The nurse is completing an admission interview for a client with Parkinson disease. Which question will
provide additional information about manifestations that the client is likely to experience?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Do you have frequent blackout spells?"
C."Have you ever been frozen in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?" - answer-C. Have you ever been
frozen in one spot, unable to move?"
Rationale:
Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing
motor activities. They may even experience being rooted to the spot and unable to move. Parkinson
disease does not typically cause option A, B, or D.
,The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube
insertion for hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot
buildup.
D. Assess for kinks or dependent loops in the tubing. - answer-D.Assess for kinks or dependent loops in
the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the drainage has
diminished. Option A is completed after assessing for any problems causing the decrease in drainage.
Option B is no longer considered standard protocol because the increase in pressure may be harmful to
the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or
dependent loops.
A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days'
duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The
client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to
which medication?
,A. Warfarin (Coumadin)
B. Ibuprofen (Motrin)
C. Nitroglycerin (Nitrostat)
D. Digoxin (Lanoxin) - answer-D. Digoxin
Rationale:
Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or
digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause
anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in
the symptoms described.
The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden
client with Huntington disease. Which care measure is most important for the nurse to supervise?
A. Oral care
B.Bathing
C. Foot care
D. Catheter care - answer-A. Oral care
Rationale:
The client with Huntington disease experiences problems with motor skills such as swallowing and is at
high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform
oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision
because they do not ordinarily pose life-threatening consequences.
A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the
clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement?
A. Advise the client to come to the clinic immediately for further assessment.
B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic.
C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription.
D. Encourage the client to keep taking the drug until seen by the health care provider. - answer-D.
Encourage the client to keep taking the drug until seen by the health care provider.
Rationale:
Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the
medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped
abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be
, very ndisruptive nto nthe nclient, nand nother nantihypertensive nmedications nmay nproduce nthe ndesired neffect
nwithout nthe nadverse neffect.
When nassigning nclients non na nmedical-surgical nfloor nto nan nRN nand na nPN, nit nis nbest nfor nthe ncharge nnurse
nto nassign nwhich nclient nto nthe nPN?
A. nA nyoung nadult nwith nbacterial nmeningitis nwith nrecent nseizures
B. nAn nolder nadult nclient nwith npneumonia nand nviral nmeningitis
C. nA nfemale nclient nin nisolation nwith nmeningococcal nmeningitis
D. nA nmale nclient n1 nday npostoperative nafter ndrainage nof na nbrain nabscess n- nanswer-B. nAn nolder nadult
nclient nwith npneumonia nand nviral nmeningitis
Rationale:
The nmost nstable nclient nis noption nB. nOptions nA, nC, nand nD nare nall nat nhigh nrisk nfor nincreased nintracranial
npressure nand nrequire nthe nexpertise nof nthe nRN nfor nassessment nand nmanagement nof ncare.
In nassessing na nclient ndiagnosed nwith nprimary naldosteronism, nthe nnurse nexpects nthe nlaboratory ntest
nresults nto nindicate na ndecreased nserum nlevel nof nwhich nsubstance?
A.Sodium
nB.Phosphate
nC.Potassium
D.Glucose n- nanswer-C. nPotassium
Rationale:
Clients nwith nprimary naldosteronism nexhibit na nprofound ndecline nin nserum nlevels nof npotassium;
nhypokalemia; nhypertension nis nthe nmost nprominent nand nuniversal nsign. nThe nserum nsodium nlevel nis
nnormal nor nelevated, ndepending non nthe namount nof nwater nresorbed nwith nthe nsodium. nOption nB nis
ninfluenced nby nparathyroid nhormone n(PTH). nOption nD nis nnot naffected nby nprimary naldosteronism.
A nclient non ntelemetry nhas na npattern nof nuncontrolled natrial nfibrillation nwith na nrapid nventricular nresponse.
nBased non nthis nfinding, nthe nnurse nanticipates nassisting nthe nphysician nwith nwhich ntreatment?
A.Administer nlidocaine, n75 nmg nintravenous npush.
nB.Perform nsynchronized ncardioversion.
C.Defibrillate nthe nclient nas nsoon nas npossible.
D.Administer natropine, n0.4 nmg nintravenous npush. n- nanswer-B.Perform nsynchronized ncardioversion.
provide additional information about manifestations that the client is likely to experience?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Do you have frequent blackout spells?"
C."Have you ever been frozen in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?" - answer-C. Have you ever been
frozen in one spot, unable to move?"
Rationale:
Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing
motor activities. They may even experience being rooted to the spot and unable to move. Parkinson
disease does not typically cause option A, B, or D.
,The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube
insertion for hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot
buildup.
D. Assess for kinks or dependent loops in the tubing. - answer-D.Assess for kinks or dependent loops in
the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the drainage has
diminished. Option A is completed after assessing for any problems causing the decrease in drainage.
Option B is no longer considered standard protocol because the increase in pressure may be harmful to
the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or
dependent loops.
A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days'
duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The
client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to
which medication?
,A. Warfarin (Coumadin)
B. Ibuprofen (Motrin)
C. Nitroglycerin (Nitrostat)
D. Digoxin (Lanoxin) - answer-D. Digoxin
Rationale:
Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or
digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause
anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in
the symptoms described.
The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden
client with Huntington disease. Which care measure is most important for the nurse to supervise?
A. Oral care
B.Bathing
C. Foot care
D. Catheter care - answer-A. Oral care
Rationale:
The client with Huntington disease experiences problems with motor skills such as swallowing and is at
high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform
oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision
because they do not ordinarily pose life-threatening consequences.
A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the
clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement?
A. Advise the client to come to the clinic immediately for further assessment.
B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic.
C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription.
D. Encourage the client to keep taking the drug until seen by the health care provider. - answer-D.
Encourage the client to keep taking the drug until seen by the health care provider.
Rationale:
Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the
medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped
abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be
, very ndisruptive nto nthe nclient, nand nother nantihypertensive nmedications nmay nproduce nthe ndesired neffect
nwithout nthe nadverse neffect.
When nassigning nclients non na nmedical-surgical nfloor nto nan nRN nand na nPN, nit nis nbest nfor nthe ncharge nnurse
nto nassign nwhich nclient nto nthe nPN?
A. nA nyoung nadult nwith nbacterial nmeningitis nwith nrecent nseizures
B. nAn nolder nadult nclient nwith npneumonia nand nviral nmeningitis
C. nA nfemale nclient nin nisolation nwith nmeningococcal nmeningitis
D. nA nmale nclient n1 nday npostoperative nafter ndrainage nof na nbrain nabscess n- nanswer-B. nAn nolder nadult
nclient nwith npneumonia nand nviral nmeningitis
Rationale:
The nmost nstable nclient nis noption nB. nOptions nA, nC, nand nD nare nall nat nhigh nrisk nfor nincreased nintracranial
npressure nand nrequire nthe nexpertise nof nthe nRN nfor nassessment nand nmanagement nof ncare.
In nassessing na nclient ndiagnosed nwith nprimary naldosteronism, nthe nnurse nexpects nthe nlaboratory ntest
nresults nto nindicate na ndecreased nserum nlevel nof nwhich nsubstance?
A.Sodium
nB.Phosphate
nC.Potassium
D.Glucose n- nanswer-C. nPotassium
Rationale:
Clients nwith nprimary naldosteronism nexhibit na nprofound ndecline nin nserum nlevels nof npotassium;
nhypokalemia; nhypertension nis nthe nmost nprominent nand nuniversal nsign. nThe nserum nsodium nlevel nis
nnormal nor nelevated, ndepending non nthe namount nof nwater nresorbed nwith nthe nsodium. nOption nB nis
ninfluenced nby nparathyroid nhormone n(PTH). nOption nD nis nnot naffected nby nprimary naldosteronism.
A nclient non ntelemetry nhas na npattern nof nuncontrolled natrial nfibrillation nwith na nrapid nventricular nresponse.
nBased non nthis nfinding, nthe nnurse nanticipates nassisting nthe nphysician nwith nwhich ntreatment?
A.Administer nlidocaine, n75 nmg nintravenous npush.
nB.Perform nsynchronized ncardioversion.
C.Defibrillate nthe nclient nas nsoon nas npossible.
D.Administer natropine, n0.4 nmg nintravenous npush. n- nanswer-B.Perform nsynchronized ncardioversion.
