NURS 230 Comprehensive Exam – Nursing Course Practice Questions and Exam Review Guide

1201. A nurse would look for which one of the following findings in the prenatal client as most indicative of placental abruption? 1. Severe nausea and vomiting 2. Painless bleeding 3. Tender to rigid abdomen 4. Normal blood pressure Answer: 3 Rationale: Signs of placental abruption include tender, rigid abdomen; pain, cramp-like to severe; dark red vaginal bleeding; and maternal shock and fetal distress. The other options are not findings in placental abruption. Test-Taking Strategy: To answer this question accurately, you must be familiar with the manifestations of this clinical problem. Remember, a sign of placental abruption includes a tender, rigid abdomen. Review the findings in placental abruption if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 217. 1202. A nurse planning care for a client with placental abruption would plan to: 1. Prepare the client for a cesarean birth 2. Administer frequent enemas until clear 3. Prepare the client for a stress test 4. Reposition the client to the left side Answer: 1 Rationale: Early diagnosis of placental abruption is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood work analysis, and either an immediate cesarean birth or vaginal delivery. The incorrect options are not helpful in managing this problem. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 3 first, because they are the least likely to be helpful in this situation. Choose correctly between the remaining options knowing that cesarean birth will deliver the baby quickly and minimize the risk of maternal and fetal death. Review the interventions for this complication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 218. 1203. A nurse overhears that a prenatal client is at risk for placental abruption. The nurse would expect to find which risk factor documented in the client’s record? 1. Gestational diabetes 2. Hyperemesis gravidarum 3. Maternal hypertension 4. Oliguria Answer: 3 Rationale: It is possible that placental abruption can result from maternal hypertension that causes degenerative changes in the small arteries that supply intervillous spaces. This results in thrombosis, causing retroplacental hematoma, and leading to placental separation. Options 1, 2, and 4 are not specific risk factors for placental abruption. Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing, and circulation. Option 3 addresses circulatory status. Review the risk factors associated with placental abruption if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 217. 1204. A nurse is giving instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation? 1. Machine wash all washable clothing, towels, and bed linens and place in a warm dryer for at least 20 minutes 2. Shave the child’s hair if pediculocide and nit-removal combs are ineffective 3. Spray the furniture and beds with insecticide 4. Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned Answer: 4 Rationale: The adult louse can survive up to 48 hours away from a host, while nits can hatch in 7 to 10 days if they are shed into the environment. Thus, 2 weeks represents a safe interval of time that prevents reinfestation from occurring. Hot water and air are used in the washer and dryer. Shaving the hair is unnecessary with proper treatment and would have an adverse psychological effect on the client. Insecticides can endanger children and animals and should not be sprayed on furniture and beds. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating option 3, because insecticides can endanger children and animals. Eliminate option 2 next because shaving the head would risk psychological harm to the child and is unnecessary. Knowing that hot water and a hot dryer are recommended, not warm (option 1), will direct you to option 4. If heat could damage clothing or linen, the items can be sealed in a plastic bag for 2 to 3 weeks in a warm place. Review these teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1375. 1205. A generally healthy 63-year-old man is seen in the ambulatory care office for a routine examination. Which statement by the client would be most important for the nurse to follow-up on? 1. “Everyone in my immediate family has died from gastrointestinal cancer.” 2. “I try to avoid overly hot or spicy foods because they give me heartburn sometimes.” 3. “I have been following the balanced diet plan that the doctor gave me.” 4. “I check my stool yearly for occult blood.” Answer: 1 Rationale: The nurse should recognize and follow-up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him, and the nurse should gather further data to understand the client’s situation. Gathering data about the types of cancer, age, and sex of affected family members, and the presence of other risk factors provides the needed information to initiate preventive education. Options 2, 3, and 4 identify appropriate client statements. Test-Taking Strategy: Use the process of elimination and note the key words most important for the nurse to follow-up on. Note that only the correct option is an item suggesting the need for further data collection. Review data collection techniques and items requiring follow-up care if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 346. 1206. A client with a tentative diagnosis of gastroesophageal reflux is going to undergo ambulatory pH monitoring. The nurse should bring which of the following items to the bedside? 1. Intravenous line insertion kit 2. Enema bag 3. Nasogastric (NG) tube 4. Subcutaneous injection syringe Answer: 3 Rationale: Ambulatory pH monitoring requires insertion of a nasogastric tube. A probe attached to the nose will assist in monitoring the pH. The other items are unnecessary. Test-Taking Strategy: Use the process of elimination. Note that the NG tube is the only option that is directly correlated with the location of the problem. Review this test if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 686-687. Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 479. 1207. A client has just undergone gastroscopy. Which action would be taken by the nurse as the most essential postprocedure nursing intervention? 1. Assist the client to gargle with a local anesthetic 2. Keep the client in a prone position 3. Maintain bed rest for the client 4. Check the gag reflex prior to giving oral foods or fluids Answer: 4 Rationale: To prevent aspiration, the client may not eat or drink after this procedure until protective airway reflexes return. The nurse must document that the gag and swallow reflexes have returned. The client would receive a local anesthetic to the throat before the procedure, not after. Positioning restrictions are not necessary following the procedure. Test-Taking Strategy: Use the process of elimination and note the key words most essential. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review these postprocedure interventions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 590. 1208. A client who has been taking indomethacin (Indocin) for gout has an order for guaiac testing of the stool. The nurse explains to the client that this test is necessary because it will detect which of the following that may be caused or affected by this medication? 1. Steatorrhea 2. Occult blood 3. pH of stool 4. Color of stool Answer: 2 Rationale: Indomethacin is a nonsteroidal anti-inflammatory medication that can cause gastrointestinal irritation. The stool guaiac test is noninvasive and is widely used as a gross screening for blood in the gastrointestinal tract. It is not used for any of the other reasons listed. Test-Taking Strategy: Specific knowledge of this common test or the side effects of indomethacin would help you to identify the correct option. Remember, the stool guaiac test is used as a gross screening for blood in the gastrointestinal tract. Review the purpose of this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 830. 1209. A client who has undergone a barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions if the client states: 1. “I will call if I haven’t had a normal bowel movement in a week.” 2. “I need to take a laxative every night from now on.” 3. “I will continue on a low residue diet for several days and limit fluids.” 4. “I should take a laxative and my stool should return to normal color.” Answer: 4 Rationale: Discharge teaching following this procedure includes that the client should take a laxative to enhance passage of remaining barium from the bowel to prevent impaction. Stools change from clay-colored back to a normal color once all barium is eliminated. The information contained in the client’s other statements does not reflect accurate discharge teaching. Test-Taking Strategy: Focus on the issue of the question, which is knowledge of items that should be reviewed as part of discharge teaching following barium enema. Recalling the effects of barium will direct you to option 4. Review these postprocedure instructions if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 219. 1210. A client with a possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom of hiatal hernia? 1. Dizziness after meals 2. Moderate right upper quadrant pain unrelated to eating 3. Difficulty swallowing 4. Left lower quadrant pain 2 hours after eating Answer: 3 Rationale: Although many clients with hiatal hernia are asymptomatic, those with symptoms usually have difficulty swallowing along with heartburn and reflux. Options 1, 2, and 4 are not related to this disorder. Test-Taking Strategy: To answer this question correctly, recall that this client has an upper gastrointestinal disorder. Knowing that pain is usually in the epigastric area, and that it correlates with food intake, will assist in eliminating each of the incorrect options. Review the manifestations associated with this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 680. 1211. A nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent reoccurrence of symptoms. Which statement would be included in the teaching? 1. “Be sure to sleep with your head elevated in bed.” 2. “This problem requires surgery.” 3. “Eat foods that are higher in fat to slow down digestion.” 4. “Lie down for at least an hour after eating.” Answer: 1 Rationale: Most clients with hiatal hernia can be managed by conservative measures, which include a low-fat diet, avoiding lying down for an hour after eating, and raising the head of the bed. Test-Taking Strategy: Use the process of elimination. Note that options 1 and 4 seem to oppose each other, making it more likely that one of them is correct. Use knowledge of this health problem to direct you to option 1. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 680. 1212. A client will undergo a barium swallow to determine whether the client has a hiatal hernia. The nurse instructs the client to: 1. Avoid eating or drinking after midnight before the test 2. Have a clear liquid breakfast on the morning of the test 3. Take all routine medications on the morning of the test 4. Limit self to two cigarettes on the morning of the test Answer: 1 Rationale: The stomach should be empty at the time of a barium swallow, because food and medications can interfere with test results. Smoking increases mucus and acid production and can also interfere with the test. For this reason, all foods, liquids, medication, and smoking are avoided before the test. Test-Taking Strategy: Use the process of elimination and focus on the issue—preparation for a barium swallow. Remember that options that are similar are not likely to be correct. Each of the incorrect options involves taking in something on the morning of the examination. Review preparation for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 220. 1213. A clinic nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports during a subsequent visit doing which of the following? 1. Eating low-fat or non-fat foods 2. Elevating the foot of the bed during sleep 3. Doing household chores immediately after eating 4. Sleeping with the head of the bed slightly down Answer: 1 Rationale: The consumption of low-fat or non-fat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep, and wait at least 1 hour after meals to perform chores. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 2 and 4. Choose correctly between the remaining options knowing that low-fat foods are helpful, while activity following meals can aggravate reflux. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 1214. A client arrives in the emergency department with bleeding esophageal varices, and the physician states that a Sengstaken-Blakemore tube will be used to try to control gastrointestinal hemorrhage. The nurse prepares for insertion via which of the following routes? 1. Percutaneous 2. Orogastric 3. Nasogastric 4. Gastrostomy Answer: 3 Rationale: A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect. Test-Taking Strategy: To answer this question accurately, you must be familiar with this type of tube and its use. Eliminate options 1 and 4 first because they are least likely to be correct. Choose between the remaining options after visualizing the tube and what it is intended to accomplish. Review this type of tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 661. 1215. A nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to: 1. Have a family member remain with the client 2. Keep scissors at the bedside 3. Give frequent oral and nasal care 4. Provide tracheal suction as needed Answer: 3 Rationale: The issue of the question is knowledge that frequent oral care, including oral suctioning, is necessary to prevent irritation to the oral and nasal mucosa. A family member’s presence will not prevent this from occurring, nor will the actions taken in options 2 and 4. Keeping scissors at the bedside is a good action; however, these are used to cut the tube if the client begins to have airway maintenance problems. Test-Taking Strategy: Focus on the issue of the question, which is prevention of necrosis and ulceration of oral and nasal mucosa. Eliminate each of the incorrect options because they do not address this problem. Note also the presence of the words “oral” and “nasal” in both the question and the correct option. Review care to the client with a Sengstaken-Blakemore tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 661. 1216. A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the client’s heart rate and blood pressure increase, and the client is having difficulty breathing. The immediate nursing action would be to: 1. Cut the tube and pull it out 2. Administer oxygen at 3 L per minute via nasal cannula 3. Call respiratory therapy 4. Stay with the client and use the call bell to summon help Answer: 1 Rationale: Sudden rupture of the esophageal balloon can cause airway obstruction, aspiration, and/or asphyxiation. The tube should be cut and removed to prevent airway obstruction. Options 3 and 4 may also be done, once the nurse first takes action to safeguard the client’s airway. Option 2 may be completed with a physician’s order, again at a slightly later time. Test-Taking Strategy: Use the process of elimination and note the key word immediate. This tells you that more than one or all actions may be partially or totally correct, but that one is better than the others. Use the ABCs—airway, breathing, and circulation. Only option 1 definitively assists in maintaining the client’s airway. Review care to the client with a Sengstaken- Blakemore tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. . 1217. A 70-year old client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which of the following data would further support this diagnosis? 1. Complaints of stress with a history of chronic renal failure 2. Frequent heartburn with a sour taste in the mouth 3. History of chronic obstructive pulmonary disease with weight gain 4. History of alcohol use, smoking, and weight loss Answer: 4 Rationale: Alcohol use, smoking, and weight loss are most commonly associated with gastric ulcers. The other options do not contain risk factors or symptoms commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease. Test-Taking Strategy: Use the process of elimination and focus on the issue—data that would support this diagnosis. Recalling that alcohol use and smoking can lead to gastric ulcer formation and that weight loss is part of the clinical picture will direct you to option 4. Review the manifestations associated with a gastric ulcer if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 184. 1218. A client with peptic ulcer disease has been prescribed to take misoprostol (Cytotec) and sucralfate (Carafate). The nurse teaches the client that these two medications will work primarily to: 1. Inhibit histamine action 2. Kill bacteria 3. Decrease stomach acid 4. Protect the gastric mucosa Answer: 4 Rationale: Both of these medications protect the stomach lining. Misoprostol increases mucus production and bicarbonate levels, while sucralfate coats the ulcer surface. Options 1 and 2 reflect histamine antagonists and antibiotics, respectively. Option 3 describes antacids. Test-Taking Strategy: Specific knowledge of the mechanism of action for these medications is needed to answer this question. Remember that both of these medications protect the stomach lining. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 721, 994. 1219. A nurse would include which of the following when reinforcing home care instructions for a client whose has peptic ulcer disease? 1. Continue to eat the same diet as before the diagnosis 2. Smoke only at bedtime 3. Learn to use stress reduction techniques 4. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief Answer: 3 Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client should also limit intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances. Test-Taking Strategy: Use the process of elimination. The issue of the question is knowledge of factors that will reduce symptoms of peptic ulcer disease. Eliminate each of the incorrect options knowing that only option 3 is consistent with minimizing the disease process. Review these treatment measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 193. 1220. A nurse is reinforcing dietary instructions to a client with peptic ulcer disease. The nurse tells the client to: 1. Include foods that will increase gastrointestinal (GI) motility 2. Eat six small meals every day 3. Consume a bland diet only 4. Eat anything as long as it does not aggravate or cause pain Answer: 4 Rationale: The client may eat any food as long as it does not aggravate or cause pain. Increased GI motility should be avoided. A traditional bland diet is no longer recommended. It is unnecessary for the client to eat six small meals per day with this disorder, although smaller sized meals are better managed by the client. Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated first knowing that GI motility should not be increased. Next eliminate options 2 and 3 because of the absolute words “every” and “only.” Review dietary measures for this disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 187. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 686. 1221. A nurse who has assisted in dietary teaching for a client with peptic ulcer disease sees the client at a routine follow-up visit. The nurse documents which of the following as the best indicator of a successful outcome for this client? 1. Need for continued PRN medications 2. A decrease in sour eructation 3. Use of only decaffeinated coffee and tea 4. Taking in increased dairy products Answer: 2 Rationale: A decrease in sour eructation (burping) represents a change in the client’s health status and is an effective indicator of a successful outcome. Option 3 represents healthy behavior by the client but is not focused on outcome specific to this disease. Options 1 and 4 are not consistent with minimizing disease symptoms. Test-Taking Strategy: Use the process of elimination and focus on the issue—a successful outcome. Begin to answer this question by eliminating options 1 and 4, which are not compatible with improved health status. Choose option 2 over 3 by focusing on the manifestations of this disease and the key word outcome. Review this disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 187. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 686. 1222. A preschool child who was admitted to the hospital with a serious respiratory tract infection develops a rash on the second day after hospitalization and is diagnosed with chickenpox (varicella). The nurse should take which of the following actions to provide safety for all children on the unit? 1. Place the child and other children who were exposed to the infected child in isolation 2. Keep siblings from visiting the infected child 3. Place only the infected child in isolation 4. Place the child in isolation and isolate immunocompromised children from the infected child Answer: 4 Rationale: The period of communicability for chickenpox is 1 day before the eruption of vesicles to about 1 week when crusts are formed. The infected child should be isolated until vesicles have dried, and other high-risk children (immunocompromised) should be isolated from the infected child. Test-Taking Strategy: Use the process of elimination. Recalling the incubation period and the period of communicability for chickenpox will direct you to option 4. Review this communicable disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 749. 1223. A client has undergone a subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item should the nurse, who is assisting in teaching the client about ongoing self-management, tell the client? 1. Stress can no longer exacerbate gastrointestinal symptoms 2. The client can resume full activity immediately 3. Follow-up visits with the physician are no longer needed 4. Smaller, more frequent meals should be eaten Answer: 4 Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually, and should minimize stressors to prevent recurrence of symptoms. The client requires ongoing medical supervision and evaluation. Test-Taking Strategy: Use the process of elimination. Option 3 can be eliminated first knowing that follow-up care is important. From the remaining options, recall that subtotal gastrectomy is often used to manage more severe gastric ulcers. With this in mind, eliminate the options that would actually increase gastrointestinal symptoms. Review care to the client following subtotal gastrectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 687. 1224. A nurse who is reinforcing instructions to a client following gastric resection should be sure to include which of the following suggestions? 1. Eat a diet high in vitamin B12 content 2. Avoid iron supplementation 3. Self-monitor for signs and symptoms of lower gastrointestinal (GI) hemorrhage 4. Take action to prevent dumping syndrome Answer: 4 Rationale: Dumping syndrome occurs in many clients after GI surgery and may occur as an early or late complication. Upper GI hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia, because the client lacks intrinsic factor needed for absorption. Instead, the client requires injection to supplement this vitamin. Iron supplements are necessary to aid the absorption of parenteral vitamin B12. Test-Taking Strategy: Use the process of elimination. Recalling the complications that occur following gastric resection will direct you to option 4. Review client instructions following this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 190. 1225. A nurse reinforces teaching with a client following gastrectomy about the signs and symptoms of pernicious anemia knowing that: 1. Once symptoms are evident, pernicious anemia is fatal 2. Regular monthly injections of vitamin B12 will prevent this complication 3. Symptoms can occur as long as 10 years after surgery 4. Most diets are deficient in all of the B vitamins Answer: 2 Rationale: Vitamin B12 deficiency occurs from lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Replacement therapy is given by the parenteral route. Symptoms generally occur within 5 years or less. Although not fatal, pernicious anemia can contribute to many other diseases. Test-Taking Strategy: Focus on the issue—pernicious anemia. Recalling that this disorder is treated with monthly injections of vitamin B12 will direct you to option 2. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 190. 1226. A nurse is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer. The nurse should focus interventions on which of the following during this timeframe? 1. Maintaining a patent nasogastric (NG) tube 2. Providing the client with an oral diet 3. Teaching symptoms of dumping syndrome 4. Promoting the use of stress reduction techniques Answer: 1 Rationale: An NG tube is inserted during surgery and is left in place for 24 to 48 hours to decompress the gastrointestinal tract, which enhances sealing of the suture line. It is essential that the NG tube does not become occluded because this could disrupt the suture lines if distention occurs. The other options are also appropriate, but at a later time. Test-Taking Strategy: Use the process of elimination. The key words are during this timeframe. This tells you that more than one or all of the options may be partially or totally correct, but that one of them is best given the time period provided. Focusing on these key words will direct you to option 1. Review care to the client following gastric surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 190-191. 1227. A nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. While carrying out this function, the nurse recalls that absorption is best defined as: 1. The transfer of nutrients into the cell by active transport 2. A chemical process involving the breakdown of foods 3. Removal by osmosis of digested food to the cells 4. The transfer of digested food molecules from the GI tract into the bloodstream Answer: 4 Rationale: Absorption is the transfer of digested food molecules into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Digestion involves the mechanical and chemical breakdown of foods. Option 3 is an incorrect statement. Test-Taking Strategy: Focus on the issue—absorption. Recalling the definition of this word will direct you to option 4. Review this definition if you had difficulty with this question. Level of Cognitive Ability: Knowledge Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 73-74. 1228. The nurse is preparing to collect data about a client by examining the abdomen. The nurse should assist the client into which of the following positions first? 1. Sims position 2. Supine with the head and feet flat 3. Supine with the head raised slightly and the knees slightly flexed 4. Semi-Fowler’s with the head raised 45 degrees and the knees flat Answer: 3 Rationale: In the supine position, the client lies on the back, and the abdominal muscles are relaxed by elevating the head and flexing the knees slightly. If the head was raised to 45 degrees, the abdomen could not be accurately assessed. Sims position is a side-lying position and would not adequately expose the abdomen for examination. Placing the head and feet flat would result in the abdominal muscles being taut. Test-Taking Strategy: Use the process of elimination. Visualize each of the positions identified and evaluate each of them against their natural ability to keep abdominal muscles relaxed. Review this data collection technique if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 779-780. 1229. A licensed practical nurse (LPN) is reinforcing follow-up teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately: 1. One day 2. Seven days 3. One week 4. Ten days Answer: 1 Rationale: It takes at least 12 to 24 hours for a substance to pass through the colon. The other timeframes listed are excessive in length. Barium should be eliminated quickly to reduce the risk of impaction from this substance. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar. From the remaining options, eliminate option 4 because the timeframe is excessive in length. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1109. 1230. A physician asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse would correctly select which of the following tubes from the unit storage area? 1. A Sengstaken-Blakemore tube 2. A nasogastric tube 3. A tube with just a single lumen 4. A tube with a larger lumen and an air vent Answer: 4 Rationale: A Salem sump is used commonly for gastric intubation, and has a larger suction lumen as well as a smaller air vent. Options 1 describes a tube used for gastroesophageal bleeding. Options 2 and 3 describe a Levin tube. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 because they are similar. From the remaining options, recalling that a Sengstaken-Blakemore tube has a balloon that controls bleeding will direct you to option 4. Review these types of tubes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, 661. 1231. A nurse has assisted to insert a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which of the following pressures? 1. Low and continuous 2. High and intermittent 3. Low and intermittent 4. High and continuous Answer: 3 Rationale: A Levin tube has no air vent, and the suction must be placed on an intermittent setting to prevent trauma to the gastric mucosa. Low pressure and intermittent suction are safer for the stomach than high pressure and continuous suction. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 4 because of the word “high.” To choose between the remaining options, you must recall that a Levin tube has no air vent. This will direct you to option 3. Review the procedure for GI decompression if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 745. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 661. 1232. A nurse is caring for a client with anorexia. The nurse plans care for the client focusing on which of the following as the primary problem? 1. Lack of nutritional knowledge 2. Impaired nutritional status 3. Depression 4. Pain Answer: 2 Rationale: A client with anorexia has decreased appetite, and this could be due to any number of causes. The nurse plans care focusing on the risk of impaired nutritional status. The other options listed may or may not contribute to the client’s problem. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer the question. This will direct you to option 2. Review the complications of anorexia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 670. 1233. A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse who is reinforcing client teaching tells the client about the need for: 1. Vitamin B12 injections 2. Vitamin B6 injections 3. Antibiotic therapy 4. Antacid use Answer: 1 Rationale: Insufficient intrinsic factor results in inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Vitamin B6 is absorbed when given orally. Antibiotic therapy and antacid use would not help to treat lack of intrinsic factor. Test-Taking Strategy: Note the key words little intrinsic factor being produced. Use knowledge of anatomy and physiology to direct you to option 1. Review this content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 190. 1234. A nurse is assisting in the care of a client in the emergency department who has right lower quadrant pain. After noting a white blood cell count of 16,500/mm3, the nurse would question an order for which of the following? 1. NPO 2. Intravenous (IV) fluids at a rate of 100 mL per hour 3. Cold pack to the abdomen 4. Milk of Magnesia Answer: 4 Rationale: A client with right lower quadrant pain may have appendicitis. This client would be NPO and given IV fluids for hydration. Cold packs may provide comfort. Laxatives are not ordered; therefore the nurse would question the Milk of Magnesia order. Test-Taking Strategy: Use the process of elimination. The key words in the question are question an order for. This tells you that correct option is an incorrect order for treatment of this client. Focusing on the data in the question will assist in directing you to option 4. Review care for the client with appendicitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 205. 1235. A nurse receives a call from the mother of a child who has a foreign body in the eye, which is clearly visible and is not imbedded. The mother asks the nurse what is the most effective way to get it out. The nurse would respond that which of the following methods would be most useful? 1. Let the object just “work its way out” 2. Touch the object gently with a cotton swab and lift it out 3. Irrigate the eye with natural tears 4. Irrigate the eye with running tap water Answer: 2 Rationale: The most effective method that would cause the least amount of trauma would be to lift the foreign body from the eye. It should not be allowed to remain and “work its way out.” Irrigating the eye may cause the foreign body to move and cause trauma in another area of the eye. Test-Taking Strategy: Use knowledge of general principles of eye safety to answer this question. Remember also that options that are similar are not likely to be correct. With this in mind, eliminate options 3 and 4 first. Choose between the remaining options knowing that the correct answer is the one that provides relief to the client without causing further harm. Review the measures to treat eye injuries if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1003. 1236. After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated by: 1. Eye drops 2. Rigid contact lenses 3. Prescription of corrective lenses 4. Keratoplasty Answer: 3 Rationale: Errors of refraction in vision include astigmatism, presbyopia, myopia, and hyperopia. Corrective lenses, or eyeglasses, are the most common method used to correct errors of refraction. Eye drops would be used for several eye conditions, most commonly glaucoma. The client may or may not need rigid contact lenses, and this is not the most common treatment. A keratoplasty is a surgical procedure for cataracts. Test-Taking Strategy: The issue of the question is the primary treatment for errors of refraction. To answer this question correctly, you must understand the nature of this problem. With this in mind, you could then eliminate options 1 and 4 easily. From the remaining options, eliminate option 2 because of the word “rigid.” Rigid lenses may or may not be required. Many clients wear soft contact lenses to correct errors of vision. Review care to the client with a refractive error if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 364-365. 1237. A nurse has reinforced discharge teaching to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further instruction if the client makes which of the following statements? 1. “I can’t lift more than 5 pounds.” 2. “I should take stool softeners to prevent straining.” 3. “I can lie on my right side.” 4. “I cannot rub my eye.” Answer: 3 Rationale: The client should not lie on the operative side in order to reduce strain on the surgical eye. The information contained in options 1, 2, and 4 is correct, and indicates proper understanding by the client of postoperative restrictions. Test-Taking Strategy: Use the process of elimination and note the key words needs further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Noting that the client had surgery on the right eye will direct you to option 3. Review client instructions following cataract surgery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 571. 1238. A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which of the following substances? 1. Amylase 2. Lipase 3. Trypsin 4. Insulin Answer: 4 Rationale: The pancreas produces both endocrine and exocrine secretions as part of its normal function. The organ secretes insulin as a key endocrine hormone to regulate the blood glucose level. Other pancreatic endocrine hormones are glucagon and somatostatin. The exocrine pancreas produces digestive enzymes such as amylase, lipase, and trypsin. Test-Taking Strategy: Use the process of elimination. Recall that the pancreas produces both endocrine and exocrine secretions. Focusing on the key word endocrine in the question will direct you to option 4. If this question was difficult, review the functions of the pancreas. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 174-175, 454-455. 1239. A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition? 1. “The brain herniates downwards and around the tentorium cerebelli.” 2. “The herniation can be unilateral or bilateral.” 3. “It involves only anterior portions of the brain.” 4. “It can cause death if large amounts of tissue are involved.” Answer: 3 Rationale: Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. It can be unilateral or bilateral and may involve anterior or posterior portions of the brain. If a large amount of tissue is involved, it can cause death because vital brain structures are compressed and become unable to perform their function. Test-Taking Strategy: Note the key words a need for further research in the stem of the question. These words indicate a false response question and that you need to select the incorrect student statement. Noting the absolute word “only” in option 3 will direct you to this option. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1497. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1646. 1240. A 1-year old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse would avoid doing which of the following to protect the infant from injury? 1. Keep a padded tongue blade at the bedside for use during a seizure 2. Refrain from giving the infant toys that have bright blinking lights 3. Keep side rails and other hard objects padded 4. Turn the client to the side during a seizure Answer: 1 Rationale: Attempting to place something in an infant’s mouth during a seizure in not helpful even if it is padded. The mouth is usually clenched, and one would have to use force to open the mouth. One must attempt to keep the airway clear and can do that by positioning (option 4). Option 2 may be helpful in preventing a seizure, while option 3 safeguards the client’s physical safety. Test-Taking Strategy: The key word in the stem of the question is avoids. With this in mind, eliminate options 3 and 4, which are obviously helpful actions. Choose between the remaining options knowing either that tongue blades can be dangerous or that avoiding toys with lights would be a helpful item. Review care to the infant with seizures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 242. 1241. A client receiving total parenteral nutrition (TPN) has a history of congestive heart failure. The physician has ordered furosemide (Lasix) 40 mg orally daily to prevent fluid overload. The nurse monitors which laboratory value to identify an adverse effect from this medication? 1. Glucose level 2. Sodium level 3. Potassium level 4. Magnesium level Answer: 3 Rationale: Furosemide is a non–potassium-sparing diuretic, and insufficient replacement of potassium may lead to hypokalemia. Although the glucose, sodium, and magnesium levels may be monitored, these laboratory values are not specific to administering furosemide. Test-Taking Strategy: Use the process of elimination. Recalling that furosemide is a non– potassium-sparing diuretic will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1242. A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which of the following data about an infant with this condition? 1. Cool upper extremities 2. Hepatomegaly 3. Blood pressure lower in the upper extremities and higher in the lower extremities 4. Bounding radial pulses, absent or weak femoral and pedal pulses Answer: 4 Rationale: When there is narrowing within the aorta, there is increased pressure proximal to the defect and decreased pressure distal to it. Therefore one would expect bounding pulses in the arms and weak or absent pulses in the femoral and/or pedal areas. With decreased blood supply to the lower extremities, that area would be cool to touch. The upper extremities would be warm. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Review each of the options listed, anticipating the effects of coarctation on the circulatory dynamics of the infant. Eliminate options 1 and 3 first, which are the opposite of the expected findings. Hepatomegaly is an associated finding if the client goes into heart failure as a complication of COA. With this in mind, eliminate option 2. Review the findings in this disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. . 1243. A nurse is reviewing a chart of a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which of the following would the nurse expect to note on data collection of the child? 1. Awake, alert, interacting with the environment 2. The ability to think clearly and rapidly is lost 3. The ability to recognize place or person is lost 4. Sleeps unless aroused and once aroused has limited interaction with the environment Answer: 4 Rationale: Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Full consciousness indicates that the child is alert, awake, orientated, and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize place or person is lost. Test-Taking Strategy: Use the process of elimination. Remember, obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Review these data collection findings if you are unfamiliar with them. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Wong, D., Perry, S., & Hockenberry, M. (2002). Maternal child nursing care (2nd ed.). St. Louis: Mosby, p. 1648. 1244. A nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing: 1. Decorticate posturing 2. Decerebrate posturing 3. Flexion of the arms and legs 4. A normal expected positioning following head injury Answer: 1 Rationale: Decorticate posturing is an abnormal flexion of the upper extremities, and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists, and an extension of the lower extremities with some internal rotation. Test-Taking Strategy: Use the process of elimination. Option 4 can be easily eliminated first. Next, eliminate option 3 because it is an incomplete description of the nurse’s observation of the child. From the remaining options, it is necessary to know the findings that occur with either decorticate or decerebrate posturing. If you had difficulty with this question, review head injuries and posturing. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 202-203. 1245. An older client complains of chronic constipation. The nurse instructs the client to: 1. Include rice and bananas in the diet 2. Increase the intake of sugar-free products 3. Increase fluid intake to at least eight glasses a day and increase dietary fiber 4. Increase potassium in the diet Answer: 3 Rationale: Increase of fluid intake and dietary fiber will help to change the consistency of the stool and make it easier for the client to pass. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client. Test-Taking Strategy: Use the process of elimination and knowledge of the physiological causes of constipation and factors that will alter consistency of stool. Remember, an increase of fluid intake and dietary fiber will help to change the consistency of the stool and make it easier for the client to pass. If you had difficulty with this question, review the interventions for constipation. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 244. 1246. A nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understood the instructions if she states that: 1. She should alternately contract and relax the muscles of the perineal area 2. The use of postpartum exercises can result in stress urinary incontinence 3. Exercise should be delayed for 4 weeks to allow healing time 4. Strenuous exercises should be started while in the hospital Answer: 1 Rationale: Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence. Test-Taking Strategy: Use the process of elimination and note the key words understood the instructions. Focusing on the issue—postpartum exercises—will direct you to option 1. Review this content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 210-211. 1247. A nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the physician has documented decorticate posturing. The nurse plans care knowing that this type of posturing indicates which of the following? 1. Damage to the midbrain 2. Damage to the pons 3. Damage to the diencephalon 4. A lesion in the cerebral hemisphere Answer: 4 Rationale: Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons. Test-Taking Strategy: Specific knowledge regarding the assessment findings related to head injuries is required to answer this question. Remember, decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. If you are unfamiliar with decorticate and decerebrate posturing, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 560. 1248. A nurse is reviewing the record of a newborn infant in the nursery and notes that the physician has documented the presence of a cephalohematoma. Based on this documentation, the nurse expects to note which of the following on data collection of the infant? 1. Swelling of the soft tissues of the head and scalp 2. Edema resulting from bleeding below the periosteum of the cranium 3. A suture split greater than 1 cm 4. A hard, rigid immobile suture line Answer: 2 Rationale: A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely due to ruptured blood vessels from head trauma during birth. It develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 identifies a caput succedaneum. Option 3 may indicate increased intracranial pressure. Option 4 may be associated with premature closure or craniosynostosis and should be investigated further. Test-Taking Strategy: Use the process of elimination. Note the relationship between cephalohematoma in the question and bleeding in the correct option. Review the characteristics of a cephalohematoma if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 49. 1249. A nurse employed in a well-baby clinic is collecting data on the language and communication developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones? 1. Use of gestures 2. Babbling sounds 3. Cooing sounds 4. Increased interest in sounds Answer: 2 Rationale: Babbling sounds are common between the ages of 3 and 4 months. Additionally, at this age crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs