- (Topic 7)
Goal setting for a client with Meniere??s disease should include which of the following?

Correct Answer:B
(A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Meniere??s disease. (C) Adequate nutrition is important, but the emphasis in Meniere??s disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.

- (Topic 4)
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

Correct Answer:A
(A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take ??time-out?? before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.

- (Topic 2)
Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:

Correct Answer:C
(A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2that is an end product of carbohydrate metabolism. (B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. (C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. (D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced.

- (Topic 7)
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:

Correct Answer:C
(A) The test results were normal, so there would be no need to repeat to determine results.
(B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.

- (Topic 1)
A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:

Correct Answer:B
(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella.
(D) A rash, especially on the cheeks, that gives a ??slapped-cheek?? appearance is characteristic of roseola.

- (Topic 4)
Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Correct Answer:A
(A) A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine. (B) Serum sodium has no relationship to gentamicin. (C) Serum calcium has no relationship to gentamicin. (D) Serum potassium has no relationship to gentamicin. If a client has impaired renal function secondary to gentamicin administration, he or she may also have hyperkalemia as a secondary disorder.