who is deaf. The nurse would intervene if which of the following behaviors is observed? 1. The nursing assistant is speaking directly to the client 2. The nursing assistant touches the client’s arm to gain his or her attention 3. The nursing assistant faces the client when speaking to the client 4. The nursing assistant overenunciates words when speaking Answer: 4 Rationale: Overenunciating words does not make lip reading easier and is demeaning to the deaf person. It is best to speak in a normal manner. Options 1, 2, and 3 are appropriate communication strategies for the client who is deaf. Test-Taking Strategy: Note the key word intervene in the question. This indicates that you are looking for an option that is an incorrect strategy when speaking to a client who is deaf. Use basic principles regarding communication to assist in directing you to option 4. If you had difficulty with this question, review communication strategies for a deaf client. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1085-1086. 1068. A nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. at home. During the admission, the client complains of chest pain. The nurse should immediately ask the client which of the following questions? 1. “Are you having any nausea?” 2. “Where is the pain located?” 3. “Are you allergic to any medications?” 4. “Do you have your nitroglycerin with you?” Answer: 2 Rationale: If a client complains of chest pain, the initial question is to ask the client about the pain intensity, location, duration, and quality. Although options 1, 3, and 4 may be a component of data collection, these would not be the initial questions in the situation. Test-Taking Strategy: Focus on the issue—the client’s chest pain. Note the relationship between the client’s complaint in the question and the correct option. If you had difficulty with this question, review cardiac assessment in a client experiencing chest pain. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection

PN~Comp~Review~CD~1001-1101 -37 Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 580. 1069. A nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. “I need to substitute eggs and whole milk for meat.” 2. “I should eliminate all cholesterol and fat from my diet.” 3. “I should use polyunsaturated oils in my diet.” 4. “I’ll need to become a strict vegetarian.” Answer: 3 Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first because of the word “all.” Next, eliminate option 4 because of the word “strict.” Recalling that the client with coronary artery disease should avoid foods high in cholesterol and fat will assist in directing you to option 3 from the remaining options. Review dietary measures for the client with coronary artery disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 580. 1070. A nurse is caring for a client with a diagnosis of agoraphobia. Which of the following behaviors does the nurse expect the client to describe when communicating with the client about the disorder? 1. A need to wash the hands several times before eating a meal 2. A fear of leaving the house 3. A fear of speaking in public 4. A fear of riding in elevators Answer: 2 Rationale: Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. Option 1 describes an obsessive-compulsive behavior. Option 3 describes a social phobia. Option 4 describes claustrophobia. Test-Taking Strategy: Use the process of elimination and focus on the key word agoraphobia to direct you to option 2. If you had difficulty with this question, review the various types of phobias. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St.

PN~Comp~Review~CD~1001-1101 -38 Louis: Mosby, pp. 185-186. 1071. A nurse is caring for a client with a diagnosis of Parkinson’s disease. The client is taking benztropine mesylate (Cogentin) orally daily. The nurse provides instructions to the spouse regarding the side effects of this medication and tells the spouse to report which side effect if it occurs? 1. Inability to urinate 2. Decreased appetite 3. Shuffling gait 4. Irregular bowel movements Answer: 1 Rationale: Urinary retention is a side effect of benztropine mesylate. The nurse should instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Options 2, 3, and 4 are unrelated to the use of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that urinary retention is a side effect and a concern with the use of this medication will direct you to option 1. If you had difficulty with this question or are unfamiliar with the side effects, review this information. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 116. 1072. A nurse is providing instructions to the client regarding the complications of peritoneal dialysis. The nurse instructs the client that which manifestation is most likely associated with the onset of peritonitis? 1. Fever 2. Clear dialysate output 3. Fatigue 4. Leaking around the catheter site Answer: 1 Rationale: The signs of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. Leaking around the catheter site is not an indication of peritonitis. Fatigue may be associated with peritonitis, but fever is the most likely sign. Test-Taking Strategy: Focus on the issue of the question—peritonitis. Option 2 can be eliminated first because it is unrelated to this complication and clear dialysate fluid is a normal finding. Option 4 is eliminated next because it is not associated with peritonitis. From the remaining options, use basic principles related to the signs of infection to assist in directing you to option 1. If you had difficulty with this question, review the signs of peritonitis. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance

PN~Comp~Review~CD~1001-1101 -39 Integrated Process: Teaching/Learning Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 699. 1073. A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The nurse most appropriately asks which of the following questions first? 1. “Have you had any abdominal discomfort?” 2. “Have you had any diarrhea?” 3. “Have you been constipated recently?” 4. “Have you had an increased amount of flatulence?” Answer: 3 Rationale: Reduced outflow from the dialysis catheter may be due to the catheter position, infection, or constipation. Constipation may contribute to a reduced outflow because peristalsis seems to aid in drainage. Options 1, 2, and 4 are unrelated to the causes of reduced outflow from the dialysis catheter. Test-Taking Strategy: Focus on the issue of the question—decreased dialysate output. Use the process of elimination, considering how each item in the options may contribute to this problem to direct you to option 3. If you had difficulty with this question, review the causes of reduced outflow in a client receiving peritoneal dialysis. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1232. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 787. 1074. A nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL of 5% dextrose with 40 mEq of potassium chloride. Which of the following if noted on the cardiac monitor indicates the presence of hyperkalemia? 1. Tall, peaked T waves 2. ST segment depression 3. Shortening of the QRS complex 4. Shortened P-R interval Answer: 1 Rationale: The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST segment depression is noted in hypokalemia. Test-Taking Strategy: Use the process of elimination. Recalling that a tall, peaked T wave occurs in this condition will direct you to option 1. If you are unfamiliar with the cardiac findings in the client with hyperkalemia, review these findings.

PN~Comp~Review~CD~1001-1101 -40 Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1581. 1075. A nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which of the following if noted on the cardiac monitor indicates the presence of hypokalemia? 1. Tall, peaked T waves 2. ST segment depression 3. Widening of the QRS complex 4. Prolonged P-R interval Answer: 2 Rationale: In the client with hypokalemia, the nurse would note ST segment depression on a cardiac monitor. The client may also exhibit a flat T wave. Options 1, 3, and 4 are cardiac findings noted in the client with hyperkalemia. Test-Taking Strategy: Use the process of elimination. Recalling that ST segment depression occurs in this condition will direct you to option 2. If you are unfamiliar with the cardiac findings in hypokalemia, review these assessment findings. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1581. 1076. A nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which of the following is initially noted in the client if hyperkalemia is present? 1. Mental status changes 2. Confusion 3. Muscle weakness 4. Depressed deep tendon reflexes Answer: 3 Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium levels initially causes muscle weakness. Mental status changes and confusion are most likely noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia. Test-Taking Strategy: Note the key word initially in the stem of the question. Eliminate options 1 and 2 first because they are similar. From the remaining options, recalling that muscle weakness is associated with hyperkalemia will direct you to option 3. If you had difficulty with this question or are unfamiliar with the signs of hyperkalemia, review this content.

PN~Comp~Review~CD~1001-1101 -41 Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1582. 1077. A nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking the: 1. Neurological and respiratory systems 2. Renal system 3. Cardiovascular system 4. Client’s mobility status Answer: 1 Rationale: The early signs of the complication of fat embolism include changes in the client’s mental status or signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment is likely to occur secondary to impaired respiratory function. The client’s mobility status is unrelated to the signs of fat embolism. Test-Taking Strategy: Note the key words earliest signs in the stem of the question. Use the process of elimination and recall the pathophysiology associated with an embolism to direct you to option 1. If you had difficulty with this question, review the early signs of fat embolism. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 823. 1078. A nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. The initial action of the nurse is to: 1. Place the client in the supine position 2. Place the client in the Fowler’s position 3. Perform a neurological assessment 4. Reassess the vital signs Answer: 2 Rationale: Clients with fractures are at risk for fat embolism. If the nurse suspects fat embolism, the nurse should place the client in a sitting (Fowler’s) position to relieve dyspnea. Supplemental oxygen is indicated to reduce the signs of hypoxia. The physician needs to be notified. A neurological assessment needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken, but this action may delay initial and required interventions. Test-Taking Strategy: Note the key words initial action in the stem of the question.

PN~Comp~Review~CD~1001-1101 -42 Eliminate option 1 first because the supine position is not likely to improve the client’s breathing. The nursing actions identified in options 3 and 4 may take too much time and therefore are also eliminated. Review initial care to the client with fat embolism if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 635. 1079. A nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right femur sustained from a fall 5 hours ago. The nurse develops a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. The nurse includes in the plan to monitor for which of the following? 1. External rotation of the right leg 2. Fever and shaking chills 3. Dyspnea and chest pain 4. Pallor, paresthesia, and pulselessness of the right lower leg Answer: 3 Rationale: The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. Option 1 is indicative of a hip fracture. Option 2 indicates signs of infection, and option 4 indicates signs of severe circulatory impairment. Test-Taking Strategy: Use the process of elimination. Recalling that this complication produces respiratory and neurological status changes will direct you to option 3. If you had difficulty with this question or are unfamiliar with the signs of fat embolism, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 145. 1080. A nurse is caring for a client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which of the following findings does the nurse identify as early signs of possible fat embolism? 1. Increased heart rate and increased oxygen saturation 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Decreased heart rate and increased restlessness Answer: 3 Rationale: Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath

PN~Comp~Review~CD~1001-1101 -43 sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because an increased heart rate would be noted. From the remaining options, eliminate option 1 because decreased oxygen saturation would be noted. If you are unfamiliar with the signs and symptoms associated with this complication of fractures, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 145. 1081. A nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of narcotic analgesic. The initial nursing action is to: 1. Contact the physician 2. Administer another dose of pain medication 3. Elevate the casted leg 4. Check the neurovascular status of the toes on the casted leg Answer: 4 Rationale: An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity. The nurse needs to obtain additional data and notify the registered nurse. The registered nurse will determine if the physician needs to be notified immediately or if other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment. Test-Taking Strategy: Use the nursing process as a guide to answer this question. Remember that data collection is the first step of the nursing process. This will direct you to option 4. If you had difficulty with this question, review the complications and nursing interventions for the client with a fracture and a casted extremity. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 143. 1082. A nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client’s casted extremity because: 1. Compartment syndrome may lead to irreversible nerve and muscle tissue injury 2. The skin under the cast is at high risk for infection 3. Alterations in the neurovascular status of the fingers may be early signs of fat embolism

PN~Comp~Review~CD~1001-1101 -44 4. The client is at high risk of neurovascular compromise until the cast is completely dry Answer: 1 Rationale: The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. The skin under the cast is not necessarily at risk for infection. The signs of other complications, such as fat embolism and skin infection, are not monitored by assessment of the neurovascular status of the casted extremity, but by other observations. The risk of compartment syndrome is related to internal or external causes of increased pressure in muscle compartments, not a result of the cast being wet. Test-Taking Strategy: Use the process of elimination. Focus on the issue—the purpose of monitoring the neurovascular status of the casted extremity. Additionally, option 1 is the only option that provides accurate information regarding compartment syndrome. Review the complications associated with compartment syndrome if you difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 144. 1083. A nurse is preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which of the following indicates an inappropriate action when collecting this specimen? 1. Instruct the client to tilt the head back 2. Ask the client to tilt the head forward, open the mouth, then place the collection swab at the back of the throat 3. Tell the client that the test will help identify microorganisms 4. Place a tongue depressor on the client’s tongue before swabbing the throat Answer: 2 Rationale: When collecting a throat culture, the client is told that the test is performed to help identify microorganisms causing the symptoms. The client is instructed to tilt the head back, and both the tonsillar pillars and the posterior pharynx wall are swabbed. A tongue depressor is used in the collection so that the swab is less likely to contact the normal flora of the mouth. The swab is immediately placed in a labeled culture tube and transported to the laboratory. Test-Taking Strategy: Note the key word inappropriate in the stem of the question. This word indicates a false response question and that you need to select the incorrect action. Visualize this procedure and use the process of elimination. If you had difficulty with this question or are unfamiliar with the procedure for obtaining a throat culture, review this procedure. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills

PN~Comp~Review~CD~1001-1101 -45 Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 1045-1046. 1084. A pulmonary angiography is being performed on a client suspected of having a pulmonary embolism. The nurse understands that which of the following is an unnecessary component of preprocedure care? 1. Contact the operating room regarding the need for the procedure 2. Obtain a signed informed consent 3. Ask the client about allergies to shellfish or contrast media 4. Shave the anticipated entry site Answer: 1 Rationale: A pulmonary angiography is not performed in the operating room; therefore it is not necessary that the nurse contact this department. An informed consent form is required. The procedure is explained to the client, and the client is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test. After the informed consent is signed, the nurse shaves and prepares the anticipated entry site. Test-Taking Strategy: Note the key word unnecessary in the stem of the question. This word indicates a false response question and that you need to select the incorrect component. Recalling that this test is diagnostic will direct you to option 1. If you are unfamiliar with this diagnostic procedure and the preprocedure care, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 734-736. 1085. A nurse is assisting in developing a plan of care for a client with Cushing’s syndrome. The client has a nursing diagnosis of Excess Fluid Volume. The nurse understands that which of the following is unnecessary to include in the plan of care? 1. Monitor daily weight 2. Monitor intake and output 3. Maintain a low-potassium and high-sodium diet 4. Monitor extremities for edema Answer: 3 Rationale: The client with Cushing’s syndrome and a nursing diagnosis of Excess Fluid Volume should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Options 1, 2, and 4 are appropriate interventions for the client with a nursing diagnosis of Excess Fluid Volume. Test-Taking Strategy: Focus on the key words Excess Fluid Volume to assist in answering the question. Also note the key word unnecessary. This word indicates a false response question and that you need to select the incorrect intervention. Use the process of elimination, recalling that a high sodium intake will contribute to the excess fluid volume. If you had difficulty with this question or are unfamiliar with the care to the client with Cushing’s syndrome and a fluid volume excess, review this content.

PN~Comp~Review~CD~1001-1101 -46 Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 471. 1086. A nurse reviews a nursing care plan and notes a nursing diagnosis of Disturbed Body Image for a client with a diagnosis of Cushing’s syndrome. The nurse identifies nursing interventions related to this nursing diagnosis and suggests to include these interventions in the plan of care. Which of the following is an inappropriate nursing intervention? 1. Encourage client expression of feelings 2. Assess the client’s understanding of the disease process 3. Encourage family members to share their feelings about the disease process 4. Encourage the client to understand that the body changes need to be dealt with Answer: 4 Rationale: Encouraging the client to understand that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client’s feelings. Options 1, 2, and 3 are most appropriate because they address the client and family feelings regarding the disorder. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer this question. Also note the key word inappropriate. This word indicates a false response question and that you need to select the incorrect intervention. Option 4 is not therapeutic because it does not allow client expression of feelings or address the client’s feelings. If you had difficulty with this question, review therapeutic communication techniques. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 472. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1087. A nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which of the following if noted in the client indicates signs and symptoms related to adrenal insufficiency? 1. Low-grade fever and hypotension 2. Hypotension and fever 3. Mental status changes and hypertension 4. Complaints of weakness and hypertension Answer: 2 Rationale: The nurse should be alert to signs and symptoms of adrenal insufficiency in a client following adrenalectomy. These signs and symptoms include weakness,

PN~Comp~Review~CD~1001-1101 -47 hypotension, fever, and mental status changes. Options 1, 3, and 4 are incorrect options. Test-Taking Strategy: Use the process of elimination. Recalling that hypotension occurs in adrenal insufficiency will assist in eliminating options 3 and 4. From the remaining options, it is necessary to know that fever is associated with this complication. If you had difficulty with this question, review the signs and symptoms of adrenal insufficiency. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877. 1088. A nurse is providing home care instructions to the client with a diagnosis of Cushing’s syndrome and prepares a list of instructions for the client. Which of the following is inappropriate to include on the list? 1. Take the medications exactly as prescribed 2. Read the labels on over-the-counter medications before purchase 3. Know the signs and symptoms of hypoadrenalism 4. Know the signs and symptoms of hyperadrenalism Answer: 2 Rationale: The client with Cushing’s syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the physician before purchasing any over-thecounter medications, and maintaining regular out-client follow-up care. The nurse should also instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism. Test-Taking Strategy: Use the process of elimination and general principles related to client teaching to direct you to option 2. Also note the key word inappropriate. This word indicates a false response question and that you need to select the incorrect instruction. Recall that the client should not take over-the-counter medications without first consulting with the physician. If you had difficulty with this question, review teaching points for the client with Cushing’s syndrome. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 472. 1089. A nurse is reviewing a plan of care for a client with Addison’s disease. The nurse notes a nursing diagnosis of Risk for Deficient Fluid Volume and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an inappropriate component of the plan of care? 1. Encourage a fluid intake of at least 3000 mL/day 2. Encourage an intake of low-sodium and low-protein foods 3. Monitor for changes in mentation

PN~Comp~Review~CD~1001-1101 -48 4. Monitor vital signs, skin turgor, and intake and output Answer: 2 Rationale: The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase the intake of sodium, protein, and complex carbohydrates. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Options 1, 3, and 4 are appropriate interventions for the client at risk for a deficient fluid volume. Test-Taking Strategy: Use the process of elimination, noting the key word inappropriate. These words indicate a false response question and that you need to select the incorrect component. Focusing on the issue—deficient fluid volume—will direct you to option 2. If you are unfamiliar with the nursing interventions related to the client at risk for deficient fluid volume, review these interventions. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 472. 1090. A nurse is reviewing the postoperative orders on a client who had a transsphenoidal hypophysectomy. Which of the following physician’s orders if noted on the record indicates the need for clarification? 1. Apply a loose dressing if any clear drainage is noted 2. Instruct the client about the need for a Medic-Alert bracelet 3. Monitor vital signs and neurological status 4. Instruct the client to avoid blowing the nose Answer: 1 Rationale: The nurse should observe for clear nasal drainage, constant swallowing, and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leakage into the sinuses. If clear drainage is noted following this procedure, the registered nurse needs to be notified who will then contact the physician. Options 2, 3, and 4 indicate appropriate postoperative interventions. Test-Taking Strategy: Note the key words need for clarification. Visualize the anatomical location of this surgical procedure. Recalling that clear drainage could indicate the presence of cerebrospinal fluid will direct you to option 1. If you are unfamiliar with the postoperative care following this procedure, review this content. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 861. 1091. A nurse reviews a plan of care for a postoperative client following thyroidectomy and notes a nursing diagnosis of Ineffective Breathing Pattern. Which of the following nursing interventions will the nurse suggest to include in the plan of care?

PN~Comp~Review~CD~1001-1101 -49 1. Maintain a supine position 2. Encourage deep breathing exercises and vigorous coughing exercises 3. Monitor neck circumference every 4 hours 4. Maintain a pressure dressing on the operative site Answer: 3 Rationale: Following thyroidectomy, the client should be placed in an upright position to facilitate air exchange. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. A pressure dressing is not placed on the operative site. The nurse should monitor the dressing closely and should loosen the dressing if necessary. Neck circumference is monitored every 4 hours to assess for postoperative edema. Test-Taking Strategy: Use the process of elimination and recall the potential for airway obstruction as a result of edema. Also, visualize the anatomical location of this operative procedure to assist in directing you to option 3. If you had difficulty with this question or are unfamiliar with the care to the client following thyroidectomy, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 463. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 885-886. 1092. A nurse is monitoring the client following thyroidectomy for signs of hypocalcemia. Which of the following signs if noted in the client most likely indicates the presence of hypocalcemia? 1. Tingling around the mouth 2. Flaccid paralysis 3. Negative Chvostek’s sign 4. Bradycardia Answer: 1 Rationale: Following thyroidectomy, the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and fingertips, muscle twitching or spasms, palpitations or dysrhythmias, and positive Chvostek’s and Trousseau’s signs. Options 2, 3, and 4 are not signs of hypocalcemia. Test-Taking Strategy: Use the process of elimination and focus on the issue— hypocalcemia. Recalling that tingling around the mouth and fingertips is an early sign of hypocalcemia will direct you to option 1. Review the signs of hypocalcemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 347.

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1093. A nurse is caring for a client following thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse if the hoarseness will subside. The nurse most appropriately tells the client that the hoarseness: 1. Indicates nerve damage 2. Is permanent 3. Will worsen before it subsides, which may take 6 months 4. Is normal during this time and will subside Answer: 4 Rationale: Hoarseness that develops or worsens in the postoperative period is usually the result of laryngeal pressure or edema and will resolve within a few days. The client should be reassured that the effects are transitory. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are similar. From the remaining options, focus on the key words most appropriately. Recalling that hoarseness that worsens is a cause for concern will eliminate option 3. If you had difficulty with this question or are unfamiliar with complications associated with thyroidectomy, review this content. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1205. 1094. A nurse is monitoring a client with Graves’ disease for signs of thyrotoxic crisis (thyroid storm). Which of the following signs and symptoms if noted in the client will alert the nurse to the presence of this crisis? 1. Low-grade fever and tachycardia 2. Fever and tachycardia 3. Restlessness and bradycardia 4. Agitation and bradycardia Answer: 2 Rationale: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur. Test-Taking Strategy: Use the process of elimination, focusing on the client’s diagnosis. Recalling that tachycardia is a sign of this complication will assist in eliminating options 3 and 4. Additionally, recalling that fever is associated with this condition will easily direct you to option 2. If you had difficulty with this question, review the signs and symptoms of thyrotoxicosis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

PN~Comp~Review~CD~1001-1101 -51 Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1200. 1095. A nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The instructor determines that the student understands the risk factors associated with this disorder if the student states that which of the following clients is at risk for thyrotoxicosis? 1. A client with hypothyroidism 2. A client with Graves’ disease who is having surgery 3. A client with diabetes mellitus scheduled for debridement of a foot ulcer 4. A client with diabetes insipidus scheduled for a diagnostic test Answer: 2 Rationale: Thyrotoxicosis is usually seen in clients with Graves’ disease with the symptoms precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, childbirth, or major surgery. It also must be recognized as a potential complication following thyroidectomy. Test-Taking Strategy: Use the process of elimination to assist in answering this question. Note the relationship between the name of the disorder and conditions presented in options 1 and 2. Recalling that this disorder occurs in the client with thyroid disease will assist in eliminating options 3 and 4. Knowing that this disorder is a state of extreme overactivity of the thyroid gland will direct you to option 2. If you had difficulty with this question, review the risk factors associated with thyrotoxicosis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1200. 1096. A nurse is caring for a client with a diagnosis of hyperparathyroidism who is taking furosemide (Lasix). The nurse provides dietary instructions to the client. Which of the following is an inappropriate instruction? 1. Increase dietary items that are high in calcium 2. Drink at least 2 to 3 L of fluid daily 3. Eat small, frequent meals and snacks if nauseated 4. Eat foods high in potassium Answer: 1 Rationale: The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption. Dietary restriction of calcium may be used as a component of therapy. The client should eat foods high in potassium especially if the client is taking furosemide. Options 2 and 3 are appropriate instructions for the client. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis. Note the key word inappropriate. This word indicates a false response question and that you need to select the incorrect instruction. Recall that in this disorder the client should

PN~Comp~Review~CD~1001-1101 -52 be instructed to follow a low-calcium diet and limit milk products. If you had difficulty with this question, review dietary measures for the client with hyperparathyroidism. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 469. 1097. A nurse has provided instructions to the client with hyperparathyroidism regarding home care measures to manage the symptoms of the disease. Which statement by the client indicates a need for further instructions? 1. “I need to space activity throughout the day.” 2. “I need to avoid exercising.” 3. “I should gauge my activity level by my energy level.” 4. “I should avoid bed rest.” Answer: 2 Rationale: The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to avoid bed rest and to use energy level as a guide to activity. The client should also be instructed to avoid high-impact activity or contact sports. Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Use the process of elimination and general principles related to home care measures to assist in directing you to option 2. If you had difficulty with this question or are unfamiliar with the home care measures for the client with hyperparathyroidism, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 469. 1098. A nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which of the following items in the diet? 1. Vegetables 2. Meat and poultry 3. Fish 4. Cereals Answer: 1 Rationale: The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals. Vegetables are allowed in the diet.

PN~Comp~Review~CD~1001-1101 -53 Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis. Recalling that the client should restrict the amount of phosphorus in the diet and knowledge of the food items that should be limited will direct you to option 1. If you had difficulty with this question and are unfamiliar with the diet specific to the client with hypoparathyroidism or the food items low in phosphorus, review this content. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 1099. A nurse has provided home care measures to the client with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction? 1. “I should perform my exercise at peak insulin time.” 2. “I should always carry a quick-acting carbohydrate when I exercise.” 3. “I should always wear a Medic-Alert bracelet.” 4. “I should avoid exercising at times when a hypoglycemic reaction is likely to occur.” Answer: 1 Rationale: The client should be instructed to avoid exercise at peak insulin time because it is at this time that a hypoglycemic reaction is likely to occur. If exercise is performed at this time, the client should be instructed to eat an hour before the exercise and drink a carbohydrate liquid. Options 2, 3, and 4 are correct statements regarding exercise, insulin, and diabetic control. Test-Taking Strategy: Note the key words need for further instruction in the stem of the question. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that a hypoglycemic reaction is likely to occur at peak insulin times will direct you to option 1. If you had difficulty with this question, review home care instructions for the client with diabetes mellitus. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 908. 1100. A nurse is caring for a client newly diagnosed with diabetes mellitus. The client tells the nurse that he is planning to eat a dinner meal at a local restaurant this week. The client asks the nurse if eating at a restaurant will affect the diabetic control and if this is allowed. Which nursing response is appropriate? 1. “You are not allowed to eat in restaurants.” 2. “If you plan to eat in a restaurant you need to skip the lunchtime meal.” 3. “You should order a half-portion meal and have fresh fruit for dessert.” 4. “You should increase your daily dose of insulin by half on the day that you plan to eat in the restaurant.”

PN~Comp~Review~CD~1001-1101 -54 Answer: 3 Rationale: Clients with diabetes mellitus are instructed to make adjustments in their total daily intake to plan for meals at restaurants or parties. Some useful strategies include ordering half portions, salads with dressing on the side, fresh fruit for dessert, and baked or steamed entrées. Clients are not instructed to skip meals or to increase their prescribed insulin dosage. Test-Taking Strategy: Use the process of elimination and eliminate option 1 first because of the absolute word “not.” Options 2 and 4 can be eliminated next, knowing that it is not appropriate to instruct a client with diabetes mellitus to skip a meal or to adjust the prescribed insulin dosage. If you had difficulty with this question, review home care measures for the client with diabetes mellitus. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1265.

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