EXAM WITH CORRECT
ANSWERS AND RATIONALE
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Exam 1
(1) A nurse is caring for a client admitted 2days ago with myocardial infection .upon
Assessment the nurse notes a new systolic murmur at the cardiac apex. The nurse
Should assess the client for which of the following conditions?
(A) A. Ventricular aneurysm
(B) Acute pericarditis
(C) Papillary muscle dysfunction
(D) Pulmonary embolism
2. Which one of the following is an uncontrollable risk factor that has been linked to
Development of coronary artery disease(CAD)
(A) Exercise
(B) Obesity
(C) Stress
(D) Heredity
Rationale:
Uncontrollable risks are factors that can not be modified like genetics, heredity, age
Controllable factors are those that are modifiable like - lifestyle(exercise, nutrition), obesity
and stress.
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, 3. A 21 year old male client is transported by ambulance to the emergency unit. He complains of
severe pain in his right chest where he struck the steering wheel. Which is the primary client
goal at this time?
A. Reduce client’s anxiety
B. Maintain adequate oxygenation
C. Decrease chest pain
D. Maintain adequate circulating volume
4. The following finding is suggestive of a pneumothorax in a patient with chest trauma;
(A) Absent breath sounds
(B) Inspiratory wheezing
(C) Dullness on chest percussion
(D) Pronounced crackles
Rationale:
Pneumothorax - collapsed lung due to changes in pressure within pleural space and chest wall,
causing air to leak out. Leading to a collapsed lung, no ventilation hence absent breath sounds.
(5) The primary reason for administering digoxin (Lanoxin) to a patient is to,
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(A) Relax the walls of the heart’s arteries.
(B) Improve the strength of the heartbeat.
(C) Prevent irregularities in ventricular contractions .
(D) Decrease inflammation of the heart wall.
Rationale :
6) The priority nursing diagnosis for a patient with heart failure and pulmonary oedema is,
(A) Risk for infection related to stasis of alveolar secretions
(B) Impaired skin integrity related to pressure
(C) Activity intolerance related to pump failure
D)Constipation related to immobility
(7) When preparing a patient for colonoscopy procedure the nurse should,
(A) Perform a high colonic washout procedure the night before the procedure (B)
Ensure the patient takes a high roughage diet with a laxative the night before
procedure
(C) Educate the patient to report any “needle prick” sensations within 12 hrs after the
procedure
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, (D) Advise the patient to take low fiber diet for 1 week before the procedure
8) The characteristics of a “Cushingoid” appearance in Cushing’s disease include,
(A) Hypotension, Kussmauls’ breathing, hunchback & diaphoresis
(B) Moon face, buffalo hump, central obesity & thin musculatur e
(C) Mood swings, slow wound healing, hypertension & tunnel vision
(D) Flushing, brittle skin, abdominal pain and encephalopathy
Rationale:
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, In women, it can cause menstrual irregularities(amenorrhea, no periods or
Menorrhagia-heavy period or irregular periods. Also, infertility, hypertrophy of the clitoris,
atrophy of vaginal muscles, deepening of voice and decreased libido may occur in women
related to inhibition of pulsatile secretion of luteinizing hormone (LH) and follicle-stimulating
hormone (FSH), which likely is due to interruption of luteinizing hormone-releasing hormone
(LHRH) pulse generation. In men, inhibition of
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