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NO.1 Prior to an amniocentesis, a fetal ultrasound is done in order to:
A. Evaluate fetal lung maturity
B. Evaluate the amount of amniotic fluid
C. Locate the position of the placenta and fetus
D. Ensure that the fetus is mature enough to perform the amniocentesis
Answer: C
Explanation:
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can
be used for gestational dating, although it does not separately determine lung
maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to
determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid
for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to
avoid needle injuries, and the test evaluates the position of the placenta and the
fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of
pregnancy.
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease
,Answer: D
Explanatio
n:
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic
on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have
the disease but must be carriers. (D) If a trait is recessive, two genes (one from each
parent) are necessary to produce an affected child.
NO.3 A female client has just died. Her family is requesting that all nursing staff leave
the room. The family's religious leader has arrived and is ready to conduct a ceremony
for the deceased in the room, requesting that only family members be present. The
nurse assigned to the client should perform the appropriate nursing action, which
might include:
A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in
client rooms
.
B. Refuse to leave the room because the client's body is entrusted in the nurse's care
until it can be brought to the morgue.
C. Tell the family that they may conduct their ceremony in the client's room;
however, the nurse must attend.
D. Respect the client's family's wishes.
Answer: D
Explanatio
n:
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the
statement is true, the nurse should show evidence of the policy to the family and
suggest alternatives, such as the hospital chapel. (B) Refusal to leave the room
demonstrates a lack of understanding related to the family's need to grieve in their
own manner. (C) The nurse should leave the room and allow the
,family privacy in their grief. (D) The family's wish to conduct a religious ceremony in
the client's room is part of the grief process. The request is based on specific cultural
and religious differences dictating social customs.
NO.4 A 10-year-old client with a pin in the right femur is immobilized in traction. He is
exhibiting behavioral changes including restlessness, difficulty with problem solving,
inability to concentrate on activities, and monotony. Which of the following nursing
implementations would be most effective in helping him cope with immobility?
A. Providing him with books, challenging puzzles, and games as diversionary activities
B. Allowing him to do as much for himself as he is able, including learning to do pin-
site care under supervision
C. Having a volunteer come in to sit with the client and to read him stories
D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the
client's position frequently
Answer: B
Explanation:
(A) These activities could be frustrating for the client if he is having difficulty with
problem solving and concentration. (B) Selfcare is usually well received by the child,
and it is one of the most useful interventions to help the child cope with immobility.
(C) This may be helpful to the client if he has no visitors, but it does little to help him
develop coping skills. (D) This will helpto prevent skin irritation or breakdown related
to immobility but will not help to prevent behavioral changes related to immobility.
NO.5 A violent client remains in restraints for several hours. Which of the following
interventions is most appropriate while he is in restraints?
, A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints
and as they are removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
Answer: D
Explanatio
n:
(A) Fluids (nourishment) should be offered at regular intervals whether the client
requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities
should be checked regularly while the client is restrained, not only before restraints
are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the
client remains agitated in restraints, vital signs should be monitored even more
closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for
exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and
circulation.
NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has
placed her on oral griseofulvin. The nurse should emphasize which of these
instructions to the mother and/or child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
Answer: D
Explanatio
n: