NURSING PRACTICE — Care of
Clients with Physiologic and
Psychosocial Alterations, Part C
Below is the complete Section 5 (Questions 1–100)
in correct exam format, with the question,answer
and a rationale for each.
1. You are teaching a patient about taking prophylactic
warfarin sodium (Coumadin). Which of these statement
indicate that the patient understands how to take the drug.
SELECT all that apply:
1.
The drug's action peak in two hours
2.
3.
Maximum dosage is not achieved until 3 to 4 days after starting the
medication
4.
5.
Effects of the drug continue 4 to 5 days after discontinuing the
medication
6.
7.
Protamine Sulfate is the antidote for Warfarin
8.
9.
I should have my blood levels tested periodically
10.
A.2,4,5
B.2,3,5
C.1,4,5
D.1,3,4
Answer: B.2,3,5
1
,Rationale: Warfarin's maximum effect is not achieved until 3 to 4
days after starting (2), its effects continue 4 to 5 days after
discontinuing (3), and patients should have periodic blood tests to
monitor INR/PT (5). Protamine sulfate is the antidote for heparin, not
warfarin (4 is incorrect). Warfarin does not peak in 2 hours (1 is
incorrect).
2. Maintaining oral hygiene for a stroke patient is important
in his care. You are teaching a family member how to give
oral care to the stroke patient. Which of the following
nursing measure is NOT APPROPRIATE when giving oral care
to such patient?
A. Cleaning the patient's mouth and teeth with a soft-bristled
toothbrush
B. Keeping portable suctioning equipment at the bedside
C. Opening the patient's mouth with a padded tongue depressor
D. Placing the patient on his back with a small pillow under the head
Answer: D. Placing the patient on his back with a small
pillow under the head
Rationale: A stroke patient should be positioned on the side
(lateral position) with the head slightly forward to allow secretions to
drain and prevent aspiration during oral care. Placing the patient flat
on the back increases the risk of aspiration.
3. Your patient has paraplegia. In giving instruction to the
watcher when changing the patient's position in bed, which
of the following is NOT APPROPRIATE?
A. Lifting the patient when moving him up in bed
B. Rolling the patient unto the side
C. Using a trapeze to help the patient lift off the bed
D. Sliding the patient to move up in bed
Answer: A. Lifting the patient when moving him up in bed
Rationale: Lifting a patient can cause injury to both the patient and
the caregiver. The appropriate technique is to slide or use a draw
sheet to move the patient up in bed, not lift.
4. A patient is experiencing mood swings after stroke. Often
times she has episodes of crying that are distressed to the
2
, family members. What is the BEST TECHNIQUE that you will
advise the family members when the patient is having
crying spells?
A. Ignore the patient during this time
B. Sit quietly with the patient until the crying episode is over
C. Tell the patient that the behavior is unacceptable
D. Attempt to divert the patient's attention
Answer: D. Attempt to divert the patient's attention
Rationale: Diverting the patient's attention during crying spells is
an effective technique for managing emotional lability after stroke.
It helps the patient refocus on other activities and reduces the
duration of the episode.
5. To prevent joint deformities of the arm and hands of a
hemiplegic patient, what are the APPROPRIATE positions will
you include in your health teachings of the family member?
SELECT all that apply.
1.
Hand in slight supination
2.
3.
Hand in slight pronation
4.
5.
Fingers slightly flexed
6.
7.
Fingers extended
8.
9.
Arm supported with pillow
10.
A.2,3,4
B.1,3,5
C.1,2,4
D.2,4,5
3
, Answer: B.1,3,5
Rationale: To prevent joint deformities in a hemiplegic patient, the
hand should be in slight supination (1), fingers slightly flexed (3),
and the arm supported with a pillow (5). This positioning prevents
contractures and maintains functional alignment.
Situation - You are a community health nurse assisting a
family in the care of their daughter suffering from the post
traumatic stress disorder
6. While caring for this client, the family notices that loud
noises cause a serious anxiety response. Which of the
following explanations by you would help the family
understand the client's response?
A. After a trauma, the client cannot respond to stimuli in an
appropriate manner
B. Clients often experience extreme fear about normal
environmental stimuli
C. Environmental triggers can cause the client to react emotionally
D. The response indicates that another emotion problem needs
investigation
Answer: C. Environmental triggers can cause the client to
react emotionally
Rationale: In PTSD, environmental triggers (such as loud noises)
can cause emotional reactions because they are associated with the
traumatic event. This explanation helps the family understand the
client's response.
7. Which of the following instructions should you include
about relationships for this client with post-traumatic stress
disorder?
A. Assess the client's discomfort when talking about feelings to
family member.
B. Explain that avoiding emotional attachment protects against
anxiety.
C. Warn the client that she will have a tendency to be over
dependent in relationships
D. Encourage the client to resume former roles as soon as possible
Answer: D. Encourage the client to resume former roles as
soon as possible
4
Clients with Physiologic and
Psychosocial Alterations, Part C
Below is the complete Section 5 (Questions 1–100)
in correct exam format, with the question,answer
and a rationale for each.
1. You are teaching a patient about taking prophylactic
warfarin sodium (Coumadin). Which of these statement
indicate that the patient understands how to take the drug.
SELECT all that apply:
1.
The drug's action peak in two hours
2.
3.
Maximum dosage is not achieved until 3 to 4 days after starting the
medication
4.
5.
Effects of the drug continue 4 to 5 days after discontinuing the
medication
6.
7.
Protamine Sulfate is the antidote for Warfarin
8.
9.
I should have my blood levels tested periodically
10.
A.2,4,5
B.2,3,5
C.1,4,5
D.1,3,4
Answer: B.2,3,5
1
,Rationale: Warfarin's maximum effect is not achieved until 3 to 4
days after starting (2), its effects continue 4 to 5 days after
discontinuing (3), and patients should have periodic blood tests to
monitor INR/PT (5). Protamine sulfate is the antidote for heparin, not
warfarin (4 is incorrect). Warfarin does not peak in 2 hours (1 is
incorrect).
2. Maintaining oral hygiene for a stroke patient is important
in his care. You are teaching a family member how to give
oral care to the stroke patient. Which of the following
nursing measure is NOT APPROPRIATE when giving oral care
to such patient?
A. Cleaning the patient's mouth and teeth with a soft-bristled
toothbrush
B. Keeping portable suctioning equipment at the bedside
C. Opening the patient's mouth with a padded tongue depressor
D. Placing the patient on his back with a small pillow under the head
Answer: D. Placing the patient on his back with a small
pillow under the head
Rationale: A stroke patient should be positioned on the side
(lateral position) with the head slightly forward to allow secretions to
drain and prevent aspiration during oral care. Placing the patient flat
on the back increases the risk of aspiration.
3. Your patient has paraplegia. In giving instruction to the
watcher when changing the patient's position in bed, which
of the following is NOT APPROPRIATE?
A. Lifting the patient when moving him up in bed
B. Rolling the patient unto the side
C. Using a trapeze to help the patient lift off the bed
D. Sliding the patient to move up in bed
Answer: A. Lifting the patient when moving him up in bed
Rationale: Lifting a patient can cause injury to both the patient and
the caregiver. The appropriate technique is to slide or use a draw
sheet to move the patient up in bed, not lift.
4. A patient is experiencing mood swings after stroke. Often
times she has episodes of crying that are distressed to the
2
, family members. What is the BEST TECHNIQUE that you will
advise the family members when the patient is having
crying spells?
A. Ignore the patient during this time
B. Sit quietly with the patient until the crying episode is over
C. Tell the patient that the behavior is unacceptable
D. Attempt to divert the patient's attention
Answer: D. Attempt to divert the patient's attention
Rationale: Diverting the patient's attention during crying spells is
an effective technique for managing emotional lability after stroke.
It helps the patient refocus on other activities and reduces the
duration of the episode.
5. To prevent joint deformities of the arm and hands of a
hemiplegic patient, what are the APPROPRIATE positions will
you include in your health teachings of the family member?
SELECT all that apply.
1.
Hand in slight supination
2.
3.
Hand in slight pronation
4.
5.
Fingers slightly flexed
6.
7.
Fingers extended
8.
9.
Arm supported with pillow
10.
A.2,3,4
B.1,3,5
C.1,2,4
D.2,4,5
3
, Answer: B.1,3,5
Rationale: To prevent joint deformities in a hemiplegic patient, the
hand should be in slight supination (1), fingers slightly flexed (3),
and the arm supported with a pillow (5). This positioning prevents
contractures and maintains functional alignment.
Situation - You are a community health nurse assisting a
family in the care of their daughter suffering from the post
traumatic stress disorder
6. While caring for this client, the family notices that loud
noises cause a serious anxiety response. Which of the
following explanations by you would help the family
understand the client's response?
A. After a trauma, the client cannot respond to stimuli in an
appropriate manner
B. Clients often experience extreme fear about normal
environmental stimuli
C. Environmental triggers can cause the client to react emotionally
D. The response indicates that another emotion problem needs
investigation
Answer: C. Environmental triggers can cause the client to
react emotionally
Rationale: In PTSD, environmental triggers (such as loud noises)
can cause emotional reactions because they are associated with the
traumatic event. This explanation helps the family understand the
client's response.
7. Which of the following instructions should you include
about relationships for this client with post-traumatic stress
disorder?
A. Assess the client's discomfort when talking about feelings to
family member.
B. Explain that avoiding emotional attachment protects against
anxiety.
C. Warn the client that she will have a tendency to be over
dependent in relationships
D. Encourage the client to resume former roles as soon as possible
Answer: D. Encourage the client to resume former roles as
soon as possible
4
