Wednesday, 27 January 2016

PRACTICE QUESTIONS PART =09 ANSWERS &RATIONALE


NCLEX PRACTICE QUESTIONS PART - 09 ANSWERS AND RATIONALES... 

[Q.NO.1 - 100 ]


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Answers and Rationales 

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1.  Answer  B  is  correct.  

The  nurse  should  check  the  client’s  immunization  record  to determine  the  date  of  the  last  tetanus  immunization.  The  nurse  should  question the  client  regarding  allergies  to  medications  before  administering  medication; therefore,  answer  A  is  incorrect.  Answer  C  is  incorrect  because  a  sling,  not  a spint,  should  be  applied  to  imimobilize  the  arm and  prevent  dependent  edema. Answer  D  is  incorrect  because  pain  medication  would  be  given  before  cleaning and dressing the wound, not afterward.  






2.  Answer D is  correct.  
Watery  vaginal  discharge  and  painless  bleeding  are associated  with  endometrial  cancer.  Frothy  vaginal  discharge  describes trichomonas  infection;  thick,  white  vaginal  discharge  describes  infection  with candida  albicans;  and  purulent  vaginal  discharge  describes  pelvic inflammatory disease. Therefore, answers A, B, and C are incorrect.  




3.  Answer A  is  correct.  Stereotactic  surgery  destroys  areas  of  the  brain responsible  for  intractable  tremors.  The  surgery  does  not  increase production  of  dopamine,  making  answer B  incorrect.  Answer C is  incorrect because  the  client  will  continue  to  need  medication.  Serotonin  production  is not associated with Parkinson’s disease; there-fore, answer D is incorrect.  

4.  Answer  D  is  correct.  
The  client  with  AIDS  should  not  drink  water  that  has  been  sitting longer  than  15  minutes  because  of  bacterial  contamination.  Answer  A  is  incorrect because  ice  water  is  not  better  for  the  client.  Answer  B  is  incorrect  because  juices should not replace water intake. Answer C is not an accurate statement.  



5.  Answer  B  is  correct.  
The  finding  that  differentiates  interstitial  cystitis  from other forms  of  cystitis  is  the  absence  of  bacteria  in  the  urine.  Answer  A  is  incorrect because  symptoms  that  include  burning  and  pain  on  urination  characterize  all forms  of  cystitis.  Answer  C  is  incorrect  because  blood  in  the  urine  is  a characteristic  of  interstitial  as  well  as  other  forms  of  cystitis.  Answer  D  is  an incorrect statement because females are affected more often than males. 




6.  Answer  B  is  correct.  Approximately  99% of  males  with  cystic  fibrosis  are sterile  due  to  obstruction  of  the  vas  deferens.  Answers  A,  C,  and  D  are  incorrect because most males with cystic fibrosis are incapable of reproduction.  




7.  Answer  B  is  correct.  
Infants  under  the  age  of  2  years  should  not  be  fed  honey because  of  the  danger  of  infection  with  Clostridium  botulinum.  Answers  A,  C, and D are not related to the situation; therefore, they are incorrect.  




8.  Answer  C  is  correct.  
Children  with  autistic  disorder  engage  in  ritualistic behaviors  and  are  easily  upset  by  changes  in  daily  routine.  Changes  in  the environment  are  usually  met  with  behaviors  that  are  difficult  to  control.  Answers A, B, and D are incorrect because they do not focus on autistic disorder.  



9.  Answer  A is  correct.  
The  degree  of  pulmonary  involvement  is  the  greatest  determinant  in  the  prognosis  of  cystic  fibrosis.  Answers  B,  C,  and  D  are  affected  by  cystic fibrosis;  however,  they  are  not  major  determinants  of  the  prognosis  of  the  disease.   
10.  Answer  A  is  correct.  Decreased  blood  pressure  and  increased  pulse  rate are  associat-ed  with  bleeding  and  shock.  Answers  B,  C,  and  D  are  within normal limits; thus, incor-rect.  




11.  Answer D is  correct.  
Early  decelerations  during  the  second  stage  of  labor are  benign  and  are  the  result  of  fetal  head  compression  that  occurs  during normal  contractions.  No  action  is  necessary  other than  documenting  the finding  on  the  flow  sheet.  Answers  A,  B,  and  C  are  interventions  for the  client with late decelerations, which reflect ureteroplacental insufficiency.  




12.  Answer  B  is  correct.  
The  client’s  statement  that  meat  should  be  thoroughly  cooked to  the  appropriate  temperature  indicates  an  understanding  of  the  nurse’s  teaching regard-ing  food  preparation.  Undercooked  meat  is  a  source  of  toxoplasmosis  cysts.   Toxoplasmosis  is  a  major  cause  of  encephalitis  in  clients  with  AIDS.  Answer  A  is incor-rect  because  fresh-ground  pepper  contains  bacteria  that  can  cause  illness in  the  client  with  AIDS.  Answer  C  is  an  incorrect  choice  because  cheese  contains molds  and  yogurt  contains  live  cultures  that  the  client  with  AIDS  must  avoid. Answer  D  is  incorrect  because  fresh  fruit  and  vegetables  contain  microscopic organisms that can cause illness in the client with AIDS.  



13.  Answer  D  is  correct.  
The  client  taking  isoniazid  should  have  a  negative  sputum  culture  within  3  months.  Continued  positive  cultures  reflect  noncompliance  with  therapy  or the  development  of  strains  resistant  to  the  medication.  Answers  A,  B,  and  C  are incorrect because there has not been sufficient time for the medication to be effective.  



14.  Answer D is  correct.  
Lyme’s  disease is  transmitted  by  ticks  found  on  deer and  mice  in  wooded  areas.  The  people  in  answers  A  and  B  have  little  risk  of the  disease.  Veterinarians  are  exposed  to  dog  ticks,  which  carry  Rocky Mountain Spotted Fever, so answer C is incorrect. 



15.  Answer  B  is  correct.  Children  ages  18–24  months  normally  have  sufficient sphincter  control  necessary  for  toilet  training.  Answer  A  is  incorrect  because  the child  is  not  developmentally  capable  of  toilet  training.  Answers  C  and  D  are incorrect choices because toilet training should already be established. 




16.  Answer A  is  correct. 
 Large  amounts  of  fluid  and  electrolytes  are  lost  in  the stools  of  the  client  with  an  ileostomy.  The  priority  of  nursing  care  is  meeting the  client’s  fluid  and  electrolyte  needs.  Answers  B  and  D do  apply  to  clients with  an  ileostomy,  but  they  are  not  the  priority  nursing  diagnosis.  Answer C does not apply to the client with an ileostomy and is, therefore, incorrect.  




17.  Answer  B  is  correct.  
Cobex  is  an  injectable  form  of  cyanocobalamin  or  vitamin  B12. Increased  Hgb  levels  reflect  the  effectiveness  of  the  medication.  Answers  A,  C,  and  D do not reflect the effectiveness of the medication; therefore, they are incorrect.  





18.  Answer  C  is  correct.  Behavior  modification  relies  on  the  principles  of  operant condi-tioning.  Tokens  or  rewards  are  given  for  appropriate  behavior.  Answers  A and  B  are  incorrect  because  they  refer  to  techniques  used  to  reduce  anxiety, such  as  thought  stopping  and  bioenergetic  techniques,  respectively.  Answer  D is  incorrect  because  it  refers  to  modeling. 




19.  Answer  C  is  correct.  
Small  pieces  of  cereal  promote  chewing  and  are easily  managed  by  the  toddler.  Pieces  of  hot  dog,  carrot  sticks,  and  raisins are unsuitable for the tod-dler because of the risk of aspiration.  




20.  Answer C is  correct.  Complications  of  TPN therapy  are  osmotic  diuresis and  hypov-olemia.  Answer A  is  incorrect  because  the  intake  and  output would  not  reflect  meta-bolic  rate.  Answer B  is  incorrect  because  the  client  is most  likely  receiving  no  oral  flu-ids.  Answer D is  incorrect  because  the complication of TPN therapy is hypovolemia, not hypervolemia. 



21.  Answer  D  is  correct. 
 L/S  ratios  are  an  indicator  of  fetal  lung  maturity.  Answer  A is  incor-rect  because  it  is  the  diagnostic  test  for  neural  tube  defects.  Answer  B  is incorrect  because  it  measures  fetal  well-being.  Answer  C  is  incorrect  because  it detects circulating antibodies against red blood cells.  



22.  Answer  A  is  correct.  
By  the  third  postpartum  day,  the  fundus  should  be  located  3  finger  widths  below  the  umbilicus.  Answer  B  is  incorrect  because  the  discharge  would  be light  in  amount.  Answer  C  is  incorrect  because  the  fundus  is  not  even  with  the  umbilicus at 3 days. Answer D is incorrect because the uterus is not enlarged.  




23.  Answer  B  is  correct.  
Rapid  discontinuation  of  TPN  can  result  in  hypoglycemia. Answer  A  is  incorrect  because  rapid  infusion  of  TPN  results  in  hyperglycemia. Answer  C  is  incor-rect  because  TPN  is  administered  through  a  central  line. Answer D is incorrect because the infusion is administered with a filter.  




24.  Answer A  is  correct.  
Kava-kava  can  increase  the  effects  of  anesthesia  and post-opera-tive  analgesia.  Answers  B,  C,  and  D  are  not  related  to  the  use  of kava-kava; therefore, they are incorrect.  



25.  Answer  C  is  correct.  
The  maximum  recommended  rate  of  an  intravenous  infusion  of potassium  chloride  is  5–10mEq  per  hour,  never  to  exceed  20mEq  per  hour.  An  intravenous  infusion  controller  is  always  used  to  regulate  the  flow.  Answer  A  is  incorrect because  potassium  chloride  is  not  given  IV  push.  Answer  B  is  incorrect  because  the infusion time is too brief. Answer D is incorrect because the infusion time is too long.  




26.  Answer  B  is  correct.  
The  normal  platelet  count  is  150,000–400,000;  therefore,  the client  is  at  high  risk  for  spontaneous  bleeding.  Answer  A  is  incorrect  because  the  WBC is  a  low  normal;  therefore,  overwhelming  infection  is  not  a  risk  at  this  time.  The  RBC  is low,  but  anemia  at  this  point  is  not  life  threatening;  therefore,  answer  C  is  incorrect. Answer D is incorrect because the serum creatinine is within normal limits.  



27.  Answer  A is  correct.  
The  nurse  should  stop  the  infusion.  The  medication  should be  restarted  through  a  new  IV  access.  Answer  B  is  incorrect  because  IV catheters  are  not  to  be  flushed.  Answer  C  is  incorrect  because  a  tourniquet would  not  be  applied  to  the  area.  Answer  D  is  incorrect  because  the  IV  should not  be  allowed  to  continue  infusing  because  the  medication  is  a  vesicant  and,  in the  event  of  infiltration,  the  tissue  would  be  damaged  or  destroyed. 




28.  Answer B is  correct.  
The  client  will  have  a  urinary  catheter  inserted  to  keep the  blad-der empty  during  radiation  therapy.  Answer A  is  incorrect  because visitors  are  allowed  to  see  the  client  for short  periods  of  time,  as  long  as  they maintain  a  distance  of  6  feet  from  the  client.  Answer C is  incorrect  because the  client  is  on  bed  rest.  Side  effects  from  radiation  therapy  include  pain, nausea, vomiting, and dehydration; therefore, answer D is incorrect.  



29.  Answer  C  is  correct.  
The  mother  does  not  need  to  place  an  external  heat  source  near the  newborn.  It  will  not  promote  healing,  and  there  is  a  chance  that  the  newborn  could be  burned,  so  the  mother  needs  further  teaching.  Answers  A,  B,  and  D  indicate  correct care of the newborn who has been circumcised and are incorrect.  



30.  Answer D is  correct.  
A sputum  specimen  for  culture  and  sensitivity  should be  obtained  before  the  antibiotic  is  administered  to  determine  whether the organism  is  sensitive  to  the  prescribed  medication.  A routine  urinalysis, complete  blood  count  and  serum  electrolytes  can  be  obtained  after  the medication is initiated; therefore, Answers A, B, and C are incorrect.  




31.  Answer  A is  correct.  Ginkgo  interacts  with  many  medications  to  increase  the  risk  of bleeding;  therefore,  bruising  or  bleeding  should  be  reported  to  the  doctor. Photosensitivity  is  not  a  side  effect  of  ginkgo;  therefore,  answer  B  is  incorrect.  Answer C is  incorrect  because  the  FDA  does  not  regulate  herbals  and  natural  products.  The client does not need to take additional vitamin E, so answer D is incorrect.  




32.  Answer B is  correct.  The  client  should  be  well  hydrated  before  and  during treatment  to  prevent  nephrotoxicity.  The  client  should  be  encouraged  to  drink 2,000–3,000mL  of  fluid  a  day  to  promote  excretion  of  uric  acid.  Answer A  is incorrect  because  it  does  not  prevent  nephrotoxicity.  Answer C is  incorrect because  the  intake  and  output  should  be  recorded  hourly.  Answer D is incorrect  because  it  refers  to  ototoxicity,  which  is  also  an  adverse  side  effect of the medication but is not accurate for this stem.  



33.  Answer  A is  correct.  
The  client  who  is  colonized  with  MRSA  will  have  no  symptoms associated  with  infection.  Answer  B  is  incorrect  because  the  client  is  more  likely  to develop  an  infection  with  MRSA  following  invasive  procedures.  Answer  C  is  incorrect because  the  client  should  not  be  placed  in  the  room  with  others.  Answer  D  is  incorrect because the client can colonize others, including healthcare workers, with MRSA.  




34.  Answer B is  correct.  
The  therapeutic  range  for vancomycin  is  1025mcg/mL.  Answer  A is  incorrect  because  the  range  is  too  low  to  be therapeutic. Answers C and D are incorrect because they are too high.




35.  Answer  A is  correct.  Pseudomembranous  colitis  resulting  from  infection  with Clostridium  difficile  produces  diarrhea  containing  blood,  mucus,  and  white  blood  cells. Answers B, C, and D are incorrect because they are not specific to infection with  Clostridium difficile.  




36.  Answer  C  is  correct.  Pyridoxine  (vitamin  B6)  is  usually  administered  with  INH (isoni-azid)  in  order  to  prevent  nervous  system side  effects.  Answers  A,  B,  and  D are  not  associated  with  the  use  of  INH;  therefore,  they  are  incorrect  choices.  



37.  Answer  A is  correct.  Factors  associated  with  the  development  of  Legionnaires’ dis-ease  include  immunosuppression,  advanced  age,  alcoholism,  and  pulmonary disease.  Answer  B  is  incorrect  because  it  is  associated  with  the  development  of SARS.  Answer  C  is  associated  with  food-borne  illness,  not  Legionnaires’  disease, and answer D is not related to the question.  



38.  Answer B is  correct.  
The  client  can  check  the  inhaler by  dropping  it  into  a container  of  water.  If  the  inhaler is  half  full,  it  will  float  upside  down  with  onefourth  of  the  contain-er  remaining  above  the  water  line.  Answers  A,  C,  and  D do not help determine the amount of medication remaining.  




39.  Answer  C  is  correct.  Following  a  nephrolithotomy,  the  client  should  be positioned  on  the  unoperative  side.  Answers  A,  B,  and  D  are  incorrect positions for the client follow-ing a nephrolithotomy.  




40.  Answer A  is  correct.  The  client  with  sickle  cell  crisis  and  sequestration  can be  expect-ed  to  have  signs  of  hypovolemia,  including  decreased  blood pressure.  Answer B  is  incorrect  because  the  client  would  have  dry  mucus membranes.  Answer C is  incorrect  because  the  client  would  have  increased respirations  because  of  pain  associated  with  sickle  cell  crisis.  Answer D is incorrect because the client’s blood pressure would be decreased. 




41.  Answer  D  is  correct.  The  first  sign  of  latex  allergy  is  usually  contact dermatitis,  which  includes  swelling  and  itching  of  the  hands.  Answers  A,  B, and C can also occur but are not the first signs of latex allergy.  




42.  Answer A  is  correct.  The  nurse  caring  for  the  client  with  disseminated herpes  zoster  (shingles) should  use  airborne  precautions  as  outlined  by  the CDC. Answer B  is  incor-rect  because  precautions  are  needed  to  prevent transmission  of  the  disease.  Answer C and  D are  incorrect  because  airborne precautions are used, not contact or droplet pre-cautions.  



43.  Answer B is  correct.  Acticoat,  a  commercially  prepared  dressing,  should be  mois-tened  with  sterile  water.  Answers  A  and  C  are  incorrect  because Acticoat  dressings  remain  in  place  up  to  5  days.  Answer D is  incorrect because normal saline should not be used to moisten the dressing.  



44.  Answer  A is  correct.  The  presence  of  a  white  or  gray  dot  (a  cat’s  eye  reflex)  in  the pupil  is  associated  with  retinoblastoma,  a  highly  malignant  tumor  of  the  eye.  The nurse  should  report  the  finding  to  the  physician  immediately  so  that  it  can  be  further evaluated.  Simply  recording  the  finding  can  delay  diagnosis  and  treatment;  therefore, answer  B  is  incorrect.  Answer  C  is  incorrect  because  it  is  not  a  variation  of  normal. Answer D is incorrect because the presence of the red reflex is a normal finding. 




45.  Answer B  is  correct.  Stage  II  indicates  that  multiple  lymph  nodes  or organs  are  involved  on  the  same  side  of  the  diaphragm.  Answer A  refers  to stage  I  Hodgkin’s  lymphoma,  answer C refers  to  stage  III  Hodgkin’s lymphoma,  and  answer D refers  to  stage  IV Hodgkin’s  lymphoma. 




46.  Answer B is  correct.  The  client  taking  methotrexate  should  avoid multivitamins  because  multivitamins  contain  folic  acid.  Methotrexate  is  a  folic acid  antagonist.  Answers  A  and  D are  incorrect  because  aspirin  and acetaminophen  are  given  to  relieve  pain  and  inflammation  associated  with rheumatoid  arthritis.  Answer C is  incorrect  because  omega  3  and  omega  6 fish oils have proven beneficial for the client with rheumatoid arthritis.  




47AIIMS DELHI STAFF NURSE EXAM PAPERS.  Answer  C  is  correct.  Fried  foods  are  not  permitted  on  a  low-residue  diet.  Answers A, B, and D are all allowed on a low-residue diet and, therefore, are incorrect.  




48.  Answer C is  correct.  The  client  with  cirrhosis  and  abdominal  ascites requires  addi-tional  protein  and  calories.  (Note:  if  the  ammonia  level increases,  protein  intake  should  be  restricted  or  eliminated.)  Answer A  is incorrect  because  the  client  needs  a  low-sodium  diet.  Answer B  is  incorrect because  the  client  does  not  need  to  increase  his  intake  of  potassium.  Answer D is incorrect because the client does not need additional fat.  




49.  Answer B is  correct.  The  most  common  symptom  reported  by  clients  with multiple  sclerosis  is  double  vision.  Answers  A,  C,  and  D are  not  symptoms commonly reported by clients with multiple sclerosis, so they are wrong. 



50.  Answer  A  is  correct.  Common  sources  of  E.  coli  are  undercooked  beef  and shellfish. Answers B, C, and D are incorrect because they are not sources of E. coli.  



51.  Answer  B  is  correct.  St.  John’s  wort  has  properties  similar  to  those  of  monoamine oxidase  inhibitors  (MAOI).  Eating  foods  high  in  tryramine  (example:  aged  cheese, chocolate,  salami,  liver)  can  result  in  a  hypertensive  crisis.  Answer  A  is  incorrect because  it  can  relieve  mild  to  moderate  depression.  Answer  C  is  incorrect  because  use of  a  sunscreen  prevents  skin  reactions  to  sun  exposure.  Answer  D  is  incorrect  because St. John’s wort should not be used with MAOI antidepressants. 



52.  Answer A  is  correct.  Foods  high  in  purine  include  dried  beans,  peas, spinach,  oat-meal,  poultry,  fish,  liver,  lobster,  and  oysters.  Answers  B,  C, and  D are  incorrect  because  they  are  low  in  purine.  Other sources  low  in purine include most vegetables, milk, and gelatin.  







53.  Answer D is  correct.  The  nurse  should  tell  the  client  to  avoid  bearing weight  on  the  axilla  when  using  crutches  because  it  can  result  in  nerve damage.  Answer A  is  incor-rect  because  the  finger width  between  the  axilla and  the  crutch  is  appropriate.  Answer B  is  incorrect  because  the  client should  bear weight  on  his  hands  when  ambulating  with  crutches.  Answer C is incorrect because it describes the correct use of the four-point gait.  




54.  Answer  A is  correct.  By  writing  down  her  suspicions,  the  nurse  leaves  herself  open for  a  suit  of  libel,  a  defamatory  tort  that  discloses  a  privileged  communication  and leads  to  a  lowering  of  opinion  of  the  client.  Defamatory  torts  include  libel  and  slander. Libel  is  a  written  statement,  whereas  slander  is  an  oral  statement.  Thus,  answer  B  is incorrect  because  it  involves  oral  statements.  Malpractice  is  an  unreasonable  lack  of skill  in  performing  professional  duties  that  result  in  injury  or  death;  therefore,  answer  C is  incorrect.  Negligence  is  an  act  of  omission  or  commission  that  results  in  injury  to  a person  or  property,  making  answer  D  incorrect.    



55.  Answer  B  is  correct.  The  client  with  bulimia  is  prone  to  tooth  erosion  and  dental caries  caused  by  frequent  bouts  of  self-induced  vomiting.  Answers  A,  C,  and  D  are findings associated with anorexia nervosa, not bulimia, and are incorrect. 




56.  Answer  B  is  correct.  Antacids  should  not  be  taken  within  2  hours  of  taking digoxin;  therefore,  the  nurse  needs  to  do  additional  teaching  regarding  the client’s  medication.  Answers  A,  C,  and  D  are  true  statements  indicating  that the client understands the nurse’s teaching, so they are incorrect.  301




57.  Answer A  is  correct.  Fever,  sore  throat,  and  weakness  need  to  be  reported immediate-ly.  Adverse  reactions  to  Thorazine  include  agranulocytosis,  which makes  the  client  vul-nerable  to  overwhelming  infection.  Answers  B,  C,  and  D are  expected  side  effects  that  occur with  the  use  of  Thorazine;  therefore,  it  is not necessary to notify the doctor immediately. 



58.  Answer  C  is  correct.  The  anterior  approach  for  cervical  discectomy  lends  itself  to covert  bleeding.  The  nurse  should  pay  particular  attention  to  bleeding  coming  from  the mouth.  Answer  A  is  incorrect  because  bleeding  will  be  obvious  on  the  surgical  dressing.  Answer  B  is  incorrect  because  complaints  of  neck  pain  are  expected  and  will  be managed  by  the  use  of  analgesics.  Answer  D  is  incorrect  because  swelling  in  the  posterior  neck  can  be  expected.  The  nurse  should  observe  for  swelling  in  the  anterior  neck as well as changes in voice quality, which can indicate swelling of the airway.  




59.  Answer  D  is  correct.  The  assessment  suggests  the  presence  of  a  diaphragmatic hernia.  The  newborn  should  be  positioned  on  the  left  side  with  the  head  and  chest elevated.  This  position  will  allow  the  lung  on  the  right  side  to  fully  inflate.  Supplemental oxygen  for  newborns  is  not  provided  by  mask,  therefore  Answer  A  is  incorrect.  Answer B  is  incor-rect  because  bowel  sounds  would  not  be  heard  in  the  abdomen  since abdominal  con-tents  occupy  the  chest  cavity  in  the  newborn  with  diaphragmatic  hernia. Inserting  a  nasogastric  tube  to  check  for  esophageal  patency  refers  to  the  newborn with esophageal atresia; therefore, answer C is incorrect.  



60.  Answer  B  is  correct.  It  takes  1–2  weeks  for  mood  stabilizers  to  achieve  a therapeutic  effect;  therefore,  antipsychotic  medications  can  also  be  used  during the  first  few  days  or  weeks  to  manage  behavioral  excitement.  Answers  A  and  D are  not  true  statements  and,  therefore,  are  incorrect.  Answer  C  is  incorrect because the combination of medications will not allow for hypomania. 



61.  Answer  D  is  correct.  The  nurse  should  first  provide  for  the  client’s  safety, including  protecting  her  from an  embarrassing  situation.  Answer  A  is  incorrect because  it  allows  the  client  to  continue  unacceptable  behavior.  Answer  B  is incorrect  because  it  does  not  stop  the  client’s  behavior.  Answer  C  is  incorrect because it focuses on the other clients, not the client with inappropriate behavior.  




62.  Answer  B  is  correct.  According  to  the  Denver  Developmental  Assessment,  a  4-yearold  should  be  able  to  state  his  first  and  last  name.  Answers  A  and  C  are  expected  abilities of a 5-year-old, and answer D is an expected ability of a 5- and 6-year-old.  




63.  Answer B is  correct.  The  mother’s  statement  reflects  the  stress  placed  on her by  her  daughter’s  chronic  mental  illness.  Answer A  is  incorrect  because there  is  no  indication  of  ineffective  family  coping.  Answer C is  incorrect because  it  is  not  the  most  appropri-ate  nursing  diagnosis.  Answer D is incorrect  because  there  is  no  indication  of  altered  parenting.   



64.  Answer  B  is  correct.  Clients  with  anorexia  nervosa  have  problems  with  developing self-identity.  They  are  often  described  by  others  as  ―passive,‖  ―perfect,‖  and  ―introverted.‖  Poor  self-identity  and  low  self-esteem  lead  to  feelings  of  personal  ineffectiveness. Answer  A  is  incorrect  because  she  will  choose  only  low-calorie  food  items.  Answer  C  is incorrect  because  the  client  with  anorexia  is  restricted  from  exercising  because  it promotes  weight  loss.  Placement  in  a  private  room  increases  the  likelihood  that  the client will continue activities that prevent weight gain; therefore, answer D is incorrect.  




65.  Answer  B  is  correct.  The  nursing  assistant  has  skills  suited  to  assisting  the client  with  activities  of  daily  living,  such  as  bathing  and  grooming.  Answer  A  is incorrect  because  the  nurse  should  monitor  the  client’s  vital  signs.  Answer  C  is incorrect  because  the  client  will  have  an  induced  generalized  seizure,  and  the nurse  should  monitor  the  client’s  response  before,  during,  and  after  the procedure.  Answer  D  is  incorrect  because  staff  does  not  remain  in  the  room with a client in seclusion; only the nurse should monitor clients who are in seclusion. 




66.  Answer  D  is  correct.  Transderm  Nitro  is  a  reservoir patch  that  releases  the medication  via  a  semipermeable  membrane.  Cutting  the  patch  allows  too  much  of  the drug  to  be  released.  Answer  A  is  incorrect  because  the  area  should  not  be  shaved;  this can  cause  skin  irritation.  Answer  B  is  incorrect  because  the  skin  is  cleaned  with  soap and  water.  Answer  C  is  incorrect  because  the  patch  should  not  be  covered  with  plastic wrap because it can cause the medication to absorb too rapidly.  




67.  Answer  A is  correct.  Cholinergic  crisis  is  the  result  of  overmedication  with  anticholinesterase  inhibitors.  Symptoms  of  cholinergic  crisis  are  nausea,  vomiting, diar-rhea,  blurred  vision,  pallor,  decreased  blood  pressure,  and  constricted  pupils. Answers  B,  C,  and  D  are  incorrect  because  they  are  symptoms  of  myasthenia crisis, which is the result of undermedication with cholinesterase inhibitors.  




68.  Answer D is  correct.  The  client  should  avoid  eating  American  and processed  cheeses,  such  as  Colby  and  Cheddar,  because  they  are  high  in sodium.  Dried  beans,  peanut  butter,  and  Swiss  cheese  are  low  in  sodium; therefore, answers A, B, and C are incor-rect.  




69.  Answer C is  correct.  According  to  the  Rule  of  Nines,  the  arm  (9%)  +  the trunk  (36%)  =  45%  TBSA burn  injury.  Answers  A,  B,  and  D  are  inaccurate calculations for the TBSA. 




70.  Answer  A is  correct.  The  client  should  void  before  the  paracentesis  to  prevent acci-dental  trauma  to  the  bladder.  Answer  B  is  incorrect  because  the  abdomen is  not  shaved.  Answer  C  is  incorrect  because  the  client  does  not  need  extra fluids,  which  would  cause  bladder  distention.  Answer  D  is  incorrect  because  the physician, not the nurse, would request an ultrasound, if needed.  




71.  Answer  C  is  correct.  Rice  cereal,  mashed  ripe  bananas,  and  strained  carrots  are appropriate  foods  for  a  6-month-old  infant.  Answer  A  is  incorrect  because  the cocoa-flavored  cereal  contains  chocolate  and  sugar,  orange  juice  is  too  acidic  for the  infant,  and  strained  meat  is  difficult  to  digest.  Answer  B  is  incorrect  because graham crack-ers  contain  wheat  flour  and  sugar.  Pudding  contains  sugar  and additives  unsuitable  for  the  6-month-old.  Answer  D  is  incorrect  because  the  white of  the  egg  contains  albu-min,  which  can  cause  allergic  reactions.    




72.  Answer  D  is  correct.  A  battery-operated  CD  player  is  a  suitable  diversion  for  the 9-year-old  who  is  receiving  oxygen  therapy  for  asthma.  He  should  not  have  an electric  player  while  receiving  oxygen  therapy  because  of  the  danger  of  fire. Answer  A  is  incor-rect  because  he  does  need  diversional  activity.  Answer  B  is incorrect  because  there  is  no  need  for  him to  wear  earphones  while  he  listening  to music. Answer C is incorrect because he can have items from home.  




73.  Answer  A is  correct.  Maturational  crises  are  normal  expected  changes  that face  the  family.  Entering  nursery  school  is  a  maturational  crisis  because  the child  begins  to  move  away  from the  family  and  spend  more  time  in  the  care  of others.  It  is  a  time  of  adjustment  for  both  the  child  and  the  parents.  Answers  B, C, and D are incorrect because they represent situational crises.  



74.  Answer  A is  correct.  The  client  with  a  history  of  phenylketonuria  should  not  use Nutrasweet  or  other  sugar  substitutes  containing  aspartame  because  aspartame is  not  adequately  metabolized  by  the  client  with  PKU.  Answers  B  and  C  indicate an  under-standing  of  the  nurse’s  teaching;  therefore,  they  are  incorrect.  The client needs to resume a low-phenylalanine diet, making answer D incorrect.  




75.  Answer  D  is  correct.  Duchenne’s  muscular  dystrophy  is  a  sex-linked  disorder, with  the  affected  gene  located  on  the  X  chromosome  of  the  mother.  Answer  A  is incorrect  because  the  affected  gene  is  not  located  on  the  autosomes.  Overreplication  of  the  X  chromosomes  in  males  is  known  as  Klinefelter’s  syndrome; therefore,  answer  B  is  incorrect.  Answer  C  is  incorrect  because  the  disorder  is not located on the Y chromo-some of the father. 



76.  Answer B is  correct.  The  nurse  and  the  client  should  work  together to  form a  contract  that  outlines  the  amount  of  time  he  spends  on  a  task.  Answer A  is incorrect  because  the  client  with  a  personality  disorder will  see  no  reason  to change.  The  nurse  should  discuss  his  behavior and  its  effects  on  others  with him,  so  answer C is  incorrect.  Answer D is  incorrect  because  the  client  will not be able to set schedules and dead-lines for himself.  



77.  Answer  A is  correct.  Zovirax  (acyclovir)  shortens  the  course  of  chickenpox; however,  the  American  Academy  of  Pediatrics  does  not  recommend  it  for  healthy children  because  of  the  cost.  Answer  B  is  incorrect  because  it  is  the  vaccine  used  to prevent  chickenpox.  Answer  C  is  incorrect  because  it  is  the  immune  globulin  given  to those  who  have  been  exposed  to  chickenpox.  Answer  D  is  incorrect  because  it  is  an antihis-tamine used to control itching associated with chickenpox.  




78.  Answer A  is  correct.  Sock  and  mitten  burns,  burns  confined  to  the  hands and  feet,  indicate  submersion  in  a  hot  liquid.  Falling  into  the  tub  would  not have  produced  sock  burns;  therefore,  the  nurse  should  be  alert  to  the possibility  of  abuse.  Answer B  and  C are  within  the  realm  of  possibility,  given the  active  play  of  the  school-aged  child;  therefore,  they  are  incorrect.  Answer D is within the realm of possibility; therefore, it is incorrect.  



79.  Answer  B  is  correct.  Assault  is  the  intentional  threat  to  bring  about  harmful or  offen-sive  contact.  The  nurse’s  threat  to  give  the  medication  by  injection can  be  considered  as  assault.  Answers  A,  C,  and  D  do  not  relate  to  the nurse’s  statement;  therefore,  they  are  incorrect. 




80.  Answer C is  correct.  A nephrostomy  tube  is  placed  directly  into  the  kidney and  should  never be  clamped  or irrigated  because  of  the  damage  that  can result  to  the  kidney.  Answers  A  and  B  are  incorrect  because  the  first  action should  be  to  relieve  pressure  on  the  affected  kidney.  Answer D is  incorrect because the tubing should not be irrigat-ed.  



81.  Answer  D  is  correct.  When  the  collection  chambers  of  the  Pleuravac  are  full,  the nurse  should  prepare  a  new  unit  for  continuing  the  collection.  Answer  A  is  incorrect because  the  unit  is  providing  suction,  so  the  amount  of  water  does  not  need  to  be increased.  Answer  B  is  incorrect  because  the  drainage  is  not  to  be  removed  using  a syringe.  Milking  a  chest  tube  requires  a  doctor’s  order,  and  because  the  tube  is draining in this case, there is no need to milk it, so answer C is incorrect.  



82.  Answer B is  correct.  The  first  action  by  the  nurse  is  to  stop  the  transfusion and  main-tain  an  IV  of  normal  saline.  Answers  A,  C,  and  D  are  incorrect because they are not the first action the nurse would take.  




83.  Answer A  is  correct.  Microwaving  can  cause  uneven  heating  and  ―hot spots‖ in  the  formula,  which  can  cause  burns  to  the  baby’s  mouth  and throat.  Answers  B,  C,  and  D are  incorrect  because  the  infant’s  formula should never be prepared using a microwave. 




84.  Answer B is  correct.  HELLP  syndrome  is  characterized  by  hemolytic anemia,  elevated  liver enzymes,  and  low  platelet  counts.  Answers  A,  C,  and D have no connection to HELLP syndrome, so they are incorrect.  



85.  Answer  C  is  correct.  Dark  green,  leafy  vegetables;  members  of  the  cabbage family;  beets;  kidney  beans;  cantaloupe;  and  oranges  are  good  sources  of  folic acid  (B9).  Answers  A,  B,  and  D  are  incorrect  because  they  are  not  sources  of folic  acid.  Meat,  liver,  eggs,  dried  beans,  sweet  potatoes,  and  Brussels  sprouts are good sources of B12; pork, fish, and chicken are good sources of B6.  



86.  Answer B is  correct.  The  client  with  preeclampsia  should  be  kept  as  quiet as  possible,  to  minimize  the  possibility  of  seizures.  The  client  should  be  kept in  a  dimly  lit  room  with  little  or  no  stimulation.  The  clients  in  answers  A,  C, and D do not require a private room; therefore, they are incorrect. 




87.  Answer  B  is  correct.  Myasthenia  gravis  is  caused  by  a  loss  of  acetylcholine receptors,  which  results  in  the  interruption  of  the  transmission  of  nerve  impulses from nerve  endings  to  muscles.  Answer  A  is  incorrect  because  it  refers  to  multiple sclerosis.  Answer  C  is  incorrect  because  it  refers  to  Guillain-Barre  syndrome. Answer D is incor-rect because it refers to Parkinson’s disease.  




88.  Answer  B  is  correct.  Osmitrol  (mannitol)  is  an  osmotic  diuretic,  which inhibits  reab-sorption  of  sodium  and  water.  The  first  indication  of  its effectiveness  is  an  increased  urinary  output.  Answers  A,  C,  and  D  do  not relate to the effectiveness of the drug, so they are incorrect.  




89.  Answer B is  correct.  The  client  with  a  suspected  subdural  hematoma  is more  critical  than  the  other  clients  and  should  be  assessed  first.  Answers  A, C, and  D have  more  stable  conditions;  therefore,  they  are  incorrect 



90.  Answer C is  correct.  When  given  within  8  hours  of  the  injury,  Solu-Medrol has  proven  effective  in  reducing  cord  swelling,  thereby  improving  motor and sensory  function.  Answer A  is  incorrect  because  Solu-Medrol  does  not prevent  spasticity.  Answer B  is  incorrect  because  Solu-Medrol  does  not decrease  the  need  for  mechanical  ventilation.  Answer D is  incorrect  because Solu-Medrol is used to reduce inflammation, not used to treat infections. 



91.  Answer B is  correct.  The  spinal  fluid  of  a  client  with  Guillain-Barre  has  an increased  protein  concentration  with  normal  or  near-normal  cell  counts. Answers A, C, and D are inaccurate statements; therefore, they are incorrect. 




92.  Answer  A  is  correct.  The  child  with  laryngotracheobronchitis  has  inspiratory  stridor and  a  harsh,  ―brassy‖  cough.  Answer  B  refers  to  the  child  with  eppiglotitis,  answer  C refers to the child with bronchiolitis, and answer D refers to the child with asthma.  



93.  Answer  D  is  correct.  Hemarthrosis  or  bleeding  into  the  joints  is  characterized by  stiff-ness,  aching,  tingling,  and  decreased  movement  in  the  affected  joint. Answers A, B, and C do not describe hemarthrosis, so they are incorrect.  



94.  Answer  C  is  correct.  The  objective  of  therapy  using  aerosol  treatments  and  chest per-cussion  and  postural  drainage  is  to  dilate  the  bronchioles  and  help  loosen secretions. Answers A, B, and D are inaccurate statements, so they are incorrect.  




95.  Answer  A is  correct.  Drooling  of  bright  red  secretions  indicates  active  bleeding. Answer  B  is  incorrect  because  the  heart  rate  is  within  normal  range  for  a  6-yearold.  Answer  C  is  incorrect  because  it  indicates  old  bleeding.  Answer  D  is  incorrect because the child would have frequent, not infrequent, swallowing.  



96.  Answer A  is  correct.  Cigarette smoking  is  the  number one  cause of  bladder cancer.  Answer B  is incorrect  because  it  is  not associated  with  bladder cancer. Answer C is  a  primary  cause  of gastric  cancer,  and  answer D is  a cause of certain types of lung can-cer. 



97.  Answer A  is  correct.  Cloudy  or whitish  dialysate  returns  should  be  reported to  the  doctor  immediately  because  it  indicates  infection  and  impending peritonitis.  Answers  B,  C,  and  D are  expected  with  peritoneal  dialysis  and  do not require the doctor’s atten-tion.  



98.  Answer C is  correct.  Nitroglycerin  tablets  should  be  used  as  soon  as  the client  first  notices  chest  pain  or discomfort.  Answer A  is  incorrect  because  the medication  should  be  used  before  engaging  in  activity.  Strenuous  activity should  be  avoided.  Answer B  is  incorrect  because  the  medication  should  be used  when  pain  occurs,  not  on  a  regular  schedule.  Answer D is  incorrect because the medication will not prevent nocturnal angina.  



99.  Answer  C  is  correct.  The  LDH  and  CK  MB  are  specific  for  diagnosing  cardiac  damage. Answers A, B, and D are not specific to cardiac function; therefore, they are incorrect. 



100.  Answer  A is  correct.  The  school-age  child  (8  or  9  years  old)  engages  in cooperative  play.  These  children  enjoy  competitive  games  in  which  there  are  rules and  guidelines  for  winning.  Answers  B  and  D  describe  peer-group  relationships  of the  preschool  child,  and  answer  C  describes  peer-group  relationships  of  the  preteen.     









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