1.
What needs of a patient does a nurse address?
Correct Answer
D. All of the above
Explanation
Nurses address a patient's physical needs through medical care, administer emotional support to alleviate stress, and attend to mental well-being by considering cognitive aspects. Their holistic approach ensures comprehensive care, fostering overall health and recovery for individuals under their supervision.
2.
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
Correct Answer
A. Elevate leg on 2 pillows
Explanation
Elevating the leg on two pillows is a nursing intervention commonly used to manage thrombophlebitis. By elevating the leg, the goal is to reduce swelling and enhance venous return, helping to alleviate symptoms and promote healing. This position aids in preventing stasis of blood in the affected leg and may contribute to overall comfort.
3.
Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones?
Correct Answer
A. Engorgement of the breasts
Explanation
Engorgement of the breasts is an example of a variation in the newborn resulting from the presence of maternal hormones. During pregnancy, maternal hormones stimulate the development of the mammary glands in the fetus. After birth, the sudden withdrawal of these hormones can lead to breast engorgement in both male and female infants. This is a temporary and normal variation that typically resolves on its own as the infant's body adjusts to the postnatal environment.
4.
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds
Correct Answer
C. "CD4 lymphocyte count is less than 200."
Explanation
The correct answer is C: "CD4 lymphocyte count is less than 200." CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these – the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.
5.
The
nursing care plan for a client with decreased adrenal function should include
Correct Answer
C. Limiting visitors
Explanation
A diagnosis of AIDS (Acquired Immunodeficiency Syndrome) is typically made when the CD4 lymphocyte count drops below 200 cells per cubic millimeter of blood, indicating severe immunosuppression. This criterion is one of the key indicators used to determine the progression of HIV infection to AIDS. The other options are not specific criteria for the diagnosis of AIDS.
6.
The nurse
is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in
removing respiratory secretions?
Correct Answer
B. Increasing oral fluid intake to 3000 cc per day
Explanation
Increasing oral fluid intake to 3000 cc per day is a reasonable and supportive intervention for a client with pneumococcal pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to mobilize and clear. While chest physiotherapy is a more direct method for removing secretions, promoting hydration is a valuable complementary measure. It is essential to consider a holistic approach to care, combining strategies that support both hydration and respiratory clearance for optimal outcomes in pneumonia management.
7.
While
assessing a client in an outpatient facility with a panic disorder, the nurse
completes a thorough health history and physical exam. Which finding is most significant for this client?
Correct Answer
B. Sense of impending doom
Explanation
A sense of impending doom is a common and characteristic symptom of panic attacks in individuals with panic disorder. It is often described as an overwhelming feeling of fear, apprehension, or impending catastrophe. This symptom distinguishes panic disorder from other anxiety disorders. Compulsive behavior, fear of flying, and predictable episodes may be associated with other anxiety disorders but are not as specific to panic disorder.
8.
The nurse
is reviewing a depressed client's history from an earlier admission.
Documentation of anhedonia is noted. The nurse understands that this finding
refers to
Correct Answer
C. Lack of enjoyment in usual pleasures
Explanation
Anhedonia is a key symptom of depression and is characterized by a diminished ability to experience pleasure or interest in activities that were previously enjoyable. It can affect various aspects of life, including hobbies, social interactions, and other activities that used to bring joy. The other options, such as difficulty sleeping, persistent suicidal thoughts, and reduced senses of taste and smell, are associated with depression but do not specifically represent anhedonia.
9.
The nurse
is caring for a client in the coronary care unit. The display on the cardiac
monitor indicates ventricular fibrillation. What should the nurse do first?
Correct Answer
C. Assess for presence of pulse
Explanation
The correct answer is C: Assess for presence of pulse
Artifact can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client’s pulse.
10.
A nurse evaluating a special needs 2-year-old in a clinic should stress which goal when talking to the child's mother?
Correct Answer
C. Promoting the child's optimal development
Explanation
Promoting optimal development is a key focus in the care of special needs children. This involves addressing the child's individual needs, milestones, and abilities, and providing interventions and support to maximize their overall development. While aspects of self-care skills and toileting may be part of the child's development plan, the overarching goal is to ensure the child reaches their highest potential in all aspects of growth and development.