1. Nurse Betty is assigned to the following clients.

The client that the nurse would see first after endorsement? a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post operatives abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 2. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: a. Assess temperature frequently. b. Provide diversional activities. c. Check circulation every 15-30 minutes. d. Socialize with other patients once a shift. 3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse Incharge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange 4. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output 5. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. My ankle looks less swollen now. b. My ankle feels warm. c. My ankle appears redder now. d. I need something stronger for pain relief 6. The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia

7. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 8. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 9.Which type of medication order might read "Vitamin K 10 mg I.M. daily 3 days?" a. Single order b. Standard written order c. Standing order d. Stat order 10.A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid stools 11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by: a. Pulling the lobule down and back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward 12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? a. Excessive fetal activity. b. Larger than normal uterus for gestational age. c. Vaginal bleeding d. Elevated levels of human chorionic gonadotropin. 13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c. Rapid respiratory rate above 40/min.

d. Rapid rise in blood pressure. 14. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: a. Presenting part is 2 cm above the plane of the ischial spines. b. Biparietal diameter is at the level of the ischial spines. c. Presenting part in 2 cm below the plane of the ischial spines. d. Biparietal diameter is 2 cm above the ischial spines. 15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: a. Contractions every 1 minutes lasting 70-80 seconds. b. Maternal temperature 101.2 c. Early decelerations in the fetal heart rate. d. Fetal heart rate baseline 140-160 bpm. 16. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous CPR 17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had: a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. b. First and second caesareans were for cephalopelvic disproportion. c. First caesarean through a classic incision as a result of severe fetal distress. d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. 18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddlers temperature is: a. Talk to the mother first and then to the toddler. b. Bring extra help so it can be done quickly. c. Encourage the mother to hold the child. d. Ignore the crying and screaming.

19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site? a. Avoid touching the suture line, even when cleaning. b. Place the baby in prone position. c. Give the baby a pacifier. d. Place the infants arms in soft elbow restraints. 20. Which action should nurse Marian include in the care plan for a 2 month old with heart failure? a. Feed the infant when he cries. b. Allow the infant to rest before feeding. c. Bathe the infant and administer medications before feeding. d. Weigh and bathe the infant before feeding. 21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infants diet? a. Skim milk and baby food. b. Whole milk and baby food. c. Iron-rich formula only. d. Iron-rich formula and baby food. 22. Nurse Patricia finds a female client who is postmyocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action? a. Call for help and note the time. b. Clear the airway c. Give two sharp thumps to the precordium, and check the pulse. d. Administer two quick blows. 23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should: a. Plan care so the client can receive 8 hours of uninterrupted sleep each night. b. Monitor vital signs every 2 hours. c. Make sure that the client takes food and medications at prescribed intervals. d. Provide milk every 2 to 3 hours. 24. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? a. Stop the I.V. infusion of heparin and notify the physician. b. Continue treatment as ordered. c. Expect the warfarin to increase the PTT. d. Increase the dosage, because the level is lower than normal.

25. A client undergone ileostomy, when should the drainage appliance be applied to the stoma? a. 24 hours later, when edema has subsided. b. In the operating room. c. After the ileostomy begin to function. d. When the client is able to begin self-care procedures. 26. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in: a. On the side, to prevent obstruction of airway by tongue. b. Flat on back. c. On the back, with knees flexed 15 degrees. d. Flat on the stomach, with the head turned to the side. 27. While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? a. Blood pressure is decreased from 160/90 to 110/70. b. Pulse is increased from 87 to 95, with an occasional skipped beat. c. The client is oriented when aroused from sleep, and goes back to sleep immediately. d. The client refuses dinner because of anorexia. 28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? a. Altered mental status and dehydration b. Fever and chills c. Hemoptysis and Dyspnea d. Pleuritic chest pain and cough 29. A ale client has active tuberculosis (TB). Which of the following symptoms will be exhibit? a. Chest and lower back pain b. Chills, fever, night sweats, and hemoptysis c. Fever of more than 104F (40C) and nausea d. Headache and photophobia 30. Mark, a 7-year-old client is brought to the emergency department. Hes tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions? a. Acute asthma b. Bronchial pneumonia c. Chronic obstructive pulmonary disease (COPD) d. Emphysema

31. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isnt taken quickly, she might have which of the following reactions? a. Asthma attack b. Respiratory arrest c. Seizure d. Wake up on his own 32. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? a. Increased elastic recoil of the lungs b. Increased number of functional capillaries in the alveoli c. Decreased residual volume d. Decreased vital capacity 33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of: a. Ascites b. Nystagmus c. Leukopenia d. Polycythemia 34. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to: a. Eliminate foods high in cellulose. b. Decrease fluid intake at meal times. c. Avoid foods that in the past caused flatus. d. Adhere to a bland diet prior to social events. 35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, I should: a. Lie on my left side while instilling the irrigating solution. b. Keep the irrigating container less than 18 inches above the stoma. c. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel. d. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure. 36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part

of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to: a. Administer Kayexalate b. Restrict foods high in protein c. Increase oral intake of cheese and milk. d. Administer large amounts of normal saline via I.V. 37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: a. 18 gtt/min b. 28 gtt/min c. 32 gtt/min d. 36 gtt/min 38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns? a. Face and neck b. Right upper arm and penis c. Right thigh and penis d. Upper trunk 39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed: a. Reactive pupils b. A depressed fontanel c. Bleeding from ears d. An elevated temperature 40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? a. take the pulse rate once a day, in the morning upon awakening b. May be allowed to use electrical appliances c. Have regular follow up care d. May engage in contact sports 41.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. c. Oxygen is administered best using a nonrebreathing mask d. Blood gases are monitored using a pulse oximeter.

42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position: a. Reduce incisional pain. b. Facilitate ventilation of the left lung. c. Equalize pressure in the pleural space. d. Increase venous return 43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? a. Perceptual disorders. b. Impending coma. c. Recent alcohol intake. d. Depression with mutism. 44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it doesnt help and refuses to take it. What should the nurse say or do? a. Withhold the drug. b. Record the clients response. c. Encourage the client to tell the doctor. d. Suggest that it takes awhile before seeing the results. 45. Dervid, an adolescent has a history of truancy from school, running away from home and barrowing other peoples things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the: a. Id b. Ego c. Superego d. Oedipal complex 46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect? a. Short-acting anesthesia b. Decreased oral and respiratory secretions. c. Skeletal muscle paralysis. d. Analgesia.

47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is: a. Serve the client a bowl of soup, buttered French bread, and apple slices. b. Increase calories, decrease fat, and decrease protein. c. Give the client pieces of cut-up steak, carrots, and an apple. d. Increase calories, carbohydrates, and protein.

ANSWER and RATIONALE 1. 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. 2. 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. 3. 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. 4. 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. 5. 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 6. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia. 7. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. 8. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.

48.What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse? a. Flat affect b. Expressing guilt c. Acting overly solicitous toward the child. d. Ignoring the child.

49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior? a. By designating times during which the client can focus on the behavior. b. By urging the client to reduce the frequency of the behavior as rapidly as possible. c. By calling attention to or attempting to prevent the behavior. d. By discouraging the client from verbalizing anxieties. 50.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby? a. Recommending a high-protein, low-fat diet. b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle. c. Allowing the client time to heal. d. Exploring the meaning of the traumatic event with the client.

Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. 9. 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 formedications 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. 10. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semiliquid 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. 11. 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. 12. 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 pregnancy-induced hypertension. Fetal activity would not be noted. 13. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.

14. 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. 15. 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. 16. 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. 17. 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. 18. 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. 19. 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.

20. 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. 21. 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. 22. 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. 23. 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. 24. 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. 25. 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. 26. 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. 27. 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. 28. 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. 29. 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. 30. 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. 31. 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. 32. 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. 33. Answer: (C) Leukopenia Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.

34. 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. 35. 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. 36. 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. 37. 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) 38. 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%. 39. Answer: (C) Bleeding from ears ationale: 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. 40. 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. 41. 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. 42. 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. 43. Answer: (A) Perceptual disorders. Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. 44. 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. 45. Answer: (C) Superego Rationale: This behavior shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego. 46. 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. 47. 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). 48. Answer: (C) Acting overly solicitous toward the child. Rationale: This behavior is an example of reaction formation, a coping mechanism. 49. 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. 50. 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.