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NEW QUESTION 444
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
- A. Tyramine
- B. Potassium-rich foods
- C. Saturated fats
- D. Tryptophan
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. (C) The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life- threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
NEW QUESTION 445
To facilitate maximum air exchange, the nurse should position the client in:
- A. Prone
- B. Flat-supine
- C. High Fowler
- D. Orthopneic
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. (B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flat-supine position places pressure on diaphragm by abdominal organs and does not promote maximum air exchange.
NEW QUESTION 446
A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:
- A. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra
- B. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum
- C. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland
- D. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland
Answer: A
Explanation:
Explanation
(A) This describes a suprapubic (transvesical) prostatectomy procedure. (B) This is the correct description of a TURP procedure. (C) This describes a perineal prostatectomy procedure. (D) This describes a retropubic (extravesical) prostatectomy procedure.
NEW QUESTION 447
A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?
- A. Phenytoin (Dilantin)
- B. Garamycin (Gentamicin)
- C. Timolol maleate (Blocadren)
- D. Prednisone
Answer: A
Explanation:
(A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin).
NEW QUESTION 448
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
- A. "I don't see your mother in the room. Let's talk about how you're feeling."
- B. "OK, I'll come back later when you're feeling more like taking your medicine."
- C. "She may be here, but I can't see her."
- D. "Why don't you finish talking to her, and I'll wait."
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.
NEW QUESTION 449
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?
- A. "Wait 4 hours between feedings so that your breasts will fill up."
- B. "Provide supplements for the child between breastfeeding so you will have enough milk."
- C. "Start the child on solid food."
- D. "Nurse the child more frequently during this growth spurt."
Answer: D
Explanation:
(A) Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.
NEW QUESTION 450
Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Elevated blood pressure, hyperventilation, and thready pulses
- B. Fever, tachycardia, and tachypnea
- C. Respiratory distress, cold skin, and pale extremities
- D. Normal pulses, hypotension, and oliguria
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock.
NEW QUESTION 451
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin.
The nurse should emphasize which of these instructions to the mother and/or child?
- A. Observe for headaches, dizziness, and anorexia.
- B. Discontinue drug therapy if food tastes funny.
- C. May discontinue medication when the child experiences symptomatic relief.
- D. Administer oral griseofulvin on an empty stomach for best results.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatic relief after 48-96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.
NEW QUESTION 452
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
- A. The same nurses will prevent infant fatigue and frustration.
- B. Primary nurses will ensure privacy.
- C. The same nurses will prevent parental fatigue and frustration.
- D. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
Answer: D
Explanation:
Explanation
(A) Consistent primary care nurses can better interpret infant cues and note feeding behaviors. (B) In nonorganic failure to thrive the parent-infant dyad has already experienced difficulties in the relationship.
These parents may already feel dissatisfied and frustrated. The primary nurse would be unable to prevent this.
(C) Assigning a primary nurse does not ensure that infant fatigue and frustration will not occur or can be prevented. (D) Providing privacy does not ensure a change in feeding behavior.
NEW QUESTION 453
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. A tension pneumothorax
- B. Pneumonia
- C. An asthma attack
- D. Pulmonary embolus
Answer: C
Explanation:
Explanation
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production.Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. (D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
NEW QUESTION 454
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
- A. Relieve anxiety
- B. Act as an anesthetic
- C. Relax muscles
- D. Reduce secretions
Answer: C
Explanation:
(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.
NEW QUESTION 455
A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?
- A. It is safe to take over-the-counter or other prescription medications with fluoxetine.
- B. Rashes or pruritus usually occur early in the therapy and are treatable without discontinuing the medication.
- C. Fluoxetine is not sedating; therefore, restrictions on driving and other hazardous activities are not necessary.
- D. A daily dose of fluoxetine may be taken in the morning or evening.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A daily dose of fluoxetine should be taken in the morning. Afternoon doses may cause nervousness and insomnia. (B) Although fluoxetine is less sedating than other antidepressants, it may still cause dizziness or drowsiness in some clients. The nurse should caution clients to avoid driving or hazardous activities until the central nervous system effects of the drug are demonstrated. (C) Rashes or pruritus do commonly occur early in therapy and respond to antihistamines or topical corticosteroids. (D) Advise the client not to take over-the-counter or other prescription drugs without consulting with the physician.
Fluoxetine does interact with other common drugs such as monoamine oxidase inhibitors, diazepam, insulin, oral antidiabetic agents, tricyclic antidepressants, and tryptophan.
NEW QUESTION 456
Which of the following signs might indicate a complication during the labor process with vertex presentation?
- A. Nausea and vomiting at 8-10 cm dilation
- B. Fetal tachycardia to 170 bpm during a contraction
- C. Appearance of dark-colored amniotic fluid
- D. Contraction lasting 60 seconds
Answer: C
Explanation:
(A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
NEW QUESTION 457
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
- A. Normal saline
- B. D5 with Ringer's lactate
- C. D5 in water
- D. Ringer's lactate
Answer: A
Explanation:
Explanation
(A) Phenytoin will precipitate if mixed with Ringer's lactate and should not be administered. (B, C) Phenytoin will precipitate if mixed with D5 in Ringer's lactate and should not be administered. (D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.
NEW QUESTION 458
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. "This is appropriate behavior for a preschooler and should not be a concern."
- B. "I understand your concern and will assist you with a referral."
- C. "Just ignore the behavior and it should disappear by age 8."
- D. "Try not to worry because you will just upset your child."
Answer: A
Explanation:
Explanation
(A) This is normal for a preschooler, and a referral is not appropriate. (B) Telling a parent not to worry is unhelpful. This response does not address the mother's concern. (C) This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. (D) This behavior is normal development for a preschooler.
NEW QUESTION 459
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. "I've been having a dull pain at the upper left shoulder."
- B. "I don't remember anything in particular, I just haven't felt well."
- C. "My legs have been numb for three months."
- D. "I've only been urinating three times a day lately."
Answer: B
Explanation:
Section: Questions Set G
Explanation:
(A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
NEW QUESTION 460
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Contact the lab and request a lithium level in 30 minutes, and call the physician.
- C. Withhold her lithium, and report her symptoms to the physician.
- D. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
Answer: C
Explanation:
(A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.
NEW QUESTION 461
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. "I should always take this medication with an antacid."
- B. "I should only take the medication if my heart rate is greater than 100 bpm."
- C. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."
- D. "I could stop taking this medication when I begin to feel better."
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.
NEW QUESTION 462
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. "I should always take this medication with an antacid."
- B. "I should only take the medication if my heart rate is greater than 100 bpm."
- C. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."
- D. "I could stop taking this medication when I begin to feel better."
Answer: C
Explanation:
Explanation
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is
>100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.
NEW QUESTION 463
On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
- A. Sitting in a chair
- B. Supine with feet elevated
- C. High Fowler
- D. Lying on the left side
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema.
NEW QUESTION 464
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
- A. Antidepressant medications
- B. Antimania medication
- C. Antipsychotic medications
- D. Antianxiety medications
Answer: D
Explanation:
(A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors. (C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
NEW QUESTION 465
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerosteromia
- B. Candidiasis
- C. Stomatitis
- D. Leukoplakia
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Xerostomia is dry mouth. (B) Candidiasis can be rubbed off, but it will bleed. (C) Leukoplakia cannot be rubbed off. (D) Stomatitis is caused by candidiasis and gram-negative bacteria.
NEW QUESTION 466
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
- A. Take more frequent naps
- B. Use artificial tears
- C. Limit activities which require focusing (close vision)
- D. Wear a patch over one eye
Answer: D
Explanation:
Explanation
(A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
NEW QUESTION 467
When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4-8) of pregnancy is so critical.
- A. Duplication of genetic information takes place.
- B. Organogenesis occurs.
- C. Kidneys begin to secrete urine.
- D. Subcutaneous fat builds up steadily.
Answer: B
Explanation:
Explanation
(A) Duplication of genetic material occurs during the preembryonic period (weeks 1-3) following conception.
The exact duplication of genetic material is essential for cell differentiation, growth, and biological maintenance of the organism. (B) Weeks 4-8, known as the embryonic period, are the time organogenesis occurs and pose the greatest potential for major congenital malformations. All major internal and external organs and systems are formed. (C) Subcutaneous fat does not develop until the latter weeks of gestation. (D) Kidneys begin to secrete urine during the 13th-16th week.
NEW QUESTION 468
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