1.

Which of the following needs is considered by nurse Barbara when she implements reverse isolation for the male client with leukemia?

o
2.

Safety and security-The client with leukemia has low resistance to infection. Protecting him from infection by implementing reverse or protective isolation technique meets his need for safety and security.

Nurse Bernard is aware that the following are characteristics of basic human needs except?

o
3.

Priorities are uniform to all individuals-Priorities may vary from individual to individual, according to stage of growth and development, life situations and other factors.

The nursing diagnosis “Body Image Disturbance” is most likely to be written for which of the following persons

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4.

A person entering the health care system after moving from wellness to illness.-A person entering a health care system most likely would experience alteration in body image.

The nurse is aware that the primary respiratory center is:

o
5.

Medulla oblongata-The primary respiratory center is the medulla oblongata. It contains the central chemoreceptors that are stimulated by high levels of carbon dioxide in the blood.

The process involved in the exchange of gases in the lungs is:

o

Diffusion-Diffusion is the exchange of gases from an area of higher pressure to an area of lower pressure.

6. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

o

Risk for injury related to thrombocytopenia -Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

7. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

o

"Have you had a respiratory infection in the last 6 months?" -Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

8. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:

o

On the right side of the heart-Pulmonic stenosis increases resistance to blood flow, causing right ventricular hyperthropy; with right ventricular failure there is an increase in pressure on the right side of the heart.

9. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to:


10.

Allow the denial but be available to discuss death-This does not remove client’s only way of coping, and it permits future movement through the grieving process when the client is ready.

A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because:

Vitamin K is not absorbed-Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile enters the duodenum via the common bile duct.

11. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be:

“I feel washed out; there isn’t much left”-The client’s statement infers an emptiness with an associated loss.

12. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to:

Provide frequent saline mouthwashes-This is soothing to the oral mucosa and helps prevent infection

1. Which of the following needs is considered by nurse Barbara when she implements reverse isolation for the male client with leukemia? o Physiologic need Safety and security Love and belongings Self esteem

o
o o 2.

Nurse Bernard is aware that the following are characteristics of basic human needs except? o o o o Priorities are uniform to all individuals. Needs may be met in different ways Needs are interrelated Needs may be deferred.

3.

The nursing diagnosis “Body Image Disturbance” is most likely to be written for which of the following persons? o o o A patient with above the knee amputation. A patient with second degree burns. A quadriplegic patient. A person entering the health care system after moving from wellness to illness.

o
4.

The nurse is aware that the primary respiratory center is:

o
o o o 5.

Medulla oblongata Pops Carotid and aortic bodies Proprioceptors

The process involved in the exchange of gases in the lungs is: o o o o Diffusion Osmosis Hydrostatic pressure Oncotic pressure

6. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? o o o o Oral mucous membrane, altered related to chemotherapy Risk for injury related to thrombocytopenia Fatigue related to the disease process Interrupted family processes related to life-threatening illness of a family member

7. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? o o o o "Have you "Have you "Have you "Have you noticed a change in sleeping habits recently?" had a respiratory infection in the last 6 months?" lost weight recently?" noticed changes in your alertness?"

8. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure: o o o o In the pulmonary vein In the pulmonary artery On the left side of the heart On the right side of the heart

9. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to: o o o o Agree and encourage the client’s denial Allow the denial but be available to discuss death Reassure the client that everything will be OK the client alone to confront the feelings of impending loss

10. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because: o o o o Vitamin K is not absorbed The ionized calcium levels falls The extrinsic factor is not absorbed Bilirubin accumulates in the plasma

11. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be: o o o o “I can’t wait to see all my friends again” “I feel washed out; there isn’t much left” “I can’t wait to get home to see my grandchild” “My husband plans for me to recuperate at our daughter’s home”

12. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to: o o o o Provide frequent saline mouthwashes Use karaya powder to decrease irritation Increase fluid intake to compensate for the diarrhea Provide meticulous skin care of the abdomen with Betadine

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