Hesi Cat

HESI CAT HESI CAT A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology clinic. What sign related to this disorder does the nurse expect to find when assessing this infant? 1 Bradycardia at rest 2 Activity-related cyanosis 3 Bounding peripheral pulses 4 Murmur at the left sternal borderANS 4 A murmur at the left sternal border is the most characteristic finding in infants and children with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left ventricle to the lower pressure right ventricle. Children with VSDs generally have tachycardia and are often acyanotic. A bounding peripheral pulse is not a common finding in children with a VSD. A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item should the nurse teach the mother to use when administering the medication? 1 Nipple 2 Calibrated syringe 3 Plastic measuring spoon 4 Bottle containing an ounce of waterANS 2 A calibrated syringe or dropper provides the most accurate measurement of the medication. Using a nipple or spoon is not an accurate way to measure medication. If the dose of medication is diluted and the infant does not drink the entire ounce, the resulting dose will be insufficient. A 2-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure, but the anemia can be treated with frequent blood transfusions. The father tells the nurse he is glad that there is a treatment that "fixes" his child's problem. Before responding, the nurse should recall that blood transfusions do what? 1 Correct the anemia, but may cause other problems 2 Reverse the anemia, but also present a risk of hepatitis 3 Are a supportive treatment; fewer will be needed as the child grows older 4 Are a replacement for defective red blood cells; they are like giving insulin to a person with diabetesANS 1 Excess iron from hemolysis of the replaced red blood cells is deposited in the organs and body tissue, causing hemosiderosis. Chelation therapy is then required. With the practice of aseptic technique and screening of donated blood, hepatitis should not occur. Red blood cell replacement depends on the child's hematologic picture; the number of transfusions is not related to age. Although red blood cells are replaced, it is erroneous to compare this treatment with insulin therapy. A 6-year-old child with autism is nonverbal and makes limited eye contact. What should the nurse do initially to promote social interaction? 1 Encourage the child to sing songs with the nurse. 2 Engage in parallel play while sitting next to the child. 3 Provide opportunities for the child to play with other children. 4 Use therapeutic holding when the child does not respond to verbal interactions.ANS 2 Entering the child's world in a nonthreatening way helps promote trust and eventual interaction with the nurse. Using therapeutic holding may be necessary when a child initiates self-mutilating behaviors. Singing songs with the child participating or providing opportunities for the child to play with other children is unrealistic at this time; playing with others is a long-term objective. A 15-year-old client tearfully states that her father has been sexually abusing her for the past 8 years. What statement should the nurse initially respond with? 1 "Which type of incidents preceded the abuse?" 2 "Sharing this information is a positive step in getting help." 3 "I have to report this to child protective services right now." 4 "What kinds of things does he do to you when he abuses you?"ANS 2 "Sharing this information is a positive step in getting help" is an emotionally supportive response; it demonstrates that sharing this information is acceptable and provides hope that the client will get help. The client needs support, and asking what incidents preceded the abuse may precipitate or increase feelings of guilt. Telling the client that the abuse must be reported immediately to child protective services is not a priority at this time and may interfere with future sharing; the client needs immediate emotional support. Asking what the father did as part of the abuse implies that the client does not know what she is talking about; the client needs support, whether the abuse is real or imagined. A 16-year-old boy with a diagnosis of adolescent adjustment disorder and his family are beginning family therapy. What is the best initial nursing approach? 1 Setting long-term goals for the family 2 Letting the client express his feelings first 3 Having the parents explain their rationale for setting firm limits 4 Encouraging each family member to share how the problem is perceivedANS 4 Family therapy must include the whole family. Each member must be considered not just individually from his or her perspective but also as a member of the whole. Identification of the problem by the people involved is the priority. The family, not the nurse, sets goals. The nurse assists the family in setting goals by acting as a facilitator. Feelings should be shared eventually, but this is not the initial focus. Setting limits may or may not be a problem within the family. A 16-year-old client has a blood pressure reading of 119/75. What is the approximate pulse pressure? Record your answer using a whole number. __________ mm HgANS The difference between the systolic and diastolic pressure is called the pulse pressure. The given blood pressure is 119/75. The difference between 119 and 75 is 44. A 28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile, because she has been trying to become pregnant unsuccessfully for 2 years. While collecting the health history the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The primary healthcare provider diagnoses the condition polycystic ovarian syndrome (PCOS). Which of the following interventions is the most important? 1 Consoling the client over her inability to have children 2 Discussing weight loss, exercise, and a balanced low-fat diet 3 Providing information to the client on how to prepare for surgery 4 Informing the client that there are no long-term complications of PCOSANS 2 Weight loss, exercise, and a balanced low-fat diet can reduce insulin and androgen levels related to PCOS. Meeting with a dietitian may be helpful. Surgery is not necessary at this time. The primary healthcare provider would most likely prescribe hormones, other medications, or both. If pregnancy does not occur, surgery is an option. Pregnancy may be possible with hormones, other medications, or both. Early detection of PCOS is important, because the condition can lead to type 2 diabetes; hypertension; cardiovascular disease; and ovarian, breast, and endometrial cancers. The nurse should encourage treatment compliance and positive lifestyle changes. A 45-year-old client is scheduled to undergo a hysterectomy and expresses concern because she has heard from friends that she will experience severe symptoms of menopause after surgery. What is the nurse's most appropriate response? 1 "You're right, but there are medicines you can take that will ease the symptoms." 2 "Sometimes that happens in women of your age, but you don't need to worry about it right now." 3 "You should probably talk to your surgeon, because I am not allowed to discuss this with you." 4 "Women may experience symptoms of menopause if their ovaries are removed with their uterus."ANS 4 A hysterectomy involves only removal of the uterus. The ovaries, which secrete estrogen and progesterone, are not removed. Therefore menopause will not be precipitated but will occur naturally. Surgical menopause is precipitated by the removal of the ovaries, not the uterus. When the ovaries are removed, an older woman might have less severe symptoms than a younger woman; however, in this instance the ovaries are not removed. Telling the client that she needs to talk to her surgeon does not answer the question. The nurse should serve as a resource. A 56-year-old man is admitted to the inpatient unit after family members report that he seems to be experiencing auditory hallucinations. The man has a history of schizophrenia and has had several previous admissions. Which statement indicates to the nurse that the client is experiencing auditory hallucinations? 1 "Get these horrible snakes out of my room!" 2 "I am not the devil! Stop calling me those names!" 3 "The food on this plate has poison in it, so take it away—I won't eat it." 4 "I did see an alien spaceship last night outside in my yard, and I've felt worse ever since."ANS 2 The client is responding to messages that he is hearing, which are auditory hallucinations. The responses regarding the snakes and the spaceship are examples of visual hallucinations because they describe what the client sees. The accusation of poisoning is the statement of a client who is suspicious and paranoid but not hallucinating. A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. While taking the nursing history the nurse expects the client to state that one of the reasons she is having surgery is because she has been experiencing what? 1 Hematuria 2 Dysmenorrhea 3 Pain on urination 4 Stress incontinenceANS 4 Increased intraabdominal pressure associated with lifting, coughing, or laughing, in conjunction with a relaxed pelvic musculature and a bladder displaced into the vagina, results in inability to suppress urination. Hematuria is usually associated with urinary tract infection, bladder tumor, or renal calculi, not with cystocele or rectocele. Dysmenorrhea is usually associated with pelvic inflammatory disease, endometriosis, or cervical stenosis, not with cystocele or rectocele; the client is probably postmenopausal. Pain on urination is usually associated with urinary infection, not with cystocele or rectocele. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently. A 62-year-old client reports to the nurse, "My eyes don't feel right and I have a gritty and sandy sensation in my eyes." What condition might this client have? 1 Retinal detachment 2 Infection of the cornea 3 Changes in tear composition 4 Hemorrhage in the vitreous humorANS 3 Decreased tear formation or changes in the tear composition because of aging or various systemic diseases may cause dryness in the eye. This may manifest in eye discomfort and a sandy, gritty, or burning sensation. Retinal detachment may cause blurred vision. Infection of the cornea may result in photophobia. A vitreous humor hemorrhage manifests as spots or floaters seen in the field of vision. A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). How often does the nurse tell the parents to bring their baby back to the clinic for a cast change? 1 Each week 2 Once a month 3 When the cast edges fray 4 If the cast becomes soiledANS 1 Casts are changed weekly to accommodate the rapid growth of early infancy. Once a month is not frequent enough in early infancy; the cast may become too tight because of the infant's rapid growth. The cast is not on the foot long enough for fraying to occur. Soiling is usually not a problem, because casts for clubfoot do not extend to the perineal area. A child is diagnosed with classic hemophilia. A nurse teaches the child's parents how to administer the plasma component factor VIII through a venous port. It is to be given three times a week. When should the parents administer this therapy? 1 Whenever a bleed is suspected 2 In the morning on scheduled days 3 At bedtime while the child is lying quietly in bed 4 On a regular schedule at the parents' convenienceANS 2 Factor VIII has a short half-life; therefore prophylactic treatment involves administering the factor on the scheduled days in the morning so the child will get the most benefit during the day, while he is most active. Prophylactic treatment is administered on a scheduled basis to prevent bleeds from occurring. Administering the drug at bedtime will limit its effectiveness because bleeds are more common when the child is active. Administering the medicine on a regular schedule at the parents' convenience does not take into consideration the properties of the drug. A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The primary healthcare provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)? 1 QRS complex 2 S-T segment 3 P wave 4 R waveANS 2 In ECG tracing, the displacement of the S-T segment is caused by an active ischemic injury in the myocardium. The QRS complex, the P wave, and the R wave are not associated with an MI. A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse? 1 Dyspnea 2 Pulse rate of 62 beats/min 3 Blood pressure of 136/88 mm Hg 4 Homan sign in the left legANS 1 One complication of deep vein thrombosis is pulmonary embolism; dyspnea is a significant sign that should be reported immediately. A low pulse rate is common for several days after birth because of the cardiovascular changes that occur during the early postpartum period. A blood pressure of 136/88 mm Hg is not significant in a client with a deep vein thrombosis. Checking for the Homan sign is contraindicated, because the clot could be dislodged. A client at 40 weeks' gestation is admitted to the birthing unit in labor. During the initial examination the nurse uses Leopold maneuvers to palpate the abdomen. The purpose of this intervention is to assess the what? 1 Station of the fetus 2 Position of the fetus 3 Duration of the contractions 4 Frequency of the contractionsANS 2 Leopold maneuvers are used specifically to identify the position of the fetus. The nurse palpates the abdomen to locate the head, back, and small parts of the fetus; the locations of these parts reveal the position of the fetus. The station can be ascertained during a vaginal examination, which is not part of the Leopold maneuvers. Duration of the contractions is timed by lightly placing the examining hand on the fundus during a contraction or observing the electronic monitor. Frequency of contractions is timed by lightly placing the examining hand on the fundus for several minutes or by observing the electronic fetal monitor. A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan? 1 1 week 2 4 months 3 2 to 6 weeks 4 48 to 72 hoursANS 3 Although the usual incubation period of syphilis is about 3 weeks, clinical symptoms may appear as early as 9 days or as long as 3 months after exposure. The usual incubation period is 21 days. A client describes his delusions in minute detail to the nurse. How should the nurse respond? 1 Changing the topic to reality-based events 2 Continuing to discuss the delusion with the client 3 Getting the client involved in a social project with peers 4 Disputing the perceptions with the use of logical thinkingANS 1 Decreasing time spent on delusions prevents reinforcement of psychotic thinking. Discussing reality-based events improves contact with reality. Encouraging discussion will give validity to the delusion. The client will have difficulty getting involved in a social activity; the activity will not stop the delusion. Challenging the client may increase anxiety. A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain 1 week later. What does the nurse identify as the cause of the posttherapeutic neuralgia? 1 Damage to the nerves 2 Untreated major depression 3 Scarring in the area of the rash 4 Continued presence of the skin rashANS 1 After the original infection has healed, the virus either remains quiescent or it may return. Posttherapeutic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months. Untreated major depression and scarring in the area of the rash are unrelated to posttherapeutic neuralgia. The rash does not cause posttherapeutic neuralgia. A client develops a nonhealing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. Which would be the best response by the nurse? 1 "Muscle weakness occurs in the legs because of a lack of exercise." 2 "Edema and cyanosis occur in the legs because they are dependent." 3 "Pain occurs in the legs while walking because there is a lack of oxygen to the muscles." 4 "Pressure occurs in the legs because of vasodilation and pooling of blood in the extremities."ANS 3 Intermittent claudication is the pain that occurs during exercise because of a lack of oxygen to muscles in the involved extremities. It is exercise, not the lack of exercise, that precipitates muscle weakness. Edema and cyanosis in the legs and pressure in the legs are related to venous problems, not an arterial problem. A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? 1 Prevents extension of the clot 2 Reduces the size of the thrombus 3 Dissolves the blood clot in the vein 4 Facilitates absorption of red blood cellsANS 1 Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells. A client diagnosed with asthma has received a prescription for an inhaler. The nurse teaches the client how to determine when the inhaler is empty, instructing the client to do what? 1 Count the number of doses taken. 2 Taste the medication when sprayed into the air. 3 Shake the canister. 4 Place the canister in water to see if it floats.ANS 1 The only way to determine if the canister is empty is to count the number of doses taken. The client is tracking the number of daily doses. It is wasteful to spray medication into the air; tasting it from the air is not an effective method of determining if the canister is empty. Shaking the canister is not effective; even if there is no more medication, some propellant may be left. It is futile to place the canister in water; the flotation test is ineffective. A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information should the nurse share with the client? 1 Cool compresses decrease facial involvement. 2 Pain occurs with transient ischemic attacks (TIAs). 3 Most clients recover from the effects in several weeks. 4 Body changes should be expected with residual effects.ANS 3 The client should be assured that the symptoms are not caused by a stroke; the majority of clients recover in a few weeks. Moist heat, not a cool compress, increases blood circulation to the nerve. Bell palsy is not caused by a TIA. Paresis or paralysis of cranial nerve VII occurs; pain is usually present. The majority of clients recover without residual effects; occasionally some clients are left with evidence of Bell palsy. Exercises may help to maintain muscle tone; also, surgery may be necessary. A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client. What should the plan include? 1 Eliminating travel plans to combat anemia-related fatigue 2 Reinforcing a positive mental attitude to improve prognosis 3 Preventing infection; the client is at risk for leukopenia 4 Restricting fluid intake; the client is at risk for congestive heart failureANS 3 The bone marrow is impaired with multiple myeloma; the effectiveness of white blood cells and immunoglobulin is reduced, which increases susceptibility to bacterial infections. Travel can be accomplished with careful planning and adequate rest periods. Although a positive mental attitude can contribute to quality of life and may even extend life, generally it does not change the prognosis. The client is encouraged to drink plenty of fluids to help dilute the Bence Jones protein fragments in the urine, which may help prevent kidney damage. A client feeling increasingly tired seeks medical care. Type 1 diabetes is diagnosed. What causes increased fatigue with type 1 diabetes? 1 Increased metabolism at the cellular level 2 Increased glucose absorption from the intestine 3 Decreased production of insulin by the pancreas 4 Decreased glucose secretion into the renal tubulesANS 3 Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue. With diabetes there is decreased cellular metabolism because of the decrease in glucose entering the cells. Glucose is not absorbed from the intestinal tract by the cells; fatigue is caused by decreased, not increased, cellular levels of glucose. Filtration and excretion of glucose by the kidneys do not regulate energy levels; if insulin production is adequate, glucose does not spill into the urine. A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary, and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. 1. Insert the catheter without applying suction 2. Assess client's vital signs and lung sounds 3. Rotate the catheter while suction is applied 4. Administer oxygen via a ventilation bagANS The nurse should first assess the client's vital signs and lung sounds to determine if suctioning is needed. Then 100% oxygen should be administered to compensate for the lack of oxygen intake during the suctioning process. Suctioning should not be applied during catheter insertion to limit trauma. Rotating the catheter during withdrawal ensures thorough removal of secretions. A client has been taking the prescribed dose of clozapine. The nurse will assess the client for which life-threatening side effect of this drug? 1 Polycythemia 2 Agranulocytosis 3 Hypertensive crisis 4 PseudoparkinsonismANS 2 Agranulocytosis occurs in 1% to 2% of clients receiving clozapine and is potentially fatal; weekly blood counts are necessary. Polycythemia is not a side effect of clozapine. Clozapine may cause hypotension; hypertensive crisis is a side effect of monoamine oxidase inhibitors. Pseudoparkinsonism may occur, but it can be managed with anticholinergic medications. A client has laparoscopic surgery to remove a calculus from the common bile duct. What postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished? 1 Stools become brown 2 Liver tenderness is relieved 3 Colic is absent after ingestion of fats 4 Serum bilirubin level returns to the expected rangeANS 1 The return of brown color to the stool indicates that bile is entering the duodenum and being converted to urobilinogen by bacteria. Liver tenderness is unrelated to bile flow. The absence of biliary colic is related to the removal of the calculus, not the flow of bile. The serum bilirubin level is not affected. A client has primary open-angle glaucoma. The nurse expects that the client will receive a prescription for which eyedrops? 1 Tetracaine 2 Cyclopentolate 3 Timolol maleate 4 Atropine sulfateANS 3 Timolol maleate is a beta-adrenergic antagonist that decreases aqueous humor production and increases outflow, thereby reducing intraocular pressure. Tetracaine is a topical anesthetic; it will not reduce the increased intraocular pressure associated with glaucoma. Cyclopentolate is contraindicated because it dilates the pupil and paralyzes ciliary muscles. Atropine sulfate, a mydriatic, is contraindicated because it dilates the pupil, obstructing drainage, which increases intraocular pressure. A client has returned from surgery with a nephrostomy tube. Which is the most essential nursing intervention for this client? 1 Ensure free drainage of urine. 2 Milk the tube every 2 hours. 3 Keep an accurate record of intake and output. 4 Instill 12 mL of normal saline every 8 hours.ANS 1 The tube must be kept patent to prevent urine backup, hydronephrosis, and kidney damage. Milking the tube every 2 hours is unnecessary. Instill no more than 5 mL of normal saline only if prescribed. Although keeping an accurate record of intake and output is important, it will not ensure free drainage of urine, which is the priority. A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? Select all that apply. 1 Psoriasis 2 Trichinosis 3 Cardiac failure 4 Diabetes mellitus 5 Bacterial endocarditisANS 25 Thin, dark-red vertical lines about 1 to 3 mm long in the nails are associated with trichinosis (parasitic disease) and bacterial endocarditis (infection of the innermost layer of the heart and heart valves). Psoriasis, diabetes mellitus, and cardiac failure are associated with yellow-brown discoloration of the nails. A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam 7.5 mg intramuscularly stat is prescribed. Diazepam is available as 5 mg/mL. How many milliliters will the nurse administer? Record your answer using one decimal place. ___ mLANS 1.5 A client is admitted for a biopsy of a tumor in her left breast. The client states, "I know it can't be cancer, because it doesn't hurt." What is the nurse's most therapeutic response? 1 "Let's hope that it isn't malignant." 2 "What do you know about breast cancer?" 3 "Most lumps in the breast are not malignant." 4 "Has your primary healthcare provider told you that it wasn't cancer?"ANS 2 Asking what the client knows about breast cancer allows the nurse to assess the client's understanding of breast cancer and to clarify any misconceptions. Saying that they should hope that the growth isn't malignant avoids an opportunity to teach, and it is a type of false reassurance. The statement may actually increase feelings of hopelessness if the lesion is determined to be malignant. Although correct, stating that most lesions are benign provides a false sense of security and avoids an opportunity to teach. Asking whether the primary healthcare provider has told the client that it wasn't cancer focuses on what the primary healthcare provider said rather than on what the client knows and may limit further communication of feelings and beliefs. A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for indicators that strangulation of the intestine may have occurred. What is an early indicator of strangulation? 1 Increased flatus 2 Projectile vomiting 3 Sharp abdominal pain 4 Decreased bowel soundsANS 3 Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia. Flatus is impeded by strangulation. Vomiting is persistent, not projectile. Decreased bowel sounds are not an early sign of obstruction; decreased bowel sounds occur after gas and fluid accumulate. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past. A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. The nurse performs an immediate appraisal, using the rule of nines. Which percentage of body surface area burned will the nurse record? 1 18% 2 22.5% 3 27% 4 36.5%ANS 2 Based on the rule of nines, the entire right lower extremity is 18%, and the anterior portion of the right upper extremity is 4.5%; 18 + 4.5 = 22.5. The calculation 18% is too small a percentage based on the rule of nines; 27% and 36.5% are too large. A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client? 1 Helping the client enter into group recreational activities 2 Convincing the client that the hospital staff is trying to help 3 Helping the client learn to trust the staff through selected experiences 4 Limiting the client's contact with others while in the hospitalANS 3 Demonstrating that the staff can be trusted is a vital initial step in the therapy program. The client is not ready to enter group activities yet and will not be until trust is established. Even proof will not convince the client with a schizoid personality that feelings of distrust are false. Arranging the client's contact with others is not realistic even if it is possible; limiting contact with other clients will not enhance trust. A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential? 1 Fundal height 2 Obstetric history 3 Time of the last meal 4 Family history of bleeding disordersANS 1 It is vital that a baseline measurement be obtained, because increasing fundal height may be a sign of concealed hemorrhage. Taking an obstetric history, ascertaining the time of the last meal, and asking about a family history of bleeding disorders are all appropriate assessments; however, none are a priority at this critical time. A client is admitted to the cardiac care unit with a diagnosis of myocardial infarction. The client asks the nurse, "What is causing the pain I am having?" Which explanation of the cause of the pain is the most appropriate response by the nurse? 1 Compression of the heart muscle 2 Release of myocardial isoenzymes 3 Rapid vasodilation of the coronary arteries 4 Inadequate oxygenation of the myocardiumANS 4 Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain. A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? Select all that apply. 1 Feeling tired 2 Rectal bleeding 3 Inability to digest fat 4 Change in the shape of stools 5 Feeling of abdominal bloatingANS 1245 Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. Passage of red blood (hematochezia) is one of the cardinal signs of rectosigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbonlike or pencil thin. Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Stool in the descending and sigmoid colon is more formed, and thus straining to pass stools, gas pains, cramping, and incomplete evacuation commonly occur. An inability to digest fat is not specific to rectosigmoid colon cancer. A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client? 1 Stop smoking 2 Control blood glucose 3 Start a walking program 4 Eat a low-fat, low-cholesterol dietANS 1 Smoking is the single most important risk factor for peripheral arterial diseases, and cessation should be encouraged. Although hyperglycemia is a contributing factor, it is not the primary risk factor for LEAD. Although a sedentary lifestyle is a contributing factor, it is not the primary risk factor for LEAD. Although a high-fat, high-cholesterol diet is a contributing factor, it is not the primary risk factor for LEAD. A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical? 1 Edema of the feet and ankles 2 Reddened and painful areas on the calves 3 Pain when exercising and thickening of the toenails 4 Ulcers around the ankles and reports of a dull ache in the legsANS 3 Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure. A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history? 1 Cystitis as an adult 2 Pleurisy as an adult 3 Childhood strep throat 4 Childhood German measlesANS 3 Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart. A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker? 1 Angina 2 Chest pain 3 Heart block 4 TachycardiaANS 3 Heart block is the primary indication for a pacemaker because there is an interference with the electrical conduction of impulses from the atria to the ventricles of the heart. The primary treatment for angina is medication; angina is not an indication for a pacemaker. The primary treatment for chest pain is medication; chest pain is not an indication for a pacemaker. The primary treatment for tachycardia is medication; tachycardia is not an indication for a pacemaker. A client is admitted to the hospital with the diagnosis of acute salmonellosis. Which priority medication will the nurse prepare to administer? 1 Opioids 2 Antacids 3 Electrolytes 4 AntidiarrhealsANS 3 Fluids of dextrose and normal saline and electrolytes are administered to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output. Opioids and antidiarrheals are not used when there is a possibility of bacterial infection because slowed peristalsis decreases excretion of the salmonella organism. Salmonellosis is an infection, not a condition caused by hyperacidity and does not require antacids. A client is admitted to the hospital with the diagnosis of severe anxiety. What should the nurse's plan of care for a client with an anxiety disorder include? 1 Promoting the suppression of anger by the client 2 Supporting the verbalization of feelings by the client 3 Encouraging the client to limit anxiety-related behaviors 4 Restricting the involvement of the client's family during the acute phaseANS 2 Freedom to ventilate feelings serves as a safety valve to reduce anxiety. The suppression of anger may increase the client's anxiety. Encouraging the client to limit anxiety-related behaviors is not therapeutic; it may increase the anxiety that the client is feeling. Restricting the involvement of the client's family during the acute phase may or may not be helpful; the client's family may provide support to the client. A client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt? 1 "I don't feel too good today." 2 "I feel much better; today is a lovely day." 3 "I feel a little better, but it probably won't last." 4 "I'm really tired today, so I'll take things a little slower."ANS 2 A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide. "I don't feel too good today"; "I feel a little better, but it probably won't last"; and "I'm really tired today, so I'll take things a little slower" are all typical of the depressed client; none of these statements signals a change in mood. A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? 1 Raise the drainage system to bed level and check its patency 2 Clamp the tube when moving the client from the bed to a chair 3 Mark the time and fluid level on the side of the drainage chamber 4 Secure the chest catheter to the wound dressing with a sterile safety pinANS 3 The fluid level and time must be marked so that the amount of drainage in the chest tube drainage system can be evaluated. The drainage system must be kept below chest level to promote drainage of the pleural space so the lungs can expand. Clamping the tube can produce backpressure, which may cause fluid to move into the pleural space from which it came, producing a tension pneumothorax. The catheter is secured by skin sutures, not to a dressing with a safety pin. A client is admitted to the psychiatric unit with the diagnosis of obsessive-compulsive disorder. The client washes her hands more than 20 times a day, and they are raw and bloody. What defense mechanism does the nurse conclude that the client is using to ease anxiety? 1 Undoing 2 Projection 3 Introjection 4 DisplacementANS 1 Undoing is an act that partially negates a previous one; the client is using this defense mechanism to atone for unacceptable acts or wishes. The client is not attributing self-thoughts or impulses to another person or group, which is called projection. The client is not absorbing into the self a hated or loved object (introjection). Displacement is the transferring of feelings from one person, object, or experience onto another, less threatening person, object, or experience. A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what? 1 Lower blood pressure 2 Prevent hypoglycemia 3 Increase cardiac output 4 Decrease fluid in the brainANS 4 Osmotic diuretics remove excessive cerebrospinal fluid (CSF), reducing intracranial pressure. Osmotic diuretics increase, not decrease, the blood pressure by increasing the fluid in the intravascular compartment. Osmotic diuretics do not directly influence blood glucose levels. Although there is an increase in cardiac output when the vascular bed expands as CSF is removed, it is not the primary purpose for administering the medication. A client is admitted with paresis of the ciliary muscles of the left eye. What function should the nurse expect to be affected? 1 Closing the eyelids 2 Convergence of both eyes 3 Ability to discriminate colors 4 Focusing the lens on near objectsANS 4 The contraction of the ciliary muscles permits the lens to return to its normal bulge and decreases focal length, promoting the ability to focus on near objects. The ciliary muscles are intrinsic (within the eyeball); the third cranial nerve (oculomotor), an extrinsic nerve, controls some movements of the eyelid. The rectus and oblique muscles of the eye are involved in convergence. Color blindness is an inherited trait. A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites? 1 Observe the client for signs of respiratory distress. 2 Percuss the client's abdomen and listen for dull sounds. 3 Palpate the lower extremities over the tibia and observe for edema. 4 Listen for decreased or absent bowel sounds while auscultating the abdomen.ANS 2 Percussing over the client's abdomen will produce a dull, not tympanic, sound if fluid is present. Respiratory distress occurs with ascites, but it is not an early sign; the client does not have ascites but is at risk for ascites at this time. Palpating the lower extremities assesses for dependent edema, not ascites. Ascites is fluid within the peritoneal cavity. Bowel sounds may be heard with developing ascites; when ascites is extensive, bowel sounds may diminish. A client is brought by ambulance to the emergency department. The client's signs and symptoms are indicative of opioid overdose. What does the nurse expect the primary healthcare provider to prescribe? 1 Naloxone 2 Methadone 3 Epinephrine 4 AmphetamineANS 1 This drug is an opioid antagonist that displaces opioids from receptors in the brain, reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will accelerate the effects of the overdose. Epinephrine will have no effect on respiratory depression stemming from of an overdose of a narcotic. Amphetamine is a stimulant, not an opioid antagonist. A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? 1 Correct hyperkalemia 2 Increase urinary output 3 Prevent respiratory acidosis 4 Increase serum calcium levelsANS 1 The 50% glucose and regular insulin infusion treats the hyperkalemia associated with kidney failure; it moves potassium from the intravascular compartment into the intracellular compartment. Insulin will not increase urinary output. Insulin is not a treatment for respiratory acidosis. Insulin and glucose do not increase serum calcium levels. A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply. 1 Fatigue 2 Dry skin 3 Insomnia 4 Intolerance to heat 5 Progressive weight gainANS 125 Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? 1 Inept 2 Eccentric 3 Impulsive 4 DependentANS 3 Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder. A client is noted to have thickened toenails that overhang the toes. The registered nurse suspects a fungal infection and instructs the student nurse to examine the fungal infection to confirm the diagnosis. Which action of the student nurse needs correction? 1 Cutting the client's fingernails straight across 2 Using the client's fingernails for assessing capillary refill 3 Using the nail appearance alone for assessing fungal infection 4 Assessing skin next to the nail to determine whether the thick nail is irritating the skinANS 3 The nurse should not consider the nail appearance alone for assessing a fungal infection but should assess the toenails and the underlying skin to confirm the diagnosis. The nurse should cut the thickened toenails straight across to prevent discomfort. Fingernails are used for assessing capillary refill. The nurse should assess the skin next to the nail to determine the irritation caused by the thickened nail. A client is prescribed uterine stimulants to augment labor. Which condition should be assessed in the client before initiating therapy? 1 Liver disease 2 Pituitary tumors 3 Pelvic inflammatory disease 4 Presence of an intrauterine deviceANS 3 Labor-inducing drugs are contraindicated in women who have pelvic inflammatory disease. Ovarian stimulants are contraindicated in women who have liver disease and pituitary tumors. Abortifacient drugs are contraindicated in women who have intrauterine devices. A client is receiving an antipsychotic medication. When assessing the client for signs and symptoms of pseudoparkinsonism, the nurse will be alert for which complication? 1 Drooling 2 Blurred vision 3 Muscle tremors 4 PhotosensitivityANS 3 Drug-induced parkinsonism presents with the classic triad of adaptations associated with Parkinson disease: rigidity, slowed movement (bradykinesia), and tremors. The anticholinergic effects of antipsychotic medication cause dry mouth, not drooling. Neither dry mouth nor drooling is related to pseudoparkinsonism. Blurred vision and photosensitivity are side effects of anticholinergic, not antipsychotic, medications. A client is receiving hydrochlorothiazide. What should the nurse monitor to best determine the effectiveness of the client's hydrochlorothiazide therapy? 1 Blood pressure 2 Decreasing edema 3 Serum sodium level 4 Urine specific gravityANS 1 Diuretics promote urinary excretion, which reduces the volume of fluid in the intravascular compartment, thus lowering blood pressure. Edema reflects multiple physiologic processes including venous competence, gravity, and disuse. The serum sodium level remains stable unless the dosage is excessive; an altered sodium level is not a therapeutic response. Although specific gravity decreases with increased urinary output, this does not reflect the desired reduction in intravascular pressure. A client is to receive conscious sedation during a cardiac catheterization. Which route of administration should the nurse explain will be used to deliver the conscious sedation? 1 Via a face mask 2 Into the epidural space 3 Through an intravenous catheter 4 Around the nerves innervating the chest wallANS 3 Conscious sedation is administered by direct intravenous (IV) injection or IV push to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. A nerve block, a type of regional anesthesia, is achieved by injection of the anesthetic agent into or around the nerves supplying the area; it interrupts sensory, motor, and sympathetic transmission. A client newly diagnosed with scleroderma states, "Where did I get this from?" How should the nurse reply? 1 "The exact cause is unknown, but it is thought to be a result of autoimmunity." 2 "The exact cause is unknown, but it is thought to be a result of ocular motility." 3 "The exact cause is unknown, but it is thought to be a result of increased amino acid metabolism." 4 "The exact cause is unknown, but it is thought to be a result of defective sebaceous gland formation."ANS 1 Scleroderma is an immunologic disorder characterized by inflammatory, fibrotic, and degenerative changes. Ocular motility, increased amino acid metabolism, and defective sebaceous gland formation are not involved in the development of scleroderma. A client on a psychiatric unit who has been hearing voices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make? 1 "You have to take your medicine." 2 "This is the medication that your healthcare provider ordered." 3 "This will help you not to hear the voices. It will only work if you take it." 4 "There must be a reason that you don't want to take your medicine."ANS 3 Telling the client that the provider wants him or her to take the medication and instructing him or her to do so presents reality and simply states the expected behavior. Explaining what the medication will do for the client is an appropriate nursing intervention. Telling the client that he or she has to take the medication is an authoritarian, not a therapeutic, statement. The client has the right to refuse medication. Telling the client that the medication has been prescribed for him or her does not tell the client what behavior is expected. Noting that there must be a reason that the client doesn't want to take the medication assumes that the client does not want to take medication, even though the client may simply not understand what to do. A client presents to the emergency department with weakness, dizziness, and difficulty breathing. The nurse performs an electrocardiogram (ECG) and notices this arrhythmia. Which arrhythmia is the client exhibiting? 1 Atrial fibrillation (AF) 2 Ventricular tachycardia (VT) 3 Junctional tachycardia 4 Supraventricular tachycardia (SVT)ANS 1 AF can be chronic or intermittent. Note the wavy baseline with uncoordinated atrial electrical activity and irregular ventricular rhythm. AF clients who have valvular disease are particularly at risk for venous thromboembolism (VTE). Symptoms depend upon the ventricular rate and, if rapid, the client can experience fatigue, weakness, shortness of breath, dizziness, anxiety, syncope, palpitations, chest discomfort, and hypotension. Clients should be monitored carefully for these complications. Some clients can be asymptomatic. VT is a rapid ventricular rate typically between 140 and 250 beats per min and characterized by wide bizarre QRS complexes. Clients exhibiting junctional tachycardia may have no P waves or inverted P waves and a rate greater than 100. SVT involves the rapid stimulation of atrial tissue at a rate of over 150 beats per min in adults. During SVT, P waves may not be visible, especially if there is a 1:1 conduction with rapid rates because the P waves are embedded in the preceding T wave. SVT may occur in healthy young people, especially women. A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? Select all that apply. 1 Polyuria 2 Sedation 3 Bradycardia 4 Dilated pupils 5 Slow respirationsANS 235 The central nervous system (CNS) depressant effect of morphine causes sedation. The CNS depressant effect of morphine causes bradycardia. The CNS depressant effect of morphine causes bradypnea. Morphine does not increase urine output. Morphine causes constriction of pupils. A client reports fever, headache, extreme tiredness, dry cough, sore throat, runny nose, muscle aches, nausea, vomiting, and diarrhea. Which organism is responsible for this condition? 1 Influenza virus 2 Toxoplasma gondii 3 Human herpes virus-8 4 Cryptosporidium murisANS 1 Fever, headache, extreme tiredness, dry cough, sore throat, runny nose, muscle aches, nausea, vomiting, and diarrhea are symptoms of influenza. Influenza is caused by the Influenza virus. Toxoplasma gondii causes fever, altered mental status, headache, and seizures. Human herpes virus-8 causes vascular lesions on the skin. Cryptosporidium muris causes watery diarrhea and weight loss. A client reports swelling of the scrotum with no pain. Which condition does the nurse anticipate in the client? 1 Chancroid 2 Hydrocele 3 Spermatocele 4 Incarcerated herniaANS 2 Unilateral or bilateral swelling of the scrotum without pain is a clinical manifestation of a hydrocele; therefore, this is what the nurse anticipates the client to have. Chancroid is manifested by papular or irregularly shaped nonindurated, pus-filled ulcers on the penis. A translucent, wormlike appearance of the scrotum is a characteristic of spermatocele. Swelling and pain in the scrotum are the clinical manifestations of incarcerated hernia. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. A client seeking advice regarding contraception asks a nurse to explain how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond? 1 "It covers the entrance to the cervical os." 2 "The openings to the fallopian tubes are blocked." 3 "The sperm are kept from reaching the vagina." 4 "It produces a spermicidal intrauterine environment."ANS 4 Intrauterine devices produce a spermicidal intrauterine environment. A copper IUD inflames the endometrium, damaging or killing sperm and preventing fertilization and/or implantation. A levonorgestrel-releasing IUD damages sperm and causes the endometrium to atrophy, thus preventing fertilization and/implantation. A diaphragm blocks the cervical os. The IUD does not act by blocking the openings to the fallopian tubes. Preventing sperm from reaching the vagina is the function of a condom. A client tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her history reveals amenorrhea for the last 2 months and pregnancy confirmation after her first missed period. What type of abortion is suspected? 1 Missed 2 Inevitable 3 Threatened 4 IncompleteANS 3 Spotting in the first trimester may indicate that the client is having a threatened abortion; any client with the possibility of hemorrhage should not be left alone, so her admission to the hospital helps ensure her safety. A missed abortion may not cause any outward signs or symptoms, except that the signs of pregnancy disappear. An inevitable abortion can be confirmed only if vaginal examination reveals cervical dilation. With an incomplete abortion some, but not all, of the products of conception have been expelled. A client tells the nurse, "A man is speaking to me from the corner of the room. Can you hear him?" How should the nurse respond? 1 "What's he saying to you? Does it make any sense?" 2 "Yes, I hear him, but I can't understand what he's saying." 3 "I don't hear him. There's no one in the corner of the room." 4 "No, I don't hear him, but is it making you uncomfortable to hear him?"ANS 4 The statement "No, I don't hear him, but is it making you uncomfortable to hear him?" points out reality, identifies potential feelings, and prevents the nurse from supporting the hallucination. Asking what the man is saying to the client and whether it makes any sense is nontherapeutic because it supports and focuses on the hallucination. "Yes, I hear him, but I can't understand what he is saying" is nontherapeutic because it supports and focuses on the hallucination; also, it is not truthful. Although denying hearing the voice and pointing out that there is no one else in the room points out reality, this statement does not focus on the client's feelings. A client undergoes dilation and curettage (D & C) after an early miscarriage (spontaneous abortion). The nurse finds her crying later in the day. What is the most appropriate statement by the nurse at this time? 1 "This must be a very difficult experience for you to deal with." 2 "You'll have other children to take the place of the one you lost." 3 "Of course you're sad now, but at least you know you can get pregnant." 4 "I know how you feel, but when a woman miscarries, it's usually for the best."ANS 1 Saying that this must be a difficult experience acknowledges the validity of the client's grief and provides the client an opportunity to talk if she wishes. Other children cannot and should not be substituted for a lost fetus. Getting pregnant is not the issue; this statement belittles the lost fetus. The nurse cannot know how the client feels. Stating that a miscarriage is for the best is patronizing and diminishes the significance of the lost fetus. A client visits a primary healthcare provider with a report of burning and a sharp pain in the sole of the foot that intensifies in the morning. Which abnormal condition does the nurse anticipate in the client? 1 Torticollis 2 Pes planus 3 Tenosynovitis 4 Plantar fasciitisANS 4 Plantar fasciitis is a condition associated with a burning sensation and sharp pain in the sole of the foot that worsens in the morning. Torticollis is a condition where the neck is twisted in an unusual position to one side. Pes planus is the abnormal flatness of the sole and arch of the foot. Tenosynovitis is a condition associated with a superficial swelling pain and tenderness along a tendon sheath. A client was administered oxytocin to induce labor, but the client was not responsive to the treatment. Which oral uterine stimulant is the next choice in this condition? 1 Misoprostol 2 Mifepristone 3 Dinoprostone 4 MethylergonovineANS 1 Misoprostol is an oral uterine stimulant that helps in inducing labor when the uterus is insensitive to oxytocin. Mifepristone can induce elective abortion. Dinoprostone induces the uterine contractions but is only available for vaginal use. Methylergonovine helps to prevent postpartum hemorrhage. A client who had surgery for a ruptured appendix develops peritonitis. Which clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply. 1 Fever 2 Hyperactivity 3 Extreme hunger 4 Urinary retention 5 Abdominal muscle rigidityANS 15 A moderate fever is associated with inflammation of the peritoneal membrane. Muscular rigidity over the affected area is a classic sign of peritonitis. Malaise, rather than hyperactivity, is often associated with peritonitis. Nausea, not hunger, is a common occurrence with peritonitis. Urinary retention may occur following surgery as a complication of anesthesia, not peritonitis. A client who has been experiencing double vision, drooping of the eyelids, and fatigue visits the neurologic clinic. A diagnosis of myasthenia gravis is made, and the healthcare provider prescribes pyridostigmine. The nurse should teach the client that it is important to take this drug based on what schedule? 1 On an empty stomach 2 One hour before meals 3 According to muscle strength 4 At the exact time intervals prescribedANS 4 Taking the medication as prescribed promotes an even therapeutic blood level, which maintains muscle strength. Because of drug-related nausea and gastric irritation, the drug should be taken with crackers or milk. Thirty, not 60, minutes before meals is recommended for maximum chewing and swallowing function. Taking the drug according to muscle strength is unsafe because it will not maintain constant therapeutic drug levels. A client who has missed two menstrual periods tells a nurse at the prenatal clinic that the home pregnancy test was positive. Her last menstrual period began on June 18. According to Nägele's rule, what is the estimated date of birth (EDB)? 1 March 8 2 March 11 3 March 1 4 March 25ANS 4 March 25 is the EDB. Using Nägele's rule, take the first day of the last menstrual period (June 18), subtract 3 months, and then add 7 days. March 8, March 11, and March 1 are incorrect calculations according to Nägele's rule. A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravidarum. She is to be maintained at home with rehydration infusion therapy. What is the priority nursing activity for the home health nurse? 1 Determining fetal well-being 2 Monitoring for signs of infection 3 Monitoring the client for signs of electrolyte imbalances 4 Teaching about changes in nutritional needs during pregnancyANS 3 Rehydration fluids contain only saline and dextrose; if the client continues to vomit, she will lose electrolytes. Monitoring the fetus is not the priority at this time. Although there is a danger of infection when an intravenous line is in place, monitoring for it is not the priority. Teaching about nutritional needs is a nontherapeutic nursing action while the client is still vomiting. A client who retired a year ago tells the nurse in the community health center, "I don't have any hobbies or interests, and since I retired I feel useless and unneeded." According to Erikson's developmental theory, with which developmental conflict is the client faced? 1 Initiative versus guilt 2 Integrity versus despair 3 Intimacy versus isolation 4 Identity versus role confusionANS 2 Integrity versus despair is the task of the older adult; this client has not adapted to triumphs and disappointments, so there is no acceptance of what life is and was; this results in feelings of despair and disgust. Initiative versus guilt is the task of the preschool period. Intimacy versus isolation is the task of the young adult. Identity versus role confusion is the task of the adolescent. A client who sustained burn injuries due to a fire and explosi