Q&A Random Selection #13 Rationale

1 C: cardiac output altered: decreased. All nursing interventions should be focused on improving cardiac output.
Increasing cardiac output is the primary goal of therapy. Comfort will improve as the client improves and the
respiratory status will improve as cardiac output increases.

2 C: Reddened tissue. As the wound granulates, redness indicates healing.

3 D: Ventricular septal defect. While assessments for conduction disturbance should be included following repair of
any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and
left ventricles. The atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart. It
extends from the atrioventricular node along each side of the interventricular septum and then divides into right and
left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn
over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of
interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances.

4 A: This response identifies instruction and verbal expectation with adaptive behavior.

5 B: "Are you thinking about killing yourself?" Sudden mood elevation and energy may signal increased risk of
suicide. The nurse must validate suicidal ideation as a beginning step in evaluating seriousness of risk.

6 C: conducting any health assessment. A mental status assessment is a critical part of baseline information, and
should be a part of every examination.

7 D: Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable

explanations for unacceptable actions. Both the teller and the listener find the rationalizations more satisfactory than
the reality.

8 D: Continue to monitor respirations. 12 respirations per minute is tolerated post-operatively. A range from 8 to 10
gives cause for concern. At that point pulse oximetry is taken to determine whether that rate is providing sufficient
oxygenation. Vigorous stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask the
registered nurse (RN) to check the findings.

9 D: Come in for evaluation of serum lithium levels regularly. This is especially important during hot weather, which
may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration.
Diuretics should be avoided, as they could result in an increased serum lithium level. Excessive thirst is a common
early finding that subsides over time but may recur. Initiation of treatment for elevated mood at times results in onset
of a depressive episode that can be accompanied by risk for self-harm. Clients should be cautioned to report any
symptoms of mood instability.

10 B: crashing. Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling referred to
as crashing.

11 B: Allow an opportunity for the teen to express feelings. Adolescents need to express their feelings. Generally,
they talk freely when given an opportunity and some privacy to do so.

12 C: decreased cardiac output. Cardiac output and urinary output are directly correlated. The nurse should suspect
a drop in cardiac output if the urinary output drops.

13 B: place the client on their side. This position keeps the airway patent and prevents aspiration.

14 D: consistent limit-setting enforced 24 hours per day. Treatment approaches that include restructuring the
personality, assisting the person with advancing developmental level and setting limits for maladaptive behavior such
as acting out.

15 D: This response gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of
sobriety. Dependency issues are significant for the client, fostering ambivalence.

16 B: there is typically a series of minor, vague complaints. Signs of abuse may not be clearly manifested and include
a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness. These may be
covert indications of abuse that go undetected. Victim complaints may be vague reflecting their ambivalence about
disclosing the abuse.

17 A: check for subcutaneous emphysema in the upper torso. Continuous bubbling in the water seal chamber is an
abnormal finding 2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule
out an air leak in the system. Thus the conclusion is that the problem is one of an air leak in the lung. This client may
need to be returned to surgery to deal with the sustained air leak. Action by the provider is required to prevent further
complications.

18 C: 2 weeks. Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling
mania. Lithium takes approximately 2 weeks to effect change in a client’s symptoms.

19 A: S3 heart sound. Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because
during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of
fluid left in the ventricles.

20 D: Falls forward when sitting. Sitting without support is expected at this age.

21 A: pulmonary circulation. Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left
ventricle and the lack of a competent valve to prevent back-flow into the pulmonary vein.

22 D: "Have you thought about how you would do it?" This response provides an opening to discuss intent and
means of committing suicide. It helps in assessing the severity of the risk, since clients who have formulated a suicide
plan are closer to suicidal behavior than those who have had vague, non-specific thoughts.

23 D: surgery will be performed in stages. Hypospadias, a condition in which the urethral opening is located on the
ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery.

24 A: Give the medication as ordered. Amoxicillin continues to be the drug of choice in the treatment of acute otitis
media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 = 200 mg per
dose. The prescribed dose is correct and should be given as ordered.

25 B: Expressing shame. Erikson describes the stage of the preschool child as being the time when there is normally
an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage.

26 B: There is a relationship between smoking and low birth weight. Nicotine reduces placental blood flow, and may
contribute to fetal hypoxia or placenta previa, decreasing the growth potential of the fetus.

27 A: learning relaxation techniques. The only factor that can enhance the client''s response to pain medication for
angina is reducing anxiety through relaxation methods. Anxiety can be great enough to make the pain medication
totally ineffective.

28 C: ask for a log of urinary output. The nurse must monitor the urine output as a priority because it is the best
indictor of renal function. The other options would be appropriate after an evaluation of the urine output.

29 C: Autocratic or authoritarian. Autocratic leadership style is suggested in this situation. It is appropriate for groups
with little education and experience who need strong direction, while a participative or democratic style is usually
more successful on nursing units

30 A: Steroids. Adverse medication effects can cause a syndrome that may or may not remit when the medication is
discontinued. Examples of drugs that can lead to ongoing side effects include: phenothiazines, corticosteroids, and
reserpine.

31 D: SA node, AV node, Bundle of His, Purkinje fibers. This is the pathway of a normal electrical impulse through the
heart.

32 B: Assess for neonatal withdrawal syndrome. Neonatal withdrawal syndrome is a cluster of findings that signal the
withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for
other substances. Initial signs are central nervous system hyper irritability and gastro-intestinal symptoms. If
withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during
the period of withdrawal.

33 A: Have respiratory support equipment available. Persons receiving neuroleptic medication experiencing torticollis
and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.

34 B: The infant is very susceptible to infections. HIV infected children are susceptible to opportunistic infections due
to a compromised immune system.

35 B: Visitation is helpful for both. Contact with the ill child helps siblings understand the reasons for hospitalization
and maintains their relationships.

36 D: Explain that this rash is not contagious and does not require isolation. Fifth Disease is a viral illness with an
uncertain period of communicability (perhaps 1 week prior to and 1 week after onset). Isolation of the child with Fifth
Disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic
crises. The parents may need written confirmation of this from the provider.

37 D: Use of therapeutic communication skills such as silence and active listening encourages verbalization of
feelings.

38 C: establish that the client is unresponsive. The first step in CPR is to establish responsiveness. The second is to
call for help, and the third is to ensure an open airway.

39 C: palpate for a thrill over the fistula. To assess for patency in a fistula or graft, the nurse auscultates for a bruit
and palpates for a thrill. The other options are not related to evaluation of patency.

40 B: often take part in active sports. An age-appropriate treatment goal is to establish an age-appropriate safe
environment. Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However,
developmental characteristics of this age group such as impulsivity, inexperience and peer pressure, place
adolescents in unsafe environments.