- (Topic 3)
A client??s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:

Correct Answer:B
(A) Increased calories may result in weight gain, but there is no indication in this question that this man??s diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin-angiotensin-aldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems.
(D) Profound diuresis occurs with diabetes insipidus, which results in weight loss.

- (Topic 4)
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?

Correct Answer:D
(A) Because the child??s appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase anorexia. (D) Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security.

- (Topic 6)
While the nurse is taking a male client??s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:

Correct Answer:C
(A) This response does not recognize normal feelings of attraction and rejects the client.
(B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.

- (Topic 4)
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:

Correct Answer:D
(A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. (B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.

- (Topic 3)
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:

Correct Answer:B
(A) Riding a stationary bicycle or walking on a treadmill is done during a stress test. (B) During an echocardiogram, the client must lie supine while a technician performs the test. To perform the test, the technician uses a conductive gel and a transducer to obtain ultrasound tracings of the heart. (C) A physician need not be present during an echocardiogram, and it is neither invasive nor painful. (D) There is no premedication required for an echocardiogram.

- (Topic 5)
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:

Correct Answer:C
(A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.