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NEW QUESTION # 18
Periwound maceration occurs when __________.
- A. The skin around the wound softens and is damaged.
- B. Selecting a dressing individualized to the type of wound.
- C. The skin around the wound dries out and hardens.
- D. Negative-pressure to "air out" the wound is used.
Answer: A
Explanation:
Section: Health Promotion and Maintenance
Explanation:
Periwound maceration, also classified as moisture associated skin damage, is the softening of the skin and damaging of connective fibers which leads to the wound drying out and hardening.
Dressing selection can help prevent this complication, and negative pressure may reduce it by reducing edema.
NEW QUESTION # 19
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. "How did you get those bruises?"
- B. "Did someone grab you by your arms?"
- C. "Do you fall often?"
- D. "What did you bump against?"
Answer: B
Explanation:
Explanation/Reference:
Explanation:
Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal. Psychosocial Integrity
NEW QUESTION # 20
You have been assigned to care for a neonate who has been diagnosed with the Tetralogy of Fallot. The mother asks you what the Tetralogy of Fallot is.
How should you respond to this mother?
- A. "The Tetralogy of Fallot is a congenital gastrointestinal disorder"
- B. "The Tetralogy of Fallot will affect the baby's reflexes"
- C. "The Tetralogy of Fallot is a congenital cardiac disorder"
- D. "The Tetralogy of Fallot will affect the baby's ability to breastfeed"
Answer: C
Explanation:
Section: Health Promotion and Maintenance
Explanation:
The Tetralogy of Fallot is a congenital cardiac disorder that is classified as a cyanotic, rather than acyanotic, congenital heart disorder that is characterized with abnormal cardiac anomalies.
There is no relationship between the Tetralogy of Fallot and reflexes or breastfeeding.
NEW QUESTION # 21
The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance.
The nurse's next action should be to__________.
- A. do nothing; the client has the right to refuse treatment
- B. educate the client about available services
- C. report the incident to the police
- D. arrange an appointment with the client's next of kin
Answer: B
Explanation:
Section: Psychosocial Integrity
Explanation:
Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services.
Frequently elders are not aware of existing programs.
NEW QUESTION # 22
The client's lab culture report is negative for a suspected infection.
A test that can correctly identify those who do not have a given disease is __________.
- A. marginal finding
- B. specific
- C. negative culture
- D. sensitive
Answer: B
Explanation:
Section: Safe and Effective Care Environment
Explanation/Reference:
Explanation:
Testing that identifies clients without a disease is said to be specific, while testing that identifies clients with a disease is said to be sensitive.
NEW QUESTION # 23
The nurse is developing a care plan for a client with severe anxiety.
An appropriate outcome for the client is that within 4 days the client should __________.
- A. Have decreased anxiety
- B. Sit quietly for 30 minutes
- C. Develop an adaptive coping mechanism
- D. Talk to the nurse for 10 minutes
Answer: D
Explanation:
Section: Psychosocial Integrity
Explanation:
Outcome criteria need to be specific, measurable, and realistic.
Talking for 10 minutes meets all of these conditions.
It is not realistic to expect a severely anxious client to sit quietly for 30 minutes.
The other statements are vague and not measurable.
NEW QUESTION # 24
Which of the following conditions has a severe complication of respiratory failure?
- A. trigeminal neuralgia
- B. Guillain-Barre syndrome
- C. Bell's palsy
- D. tetanus
Answer: B
Explanation:
Section: Physiological Integrity
Explanation:
Guillain-Barre syndrome has a severe complication of respiratory failure.
The remaining choices are peripheral nerve conditions, like Guillain-Barre. However, they do not lead to such a severe complication.
NEW QUESTION # 25
An adult who had been abused as a child is discussing the group therapy program.
Which statement indicates that the client has gained insight?
- A. "The program has given me the courage to tell my mother how I felt about her role in my hurt."
- B. "I think I was a lonely child because I could not tell anyone about my abuse."
- C. "There are so many people just like me, who are just normal people that had bad things happen to them."
- D. "I am now aware of how deep-seated my anger is. Before I did not realize I was angry."
Answer: D
Explanation:
Section: Psychosocial Integrity
Explanation:
Children who are abused learn to cope with the painful experiences by ignoring painful feelings and avoiding getting close to people.
As adults, victims of abuse usually continue to repress feelings, avoid close interpersonal relationships, and frequently use alcohol or drugs to block painful memories.
Long-term effects in adults might include criminal/violent behavior (for adult males), substance abuse, and a variety of social and emotional problems (including suicidal thoughts, anxiety, hostility, dissociation, and interpersonal difficulties).
NEW QUESTION # 26
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. be comfortable with your sexual preference first.
- B. explain how your relationship with the child changes because of the discussion.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. disclose the information before the child knows or suspects.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion. Choices 1, 2, and 3 are all important aspects of the disclosure. As children grow, they might have additional questions. Preschool children might not understand the absence of a father or mother. Schoolage children might be troubled that their family isn't like their friends' families.
Adolescents might become reluctant to discuss it or accept it even though they expressed acceptance at an earlier age. In general the earlier children are informed, the easier it is for them to accept and assimilate the information. Nurses need to be nonjudgmental and learn how to express and accept these differences so that they can keep the nurse-child-family relationship intact. Health Promotion and Maintenance
NEW QUESTION # 27
The most effective nursing strategy to assist a client in recognizing and using personal strength includes:
- A. assisting the client in maintaining an external locus of control.
- B. listening to the client and providing advice as needed.
- C. promoting the client's active external thinking.
- D. encouraging the client's self-identification of strengths.
Answer: D
Explanation:
Encouraging the client to identify his own strengths is the most effective strategy.
Psychosocial Integrity
NEW QUESTION # 28
A nurse doing a home health visit consults with a male patient that has a diagnosis of CAD and COPD.
The patient is currently taking Ventolin, Azmacort, Aspirin, and Theophylline. The patient complains of upset stomach, nausea and feeling uncomfortable. The nurse should:
- A. Recommend the patient schedule a doctor's visit the next day.
- B. Recommend the patient position himself in right sidelying.
- C. Recommend a hold on the drug-Azmacort
- D. Contact the patient's physician immediately
Answer: D
Explanation:
Explanation/Reference:
Explanation:
Consult the physician immediately, due to the fact that theophylline toxicity may be occurring.
NEW QUESTION # 29
A client expresses anxiety about having magnetic resonance imaging performed.
Which of the following is an appropriate response by the nurse?
- A. "There is no discomfort with this test, so don't be anxious."
- B. "You can receive a sedative to help you relax during the test."
- C. "The test won't last long, so you can handle it."
- D. "There is absolutely nothing to worry about."
Answer: B
Explanation:
Section: Physiological Integrity
Explanation:
This statement reassures the client that there is a solution for relief of his anxiety.
The other responses minimize the client's feelings.
NEW QUESTION # 30
For which of the following conditions might blood be drawn for uric acid level?
- A. gout
- B. diverticulitis
- C. asthma
- D. meningitis
Answer: A
Explanation:
Section: Physiological Integrity
Explanation:
Uric acid levels are indicated for clients with gout.
NEW QUESTION # 31
An Asian family has an elderly member with latestage Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response to the family by the nurse?
- A. "What can I do to assist you to care for him at home?"
- B. "You really need to listen to what the physician says."
- C. "You will get too tired to take care of him at home."
- D. "You are too busy to be taking care of an elderly person."
Answer: A
Explanation:
This is the only culturally sensitive statement. Many Asian cultures have a high respect for elders, and members of these cultures might not consider placement in a long-term care facility. This is because they feel it is more respectful for them to care for the family member at home. The nurse might be able to assist the family by determining what community resources are available to assist them.Reduction of Risk Potential
NEW QUESTION # 32
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with over dosage?
- A. Memory loss and lack of appetite
- B. Tinnitus and spasticity
- C. Heightened reflexes
- D. Confusion and fatigue
Answer: D
Explanation:
Explanation/Reference:
Explanation:
Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.
NEW QUESTION # 33
Client room environments should include:
- A. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- B. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- C. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- D. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
Answer: C
Explanation:
Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.Basic Care and Comfort
NEW QUESTION # 34
The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
- A. hemoglobin A1c level
- B. serum lipid profile results
- C. fasting blood glucose level
- D. triceps skinfold measurement
Answer: D
Explanation:
Explanation/Reference:
Explanation:
Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition.
Physiological Adaptation
NEW QUESTION # 35
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
- A. medication administration: skin
- B. anxiety reduction
- C. grief work facilitation
- D. vital signs monitoring
Answer: C
Explanation:
Explanation/Reference:
Explanation:
Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution. Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns. Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns. Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns. Health Promotion and Maintenance
NEW QUESTION # 36
The intravenous route is potentially the most dangerous route of drug administration because __________.
- A. it is expensive and nursing intensive
- B. the client always has more side effects
- C. the IV might infiltrate
- D. rapid administration of a drug can lead to toxicity
Answer: D
Explanation:
Section: Physiological Integrity
Explanation:
The bioavailability of the injected medication is 100% and might lead to toxicity.
An IV infiltration can cause serious problems with tissue necrosis, but this is not life threatening.
Expensive and time consuming do not equate with dangerous.
Choice "the client always has more side effects" is not always true.
NEW QUESTION # 37
While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on knowledge that:
- A. people with psychiatric disorders are more prone to substance abuse.
- B. psychiatric illness is more prevalent in addicted populations.
- C. substance disorders are easily detected and diagnosed in acute-care psychiatric settings.
- D. undetected substance problems have no real effect on treatment of psychiatric disorders.
Answer: A
Explanation:
The failure to address substance abuse among clients with psychiatric disorders interferes with treatment effectiveness and contributes to relapse. Misdiagnosis of a psychiatric disorder, suboptimal pharmacological treatment, neglect of appropriate interventions, or an inappropriate referral might also occur.PsychosocialIntegrity
NEW QUESTION # 38
You are preparing a sterile field for an operating room surgical procedure.
When should you stop the preparation of this sterile field?
- A. When you turn your upper body only away from the field because the surgeon calls your name.
- B. When you have placed a sterile item only 1 inch and not 2 inches from the edge of the sterile field.
- C. When you have accidentally poured a sterile liquid into a container that was on the sterile field.
- D. When you have completely finished the field. You cannot stop the set up until it is all done.
Answer: A
Explanation:
Section: Safe and Effective Care Environment
Explanation:
You must stop the preparation of the sterile field and begin all over again when you have turned your upper body away from the field because sterile technique has been violated and the sterility of the field has been broken even when on turns away from the sterile field even for a second.
Sterile items must be placed within one inch, not two inches from the edge of the sterile field.
Lastly, sterile solutions can be poured into sterile containers on the sterile field without breaking the techniques required according to surgical asepsis.
NEW QUESTION # 39
Which of these is not a stage of group therapy development?
- A. discovery stage
- B. termination stage
- C. working stage
- D. initial stage
Answer: A
Explanation:
Section: Psychosocial Integrity
NEW QUESTION # 40
After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately?
- A. weight gain
- B. uterine bleeding
- C. fluid retention
- D. breast tenderness
Answer: B
Explanation:
Section: Health Promotion and Maintenance
Explanation:
Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately.
Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy.
They should be noted in the record and reported to the physician, but they are not urgent.
NEW QUESTION # 41
How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 4 feet
- B. 2 feet
- C. 6 feet
- D. 1 foot
Answer: C
Explanation:
Section: Safe and Effective Care Environment
Explanation:
The nurse should stand about 6 feet from the source of the fire.
Getting closer might put the nurse in danger.
NEW QUESTION # 42
The ethical principle of keeping professional promises or obligations is:
- A. fidelity.
- B. beneficence.
- C. veracity.
- D. autonomy.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
The ethical principle of veracity is truth-telling. Autonomy is client self-determination (that is, clients making their own decisions). Beneficence is the principle of doing good, which is a foundation of nursing care.
Coordinated Care
NEW QUESTION # 43
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