Fundamentals Of Nursing NCLEX Quiz 37

1. The nurse is assessing a client who states her last menstrual period was March 17. and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?

08/11/2017

15/05/2017

21/02/2017

24/12/2017

Naegele’s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

Explanation

Naegele’s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

2. A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition. the nurse should instruct her to

Increase her fluid intake to three liters/day.

Request a prescription for a laxative from her physician.

Stop taking iron supplements.

Take two tablespoons of mineral oil daily.

In pregnancy. constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake. increase roughage in the diet. and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy. as ordered. and should not be discontinued. The client should increase fluid intake. increase roughage in the diet. and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A. D. E. K) if taken near mealtimes.

Explanation

In pregnancy. constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake. increase roughage in the diet. and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy. as ordered. and should not be discontinued. The client should increase fluid intake. increase roughage in the diet. and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A. D. E. K) if taken near mealtimes.

3. The nurse should recognize that all of the following physical changes of the head and face are associated with the aging client except:

Pronounced wrinkles on the face.

Decreased size of the nose and ears.

Increased growth of facial hair.

Neck wrinkles.

The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles about the eyebrows. lips. cheeks. and outer edges of the eye orbit. The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most older adults. The aging process shortens the platysma muscle. which contributes to neck wrinkles.

Explanation

The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles about the eyebrows. lips. cheeks. and outer edges of the eye orbit. The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most older adults. The aging process shortens the platysma muscle. which contributes to neck wrinkles.

4. A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?

“Good morning. Do you remember where you are?”

“Hello. My name is Elaine Jones and I am your nurse for today.”

“How are you today? Remember. you’re in the hospital.”

“Good morning. You’re in the hospital. I am your nurse Elaine Jones.”

As cognitive ability declines. the nurse provides a calm. predictable environment for the client. This response establishes time. location and the caregiver’s name.

Explanation

As cognitive ability declines. the nurse provides a calm. predictable environment for the client. This response establishes time. location and the caregiver’s name.

5. Which of these statements. when made by the nurse. is most effective when communicating with a 4-year-old?

“Tell me where you hurt.”

“Other children like having their blood pressure taken.”

“This will be like having a little stick in your arm.”

“Anything you tell me is confidential.”

Four-year-olds are egocentric and interested in having the focus on themselves. They will not be interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential communication is most appropriate for the adolescent. In addition. confidentiality is not maintained if the child plans to harm themselves. harm someone else. or discloses abuse.

Explanation

Four-year-olds are egocentric and interested in having the focus on themselves. They will not be interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential communication is most appropriate for the adolescent. In addition. confidentiality is not maintained if the child plans to harm themselves. harm someone else. or discloses abuse.

6. A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?

Ask the client if there are second thoughts about having the procedure

Notify the anesthesia department and the surgeon of the client’s refusal

Ask the client if the preference would be to remove the dentures in the operating room receiving area

Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client’s sense of self-esteem and self-concept.

Explanation

Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client’s sense of self-esteem and self-concept.

7. When assessing a newborn whose mother consumed alcohol during the pregnancy. the nurse would assess for which of these clinical manifestations?

Wide-spaced eyes. smooth philtrum. flattened nose

Strong tongue thrust. short palpebral fissures. simian crease

Negative Babinski sign. hyperreflexia. deafness

Shortened limbs. increased jitteriness. constant sucking

The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A.

Explanation

The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A.

8. All of the following characteristics would indicate to the nurse that an elder client might experience undesirable effects of medicines except:

Increased oxidative enzyme levels.

Alcohol taken with medication.

Medications containing magnesium.

Decreased serum albumin.

Oxidative enzyme levels decrease in the elderly. which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly. resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentiate or interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are less therapeutic effects and increased drug interactions.

Explanation

Oxidative enzyme levels decrease in the elderly. which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly. resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentiate or interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are less therapeutic effects and increased drug interactions.

9. The family of a 6-year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children?

Growth problems will occur if the fracture involves the periosteum

Epiphyseal fractures often interrupt a child’s normal growth pattern

Children usually heal very quickly. so growth problems are rare

Adequate blood supply to the bone prevents growth delay after fractures

Epiphyseal fractures often interrupt a child’s normal growth pattern

Explanation

Epiphyseal fractures often interrupt a child’s normal growth pattern

10. When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck. the nurse should provide teaching regarding which of the following procedures?

Dermabrasion

Rhinoplasty

Blepharoplasty

Rhytidectomy

Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin. which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars. severe acne. and pigment from tattoos. Rhinoplasty is done to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.

Explanation

Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin. which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars. severe acne. and pigment from tattoos. Rhinoplasty is done to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.