- (Topic 5)
A female client at 36 weeks?? gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:

Correct Answer:D
(A) Placental maturity is assessed by a biophysical profile. (B) L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of6 may indicate this condition. (C) Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. (D) An L/S ratio>2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity.

- (Topic 7)
A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

Correct Answer:A
(A) Disorientation is the first sign of sepsis in burn children. (B) Low-grade fever is not indicative of sepsis. (C) Diarrhea is not indicative of sepsis. (D) Hypertension is not indicative of sepsis.

- (Topic 5)
An 82-year-old former restaurant owner walks to the nursing station and states, ??I have to go. The restaurant opens at 11 am.?? Which response by the nurse is the most appropriate?

Correct Answer:C
(A) This response cuts off communication with the client. It does not address her feelings.
(B) Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. (C) Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. (D) This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.

- (Topic 6)
Before giving methergine postpartum, the nurse should assess the client for:

Correct Answer:B
(A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.

- (Topic 6)
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

Correct Answer:D
(A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should know to notify the physician or hospital if they occur. (C) The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

- (Topic 7)
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, ??Nobody in here seems to really care about the clients. I thought nurses cared about people!?? The client is exhibiting the ego defense mechanism:

Correct Answer:C
(A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client??s comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one??s feelings, behaviors, or motives. The client??s comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual??s inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client??s comment reveals that she is not engaging in sublimation.