- (Topic 4)
A 47-year-old client comes to the emergency department complaining of moderate flank, abdominal, and testicular pain with nausea of 4 hours?? duration. After physical examination and obtaining the client??s history, the physician suspects urethral obstruction by calculi. The nurse realizes that the physician will order which one of the following diagnostic studies to best confirm the diagnosis?
Correct Answer:C
(A) Cystoscopy is an endoscopic procedure that uses an instrument (a cystoscope) to visualize the internal bladder and ureter structures and to capture and remove an obstructing stone. (B) Kidney, ureter, bladder x-ray is used to outline gross structural changes in the kidneys, ureter, and bladder and will determine the general location of a stone. (C) An intravenous pyelogram with excretory urogram is used to visualize the kidneys, kidney pelvis, ureters, and bladder. This procedure is used specifically to determine whether urethral obstruction is partial or complete; it shows the exact location of the stone and dilation of the ureter above the stone. (D) Ureterolithotomy is a surgical procedure in which the ureter is incised and the stone is manually removed because the stone is unable to pass through the ureter independently.
- (Topic 5)
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer:C
(A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K (AquaMEPHYTON) assists the infant??s clotting mechanism. (C) Excessive bilirubin accumulates when the infant??s liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
- (Topic 7)
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
Correct Answer:C
(A) An adult diazepam dosage for treatment of anxiety is 2–10 mg PO 2–4 times daily. The order as written would place a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.
- (Topic 3)
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
Correct Answer:C
(A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn. (C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure.
- (Topic 6)
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, ??Isn??t that a lot??? The nurse??s best response is:
Correct Answer:C
(A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband??s fears. (B) This response is ??passing the buck?? unnecessarily. The information needed to appropriately answer the husband??s question is well within the nurse??s knowledge base. (C) The most common range for affective disorders is 6–10 treatments. This response confirms and reinforces the physician??s plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husband??s underlying concerns about his wife.
- (Topic 4)
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
Correct Answer:D
(A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.