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1.The registered nurse (RN) notifies the spouse of a client who was admitted to
hospice with shallow respirations, of a change in the client's condition. Over the
past hour, the client's respiratory pattern has changed to a Cheyne Stokes
pattern.After receiving this information, the client's spouse begins vacuuming
around the bed. Which stage of grief is the spouse displaying during the visit?
A. Acceptance.
B. Denial.
C. Bargaining.
D. Depression. - ANSWER -ANS: B
The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model
by ignoring that the client's death is imminent. (A, C, and D) are stages of grief that
are not being displayed by the client's spouse during this observation.
1.A client is admitted for dehydration, weight loss, and a flat affect. After
reviewing the client's history, the registered nurse (RN) discovers that the client's
spouse died 2 weeks ago. Which nursing interventions should the RN implement to
help the client begin the process of dealing with loss? (Select all that apply.)
A. Establish trust by creating an safe atmosphere for sharing.
B. Share personal stories about how other clients dealt with grief.
C. Help the client identify ways to adapt lifestyle to accommodate loss.
D. Assure the client that their grief will last a short period of time.
E. Explore ways to assist the client to make new emotional investments. -
ANSWER -ANS: A, C, E
(A, C, and E) are correct, and these interventions aid the client in maneuvering
through the stages of grieving and establishing a foundation to continue life.
Assisting the client in finding a support group and sharing stories of other clients
can be misconstrued as a violation of HIPPA rights of other clients (B). Each client
deals with grief differently, so offering a time line for grieving (D) is not an
expected outcome for this client and offers false reassurance.
2.The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD).
What assessment should the RN identify and document that is consistent with
PUD? (Select all that apply).
A. Hematemesis.
,B. Gastric pain on an empty stomach.
C. Colic-like pain with fatty food ingestion.
D. intolerance of spicy foods.
E. Diarrhea and stearrhea. - ANSWER -ANS: A, B, D
(A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain
(B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not
consistent with PUD.
3.The registered nurse (RN) is caring for a client with a newly placed nasogastric
tube (NGT). Once the placement of the NG tube is verified by x-ray, which
technique should the RN use as a reliable method to ensure the NGT is not
displaced?
A. Check pH of aspirated stomach contents obtained from the NGT.
B. Auscultate over the epigastrium while injecting air into the NGT.
C. Disconnect and place the end of NGT in water to see if bubbles appear.
D. Listen for hyperactive bowel sounds in all four quadrants of abdomen. -
ANSWER -ANS: A
Checking the pH of the aspirate (A) is the best method to validate that the NGT is
not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of
gastric acid. (B, C and D) are not reliable methods to ensure the NGT placement in
the stomach.
4.The registered nurse (RN) is evaluating a client who presents with symptoms of
viral gastroenteritis. Which assessment finding should the RN report to the
healthcare provider?
A. Dry mucous membranes and lips.
B. Rebound abdominal tenderness over right lower quadrant.
C. Dizziness when client ambulates from a sitting position.
D. Poor skin turgor over client's wrist. - ANSWER -ANS: B
RLQ rebound abdominal tenderness (B) may be related to acute appendicitis and
should be reported to the healthcare provider. (A, C and D) are expected findings
associated with gastroenteritis that are not urgent findings or life threatening.
5.A client is newly diagnosed with diverticulosis. The registered nurse (RN) is
assessing the client's basic knowledge about the disease process. Which statement
by the client conveys the client's understanding of the etiology of diverticula?
A. Over use of laxatives for bowel regularity result in loss of peristaltic tone.
B. Inflammation of the colon mucosa cause growths that protrude into the colon
lumen.
C. Diverticulosis is the result of high fiber diet and sedentary life style.
, D. Chronic constipation causes weakening of colon wall which result in out-
pouching sacs. - ANSWER -ANS: D
A client who has chronic constipation (D) often strains to pass constipated stool
which increases intestinal pressure that weakens the intestinal walls and causes
out-pouching sacs, called diverticula which commonly occur in the sigmoid.
Regular use of laxatives (A) can result in the bowel's dependency on laxative to
stimulate intestinal motility, but constipation due to lack of fiber in the diet, not
(C), is a predisposing factor for formation of diverticula. Growths that protrude
into the colon lumen are polyps (B), which are often pre-cancerous lesions.
6.The registered nurse (RN) is teaching a client who is being discharged after
treatment of tuberculosis (TB). Which cultural issues should the RN assess when
preparing the client for discharge? (Select all that apply.)
A. Native language.
B. Education level.
C. Type of lifestyle.
D. Previous medical history.
E. Financial resources. - ANSWER -ANS: A, B, C, D
(A, B, C and D) are correct. To ensure compliance, language (A), education (B),
lifestyle (C), and financial resources (D) should be considered when preparing the
client's discharge instructions about continued treatment of TB. (E) does not
directly impact compliance with long term treatment of TB.
7.A female client is recently diagnosed with Sarcoidosis. The client tells the
registered nurse (RN) that she does not understand why she has this. When
teaching about the occurrence of sarcoidosis, the RN should include that
sarcoidosis most commonly occurs with which ethnic group of women?
A. African American women.
B. Caucasian women.
C. Asian women.
D. Hispanic women. - ANSWER -ANS: A
Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has
shown presence in relatives due to multiple genes that together to increase the
susceptibility of developing the disease, which most commonly occurs in African
American women and women of Northern European heritage (A). (B, C, and D)
have a lower percentage of women affected by sarcoidosis than African American
women.
8.The registered nurse (RN) is making early morning rounds on a group of clients
when a client begins exhibiting symptoms of an acute asthma attack. The RN