COMPREHENSIVE EXAM #1
QUESTIONS AND ANSWERS
A nurse is assessing a 12-month-old infant during a well-child visit. Which of the
following findings should the nurse report to the provider?
Closed anterior fontanel
Eruption of six teeth
Birth weight doubled
Birth length increased by 50% - Answer-Answer: 3. By the age of 12 months, the
infant's birth weight should have tripled. Therefore, the nurse should report this finding
to the provider.
1 does not need reported. By the age of 12 to 18 months, the infant's anterior fontanel
should close.
2 does not need reported. By the age of 12 months, the infant should have six to eight
teeth erupted.
4 does not need reported. By the age of 12 months, the infant's birth length should
increase by 50%.
A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too
much. His family was like that when he was growing up. He always apologizes and
regrets hurting me." What risk factor was most predictive for the husband to become
abusive? Provide a rationale for your answer.
History of family violence
Loss of employment
Abuse of alcohol
Poverty - Answer-Yes. Answer: 1.
An abuse-prone individual is an individual who has experienced family violence and was
often abused as a child. This phenomenon is part of the cycle of violence. The other
options may be present but are not as predictive. However, the consumption of alcohol
or drugs has been frequently found within abusive relationships.
Abuse victims often report that the abuser is very controlling of the victim or family
activities, even to the point of paranoia. Abusers also tend to be very jealous or
possessive. They gain power by using intimidation. Abusers isolate the victim from
others.
The abuser usually has low self-esteem and poor social skills.
, There is a real danger an abuser may kill the victim. Women often stay with their
abusers due to economic reasons.
A client with end-stage kidney disease is receiving continuous ambulatory peritoneal
dialysis. The nurse is monitoring the client for manifestations of complications
associated with peritoneal dialysis. Select all that apply.
Pruritus
Oliguria
Tachycardia
Cloudy outflow
Abdominal pain
Nausea/Vomiting - Answer-Answer: 3, 4, 5, 6
1 is not correct. Severe itching (pruritus) is caused by metabolic waste products that are
deposited in the skin; dialysis removes metabolic waste products, preventing this
adaptation associated with kidney failure.
2 is not correct. The production of abnormally small amounts of urine (oliguria) is a sign
of kidney failure, not a complication of peritoneal dialysis.
3 is correct. Tachycardia can be caused by peritonitis, a complication of peritoneal
dialysis; the heart rate increases to meet the metabolic demands associated with
infection.
4 is correct. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of
peritonitis; it is caused by the constituents associated with an infectious process.
5 is correct. Abdominal pain is associated with peritonitis, a complication of peritoneal
dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary
muscle spasms.
6 is correct. Nausea and vomiting are manifestations of peritonitis
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention
should the nurse implement first?
a. Call a code immediately
b. Assess the client for a pulse
c. Begin chest compressions
d. Continue to monitor the client - Answer-Yes, answer: b. The nurse must first
determine if the client has a pulse. Remember if the patient is in VFib or VTach without
a pulse, this IS a shockable rhythm and the priority is to defibrillate. Always locate the
AED or crash cart before starting CPR.
QUESTIONS AND ANSWERS
A nurse is assessing a 12-month-old infant during a well-child visit. Which of the
following findings should the nurse report to the provider?
Closed anterior fontanel
Eruption of six teeth
Birth weight doubled
Birth length increased by 50% - Answer-Answer: 3. By the age of 12 months, the
infant's birth weight should have tripled. Therefore, the nurse should report this finding
to the provider.
1 does not need reported. By the age of 12 to 18 months, the infant's anterior fontanel
should close.
2 does not need reported. By the age of 12 months, the infant should have six to eight
teeth erupted.
4 does not need reported. By the age of 12 months, the infant's birth length should
increase by 50%.
A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too
much. His family was like that when he was growing up. He always apologizes and
regrets hurting me." What risk factor was most predictive for the husband to become
abusive? Provide a rationale for your answer.
History of family violence
Loss of employment
Abuse of alcohol
Poverty - Answer-Yes. Answer: 1.
An abuse-prone individual is an individual who has experienced family violence and was
often abused as a child. This phenomenon is part of the cycle of violence. The other
options may be present but are not as predictive. However, the consumption of alcohol
or drugs has been frequently found within abusive relationships.
Abuse victims often report that the abuser is very controlling of the victim or family
activities, even to the point of paranoia. Abusers also tend to be very jealous or
possessive. They gain power by using intimidation. Abusers isolate the victim from
others.
The abuser usually has low self-esteem and poor social skills.
, There is a real danger an abuser may kill the victim. Women often stay with their
abusers due to economic reasons.
A client with end-stage kidney disease is receiving continuous ambulatory peritoneal
dialysis. The nurse is monitoring the client for manifestations of complications
associated with peritoneal dialysis. Select all that apply.
Pruritus
Oliguria
Tachycardia
Cloudy outflow
Abdominal pain
Nausea/Vomiting - Answer-Answer: 3, 4, 5, 6
1 is not correct. Severe itching (pruritus) is caused by metabolic waste products that are
deposited in the skin; dialysis removes metabolic waste products, preventing this
adaptation associated with kidney failure.
2 is not correct. The production of abnormally small amounts of urine (oliguria) is a sign
of kidney failure, not a complication of peritoneal dialysis.
3 is correct. Tachycardia can be caused by peritonitis, a complication of peritoneal
dialysis; the heart rate increases to meet the metabolic demands associated with
infection.
4 is correct. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of
peritonitis; it is caused by the constituents associated with an infectious process.
5 is correct. Abdominal pain is associated with peritonitis, a complication of peritoneal
dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary
muscle spasms.
6 is correct. Nausea and vomiting are manifestations of peritonitis
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention
should the nurse implement first?
a. Call a code immediately
b. Assess the client for a pulse
c. Begin chest compressions
d. Continue to monitor the client - Answer-Yes, answer: b. The nurse must first
determine if the client has a pulse. Remember if the patient is in VFib or VTach without
a pulse, this IS a shockable rhythm and the priority is to defibrillate. Always locate the
AED or crash cart before starting CPR.
