ADN Level 3 Final Exam - Questions With
Complete Solutions
A 13-year-old child is diagnosed with Ewing's sarcoma of the femur.
After a course of radiation and chemotherapy, it has been decided
that leg amputation is necessary. After the amputation, the child
becomes very frightened because of aching and cramping felt in the
missing limb. Which nursing statement would be appropriate to
assist in alleviating the child's fear?
a) "This aching and cramping is normal and temporary and will
subside."
b) "This normally occurs after the surgery and we will teach you
ways to deal with it."
c) "The pain medication that I give you will take these feelings
away."
d) "This pain is not real pain, and relaxation exercises will help it go
away." Correct Answer - A. After amputation, phantom limb
pain is a temporary condition that some children may experience.
This sensation of burning, aching, or cramping in the missing limb is
most distressing to the child. The child needs to be reassured that
the condition is normal and only temporary. Options 2, 3, & 4 are
inappropriate to the child. Use therapeutic communication
techniques. Note that the subject of the question relates to
alleviating the child's fear. Options 2, 3, & 4 imply that this pain may
be permanent. Review care of a child after amputation if you had
difficulty with this question.
,The nurse is assigned to care for a client with complete right-sided
hemiparesis. The nurse plans care knowing that in this condition:
a) the client has complete bilateral paralysis of the arms and legs
b) the client has weakness on the right side of the body, including
the face and tongue
c) the client has lost the ability to move the right arm but is able to
walk independently
d) the client has lost the ability to ambulate independently but is
able to feed and bathe himself or herself without assistance.
Correct Answer - B. Hemiparesis is a weakness of one side of the
body that may occur after a stroke. Complete hemiparesis is
weakness of the face and tongue, arm, and leg on one side. Complete
bilateral paralysis does not occur in this condition. The client with
right-sided hemiparesis has weakness of the right arm and leg and
needs assistance with feeding, bathing, and ambulating. Use the
process of elimination. Note the strategic words complete right-
sided and focus on the subject: hemiparesis. Recalling that
hemiparesis indicates weakness and focusing on the strategic words
will direct you to option B. Review the description of hemiparesis
and care of the client with hemiparesis if you had difficulty with this
question.
A nurse is caring for a child recently diagnosed with cerebral palsy,
and the parents of the child ask the nurse about the disorder. The
nurse bases her response on the understanding that cerebral palsy
is:
,a) An infectious disease of the central nervous system
b) An inflammation of the brain as a result of a viral illness
c) A congenital condition that results in moderately to severe
retardation
d) A chronic disability characterized by impaired muscle movement
and posture Correct Answer - D. Cerebral palsy is a chronic
disability characterized by impaired movement and posture
resulting from an abnormality in the extrapyramidal or pyramidal
motor system.
Meningitis is an infection process of the CNS.
Encephalitis is an inflammation of the brain that occurs as a result of
a viral illness or CNS infection.
Down syndrome is an example of a congenital condition that results
in moderate to severe retardation.
Use the process of elimination. Eliminate options 1&2 first, noting
that they are comparable or alike. Next, note the relationship
between the words "palsy" in the question and "impaired muscle
movement" in D.
A 32-year-old woman recently diagnosed with Hodgkin's disease is
admitted for staging by undergoing a bone marrow aspiration and
biopsy. To obtain more information about the client's nutrition
status the nurse should review the results of which of the following
tests?
, a) Albumin level.
b) Reticulocyte count.
c) Red blood cell count.
d) Direct and indirect bilirubin levels. Correct Answer - A-
Serum albumin levels help determine whether protein intake is
sufficient. Proteins are broken down into amino acids during
digestion. Amino acids are absorbed in the small intestine, and
albumin is built from amino acids. The red blood cell count, bilirubin
levels, and reticulocyte count do not indicate protein intake.
An infant underwent surgery to remove a myelomeningocele. The
infant has bulging fontanels. Which of the following is the nurse's
best action?
a) Calm the infant
b) Teach parent about procedure
c) Notify the healthcare provider
d) Reposition infant Correct Answer - C - Bulging fontanels in
an infant may indicated increased intracranial pressure, a possible
postoperative complication. Calming the infant, teaching the parent,
and repositioning the infant will not address the underlying
problem of increased intracranial pressure within the skull. Calling
the healthcare provider is indicated.
Complete Solutions
A 13-year-old child is diagnosed with Ewing's sarcoma of the femur.
After a course of radiation and chemotherapy, it has been decided
that leg amputation is necessary. After the amputation, the child
becomes very frightened because of aching and cramping felt in the
missing limb. Which nursing statement would be appropriate to
assist in alleviating the child's fear?
a) "This aching and cramping is normal and temporary and will
subside."
b) "This normally occurs after the surgery and we will teach you
ways to deal with it."
c) "The pain medication that I give you will take these feelings
away."
d) "This pain is not real pain, and relaxation exercises will help it go
away." Correct Answer - A. After amputation, phantom limb
pain is a temporary condition that some children may experience.
This sensation of burning, aching, or cramping in the missing limb is
most distressing to the child. The child needs to be reassured that
the condition is normal and only temporary. Options 2, 3, & 4 are
inappropriate to the child. Use therapeutic communication
techniques. Note that the subject of the question relates to
alleviating the child's fear. Options 2, 3, & 4 imply that this pain may
be permanent. Review care of a child after amputation if you had
difficulty with this question.
,The nurse is assigned to care for a client with complete right-sided
hemiparesis. The nurse plans care knowing that in this condition:
a) the client has complete bilateral paralysis of the arms and legs
b) the client has weakness on the right side of the body, including
the face and tongue
c) the client has lost the ability to move the right arm but is able to
walk independently
d) the client has lost the ability to ambulate independently but is
able to feed and bathe himself or herself without assistance.
Correct Answer - B. Hemiparesis is a weakness of one side of the
body that may occur after a stroke. Complete hemiparesis is
weakness of the face and tongue, arm, and leg on one side. Complete
bilateral paralysis does not occur in this condition. The client with
right-sided hemiparesis has weakness of the right arm and leg and
needs assistance with feeding, bathing, and ambulating. Use the
process of elimination. Note the strategic words complete right-
sided and focus on the subject: hemiparesis. Recalling that
hemiparesis indicates weakness and focusing on the strategic words
will direct you to option B. Review the description of hemiparesis
and care of the client with hemiparesis if you had difficulty with this
question.
A nurse is caring for a child recently diagnosed with cerebral palsy,
and the parents of the child ask the nurse about the disorder. The
nurse bases her response on the understanding that cerebral palsy
is:
,a) An infectious disease of the central nervous system
b) An inflammation of the brain as a result of a viral illness
c) A congenital condition that results in moderately to severe
retardation
d) A chronic disability characterized by impaired muscle movement
and posture Correct Answer - D. Cerebral palsy is a chronic
disability characterized by impaired movement and posture
resulting from an abnormality in the extrapyramidal or pyramidal
motor system.
Meningitis is an infection process of the CNS.
Encephalitis is an inflammation of the brain that occurs as a result of
a viral illness or CNS infection.
Down syndrome is an example of a congenital condition that results
in moderate to severe retardation.
Use the process of elimination. Eliminate options 1&2 first, noting
that they are comparable or alike. Next, note the relationship
between the words "palsy" in the question and "impaired muscle
movement" in D.
A 32-year-old woman recently diagnosed with Hodgkin's disease is
admitted for staging by undergoing a bone marrow aspiration and
biopsy. To obtain more information about the client's nutrition
status the nurse should review the results of which of the following
tests?
, a) Albumin level.
b) Reticulocyte count.
c) Red blood cell count.
d) Direct and indirect bilirubin levels. Correct Answer - A-
Serum albumin levels help determine whether protein intake is
sufficient. Proteins are broken down into amino acids during
digestion. Amino acids are absorbed in the small intestine, and
albumin is built from amino acids. The red blood cell count, bilirubin
levels, and reticulocyte count do not indicate protein intake.
An infant underwent surgery to remove a myelomeningocele. The
infant has bulging fontanels. Which of the following is the nurse's
best action?
a) Calm the infant
b) Teach parent about procedure
c) Notify the healthcare provider
d) Reposition infant Correct Answer - C - Bulging fontanels in
an infant may indicated increased intracranial pressure, a possible
postoperative complication. Calming the infant, teaching the parent,
and repositioning the infant will not address the underlying
problem of increased intracranial pressure within the skull. Calling
the healthcare provider is indicated.
