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TEST I Answers and Rationale Foundation of Professional Nursing Practice 1.

. Answer: (D) The actions of a reasonably prudent nurse with similar education and experience. Rationale: The standard of care is determined by the average degree of skill, care, and diligence by nurses in similar circumstances. 2. Answer: (B) I.M Rationale: With a platelet count of 22,000/l, the clients tends to bleed easily. Therefore, the nurse should avoid using the I.M. route because the area is a highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. 3. Answer: (C) Digoxin 0.125 mg P.O. once daily Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage. 4. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion. Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. 5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea. Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided. 6. Answer: (C) Check circulation every 15-30 minutes. Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the clients circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs. 7. Answer: (A) Prevent stress ulcer Rationale: Curlings ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers. 8. Answer: (D) Continue to monitor and record hourly urine output

Rationale:

Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour).

Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. 9. Answer: (B) My ankle feels warm. Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application 10. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia. 11. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. 12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. 13. Answer: (B) Standard written order Rationale: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. 14. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. 15. Answer: (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear

canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. 16. Answer: (A) Protect the irritated skin from sunlight. Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approach is the avoidance of strong sunlight. 17. Answer: (C) Assist the client in removing dentures and nail polish. Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. 18. Answer: (D) Sudden onset of continuous epigastric and back pain. Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the inflammatory process in the pancreas. 19. Answer: (B) Provide high-protein, high-carbohydrate diet. Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day. 20. Answer: (A) Blood pressure and pulse rate. Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion. 21. Answer: (D) Immobilize the leg before moving the client. Rationale: If the nurse suspects a fracture, splinting the area before moving the client is imperative. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client. 22. Answer: (B) Admit the client into a private room. Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation. 23. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority.

24. Answer: (B) Place the client on the left side in the Trendelenburg position. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration. 25. Answer: (A) Autocratic. Rationale: The autocratic style of leadership is a task-oriented and directive. 26. Answer: (D) 2.5 cc Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter. 27. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr. 28. Answer: (B) Assess the client for presence of pain. Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the clients comfort. 29. Answer: (A) BP 80/60, Pulse 110 irregular Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia. 30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the clients chart. Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options 31. Answer: (B) Evaluation Rationale: Evaluation includes observing the person, asking questions, and comparing the patients behavioral responses with the expected outcomes. 32. Answer: (C) History of present illness Rationale: The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the persons needs.

33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh. Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip. 34. Answer: (C) Stage III Rationale: Clinically, a deep crater or without undermining of adjacent tissue is noted. 35. Answer: (A) Second intention healing Rationale: When wounds dehisce, they will allowed to heal by secondary intention 36. Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. 37. Answer: (A) 0.75 Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation. 75 mg/X ml = 100 mg/1 ml To solve for X, cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0.75 ml (or ml) = X 38. Answer: (D) Its a measure of effect, not a standard measure of weight or quantity. Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. 39. Answer: (B) 38.9 C Rationale: To convert Fahrenheit degreed to Centigrade, use this formula C = (F 32) 1.8 C = (102 32) 1.8 C = 70 1.8 C = 38.9 40. Answer: (C) Failing eyesight, especially close vision. Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older). 41. Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isnt secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage not to prevent leaks. 42. Answer: (A) Check the clients identification band.

Rationale: Checking the clients identification band is the safest way to verify a clients identity because the band is assigned on admission and isnt be removed at any time. (If it is removed, it must be replaced). Asking the clients name or having the client repeated his name would be appropriate only for a client whos alert, oriented, and able to understand what is being said, but isnt the safe standard of practice. Names on bed arent always reliable 43. Answer: (B) 32 drops/minute Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2.1 ml/minute To find the number of drops per minute: 2.1 ml/X gtt = 1 ml/ 15 gtt X = 32 gtt/minute, or 32 drops/minute 44. Answer: (A) Clamp the catheter Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isnt available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion. 45. Answer: (D) Auscultation, percussion, and palpation. Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation. 46. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth. 47. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation.

48. Answer: (B) Once per year Rationale: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary. 49. Answer: (A) Respiratory acidosis Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above normal. 50. Answer: (B) To provide support for the client and family in coping with terminal illness. Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesnt focus on counseling regarding health care costs. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice. 51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurses realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physicians order. Massaging with an astringent can further damage the skin. 52. Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the clients foot. Beginning at the ankle, lower thigh, or knee does not promote venous return. 53. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. 54. Answer: (A) Throbbing headache or dizziness Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops tolerance 55. Answer: (D) Check the clients level of consciousness

Rationale: Determining unresponsiveness is the first step assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output. 56. Answer: (B) On the affected side of the client. Rationale: When walking with clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet. 57. Answer: (A) Urine output: 45 ml/hr Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues. 58. Answer: (D ) Obtaining the specimen from the urinary drainage bag. Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system. 59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call. Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. However, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the clients reach. Additionally, the clients door should be closed or the room curtains pulled around the bathing area. 60. Answer: (C) Use a sterile plastic container for obtaining the specimen. Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid.

61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it. 62. Answer: (C) Draws one line to cross out the incorrect information and then initials the change. Rationale: To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. An error is never erased and correction fluid is never used in the medical record. 63. Answer: (C) Secures the client safety belts after transferring to the stretcher. Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from falling off the stretcher. 64. Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless the nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are not necessary. 65. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for client with weakness of the arm and leg on one side. However, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. 66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit

up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. 67. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. 68. Answer: (A) Keep the identities of the subject secret Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source. 69. Answer: (A) Descriptive- correlational Rationale: Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection. 70. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential. 71. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. 72. Answer: (C) Primary source Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator. In contrast to this is a secondary source, which is written by someone other than the original researcher. 73. Answer: (A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence. 74. Answer: (C) Res ipsa loquitor Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act. 75. Answer: (B) The Board can investigate violations of the nursing law and code of ethics Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed.

76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed since the license has been revoked. 77. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem, the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers. 78. Answer: (B) Hawthorne effect Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation. 79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each. Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. 80. Answer: (B) Madeleine Leininger Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture. 81. Answer: (A) Random Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. 82. Answer: (A) Degree of agreement and disagreement Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study 83. Answer: (B) Sr. Callista Roy Rationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode. 84. Answer: (A) Span of control

Rationale: Span of control refers to the number of workers who report directly to a manager. 85. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery, including the risks involved and the alternative solutions. In giving consent it is done with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. 86. Answer: (C) Avoid wearing canvas shoes. Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers. 87. Answer: (D) Ground beef patties Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair. 88. Answer: (D) Sims left lateral Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. The supine and prone positions are inappropriate and uncomfortable for the client. 89. Answer: (A) Arrange for typing and cross matching of the clients blood. Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. The other options, although appropriate when preparing to administer a blood transfusion, come later. 90. Answer: (A) Independent Rationale: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn't exist.

91. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into action. 92. Answer: (B) To observe the lower extremities Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood. 93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea. Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of lifethreatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the transfusion. 94. Answer: (B) Decrease the rate of feedings and the concentration of the formula. Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours. 95. Answer: (D) Roll the vial gently between the palms. Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

96. Answer: (B) Assist the client to the semi-Fowler position if possible. Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen. 97. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy. 98. Answer: (B) Immediately before administering the next dose. Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose. 99. Answer: (A) The nurse can implement medication orders quickly. Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations. 100. Answer: (C) Shifting dullness over the abdomen. Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.

TEST II Answers and Rationale Community Health Nursing and Care of the Mother and Child 1. Answer: (A) Inevitable Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.

2. Answer: (B) History of syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. 3. Answer: (C) Monitoring apical pulse Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. 4. Answer: (B) Increased caloric intake Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mothers demand for insulin and is referred to as the diabetogenic effect of pregnancy. 5. Answer: (A) Excessive fetal activity. Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancyinduced hypertension. Fetal activity would not be noted. 6. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate. 7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines. 8. Answer: (A) Contractions every 1 minutes lasting 70-80 seconds. Rationale: Contractions every 1 minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued. 9. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.

10. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery. 11. Answer: (A) Talk to the mother first and then to the toddler. Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. 12. Answer: (D) Place the infants arms in soft elbow restraints. Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons shouldnt be placed in a babys mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. 13. Answer: (B) Allow the infant to rest before feeding. Rationale: Because feeding requires so much energy, an infant with heart failure should rest before feeding. 14. Answer: (C) Iron-rich formula only. Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldnt receive solid food, even baby food until age 6 months. 15. Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants cant sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects. 16. Answer: (D) Public health nursing focuses on preventive, not curative, services. Rationale: The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services. 17. Answer: (B) Efficiency Rationale: Efficiency is determining whether the goals were attained at the least possible cost.

18. Answer: (D) Rural Health Unit Rationale: R.A. 7160 devolved basic health services to local government units (LGUs ). The public health nurse is an employee of the LGU. 19. Answer: (A) Mayor Rationale: The local executive serves as the chairman of the Municipal Health Board. 20. Answer: (A) 1 Rationale: Each rural health midwife is given a population assignment of about 5,000. 21. Answer: (B) Health education and community organizing are necessary in providing community health services. Rationale: The community health nurse develops the health capability of people through health education and community organizing activities. 22. Answer: (B) Measles Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program. 23. Answer: (D) Core group formation Rationale: In core group formation, the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program. 24. Answer: (D) To maximize the communitys resources in dealing with health probl ems. Rationale: Community organizing is a developmental service, with the goal of developing the peoples self-reliance in dealing with community health problems. A, B and C are objectives of contributory objectives to this goal. 25. Answer: (D) Terminal Rationale: Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease). 26. Answer: (A) Intrauterine fetal death. Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC. 27. Answer: (C) 120 to 160 beats/minute Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system.

28. Answer: (A) Change the diaper more often. Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation. 29. Answer: (D) Endocardial cushion defect Rationale: Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or polysplenia. 30. Answer: (B) Decreased urine output Rationale: Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels. 31. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive menstrual period. 32. Answer: (C) Blood typing Rationale: Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. Approximately 40% of a womans cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding. 33. Answer: (D) Physiologic anemia Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. 34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mothers arms and drooling. Rationale: The infant with the airway emergency should be treated first, because of the risk of epiglottitis. 35. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. 36. Answer: (D) Early in the morning Rationale: Based on the nurses knowledge of microbiology, the specimen should be collected early in the morning. The rationale for this timing is that, because the female worm lays eggs at night around the perineal area, the first bowel movement of the day will yield the best results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test.

37. Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This condition results in irritability and changes in level of consciousness, as well as seizure disorders, hyperactivity, and learning disabilities. 38. Answer: (D) I really need to use the diaphragm and jelly most during the middle of my menstrual cycle. Rationale: The woman must understand that, although the fertile period is approximately mid-cycle, hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm should be inserted before every intercourse. 39. Answer: (C) Restlessness Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are associated with a change in color, such as pallor or cyanosis. 40. Answer: (B) Walk one step ahead, with the childs hand on the nurses elbow. Rationale: This procedure is generally recommended to follow in guiding a person who is blind. 41. Answer: (A) Loud, machinery-like murmur. Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus. 42. Answer: (C) More oxygen, and the newborns metabolic rate increases. Rationale: When cold, the infant requires more oxygen and there is an increase in metabolic rate. Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption, therefore, the newborn increase heat production. 43. Answer: (D) Voided Rationale: Before administering potassium I.V. to any client, the nurse must first check that the clients kidneys are functioning and that the client is voiding. If the client is not voiding, the nurse should withhold the potassium and notify the physician. 44. Answer: (c) Laundry detergent Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The topical allergen that is the most common causative factor is laundry detergent. 45. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity, but the flow will be slow enough not to overload the stomach too rapidly. 46. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken pox. Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults.

47. Answer: (D) Consult a physician who may give them rubella immunoglobulin. Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant women. 48. Answer: (A) Contact tracing Rationale: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as sexually transmitted diseases. 49. Answer: (D) Leptospirosis Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like rats. 50. Answer: (B) Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea. 51. Answer: (A) Hemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children. 52. Answer: (B) Buccal mucosa Rationale: Kopliks spot may be seen on the mucosa of the mouth or the throat. 53. Answer: (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds. 54. Answer: (B) Severe dehydration Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or nasogastric tube. When the foregoing measures are not possible or effective, then urgent referral to the hospital is done. 55. Answer: (A) 45 infants Rationale: To estimate the number of infants, multiply total population by 3%.

56. Answer: (A) DPT Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8 C only. OPV and measles vaccine are highly sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on Immunization. 57. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. 58. Answer: (D) 5 skin lesions, positive slit skin smear Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. 59. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. 60. Answer: (B) Ask where the family resides. Rationale: Because malaria is endemic, the first question to determine malaria risk is where the clients family resides. If the area of residence is not a known endemic area, ask if the child had traveled within the past 6 months, where she was brought and whether she stayed overnight in that area. 61. Answer: (A) Inability to drink Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken. 62. Answer: (A) Refer the child urgently to a hospital for confinement. Rationale: Baggy pants is a sign of severe marasmus. The best management is urgent referral to a hospital. 63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly. Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. Teach the mother to give Oresol more slowly. 64. Answer: (B) Some dehydration Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is classified as having SOME DEHYDRATION if he

shows 2 or more of the following signs: restless or irritable, sunken eyes, the skin goes back slow after a skin pinch. 65. Answer: (C) Normal Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. 66. Answer: (A) 1 year Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection. 67. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning. 68. Answer: (B) 6 months Rationale: After 6 months, the babys nutrient needs, especially the babys iron requirement, can no longer be provided by mothers milk alone. 69. Answer: (C) 24 weeks Rationale: At approximately 23 to 24 weeks gestation, the lungs are developed enough to sometimes maintain extrauterine life. The lungs are the most immature system during the gestation period. Medical care for premature labor begins much earlier (aggressively at 21 weeks gestation) 70. Answer: (B) Sudden infant death syndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with the supine position. Suffocation would be less likely with an infant supine than prone and the position for GER requires the head of the bed to be elevated. 71. Answer: (C) Decreased temperature Rationale: Temperature instability, especially when it results in a low temperature in the neonate, may be a sign of infection. The neonates color often changes with an infection process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy. 72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale: The small-forgestation neonate is at risk for developing polycythemia during the transitional period in an

attempt to decrease hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores. 73. Answer: (C) Desquamation of the epidermis Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate. 74. Answer: (C) Respiratory depression Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. The serum blood sugar isnt affected by magnesium sulfate. The neonate would be floppy, not jittery. 75. Answer: (C) Respiratory rate 40 to 60 breaths/minute Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional period. Nasal flaring, respiratory rate more than 60 breaths/minute, and audible grunting are signs of respiratory distress. 76. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants arent given tub bath but are sponged off until the cord falls off. Petroleum jelly prevents the cord from drying and encourages infection. Peroxide could be painful and isnt recommended. 77. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. Bulging fontanelles are a sign of intracranial pressure. Simian creases are present in 40% of the neonates with trisomy 21. Cystic hygroma is a neck mass that can affect the airway. 78. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery. 79. Answer: (D) The parents interactions with each other. Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the newborn, expressing interest

about the newborn's size, and indicating a desire to see the newborn are behaviors indicating parental bonding. 80. Answer: (B) Instructing the client to use two or more peripads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourthdegree laceration. 81. Answer: (C) What is your expected due date? Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons. 82. Answer: (D) Aspirate the neonates nose and mouth with a bulb syringe. Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective. 83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes. 84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated.

85. Answer: (A) 110 to 130 calories per kg. Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. 86. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks gestation, then twins dont gain weight as rapidly as singletons of the same gestational age. The placenta can no longer keep pace with the nutritional requirements of both fetuses after 32 weeks, so theres some growth retardation in twins if they remain in utero at 38 to 40 weeks. 87. Answer: (A) conjoined twins Rationale: The type of placenta that develops in monozygotic twins depends on the time at which cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after fertilization. Cleavage that occurs less than 3 day after fertilization results in diamniotic dicchorionic twins. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs between days 8 to 13 result in monoamniotic monochorionic twins. 88. Answer: (D) Ultrasound Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination shouldnt be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring wont detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta separation. 89. Answer: (A) Increased tidal volume Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and out of the respiratory tract with each breath. The expiratory volume and residual volume decrease as the pregnancy progresses. The inspiratory capacity increases during pregnancy. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state. 90. Answer: (A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic drugs are contraindicated in

pregnancy. Long-acting insulin usually isnt needed for blood glucose control in the client with gestational diabetes. 91. Answer: (D) Seizure Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. Hypomagnesemia isnt a complication of preeclampsia. Antihypertensive drug other than magnesium are preferred for sustained hypertension. Magnesium doesnt help prevent hemorrhage in preeclamptic clients. 92. Answer: (C) I.V. fluids Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually arent necessary. Diuretic wouldnt be used unless fluid overload resulted. 93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity. 94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered positive. 95. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesnt cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. 96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells.

97. Answer: (C) Supine position Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle. 98. Answer: (B) Irritability and poor sucking. Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies. 99. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution. 100. Answer: (B) Uterine atony Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

TEST III Answers and Rationale Care of Clients with Physiologic and Psychosocial Alterations 1. Answer: (C) Loose, bloody Rationale: Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.

2. Answer: (A) On the clients right side Rationale: The client has left visual field blindness. The client will see only from the right side. 3. Answer: (C) Check respirations, stabilize spine, and check circulation Rationale: Checking the airway would be priority, and a neck injury should be suspected. 4. Answer: (D) Decreasing venous return through vasodilation. Rationale: The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard. 5. Answer: (A) Call for help and note the time. Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the clients phone and giving the hospital code for cardiac arrest and the clients room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure. 6. Answer: (C) Make sure that the client takes food and medications at prescribed intervals. Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate. 7. Answer: (B) Continue treatment as ordered. Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level. 8. Answer: (B) In the operating room. Rationale: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated. 9. Answer: (B) Flat on back. Rationale: To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.

10. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately. Rationale: This finding suggest that the level of consciousness is decreasing. 11. Answer: (A) Altered mental status and dehydration Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response. 12. Answer: (B) Chills, fever, night sweats, and hemoptysis Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isnt usual. Clients with TB typically have low-grade fevers, not higher than 102F (38.9C). Nausea, headache, and photophobia arent usual TB symptoms. 13. Answer:(A) Acute asthma Rationale: Based on the clients history and symptoms, acute asthma is the most likely diagnosis. Hes unlikely to have bronchial pneumonia without a productive cough and fever and hes too young to have developed (COPD) and emphysema. 14. Answer: (B) Respiratory arrest Rationale: Narcotics can cause respiratory arrest if given in large quantities. Its unlikely the client will have asthma attack or a seizure or wake up on his own. 15. Answer: (D) Decreased vital capacity Rationale: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume. 16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias havent been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but arent as significant as PVCs in the situation. 17. Answer: (B) Avoid foods high in vitamin K Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but isnt effect of taking an anticoagulant. An electric razor-not a straight

razor-should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen should be used to pain relief. 18. Answer: (C) Clipping the hair in the area Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions and depilatories can irritate the skin. 19. Answer: (A) Bone fracture Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones. Estrogen deficiencies result from menopause-not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isnt a complication of osteoporosis. Dowagers hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. 20. Answer: (C) Changes from previous examinations. Rationale: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant. 21. Answer: (C) Balance the clients periods of activity and rest. Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. 22. Answer: (B) Increase his activity level. Rationale: The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 23. Answer: (A) Laminectomy Rationale: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning. Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. 24. Answer: (D) Avoiding straining during bowel movement or bending at the waist. Rationale: The client should avoid straining, lifting heavy objects, and coughing harshly because these

activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) not 5lb. instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses. 25. Answer: (D) Before age 20. Rationale: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self- examination before age 20, preferably when he enters his teens. 26. Answer: (B) Place a saline-soaked sterile dressing on the wound. Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the clients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it. 27. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods. Rationale: Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by shallower respirations with apneas periods. Biots respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath. Kussmauls respirationa are rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate. 28. Answer: (B) Fine crackles Rationale: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. 29. Answer: (B) The airways are so swollen that no air cannot get through Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air cant get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles do not replace wheezes during an acute asthma attack. 30. Answer: (D) Place the client on his side, remove dangerous objects, and protect his head. Rationale: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration.

31. Answer: (B) Kinked or obstructed chest tube Rationales: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage wont cause a tension pneumothorax. Excessive water wont affect the chest tube drainage. 32. Answer: (D) Stay with him but not intervene at this time. Rationale: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone. 33. Answer: (B) Current health promotion activities Rationale: Recognizing an individuals positive health measures is very useful. General health in the previous 10 years is important, however, the current activities of an 84 year old client are most significant in planning care. Family history of disease for a client in later years is of minor significance. Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. 34. Answer: (C) Place the client in a side lying position, with the head of the bed lowered. Rationale: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and should not be used. 35. Answer: (C) Pneumonia Rationale: Fever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isnt having an MI. the client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurses suspicions. 36. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism Rationale: Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client

with a history of alcoholism, are at extremely high risk for developing TB. A high school student, day- care worker, and businessman probably have a much low risk of contracting TB. 37. Answer: (C ) To determine the extent of lesions Rationale: If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest X-ray cant determine if this is a primary or secondary infection. 38. Answer: (B) Bronchodilators Rationale: Bronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflow. Beta- adrenergic blockers arent used to treat asthma and can cause broncho- constriction. Inhaled oral steroids may be given to reduce the inflammation but arent used for emergency relief. 39. Answer: (C) Chronic obstructive bronchitis Rationale: Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema. 40. Answer: (A) The patient is under local anesthesia during the procedure Rationale: Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia. 41. Answer: (D) Raise the side rails Rationale: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety. 42. Answer: (A) Crowd red blood cells Rationale: The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur. 43. Answer: (B) Leukocytosis Rationale: Chronic Lymphocytic leukemia (CLL) is characterized by increased production of leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells within the bone marrow, spleen and liver. 44. Answer: (A) Explain the risks of not having the surgery Rationale: The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses

the nurse should notify the physician and the nurse supervisor and then record the clients refusal in the nurses notes. 45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem) Rationale: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and dont require immediate attention). The lowest priority is the 89-year-old with end-stage right-sided heart failure, who requires time-consuming supportive measures. 46. Answer: (C) Cocaine Rationale: Because of the clients age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbiturate overdose may trigger respiratory depression and slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. 47. Answer: (B) Nonmobile mass with irregular edges Rationale: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction not eversion may be a sign of cancer. 48. Answer: (C) Radiation Rationale: The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer. 49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the

tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3. 50. Answer: (D) "Keep the stoma moist." Rationale: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. 51. Answer: (B) Lung cancer Rationale: Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma. 52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus. 53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer. Rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect. 54. Answer: (D) "Remain supine for the time specified by the physician." Rationale: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

55. Answer: (C) Sigmoidoscopy Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer. 56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. 57. Answer: (A) Liver Rationale: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites. 58. Answer: (D) The client wears a watch and wedding band. Rationale: During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field. 59. Answer: (C) The recommended daily allowance of calcium may be found in a wide variety of foods. Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures. 60. Answer: (C) Joint flexion of less than 50% Rationale: Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the

instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections. Joint pain may be an indication, not a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this procedure. 61. Answer: (D) Gouty arthritis Rationale: Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate deposits don't occur in septic or traumatic arthritis. Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial lining. Traumatic arthritis results from blunt trauma to a joint or ligament. Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees. 62. Answer: (B) 30 ml/hou Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour. 63. Answer: (B) Loss of muscle contraction decreasing venous return Rationale: In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with a stroke, but dont appear with swelling. DVT may develop in clients with a stroke but is more likely to occur in the lower extremities. A stroke isnt linked to protein loss. 64. Answer: (B) It appears on the distal interphalangeal joint Rationale: Heberdens nodes appear on the distal interphalageal joint on both men and women. Bouchards node appears on the dorsolateral aspect of the proximal interphalangeal joint. 65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is systemic Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isnt genderspecific, but rheumatoid arthritis is. Clients have dislocations and subluxations in both disorders. 66. Answer: (C) The cane should be used on the unaffected side Rationale: A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints. 67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct

substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin. 68. Answer: (C) colchicines Rationale: A disease characterized by joint inflammation

(especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout. 69. Answer: (A) Adrenal cortex Rationale: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. 70. Answer: (C) They debride the wound and promote healing by secondary intention Rationale: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing. 71. Answer: (A) Hyperkalemia Rationale: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia. 72. Answer: (C) Restricting fluids Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

73. Answer: (D) glycosylated hemoglobin level. Rationale: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. 74. Answer: (C) 4:00 pm Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m. 75. Answer: (A) Glucocorticoids and androgens Rationale: The adrenal glands have two

divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines epinephrine and norepinephrine. 76. Answer: (A) Hypocalcemia Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery. 77. Answer: (D) Carcinoembryonic antigen level Rationale: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer. 78. Answer: (B) Dyspnea, tachycardia, and pallor Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache.

Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction. 79. Answer: (D) "I'll need to have a C-section if I become pregnant and have a baby." Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIVpositive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV positive can give birth to a baby who's HIV negative. 80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors." Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS. 81. Answer: (B) Pallor, tachycardia, and a sore tongue Rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. 82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. Rationale: To reverse anaphylactic shock, the nurse first should administer

epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority. 83. Answer: (D) bilateral hearing loss. Rationale: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain or fine

motor tremors. Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis. 84. Answer: (D) Lymphocyte Rationale: The lymphocyte provides adaptive immunity

recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production. 85. Answer: (A) moisture replacement. Rationale: Sjogren's syndrome is an autoimmune

disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's syndrome. 86. Answer: (C) stool for Clostridium difficile test. Rationale: Immunosuppressed clients for example, clients receiving chemotherapy, are at risk for infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea. 87. Answer: (D) Western blot test with ELISA. Rationale: HIV infection is detected by

analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test electrophoresis of antibody proteins is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. E- rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test.

88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Rationale: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes. 89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time Rationale: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC. 90. Answer: (D) Strawberries Rationale: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions. 91. Answer: (B) A client with cast on the right leg who states, I have a funny feeling in my right leg. Rationale: It may indicate neurovascular compromise, requires immediate assessment. 92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills. Rationale: The client is at risk for peritonitis; should be assessed for further symptoms and infection. 93. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained. Rationale: Carpal spasms indicate hypocalcemia. 94. Answer: (D) Use comfort measures and pillows to position the client. Rationale: Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief. 95. Answer: (B) Warm the dialysate solution. Rationale: Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or h eating pad; dont use microwave oven.

96. Answer: (C) The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. Rationale: The cane acts as a support and aids in weight bearing for the weaker right leg. 97. Answer: (A) Ask the womans family to provide personal items such as photos or mementos. Rationale: Photos and mementos provide visual stimulation to reduce sensory deprivation. 98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. Rationale: A walker needs to be picked up, placed down on all legs. 99. Answer: (C) Isolation from their families and familiar surroundings. Rationale: Gradual loss of sight, hearing, and taste interferes with normal functioning. 100. Answer: (A) Encourage the client to perform pursed lip breathing. Rationale: Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.

TEST IV Answers and Rationale Care of Clients with Physiologic and Psychosocial Alterations 1. Answer: (C) Hypertension Rationale: Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection. 2. Answer: (A) Pain Rationale: Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority. 3. Answer: (D) Decrease the size and vascularity of the thyroid gland. Rationale: Lugols solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed. 4. Answer: (A) Liver Disease Rationale: The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen. 5. Answer: (C) Leukopenia Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.

6. Answer: (C) Avoid foods that in the past caused flatus. Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy. 7. Answer: (B) Keep the irrigating container less than 18 inches above the stoma. Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated. 8. Answer: (A) Administer Kayexalate Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level. 9. Answer:(B) 28 gtt/min Rationale: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 10. Answer: (D) Upper trunk Rationale: The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%. 11. Answer: (C) Bleeding from ears Rationale: The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation. 12. Answer: (D) may engage in contact sports Rationale: The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. 13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the clients hypoxic drive.

14. Answer: (B) Facilitate ventilation of the left lung. Rationale: Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. 15. Answer: (A) Food and fluids will be withheld for at least 2 hours. Rationale: Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours. 16. Answer: (C) hyperkalemia. Rationale: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate. 17. Answer: (A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. Rationale: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. 18. Answer: (A) The left kidney usually is slightly higher than the right one. Rationale: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2") wide, and 2.5 cm (1") thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae. 19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl. Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated, reflecting

CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%. 20. Answer: (D) Alteration in the size, shape, and organization of differentiated cells Rationale: Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia. 21. Answer: (D) Kaposi's sarcoma Rationale: Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS. 22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage Rationale: The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias. 23. Answer: (A) Auscultate bowel sounds. Rationale: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort. 24. Answer: (B) Lying on the left side with knees bent Rationale: For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.

25. Answer: (A) Blood supply to the stoma has been interrupted Rationale: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color. 26. Answer: (A) Applying knee splints Rationale: Applying knee splints prevents leg

contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs. 27. Answer: (B) Urine output of 20 ml/hour. Rationale: A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit. 28. Answer: (A) Turn him frequently. Rationale: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. 29. Answer: (C) In long, even, outward, and downward strokes in the direction of hair growth Rationale: When applying a topical agent, the nurse should begin at the midline and use long,

even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation. 30. Answer: (A) Beta -adrenergic blockers Rationale: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload). 31. Answer: (C) Raised 30 degrees Rationale: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure cant be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowlers position, the veins would be barely discernible above the clavicle. 32. Answer: (D) Inotropic agents Rationale: Inotropic agents are administered to increase the force of the hearts contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart. 33. Answer: (B) Less than 30% of calories form fat Rationale: A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client. 34. Answer: (C) The emergency department nurse calls up the latest electrocardiogram results to check the clients progress Rationale: The emergency department nurse is no longer directly involved with the clients care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call

physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesnt breach confidentiality. 35. Answer: (B) Check endotracheal tube placement. Rationale: ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the cl ients arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter not symptomatic bradycardia. 36. Answer: (C) 95 mm Hg Rationale: Use the following formula to calculate MAP MAP = systolic + 2 (diastolic) MAP=286 mm HG 3 MAP=126 mm Hg + 2 (80 mm Hg) 3 MAP=95 mm Hg 3

37. Answer: (C) Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. Rationale: An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity. 38. Answer: (D) Heparin-associated thrombosis and thrombocytopenia (HATT) Rationale: HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells. 39. Answer: (B) Corticosteroids Rationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.

40. Answer: (D) Xenogeneic Rationale: An xenogeneic transplant is between is between human and another species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual. 41. Answer: (B) Rationale: Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to VIIIa are part of the intrinsic pathway. 42. Answer: (C) Essential thrombocytopenia Rationale: Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency vitus. The disorder known as von Willebrands disease is a type of hemophilia and isnt linked to SLE. Moderate to severe anemia is associated with SLE, not polycythermia. Dresslers syndrome is pericarditis that occurs after a myocardial infarction and isnt linked to SLE. 43. Answer: (B) Night sweat Rationale: In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isnt associated with Hodgkins disease, nor is hypothermia. Moreover, splenomegaly and pericarditis arent symptoms. Persistent hypothermia is associated with Hodgkins but isnt an early sign of the disease. 44. Answer: (D) Breath sounds Rationale: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it wont help detect pneumonia. 45. Answer: (B) Muscle spasm Rationale: Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. The other options, which reflect parts of the nervous system, arent usually affected by MM. 46. Answer: (C)10 years Rationale: Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.

47. Answer: (A) Low platelet count Rationale: In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places. 48. Answer: (D) Hodgkins disease Rationale: Hodgkins disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesnt last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they dont show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesnt cause lymph node enlargement. 49. Answer: (C) A Rh-negative Rationale: Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. Its important that a person with Rh- negative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops antiRh agglutinins, and sub sequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells. 50. Answer: (B) I will call my doctor if Stacy has persistent vomiting and diarrhea. Rationale: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy. 51. Answer: (D) This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture. Rationale: This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the childs disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture. 52. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed. Rationale: Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.

53. Answer: (C) Immediately discontinue the infusion Rationale: Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication. 54. Answer: (C) Chronic obstructive bronchitis Rationale: Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma dont exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic. 55. Answer: (D) Emphysema Rationale: Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. Theyre pink and usually breathe through pursed lips, hence the term puffer. Clients with ARDS are usually acutely short of breath. Clients with asthma dont have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance. 56. Answer: D 80 mm Hg Rationale: A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected. 57. Answer: (C) Respiratory acidosis Rationale: Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis. 58. Answer: (C) Respiratory failure Rationale: The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesnt manifest these signs. 59. Answer: (D) Elevated serum aminotransferase Rationale: Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate

dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues. 60. Answer: (A) Impaired clotting mechanism Rationale: Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism. 61. Answer: (B) Altered level of consciousness Rationale: Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells. 62. Answer: (C) Ill lower the dosage as ordered so the drug causes only 2 to 4 stools a day. Rationale: Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating. 63. Answer: (B) Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. Rationale: Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When ruptured occurs, the pain is constant because it cant be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldnt increase. For the same reason, the RBC count is decreased not increased. The WBC count increases as cell migrate to the site of injury. 64. Answer: (D) Apply gloves and assess the groin site Rationale: Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.

65. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA) Rationale: PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool not a treatment. 66. Answer: (B) Cardiogenic shock Rationale: Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isnt a shock state, though a severe MI can lead to shock. 67. Answer: (C) Kidneys excretion of sodium and water Rationale: The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one cant travel without the other. 68. Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle. Rationale: Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensinconverting enzyme inhibitors decrease blood pressure due to their action on angiotensin. 69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer Rationale: Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE. 70. Answer: (C) Narcotics are avoided after a head injury because they may hide a worsening condition. Rationale: Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldnt acetaminophen is strong enough ignores the mothers question and therefore isnt appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reyes

syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness. 71. Answer: (A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) Rationale: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2. 72. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome Rationale: Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. Theres no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. Theres no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care. 73. Answer: (C) Decreases inflammation Rationale: Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesnt replace estrogen, decrease infection, or decrease bone demineralization. 74. Answer: (C) Osteoarthritis is the most common form of arthritis Rationale: Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly. 75. Answer: (C) Myxedema coma Rationale: Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn't life-threatening. 76. Answer: (B) An irregular apical pulse Rationale: Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of

hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome. 77. Answer: (D) Below-normal urine osmolality level, above-normal serum osmolality level Rationale: In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a belownormal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels. 78. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Rationale: Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A high- carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low. 79. Answer: (D) Hyperparathyroidism Rationale: Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria. 80. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." Rationale: Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects. 81. Answer: (C) High corticotropin and high cortisol levels Rationale: A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be

associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands. 82. Answer: (D) Performing capillary glucose testing every 4 hours Rationale: The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection. 83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m. Rationale: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. 84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test Rationale: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs. 85. Answer: (B) "Rotate injection sites within the same anatomic region, not among different regions." Rationale: The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug

absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily. 86. Answer: (D) Below-normal serum potassium level Rationale: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS. 87. Answer: (D) Maintaining room temperature in the low-normal range Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods. 88. Answer: (A) Fracture of the distal radius Rationale: Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture of the olecranon, humerus, or carpal scaphoid. 89. Answer: (B) Calcium and phosphorous Rationale: In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren't involved in the development of osteoporosis. 90. Answer: (A) Adult respiratory distress syndrome (ARDS) Rationale: Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed arent typically associated with smoke inhalation and severe hypoxia. 91. Answer: (D) Fat embolism Rationale: Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. Its unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesnt produce progressive hypoxia.

92. Answer: (D) Spontaneous pneumothorax Rationale: A spontaneous pneumothorax occurs when the clients lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation. 93. Answer: (C) Pneumothorax Rationale: From the trauma the client experienced, its unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard. 94. Answer: (C) Serous fluids fills the space and consolidates the region Rationale: Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air cant be left in the space. Theres no gel that can be placed in the pleural space. The tissue from the other lung cant cross the mediastinum, although a temporary mediastinal shift exits until the space is filled. 95. Answer: (A) Alveolar damage in the infracted area Rationale: The infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. Theres a loss of lung parenchyma and subsequent scar tissue formation. 96. Answer: (D) Respiratory alkalosis Rationale: A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis. 97. Answer: (A) Air leak Rationale: Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesnt normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber. 98. Answer: (B) 21 Rationale: 3000 x 10 divided by 24 x 60. 99. Answer: (B) 2.4 ml Nursing Crib Student Nurses Community 174

Rationale: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml. 100. Answer: (D) I should put on the stockings before getting out of bed in the morning. Rationale: Promote venous return by applying external pressure on veins.

TEST V Answers and Rationale Care of Clients with Physiologic and Psychosocial Alterations 1. Answer: (D) Focusing Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. The nurse didnt restate the question, make observation, or ask further question (exploring). 2. Answer: (D) Remove all other clients from the dayroom. Rationale: The nurses first p riority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other clients. 3. Answer: (A) The client is disruptive. Rationale: Group activity provides too much stimulation, which the client will not be able to handle (harmful to self) and as a result will be disruptive to others. 4. Answer: (C) Agree to talk with the mother and the father together. Rationale: By agreeing to talk with both parents, the nurse can provide emotional support and further assess and validate the familys needs. 5. Answer: (A) Perceptual disorders. Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. 6. Answer: (D) Suggest that it takes awhile before seeing the results. Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the therapeutic blood level is reached. 7. Answer: (C) Superego Rationale: This behavior shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego.

8. Answer: (C) Skeletal muscle paralysis. Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation. 9. Answer: (D) Increase calories, carbohydrates, and protein. Rationale: This client increased protein for tissue building and increased calories to replace what is burned up (usually via carbohydrates). 10. Answer: (C) Acting overly solicitous toward the child. Rationale: This behavior is an example of reaction formation, a coping mechanism. 11. Answer: (A) By designating times during which the client can focus on the behavior. Rationale: The nurse should designate times during which the client can focus on the

compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to or try to prevent the behavior. Trying to prevent the behavior may cause pain and terror in the client. The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior. 12. Answer: (D) Exploring the meaning of the traumatic event with the client. Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. The client must explore the meaning of the event and won't heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate. A special diet isn't indicated unless the client also has an eating disorder or a nutritional problem. 13. Answer: (C) "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." Rationale: The nurse must be honest with the client by telling her that the paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The client will benefit from psychiatric treatment, which will help her understand the underlying cause of her symptoms. After the

psychological conflict is resolved, her symptoms will disappear. Saying that it must be awful not to be able to move her legs wouldn't answer the client's question; knowing that the cause is psychological wouldn't necessarily make her feel better. Telling her that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict. 14. Answer: (C) fluvoxamine (Luvox) and clomipramine (Anafranil) Rationale: The

antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. Librium and Valium may be helpful in treating anxiety related to OCD but aren't drugs of choice to treat the illness. The other medications mentioned aren't effective in the treatment of OCD. 15. Answer: (A) A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days. Rationale: The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Blood level checks aren't necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported. 16. Answer: (B) Severe anxiety and fear. Rationale: Phobias cause severe anxiety (such as a panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia, and elevated blood pressure. Insomnia, an inability to concentrate, and weight loss are common in depression. Withdrawal and failure to distinguish reality from fantasy occur in schizophrenia. 17. Answer: (A) Antidepressants Rationale: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks isn't clearly understood. Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms of anxiety but don't relieve the anxiety itself. Antipsychotic drugs are inappropriate because clients who experience panic attacks aren't psychotic. Mood stabilizers aren't indicated because panic attacks are rarely associated with mood changes. 18. Answer: (B) 3 to 5 days Rationale: Monoamine oxidase inhibitors, such as tranylcypromine, have an onset of action of approximately 3 to 5 days. A full clinical response may be delayed for 3 to 4 weeks. The therapeutic effects may continue for 1 to 2 weeks after discontinuation.

19. Answer: (B) Providing emotional support and individual counseling. Rationale: Clients in the first stage of Alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. The other options are appropriate during the second stage of Alzheimer's disease, when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition. 20. Answer: (C) Emotional lability, euphoria, and impaired memory Rationale: Signs of

antianxiety agent overdose include emotional lability, euphoria, and impaired memory. Phencyclidine overdose can cause combativeness, sweating, and confusion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation. Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure. 21. Answer: (D) A low tolerance for frustration Rationale: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without other plans for employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships. 22. Answer: (C) Methadone Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesnt have the same deterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. 23. Answer: (B) Hallucinations Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.

24. Answer: (C) Set up a strict eating plan for the client. Rationale: Establishing a consistent eating plan and monitoring the clients weight are very important in this disorder. The family and friends should be included in the clients care. The client should be monitored during meals -not given privacy. Exercise must be limited and supervised. 25. Answer: (A) Highly important or famous. Rationale: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. 26. Answer: (D) Listening attentively with a neutral attitude and avoiding power struggles. Rationale: The nurse should listen to the clients requests, express willingness to seriously consider the request, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldnt try to restrain the client when he feels the need to move around as long as his activity isnt harmful. High calorie finger foods should be offered to supplement the clients diet, if he cant remain seated long enough to eat a complete meal. The nurse shouldnt be forced to stay seated at the table to finid=sh a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice. 27. Answer: (D) Denial Rationale: Denial is unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association. 28. Answer: (B) Paranoid thoughts Rationale: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships. 29. Answer: (C) Identify anxiety-causing situations Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-

causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. 30. Answer: (A) Tension and irritability Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increase the heart rate and blood flow. Diarrhea is a common adverse effect so option D in is incorrect. 31. Answer: (B) No, I do not hear your voices, but I believe you can hear them. Rationale: The nurse, demonstrating knowledge and understanding, accepts the clients perceptions even though they are hallucinatory. 32. Answer: (C) Confusion for a time after treatment Rationale: The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. 33. Answer: (D) Acceptance stage Rationale: Communication and intervention during this stage are mainly nonverbal, as when the client gestures to hold the nurses hand. 34. Answer: (D) A higher level of anxiety continuing for more than 3 months. Rationale: This is not an expected outcome of a crisis because by definition a crisis would be resolved in 6 weeks. 35. Answer: (B) Staying in the sun Rationale: Haldol causes photosensitivity. Severe sunburn can occur on exposure to the sun. 36. Answer: (D) Moderate-level anxiety Rationale: A moderately anxious person can ignore peripheral events and focuses on central concerns. 37. Answer: (C) Diverse interest Rationale: Before onset of depression, these clients usually have very narrow, limited interest. 38. Answer: (A) As their depression begins to improve Rationale: At this point the client may have enough energy to plan and execute an attempt. 39. Answer: (D) Disturbance in recalling recent events related to cerebral hypoxia. Rationale: Cell damage seems to interfere with registering input stimuli, which affects the ability to register

and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structure. 40. Answer: (D) Encouraging the client to have blood levels checked as ordered. Rationale: Blood levels must be checked monthly or bimonthly when the client is on maintenance therapy because there is only a small range between therapeutic and toxic levels. 41. Answer: (B) Fine hand tremors or slurred speech Rationale: These are common side effects of lithium carbonate. 42. Answer: (D) Presence Rationale: The constant presence of a nurse provides emotional support because the client knows that someone is attentive and available in case of an emergency. 43. Answer: (A) Clients perception of the presenting problem. Rationale: The nurse can be most therapeutic by starting where the client is, because it is the clients concept of the problem that serves as the starting point of the relationship. 44. Answer: (B) Chocolate milk, aged cheese, and yogurt Rationale: These high -tyramine foods, when ingested in the presence of an MAO inhibitor, cause a severe hypertensive response. 45. Answer: (B) 4 to 6 weeks Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks. 46. Answer: (D) Males are more likely to use lethal methods than are females Rationale: This finding is supported by research; females account for 90% of suicide attempts but males are three times more successful because of methods used. 47. Answer: (C) "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." Rationale: The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended, as in option A. Option B is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. Judgmental remarks, such as option D, may decrease the client's self-esteem. 48. Answer: (C) lithium carbonate (Lithane) Rationale: Lithium carbonate, an antimania drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including maniclike activity. Lithium helps

control the affective component of this disorder. Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don't respond to other antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and that undergoing cocaine detoxification. 49. Answer: (B) Report a sore throat or fever to the physician immediately. Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially lifethreatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/l, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. 50. Answer: (C) Neuroleptic malignant syndrome. Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. 51. Answer: (B) Advising the client to sit up for 1 minute before getting out of bed. Rationale: To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for 1 minute before getting out of bed. Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. In these cases, the dosage may be reduced or the physician may prescribe nortriptyline, another tricyclic antidepressant. Orthostatic hypotension disappears only when the drug is discontinued. 52. Answer: (D) Dysthymic disorder. Rationale: Dysthymic disorder is marked by feelings of depression lasting at least 2 years, accompanied by at least two of the following symptoms: sleep disturbance, appetite disturbance, low energy or fatigue, low self- esteem, poor concentration, difficulty making decisions, and hopelessness. These symptoms may be relatively continuous or separated by intervening periods of normal mood that last a few days to a few weeks.

Cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration marked by numerous periods of depression and hypomania. Atypical affective disorder is characterized by manic signs and symptoms. Major depression is a recurring, persistent sadness or loss of interest or pleasure in almost all activities, with signs and symptoms recurring for at least 2 weeks. 53. Answer: (C) 30 g mixed in 250 ml of water Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested, or a minimum dose of 30 g, mixed in 250 ml of water. Doses less than this will be ineffective; doses greater than this can increase the risk of adverse reactions, although toxicity doesn't occur with activated charcoal, even at the maximum dose. 54. Answer: (C) St. John's wort Rationale: St. John's wort has been found to have serotoninelevating properties, similar to prescription antidepressants. Ginkgo biloba is prescribed to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant that is similar to ephedrine. 55. Answer: (B) Sodium Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium. 56. Answer: (D) It's characterized by an acute onset and lasts hours to a number of days Rationale: Delirium has an acute onset and typically can last from several hours to several days. 57. Answer: (B) Impaired communication. Rationale: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimer's disease. During the early stage of this disease, subtle personality changes may also be present. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior. Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired

communication, such as inappropriate conversation, actions, and responses. During the late stage, the client can't perform self-care activities and may become mute.

58. Answer: (D) This medication may initially cause tiredness, which should become less bothersome over time. Rationale: Sedation is a common early adverse effect of imipramine, a tricyclic antidepressant, and usually decreases as tolerance develops. Antidepressants aren't habit forming and don't cause physical or psychological dependence. However, after a long course of high-dose therapy, the dosage should be decreased gradually to avoid mild withdrawal symptoms. Serious adverse effects, although rare, include myocardial infarction, heart failure, and tachycardia. Dietary restrictions, such as avoiding aged cheeses, yogurt, and chicken livers, are necessary for a client taking a monoamine oxidase inhibitor, not a tricyclic antidepressant. 59. Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately. 60. Answer: (D) Opioid withdrawal Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation. 61. Answer: (A) Regression Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event. 62. Answer: (A) Abnormal movements and involuntary movements of the mouth, tongue, and face. Rationale: Tardive dyskinesia is a severe reaction associated with long term use of antipsychotic medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (fly catcher tongue), and face.

63. Answer: (C) Blurred vision Rationale: At lithium levels of 2 to 2.5 mEq/L the client will experienced blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrythmias, peripheral vascular collapse, and death. 64. Answer: (C) No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. Rationale: The best indicator that the behavior is controlled, if the client exhibits no signs of aggression after partial release of restraints. Options A, B, and D do not ensure that the client has controlled the behavior. 65. Answer: (A) increased attention span and concentration Rationale: The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability. 66. Answer: (C) Moderate Rationale: The child with moderate mental retardation has an I.Q. of 35- 50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35. 67. Answer: (D) Rearrange the environment to activate the child Rationale: The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be re-channeling through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling. 68. Answer: (B) cocaine Rationale: The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations. 69. Answer: (B) insidious onset Rationale: Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.

70. Answer: (C) Claustrophobia Rationale: Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers. 71. Answer: (A) Revealing personal information to the client Rationale: Counter-transference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past. 72. Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia. 73. Answer: (C) A living, learning or working environment. Rationale: A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms; limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu. 74. Answer: (B) Transference Rationale: Transference is a positive or negative feeling associated with a significant person in the clients past that are unconsciously assigned to another A. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. Countert-transference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the clients refusal to submit himself to the care of the nurse

75. Answer: (B) Adventitious Rationale: Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life 76. Answer: (C) Major depression Rationale: The DSM-IV-TR classifies major depression as an Axis I disorder. Borderline personality disorder as an Axis II; obesity and hypertension, Axis III. 77. Answer: (B) Transference Rationale: Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the clients past to another person. Intellectualization is a defense mechanism in which the client avoids dealing with emotions by focusing on facts. Triangulation refers to conflicts involving three family members. Splitting is a defense mechanism commonly seen in clients with personality disorder in which the world is perceived as all good or all bad. 78. Answer: (B) Hypochondriasis Rationale: Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients with hypochondriasis. In many cases, the GI system is affected. Conversion disorders are characterized by one or more neurologic symptoms. The clients symptoms dont suggest severe anxiety. A client experiencing sublimation channels maladaptive feelings or impulses into socially acceptable behavior 79. Answer: (C) Hypochondriasis Rationale: Hypochodriasis in this case is shown by the clients belief that she has a serious illness, although pathologic causes have been eliminated. The disturbance usually lasts at lease 6 with identifiable life stressor such as, in this case, course examinations. Conversion disorder s are characterized by one or more neurologic symptoms. Depersonalization refers to persistent recurrent episodes of feeling detached from ones self or body. Somatoform disorders generally have a chronic course with few remissions. 80. Answer: (A) Triazolam (Halcion) Rationale: Triazolam is one of a group of sedative hypnotic medication that can be used for a limited time because of the risk of dependence. Paroxetine is a scrotonin-specific reutake inhibitor used for treatment of depression panic disorder, and obsessive-compulsive disorder. Fluoxetine is a scrotonin-specific reuptake inhibitor used for depressive disorders and obsessive-compulsive disorders. Risperidome is indicated for psychotic disorders.

81. Answer: (D) It promotes emotional support or attention for the client Rationale: Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention. Primary gain enables the client to avoid some unpleasant activity. A dysfunctional family may disregard the real issue, although some conflict is relieved. Somatoform pain disorder is a preoccupation with pain in the absence of physical disease. 82. Answer: (A) I went to the mall with my friends last Saturday Rationale: Clients with panic disorder tent to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors. Hyperventilating is a key symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic disorder. The client taking medications for panic disorder; such as tricylic antidepressants and benzodiazepines, must be weaned off these drugs. Most clients with panic disorder with agoraphobia dont have nutritional problems. 83. Answer: (A) Im sleeping better and dont have nightmares Rationale:MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individual with posttraumatic stress disorder. MAO inhibitors arent used to help control flashbacks or phobias or to decrease the craving for alcohol. 84. Answer: (D) Stopping the drug can cause withdrawal symptoms Rationale: Stopping antianxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms. Stopping a benzodiazepine doesnt tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties. 85. Answer: (B) Behavioral difficulties Rationale: Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood. Anxiety disorder is more commonly associated with small children rather than with adolescents. Cognitive impairment is typically associated with delirium or dementia. Labile mood is more characteristic of a client with cognitive impairment or bipolar disorder. 86. Answer: (D) Its a mood disorder similar to major depression but of mild to moderate severity Rationale: Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity. Cyclothymic disorder is a mood disorder characterized by a mood range from moderate depression to hypomania. Bipolar I disorder is characterized by a

single manic episode with no past major depressive episodes. Seasonal- affective disorder is a form of depression occurring in the fall and winter. 87. Answer: (A) Vascular dementia has more abrupt onset Rationale: Vascular dementia differs from Alzheimers disease in that it has a more abrupt onset and runs a highly variable course. Personally change is common in Alzheimers disease. The duration of delirium is usually brief. The inability to carry out motor activities is common in Alzheimers disease. 88. Answer: (C) Drug intoxication Rationale: This client was taking several medications that have a propensity for producing delirium; digoxin (a digitalis glycoxide), furosemide (a thiazide diuretic), and diazepam (a benzodiazepine). Sufficient supporting data dont exist to suspect the other options as causes. 89. Answer: (D) The client is experiencing visual hallucination Rationale: The presence of a sensory stimulus correlates with the definition of a hallucination, which is a false sensory perception. Aphasia refers to a communication problem. Dysarthria is difficulty in speech production. Flight of ideas is rapid shifting from one topic to another. 90. Answer: (D) The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. Rationale: Minor memory problems are distinguished from dementia by their minor severity and their lack of significant interference with the clients social or occupational lifestyle. Other options would be included in the history data but dont directly correlate with the clients lifestyle. 91. Answer: (D) Loose association Rationale: Loose associations are conversations that constantly shift in topic. Concrete thinking implies highly definitive thought processes. Flight of ideas is characterized by conversation thats disorganized from the onset. Loose associations dont necessarily start in a cogently, then becomes loose. 92. Answer: (C) Paranoid Rationale: Because of their suspiciousness, paranoid personalities ascribe malevolent activities to others and tent to be defensive, becoming quarrelsome and argumentative. Clients with antisocial personality disorder can also be antagonistic and argumentative but are less suspicious than paranoid personalities. Clients with histrionic

personality disorder are dramatic, not suspicious and argumentative. Clients with schizoid personality disorder are usually detached from other and tend to have eccentric behavior. 93. Answer: (C) Explain that the drug is less affective if the client smokes Rationale: Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Serotonin syndrome occurs with clients who take a combination of antidepressant medications. Olanzapine doesnt cause euphoria, and extrapyramidal adverse reactions arent a problem. However, the client should be aware of adverse effects such as tardive dyskinesia. 94. Answer: (A) Lack of honesty Rationale: Clients with antisocial personality disorder tent to engage in acts of dishonesty, shown by lying. Clients with schizotypal personality disorder tend to be superstitious. Clients with histrionic personality disorders tend to overreact to frustrations and disappointments, have temper tantrums, and seek attention. 95. Answer: (A) Im not going to look just at the negative things about myself Rationale: As the clients makes progress on improving self-esteem, self- blame and negative self evaluation will decrease. Clients with dependent personality disorder tend to feel fragile and inadequate and would be extremely unlikely to discuss their level of competence and progress. These clients focus on self and arent envious or jealous. Individuals with dependent personality disorders dont take over situations because they see themselves as inept and inadequate. 96. Answer: (C) Assess for possible physical problems such as rash Rationale: Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have as in-depth assessment of physical complaints that may spill over into their delusional symptoms. Talking with the client wont provide as assessment of his itching, and itching isnt as adverse reaction of antipsychotic drugs, calling the physician to get the clients medication increased doesnt address his physical complaints. 97. Answer: (B) Echopraxia Rationale: Echopraxia is the copying of anothers behaviors and is the result of the loss of ego boundaries. Modeling is the conscious copying of someones behaviors. Ego-syntonicity refers to behaviors that correspond with the individuals sense of self. Ritualism behaviors are repetitive and compulsive.

98. Answer: (C) Hallucination Rationale: Hallucinations are sensory experiences that are misrepresentations of reality or have no basis in reality. Delusions are beliefs not based in reality. Disorganized speech is characterized by jumping from one topic to the next or using unrelated words. An idea of reference is a belief that an unrelated situation holds special meaning for the client. 99. Answer: (C) Regression Rationale: Regression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia. Projection is a defense mechanism in which one blames others and attempts to justify actions; its used primarily by people with paranoid schizophrenia and delusional disorder. Rationalization is a defense mechanism used to justify ones action. Repression is the basic defense mechanism in the neuroses; its an involuntary exclusion of painful thoughts, feelings, or experiences from awareness. 100.Answer: (A) Should report feelings of restlessness or agitation at once Rationale: Agitation and restlessness are adverse effect of haloperidol and can be treated with antocholinergic drugs. Haloperidol isnt likely to cause photosensitivity or control essential hypertension. Although the client may experience increased concentration and activity, these effects are due to a decreased in symptoms, not the drug itself.