EVOLVE STUDY GUIDE WITH TESTED
SOLUTIONS
◉ Which of the following cardiac rhythms is represented in the
image?
A.Normal sinus rhythm
B.Sinus tachycardia
C.Ventricular fibrillation
D.Atrial fibrillation. Answer: C
Rationale:
Ventricular fibrillation (C) is a life-threatening arrhythmia
characterized by irregular undulations of varying amplitudes. (A, B,
and D) are not represented in the image.
◉ An adult client with a medical diagnosis of substance abuse and
schizophrenia was recently switched from oral fluphenazine HCl
(Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate)
because of medication noncompliance. What should the nurse teach
the client and family about this change in medication regimen?
A.Long-acting medication is more effective than daily medication.
B.A client with substance abuse must not take any oral medications.
C.There will continue to be a risk of alcohol and drug interaction.
,D.Support groups are only helpful for substance abuse treatment..
Answer: C
Rationale:
Alcohol enhances the side effects of Prolixin. The half-life of Prolixin
PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2
to 4 weeks. Therefore, the side effects of drinking alcohol are far
more severe when the client drinks alcohol after taking the long-
acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect
information.
◉ A client comes to the obstetric clinic for her first prenatal visit and
complains of feeling nauseated every morning. The client tells the
nurse, "I'm having second thoughts about wanting to have this baby."
Which response is best for the nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you are
not feeling well."
B."I think you should discuss these feelings with your health care
provider."
C."How does the father of your child feel about your having this
baby?"
D."Tell me about these second thoughts you are having about this
pregnancy.". Answer: D
Rationale:
Although ambivalence is normal during the first trimester, (D) is the
best nursing response at this time. It is reflective and keeps the lines
of communication open. (A) is not the best response because it
,offers false reassurance. (B) dismisses the client's feelings. The
nurse should use communication skills that encourage this type of
discussion, not shift responsibility to the care provider. (C) may
eventually be discussed, but it is not the most important information
to obtain at this time.
◉ A nurse performs an initial admission assessment of a 56-year-old
client. Which factor(s) would indicate that the client is at risk for
metabolic syndrome? (Select all that apply.)
A.Abdominal obesity
B.Sedentary lifestyle
C.History of hypoglycemia
D.Hispanic or Asian ethnicity
E.Increased triglycerides. Answer: A,B,D,E
Rationale:
Metabolic syndrome is a name for a group of risk factors that
increase the risk for coronary artery disease, type 2 diabetes, and
stroke (A, B, D, and E). Hypoglycemia is not a risk factor for
metabolic syndrome (C).
◉ The nurse administers regular insulin (human), 8 units
subcutaneously, to a client at 8:00 am, 30 minutes before breakfast.
At what time is the client most at risk for a hypoglycemic reaction?
A.9:30 am
B.10:30 am
, C.12:00 pm
D.3:00 pm. Answer: B
Rationale:
Regular insulin is short-acting and peaks between 2 and 3 hours
after administration (B). The client is most at risk for a hypoglycemic
reaction during the peak times. (A, C, and D) are not high-risk times
for the client to experience hypoglycemia because they do not fall
within the peak time.
◉ Which intervention is most important when caring for a client
immediately after electroconvulsive therapy (ECT)?A.Reorient the
client to surroundings.
B.Assess blood pressure every 15 minutes.
C.Determine if muscle soreness is present.
D.Maintain a patent airway.. Answer: D
Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures to
prevent aspiration and maintain a patent airway (D). Patients may
be confused after ECT (A), but reorientation is not as high a priority
as the airway. Although vital signs should be assessed, the airway is
a higher priority (B). Muscle soreness is an expected finding after
ECT (C).
SOLUTIONS
◉ Which of the following cardiac rhythms is represented in the
image?
A.Normal sinus rhythm
B.Sinus tachycardia
C.Ventricular fibrillation
D.Atrial fibrillation. Answer: C
Rationale:
Ventricular fibrillation (C) is a life-threatening arrhythmia
characterized by irregular undulations of varying amplitudes. (A, B,
and D) are not represented in the image.
◉ An adult client with a medical diagnosis of substance abuse and
schizophrenia was recently switched from oral fluphenazine HCl
(Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate)
because of medication noncompliance. What should the nurse teach
the client and family about this change in medication regimen?
A.Long-acting medication is more effective than daily medication.
B.A client with substance abuse must not take any oral medications.
C.There will continue to be a risk of alcohol and drug interaction.
,D.Support groups are only helpful for substance abuse treatment..
Answer: C
Rationale:
Alcohol enhances the side effects of Prolixin. The half-life of Prolixin
PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2
to 4 weeks. Therefore, the side effects of drinking alcohol are far
more severe when the client drinks alcohol after taking the long-
acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect
information.
◉ A client comes to the obstetric clinic for her first prenatal visit and
complains of feeling nauseated every morning. The client tells the
nurse, "I'm having second thoughts about wanting to have this baby."
Which response is best for the nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you are
not feeling well."
B."I think you should discuss these feelings with your health care
provider."
C."How does the father of your child feel about your having this
baby?"
D."Tell me about these second thoughts you are having about this
pregnancy.". Answer: D
Rationale:
Although ambivalence is normal during the first trimester, (D) is the
best nursing response at this time. It is reflective and keeps the lines
of communication open. (A) is not the best response because it
,offers false reassurance. (B) dismisses the client's feelings. The
nurse should use communication skills that encourage this type of
discussion, not shift responsibility to the care provider. (C) may
eventually be discussed, but it is not the most important information
to obtain at this time.
◉ A nurse performs an initial admission assessment of a 56-year-old
client. Which factor(s) would indicate that the client is at risk for
metabolic syndrome? (Select all that apply.)
A.Abdominal obesity
B.Sedentary lifestyle
C.History of hypoglycemia
D.Hispanic or Asian ethnicity
E.Increased triglycerides. Answer: A,B,D,E
Rationale:
Metabolic syndrome is a name for a group of risk factors that
increase the risk for coronary artery disease, type 2 diabetes, and
stroke (A, B, D, and E). Hypoglycemia is not a risk factor for
metabolic syndrome (C).
◉ The nurse administers regular insulin (human), 8 units
subcutaneously, to a client at 8:00 am, 30 minutes before breakfast.
At what time is the client most at risk for a hypoglycemic reaction?
A.9:30 am
B.10:30 am
, C.12:00 pm
D.3:00 pm. Answer: B
Rationale:
Regular insulin is short-acting and peaks between 2 and 3 hours
after administration (B). The client is most at risk for a hypoglycemic
reaction during the peak times. (A, C, and D) are not high-risk times
for the client to experience hypoglycemia because they do not fall
within the peak time.
◉ Which intervention is most important when caring for a client
immediately after electroconvulsive therapy (ECT)?A.Reorient the
client to surroundings.
B.Assess blood pressure every 15 minutes.
C.Determine if muscle soreness is present.
D.Maintain a patent airway.. Answer: D
Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures to
prevent aspiration and maintain a patent airway (D). Patients may
be confused after ECT (A), but reorientation is not as high a priority
as the airway. Although vital signs should be assessed, the airway is
a higher priority (B). Muscle soreness is an expected finding after
ECT (C).
