Q&A Random Selection #14

1 C: Precautions with position changes. Because multiple myeloma is a condition in which neoplastic plasma cells
infiltrate the bone marrow resulting in osteoporosis, clients are at high risk for pathological fractures.

2 C: All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern.
Other information of interest is that cystic fibrosis is an autosomal recessive disease. For these parents there is a
25% chance that each pregnancy will result in a child with cystic fibrosis.

3 C: According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may
become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-
esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of elders as
ego integrity vs despair.

4 B: Large wooden puzzle. Appropriate toys for this child''s age include items such as push-pull toys, blocks,
pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.

5 C: Obesity. Many factors contribute to the high rate of obesity in school aged children. These include heredity,
sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.

6 C: provides antibodies. Breast milk is ideal for the preterm baby who needs additional protection against infection
through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.

7 C: Continue with the present formula. The recommended age for switching from formula to whole milk is 12 months.
Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.

8 A: Red reflex test. A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious
defects of the cornea, aqueous chamber, lens, and vitreous chamber.

9 C: Lung remodeling and permanent changes in lung function will result. While an asthma attack is an acute event
from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and
permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which
leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways,
leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway
obstruction. These long-term consequences should help reinforce the need for daily management of the disease
whether or not the client "feels better."

10 D: Note patterns of increased blood pressure. Evaluation for hypertension is a key assessment in the course of
the disease.

11 B: Yin, the negative force that represents darkness, cold, and emptiness. Chinese folk medicine proposes that
health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by
darkness, cold and emptiness.Excessive yin predisposes one to nervousness.

12 A: ask the client about the refusal of certain pain medications. Beliefs regarding pain are one of the oldest
culturally-related research areas in health care. Astute observations and careful assessments must be completed to
determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to
each person within a cultural explanatory framework.

13 C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation
and minimize confusion and anxiety.

14 C: Percussion (clapping) should be only done in the area of the rib cage.

15 D: occlusive moist dressing. This wound has granulation tissue present and must be protected. The use of a
moisture retentive dressing is the best choice because moisture supports wound healing.

16 A: Age of the child. During the preschool period children are using their rapidly growing vocabulary faster than
they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in
speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most
important in determining if any true dysfunction might be occurring.

17 A: Activity intolerance describes a condition in which the client''s physiological capacity for activities is
compromised.
18 B: Social isolation related to altered thought processes. Hostile alertness and absence of involvement with people
are findings supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of
medication suggest altered thinking processes.

19 A: Maintaining and preserving function. To maintain quality of life, the plan for care must emphasize preserving
function. Proper body positioning and posture, and active and passive range of motion exercises are important
interventions for maintaining function of affected joints.

20 C: "All the pants have become tight around the waist." Parents often recognize the increasing abdominal girth first.
This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.

21 C: Distended neck veins. In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood
cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.

22 C: Comforting and distraction, key approaches in validation therapy are the kindest and most effective for clients
who have advancing dementia. The distressed, disoriented client should be gently oriented to reduce fear and
increase the sense of safety and security, but reorientation often is ineffective when the client has moderate dementia
and/or is upset. Environmental changes provoke stress and fear, especially in clients suffering from Alzheimer’s
disease.

23 B: Medication compliance. Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms
of schizophrenia. Compliance with daily doses is a critical assessment finding.

24 A: Oral ingestion. The greatest risk for young children is from oral ingestion. While children under age 6 may come
in contact with other poisons or inhale toxic fumes, these are not common.

25 B: The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell
levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is
appropriate.

26 C: Sit without support. The age at which the normal child develops the ability to sit steadily without support is 8
months.

27 A: Stand on 1 foot. At this age, gross motor development allows a child to balance on 1 foot.

28 C: Psychomotor retardation or agitation. Somatic or physiologic symptoms of depression include: fatigue,

psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances,
disturbances in appetite, gastrointestinal complaints and impaired libido.

29 B: Place client on a pressure reducing support surface. This client is at greatest risk for skin breakdown because
of immobility and decreased sensation. The first action should be to choose and then place the client on the best
support surface to relieve pressure, shear and friction forces.

30 B: 20 month-old who has just learned to climb stairs. Toddlers are at most risk for poisoning because they are
increasingly mobile, need to explore and engage in autonomous behavior.

31 A: headed for relapse. It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for
clients to acknowledge that relapse is a possibility and to identify early signs of relapse.

32 B: When the client threatens self-harm and harm to others. Privacy and confidentiality of all client information is
protected with the exception of the client who threatens self harm or endangering the public. (Tarasoff decision,1974)

33 B: In both arms. Blood pressure should be taken in both arms due to the fact that one subclavian artery may be
stenosed, causing a false high in that arm.

34 B: Flexion of the hip and knees with passive flexion of the neck. This is known as a positive Brudzinski’s sign
(flexion of hip and knees with passive flexion of the neck). A positive Kernig’s sign, the inability to extend the knee to
more than 135 degrees without pain behind the knee while the hip is flexed, usually establishes the diagnosis of
meningitis.

35 D: Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the
abuser to become nonviolent.

36 D: bounding pulses in the arms. Coarctation of the aorta, a narrowing or constriction of the descending aorta,
causes increased blood flow to the upper extremities resulting in increased pressure and pulses.

37 C: This breathing pattern is normal. Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea
often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.
38 D: Ping-pong. This provides an outlet for physical energy and requires limited attention. The other options would
over-tax the client’s level of self-control.

39 B: Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to
safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.

40 C: remaining with client until oriented. The client awakens post-procedure 20-30 minutes after treatment and
appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self
care. The time frame will vary, but it will not take several hours.