1. ANSWER A. Pain disorder is a somatoform disorder involving severe pain in one or more anatomic sites causing severe distress or impaired function. The statement, “I need to have a good cry about all the pain I’ve been in and then not dwell on it,” indicates improvement because the client has a realistic view of the physical symptoms and pain and is willing to let them go and move on. The other statements indicate the continued presence of denial, lack of insight, and the need for symptoms to manage anxiety.
2. ANSWER D. The nurse needs to collect additional information about the client’s complaint of hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor won’t visit indirectly reinforces the delusion about the neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first.
3. ANSWER C. A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.
4. ANSWER D. Serum osmolality indicates the water balance of the body. A normal plasma osmolality between 275 and 295 mOsm/kg would indicate that the fluid volume excess has been resolved. A weight reduction of 10% may not necessarily return the client to a state of normal serum osmolality. Clients with excess fluid volume do not necessarily have pain or abnormal arterial blood gas values.
5. ANSWER C. Exactly why rheumatic fever follows a streptococcal infection is not known, but it is theorized that an antigen–antibody response occurs to an M protein present in certain strains of streptococci. The antibodies developed by the body attack certain tissues, such as in the heart and joints. Antistreptolysin O titer findings show elevated or rising antibody levels. This blood finding is the most reliable evidence indicating a streptococcal infection.
6. ANSWER C. The nurse should call the surgeon’s office so that arrangements can be made for the client to donate a unit of his blood for possible future autotransfusion. This must be done in sufficient time before surgery so that the client is not at risk for being anemic at the time of the scheduled procedure. The client’s request must be scheduled through the surgeon’s office because the surgeon has ultimate responsibility for the client. The nurse can document that the surgeon’s office was notified of the client’s request. Notifying the hematology laboratory would not be an appropriate response.
7. ANSWER A. High colonic irrigation can increase the risk of perforation in a distended and inflamed colon. Tapwater is hypotonic in the bowel and would draw increased fluid into the area. The other orders are part of standard preparation for intestinal surgery.
8. ANSWER A and C. When a client is to collect stool for occult blood, the nurse should include instructions to avoid eating meat, especially red meat, for 1 to 3 days before the sample collection because meat eliminated in the stool can lead to false-positive results. Eating foods high in fiber a few days prior to sample collection may be recommended because doing so improves the chances of finding occult blood if a lesion is present. The client should take stool samples from different sites of the stool for a better sample, and more than one stool specimen may be ordered to detect intermittent bleeding. The stool sample should be covered to protect everyone from body secretions, in compliance with Standard Precautions. The specimen does not have to be sent to the lab immediately like a Culture and Sensitivity testing where the bacterial count will change within a short period of time. Some medications, herbs, foods, and activities can lead to false results of the occult testing. For example, iron pills, turnips, and horseradish lead to false-positive results. Vitamin C leads to false-negative results. Some anti-inflammatory drugs and aspirin should be avoided due to antiplatelet properties that increase the tendency for gastrointestinal bleeding. The statement about continuing usual daily activities may or may not be appropriate. The nurse needs to determine the client’s usual activities and exercise routines. The reply depends on the client’s response to what is usual.
9. ANSWER C. The most appropriate intervention is to offer the client frequent mouth care to moisten the dry oral mucosa. Reexplaining why the client cannot drink may be helpful but will not relieve her thirst. Ice chips cannot be given to a client who is NPO. Diverting the client’s attention does not treat her basic complaint.
10. ANSWER B. This client is demonstrating classic symptoms of hypothyroidism. Primary hypothyroidism results from pathologic changes in the thyroid gland. In this case, the thyroid gland is unable to secrete sufficient amounts of thyroid hormone, leading to a decrease in cellular metabolic activity, decreased oxygen consumption, and decreased heat production. Cushing’s disease is manifested by a “buffalo hump,” moonface, hypertension, fatigability, and weakness, resulting from the inappropriate release of cortisol. Hyperthyroidism, or Grave’s disease, is manifested by increased appetite with weight loss, increased anxiety, hand tremors, palpitations, heat intolerance, and insomnia. A pituitary tumor can manifest in a wide variety of symptoms, depending on the location.
11. ANSWER C. After the symptoms of puberty, such as increased hair growth and enlargement of the breasts, are noticed, menstruation typically begins within 30 months.
12. ANSWER B. Epstein’s pearls are tiny, hard, white nodules found in the mouth of some neonates. They are considered normal and usually disappear without treatment. Koplik’s spots, associated with measles in children, are patchy and bright red with a bluish-white speck in the middle. Precocious teeth are actual teeth that some neonates have at birth. Usually only one or two teeth are present. Candida albicans or thrush is not apparent in the mouth immediately after birth but may appear a day or two later. This infection is manifested by yellowish-white spots or lesions that resemble milk curds and bleed when attempts are made to wipe them away
13. ANSWER A and B. The initial signs of EA and TEF include lots of frothy mucus and unexplained episodes of cyanosis usually caused by overflow of mucus from the esophagus. Loose stools and poor gag reflex are not signs of TEF. Initial weight loss is common in newborns and not related to TEF.
14. ANSWER A. An adequate circulatory status is the most important factor for supporting the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues. A fluid intake of 2,000 to 3,000 mL/day, if not contraindicated, is recommended to provide hydration to the client’s tissues.
15. ANSWER B. The nurse’s initial response would be to withhold the digoxin (Lanoxin). The nurse should then notify the physician if the apical pulse is 60 bpm or lower because of the potential for digoxin toxicity. The charge nurse does not need to be notified, but the nurse does need to document the notification and follow-up in the chart.
16. ANSWER B. In an emergency where the neonate’s head is already delivering, the first action by the nurse should be to check for the presence of a cord around the neonate’s neck. If the cord present, the nurse should gently remove it from the neck. The client should be told to breathe gently and avoid forceful bearing-down efforts, which could lead to lacerations. Although blood and bodily fluid precautions are always present in client care, this is an emergency. If at all possible, the nurse should don gloves. Suctioning of the mouth can be done once the nurse has checked to ensure that the cord is not around the neonate’s neck. Telling the mother that help is on the way is not reassuring, because emergency medical technicians may take some time to arrive. Delivery is imminent because the neonate’s head is delivering.
17. ANSWER B. The ulna will heal in approximately 12 weeks. The femur takes approximately 24 weeks to heal because of the size of the bone and the muscle forces exerted on the femur. Skeletal traction does not delay healing but can actually promote healing by properly aligning the fracture.
18. ANSWER B. The client needs to know that there is a cause for the delirium, that there is hope for treatment, and that medications can help decrease anxiety. Giving medications can help the anxiety, but the client also needs an explanation about the condition. Saying that the more the client worries, the worse the delirium will get is inappropriate and most likely would add to the client’s level of anxiety.
19. ANSWER A. The client understands the instructions when she says she should avoid contact sports because they may result in injury to the client and/or the fetus. Learning to ski while pregnant is not recommended because injury may occur. Scuba diving should be avoided because depth pressures could cause fetal damage. Hot tubs should be avoided during the first trimester because sitting in them can result in fetal hyperthermia and fetal hypoxia. Mild exercises, such as walking, can help strengthen the muscles and prevent some discomforts, such as backache.
20. ANSWER A. Cardiogenic shock is a negative outcome of a myocardial infarction that involves a significant amount of cardiac tissue. Lack of blood and oxygen leads to death of the contractile elements of the tissue, resulting in pump failure. Hypovolemic shock results from blood loss. Neurogenic shock results from loss of sympathetic tone. Metabolic acidosis is commonly caused by uncontrolled diabetes mellitus.