Q&A Random Selection #17 Rationale

1 B: Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into
professional prescriptions and interventions. The challenge for the health care provider is to understand the client''s
perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling
professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care
values to that they can maintain their well-being, recover from illness or face handicaps and/or death."

2 D: Candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a soft cloth
are unsuccessful.

3 B: mental disorder. Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical
dependence.

4 A: Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the
health care provider''s direction. During this time, alcohol must be avoided.

5 D: The nurse’s understanding of the client rests on the comprehensiveness of assessment data obtained by
listening to the client’s self revelation.

6 D: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein)
levels, excess free (unbound) drug can cause exaggerated and dangerous effects.

7 A: The manifestations of Addison''s disease due to mineralocorticoid deficiency, resulting from renal sodium
wasting and potassium retention, include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.

8 B: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on
bed rest and the provider notified immediately.

9 B: Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the
medicine toward the side or the back of the mouth, gagging will be reduced.

10 A: In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency.
No change in feedings is indicated.

11 B: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the
right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before
implementing change. To smooth acceptance of the change, restraining factors need to be evaluated. The manager
wants to build the staff''s skills at implementing change. Helping the committee evaluate its decision-making is a
useful step before rejecting or implementing the change. When possible all affected by the change should be involved
in the planning. The question is whether staff input has been thoroughly taken into consideration.

12 A: Acceptance of the pregnancy. During the first trimester the maternal focus is directed toward acceptance of the
pregnancy and adjustment to the minor discomforts.

13 B: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the
drug, which can occur with continuous patch use.

14 D: Color. Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal
adaptation in the newborn.

15 B: SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may
occur with this combination of drugs.

16 B: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one
area.

17 A: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing
and turning the child should be done carefully. The other options are similar but not the most specific.

18 A: Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug

formulations are designed to release the drug over an extended period of time. If crushed, as would be required for
gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The
provider must substitute another medication.

19 A: The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye
contact, gestures, and body language toward the client and family are important factors to enhance rapport and
understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.
20 A: The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an
incident that a co-worker can resolve without referral to a manager.

21 C: Open ended questions encourage further discussion and conversation, thereby eliciting further information.

22 D: Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3
months and can be used to monitor client adherence to the therapeutic regimen.

23 C: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary
embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.

24 A: Separation anxiety. While a toddler will experience all of the stresses, separation from parents is the major
stressor.

25 A: "Cupping" is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting
alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the
painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness
of the illness. There is typically no need to ask an adult’s family members.

26 A: Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is
surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction
ropes and pulleys are applied.

27 C: Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and
believing are the only right, proper, and natural ways, can be a major barrier to providing culturally conscious care.
Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one''s own are strange, bizarre, or
unenlightened, and therefore wrong. Ethnocentrism refers to the unconscious tendency to look at others through the
lens of one''s own cultural norms and customs and to take for granted that one''s own values are the only objective
reality. At a more complex level, the ethnocentrist regards others as inferior or immoral and believes his or her own
ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of his or her own value
judgments.

28 D: A major manifestation of rheumatic fever that reflects central nervous system involvement is chorea. Early
symptoms of chorea include behavior changes and clumsiness. Chorea is characterized by sudden, aimless, irregular
movements of the extremities, involuntary facial grimaces, speech disturbances, emotional lability, and muscle
weakness. Chorea is transitory and all manifestations eventually disappear.

29 C: Children with AGN who have edema, hypertension oliguria and azotemia may have dietary restrictions limiting
sodium, fluids, protein and potassium. Giving the child a short explanation and offering to talk about an alternative is
appropriate for this age.

30 D: The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance
and related issues are not affected at this time.

31 B: Networking, mentoring, and coalition building are positive uses of personal power to meet goals.

32 A: A decision grid allows the group to visually examine alternatives and evaluate them quantitatively with
weighting.

33 D: Ischemic pain is relieved by placing feet in a dependent position. This position improves peripheral perfusion.

34 C: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve
respiratory muscle coordination.

35 A: With psychological dependence, it is the client’s thoughts and attitude toward alcohol that produce craving and
compulsive use.

36 A: Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.

37 C: Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference
for the amount of drainage.

38 D: Pre-anesthesia work-up. ECT is delivered under general anesthesia and the client should be prepared as for
any procedure involving anesthesia.