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NEW QUESTION NO: 6
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
A. Reduce his anxiety
B. Avoid going to psychotherapy
C. Manipulate the health team members
D. Increase his self-image by showing higher standards than the fellow clients
Answer: A
Explanation/Reference:
Explanation:
(A) These behaviors are attempts to relieve anxiety. (B) Avoidance is not a pattern in the obsessive client.
(C) Although these behaviors may seem to manipulate others, that is not the purpose behind the activity.
(D) Inflated self-esteem is not a characteristic of the severely anxious client.
NEW QUESTION NO: 7
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?
A. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract."
B. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement."
C. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract."
D. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."
Answer: C
Explanation/Reference:
Explanation:
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.
NEW QUESTION NO: 8
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
A. Decreases the overall time of the labor process
B. Prolongs the client's first stage of labor
C. Decreases the time of the client's first stage of labor
D. Prolongs the client's third stage of labor
Answer: B
Explanation/Reference:
Explanation:
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
NEW QUESTION NO: 9
A client has ascites, which is caused by:
A. Decreased plasma proteins
B. Electrolyte imbalance
C. Decreased renal function
D. Portal hypertension
Answer: A
Explanation/Reference:
Explanation:
(A) A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity. (B) Fluid and electrolyte imbalance may occur as a result of the ascites. (C) Ascites is a result of hepatic malfunction, not renal malfunction. (D) Portal hypertension causes esophageal varices, not ascites.
NEW QUESTION NO: 10
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
A. Bargaining with the client as a strategy to control the behavior
B. Redirecting the client
C. Providing a consistent set of guidelines and rules
D. Assigning the client to different staff persons each day
Answer: C
Explanation/Reference:
Explanation:
(A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client.
(B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior.
Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct.
Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.
NEW QUESTION NO: 11
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
A. Blood pressure increase from 100/80 to 115/85 after lunch
B. Headache that is unresponsive to acetaminophen (Tylenol)
C. Pulse rate ranges between 68 bpm and 76 bpm
D. Temperature rise to 102_F rectally
Answer: D
Explanation/Reference:
Explanation:
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between
68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
NEW QUESTION NO: 12
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests?
A. Number of platelets
B. WBC count
C. Hemoglobin level
D. Number of lymphocytes
Answer: A
Explanation/Reference:
Explanation:
(A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.
NEW QUESTION NO: 13
A client is diagnosed with organic brain disorder. The nursing care should include:
A. Organized, safe environment
B. Long, extended family visits
C. Detailed explanations of procedures
D. Challenging educational programs
Answer: A
Explanation/Reference:
Explanation:
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple explanations are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.
NEW QUESTION NO: 14
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
A. Within therapeutic range
B. Below therapeutic range
C. Above therapeutic range
D. At a level of toxic poisoning
Answer: A
Explanation/Reference:
Explanation:
(A) This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher.
NEW QUESTION NO: 15
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:
A. Akathisia
B. Akinesia
C. Dystonia
D. Opisthotonos
Answer: A
Explanation/Reference:
Explanation:
(A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
NEW QUESTION NO: 16
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
A. Tumor size
B. Axillary node status
C. Client's previous history of disease
D. Client's level of estrogen-progesterone receptor assays
Answer: B
Explanation/Reference:
Explanation:
(A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.