Pre-Board Nursing Exam for December 2013 NLE

ANSWER: Deep pain ; RATIONALE: Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from organs in any body activity. Acute pain is rapid in onset, usually temporary (less than 6 months), and subsides spontaneously. Chronic pain is marked by gradual onset and lengthy duration (more than 6 months). Superficial pain has abrupt onset with sharp, stinging quality.

ANSWER: Encouraging gentle range-of-motion exercises after administering aspirin and before rising ; RATIONALE: Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising. Strict limitation of motion only increases the client’s pain. Having others transfer the client into a wheelchair does not increase his feelings of dependency. Massage increases inflammation and should be avoided with this client.

ANSWER: Assessing the client to rule out possible complications secondary to surgery ; RATIONALE: The nurse immediate action should be assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. The health care provider ordered the pain medication for routine postoperative pain that is expected after abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence. The nurse should never administer pain medication without assessing the client first. Obtaining an order for a strong medication may be appropriate after the nurse assesses the client and checks the chart to see whether the current analgesic is infective. Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. Pain is subjective, and each person has his own level of pain tolerance. The nurse must always believe the client’s complaint of pain.

ANSWER: Using transcutaneous electric nerve stimulation ; RATIONALE: Nonpharmacologic pain relief interventions include cutaneous stimulation, back rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and more. Hypnosis is considered an alternative therapy. Medications are pharmacologic measures. Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it is not specific to pain relief.

ANSWER: Prevent metabolic breakdown of xanthine to uric acid ; RATIONALE: The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.

ANSWER: RH negative, RH positive ; RATIONALE: Rhogam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.

ANSWER: History of steroid-dependent asthma ; RATIONALE: A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status, requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. An oxygen saturation of 95%, mild work of breathing, and absence of intercostals or substernal retractions are all normal findings.

ANSWER: Type A-delta fibers ; RATIONALE: Type A-delta fibers conduct impulses at a very rapid rate and are responsible for transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only type A-delta fibers transmit sharp, piercing pain. Somatic efferent fibers affect the voluntary movement of skeletal muscles and joints. Type C fibers transmit sensory input at a much slower rate and produce a slow, chronic type of pain. The autonomic system regulates involuntary vital functions and organ control such as breathing.

ANSWER: “Our child must maintain these dietary restrictions lifelong.” ; RATIONALE: A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. The other options are incorrect because signs and symptoms will reappear if the patient eats prohibited foods.

ANSWER: Tachypnea ; RATIONALE: The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered white blood cell or platelet counts are not specific signs of metabolic imbalance.

ANSWER: Recent motor vehicle crash while changing lanes ; RATIONALE: Typically, the client with chronic open-angle glaucoma experiences a gradual loss in peripheral vision leading to tunnel vision. Being involved in a motor vehicle crash while changing lanes suggests the disorder. The client may experience insidious blurring, decreased accommodation, mild aching eyes and, eventually, halos around the lights as intraocular pressure increases. Flashes of light and floaters are characteristic of retinal detachment. Nausea, headache, and eye redness are seen with an episode of acute (sudden) closed-angle closure. Double vision occurs when one eye has a lens and other is aphakic.

ANSWER: Vertigo ; RATIONALE: Ménière’s disease is characterized by sudden, severe episodes of vertigo during which the client has a sensation of spinning. Dizziness is not vertigo and must be distinguished from true rotational vertigo. A feeling of pressure but not pain is also characteristic, and hearing loss os progressive, not sudden.

ANSWER: 18 months ; RATIONALE: The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at age 24, 30, and 36 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6 months. Regular dental visits should begin at age 24 months.

ANSWER: Instituting droplet precautions ; RATIONALE: Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don’t take priority.

ANSWER: Start prophylactic AZT treatment ; RATIONALE: AZT treatment is the most critical intervention.

ANSWER: The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. ; RATIONALE: It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.

ANSWER: Closed anterior and posterior fontanels ; RATIONALE: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

ANSWER: Safety guidelines ; RATIONALE: The nurse always should reinforce safety guidelines when teaching parents how to care for their child. By giving anticipatory guidance the nurse can help prevent many accidental injuries. For parents of a 9-month-old infant, it is too early to discuss nursery schools or toilet training. Because surgery is not used gastroenteritis, this topic is inappropriate.

ANSWER: Allow the child to feed herself ; RATIONALE: The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices, not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.

ANSWER: The patient will be admitted to the surgical unit and resection will be scheduled. ; RATIONALE: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist.

ANSWER: Low-sodium ; RATIONALE: It is taught that Ménière’s disease is caused by edema of the semicircular canals. A low-sodium diet is often prescribed in conjunction with diuretic therapy. Protein intake should have no relation to Ménière’s disease, but hypoproteinemia may aggravate edema. FIber and potassium have not been identified as instrumental in the development of Ménière’s disease.

ANSWER: Corgard ; RATIONALE: Corgard could be removed from the refrigerator.

ANSWER: Change the dressing and document the clean appearance of the wound site. ; RATIONALE: A moderate amount of serous drainage from a recent surgical site is a sign of normal healing. Purulent drainage would indicate the presence of infection. A soiled dressing should be changed to avoid bacterial growth and to examine the appearance of the wound. The surgical site is typically covered by gauze dressings for a minimum of 48-72 hours to ensure that initial healing has begun.

ANSWER: Is highly sensitive to criticism ; RATIONALE: In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a friend.

ANSWER: Apply cool air under the cast with a blow-dryer ; RATIONALE: Itching underneath a cast can be relieved by directing blow-dryer, set, on the cool setting, toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch.

ANSWER: Hypercalcaemia ; RATIONALE: Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion.

ANSWER: Parkinson’s disease type symptoms ; RATIONALE: Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.

ANSWER: Monitor respiratory rate. ; RATIONALE: Morphine sulfate can suppress respiration and respiratory reflexes, such as cough. Patients should be monitored regularly for these effects to avoid respiratory compromise. Morphine sulfate does not significantly affect urine output, heart rate, or body temperature.

ANSWER: Streptokinase ; RATIONALE: Streptokinase is a clot busting drug and the best choice in this situation.

ANSWER: Naproxen sodium (Naprosyn). ; RATIONALE: Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Furosemide is a loop diuretic and is contraindicated in a patient with gastritis.

ANSWER: IgG ; RATIONALE: IgG is the only immunoglobulin that can cross the placental barrier.

ANSWER: “I will be totally deaf in my left ear, but the dizziness will be gone.” ; RATIONALE: A labyrinthectomy is the most radical procedure for Ménière’s disease. It involves resection of the vestibular nerve or total removal of the labyrinth by the transcanal route. Although this procedure controls the disorder, it results in deafness in the affected ear. With this procedure, inner ear packing is not used, and a stoma is not created.

ANSWER: Air hunger. ; RATIONALE: Patients with pulmonary edema experience air hunger, anxiety, and agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing caused by laryngeal swelling or spasm and is not associated with pulmonary edema.

ANSWER: Instructing the client to look up prior to administering the medication ; Wiping the excess medication from the inner to the outer canthus ; Pressing on the nasal-lacrimal canal ; RATIONALE: The nurse is administering medication into the left eye (OS) for ophthalmic surgery, which includes instructing the client to look up, administering the medication into the lower conjunctiva, pressing on the nasal-lacrimal canal to prevent systemic drug absorption, and wiping excess secretions with a sterile cotton ball from the inner to outer canthus. The abbreviation for the right eye is OD and both eyes is OU.

ANSWER: Prior infection with group A Streptococcus within the past 10-14 days. ; RATIONALE: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

ANSWER: “Leave the diaper off while the infant sleeps.” ; RATIONALE: Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the condition. Switching to cloth diapers isn’t necessary; in fact, that may make the rash worse. Baby wipes contain alcohol, which may worsen the condition. Extra fluids won’t make the rash better.

ANSWER: Anorexia nervosa ; RATIONALE: All of the clinical signs and symptoms point to a condition of anorexia nervosa.

ANSWER: Cerebral edema ; RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increase intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid of blood.

ANSWER: A patient with a history of ventricular tachycardia and syncopal episodes. ; RATIONALE: An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. A patient recovering well from coronary bypass would not need the device. Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.

ANSWER: Gown, gloves, mask, and eye goggles or eye shield ; RATIONALE: The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.

ANSWER: Cl. difficile ; RATIONALE: Cl. difficile has not been linked to meningitis.

ANSWER: Iron-rich formula only ; RATIONALE: The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. The Academy doesn’t recommend whole milk until age 12 months, and skim milk until after age 2 years.

ANSWER: 120 days. ; RATIONALE: RBC’s last for 120 days in the body.

ANSWER: Measuring head circumference ; RATIONALE: Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus, and is a key part of routine infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A lumbar puncture isn’t appropriate.

ANSWER: Nitro-dur ; RATIONALE: All of the others have can cause photosensitivity reactions.

ANSWER: The effects of PKU are reversible. ; RATIONALE: The effects of PKU stay with the infant throughout their life.

ANSWER: Left-side lying ; RATIONALE: When retinal detachment occurs, the client is positioned so that the area of detachment is dependent. For this client, the left-side lying position is used. Positioning the client in the Fowler, supine, or right-side lying position would not place the detached area in a dependent position.

ANSWER: Ineffective airway clearance related to edema ; RATIONALE: Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Body image disturbance, impaired urinary elimination, and infection are all integral parts of burn management but aren’t the first priority.

ANSWER: Applying pressure on the inner canthus ; RATIONALE: Systemic absorption and subsequent adverse effects may occur if the medication enters the nasolacrimal canal. The nurse therefore applies pressure to the inner canthus, causing occlusion of this canal and minimizing the risk for systemic adverse effects. Applying pressure on the eyelid rim would not occlude this canal. Having the client close his eyes tightly may cause some of the medication to be expelled. Positioning has no effect on the blood flow of medication into the nasolacrimal canal and subsequent absorption.

ANSWER: Call the poison control center ; RATIONALE: Before interviewing in any way, the parents should call the poison control center for specific directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe.

ANSWER: Aspirin ; RATIONALE: All of the others can cause urine discoloration.

ANSWER: Contaminated food. ; RATIONALE: Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Hepatitis B, C, and D are transmitted through infected bodily fluids.

ANSWER: Maintaining a consistent, structured environment ; RATIONALE: The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent, structured environment that provides interaction with the infant to promote growth and development. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

ANSWER: Glucagon treats hypoglycemia resulting from insulin overdose. ; RATIONALE: Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.

ANSWER: Autonomic neuropathy ; RATIONALE: Autonomic neuropathy can cause inability to urinate.

ANSWER: Use the heel of one hand for sternal compressions ; RATIONALE: The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the heels of both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12.

ANSWER: Latex ; RATIONALE: Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex. Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.

ANSWER: A patient on bed rest who must maintain a supine position. ; RATIONALE: Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position. It should be taken upon rising in the morning with 8 ounces of water on an empty stomach to increase absorption. The patient should not eat or drink for 30 minutes after administration and should not lie down. ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship.

ANSWER: The tumor extended beyond the kidney but was completely resected. ; RATIONALE: The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual non hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

ANSWER: A history of hepatitis C five years previously. ; RATIONALE: Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis (gallbladder disease), diverticulosis, and history of Crohn’s disease do not preclude blood donation.

ANSWER: Increased interest in play ; RATIONALE: One of the most valuable clues to pain is a behavior change: A child who’s pain-free likes to play. A child in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain; decreased urine output may signify dehydration.

ANSWER: If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. ; RATIONALE: When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.

ANSWER: The patient suddenly complains of chest pain and shortness of breath. ; RATIONALE: Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia.

ANSWER: Increased physical activity and daily exercise will help decrease discomfort associated with the condition. ; RATIONALE: Physical activity and daily exercise can help to improve movement and decrease pain in osteoarthritis. Joint pain and stiffness are often at their worst during the early morning after several hours of decreased movement. Acetaminophen is a pain reliever, but does not have anti-inflammatory activity. Ibuprofen is a strong anti-inflammatory, but should always be taken with food to avoid GI distress.

ANSWER: Coumadin ; Finasteride ; RATIONALE: are both contraindicated with pregnancy.

ANSWER: Urine specific gravity of 1.040. ; Urine output of 350 ml in 24 hours. ; Brown (“tea-colored”) urine. ; RATIONALE: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea colored” urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

ANSWER: Calling for help immediately ; RATIONALE: Because the client cannot speak, a total airway obstruction has occurred. The client is in acute distress and requires emergency treatment. Leaving the client alone to clear the throat would be appropriate for a client with partial airway obstruction, as evidenced by choking but with an ability to speak. Adequate humidification is appropriate for the client with recurrent epistaxis or nasal congestion. It does not matter what the client is choking on.

ANSWER: X-ray the leg. ; RATIONALE: Following triage, an x-ray should be performed to rule out fracture. Ice, not heat, should be applied to a recent sports injury. An elastic bandage may be applied and pain medication given once fracture has been excluded.

ANSWER: A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. ; RATIONALE: The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A postoperative patient also requires close monitoring and cardiac experience.

ANSWER: Inadequate tissue perfusion leading to nerve damage. ; RATIONALE: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

ANSWER: Sudden weight gain. ; RATIONALE: Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. When diuretic therapy is inadequate, one would expect an increase in blood pressure, tachypnea, and tachycardia to result.

ANSWER: Frequent swallowing ; RATIONALE: After nasal surgery, drainage tricking down the posterior pharynx (seen with a flashlight) accompanied by frequent swallowing, belching, or hematemesis indicate continued bleeding. Anxiety is common because of the necessity to breathe through the mouth. Discoloration around the eyes occurs with surgical trauma and is to be expected. Tarry stools indicate previous, but not current bleeding.

ANSWER: Providing a safe, quiet, dimly lit environment with enforced bed rest ; RATIONALE: Ménière’s disease is a chronic disorder of the inner ear involving sensorineural hearing loss, severe vertigo, and tinnitus. Typically, the client experiences sudden episodes of od severe whirling vertigo with an inability to stand or walk, buzzing tinnitus that worsens before and during an episode, nausea, vomiting, and diaphoresis. The client’s safety must be ensured along with decreasing exposure to extraneous stimuli. This is accompanied by providing the client with a quiet, dimly lit environment and bed rest. Instructions about removing cerumen are appropriate for a client with cerumen impaction. Speaking slowly and distinctly in a low-pitched, clear voice without yelling is appropriate for clients experiencing a hearing loss. Clients with Ménière’s disease are not deaf during acute exacerbations. However, hearing loss may occur after repeated episodes. Ear drops are not the treatment of choice for an acute attack of Ménière’s disease.

ANSWER: Weight gain ; RATIONALE: Weight gain is associated with CHF and congenital heart deficits.

ANSWER: Compressing the nares to the septum for 5 to 10 minutes ; RATIONALE: When a client experiences epistaxis, the nurse should compress the soft outer portion of the nares against the septum for approximately 5 to 10 minutes. the client should sit upright, breathe through the mouth, and refrain from talking. Performing abdominal thrusts is appropriate for the client with a foreign-body aspiration. Applying an ice collar to the neck is commonly done for a client after a tonsillectomy. Warm saline throat gargles are appropriate for the client with pharyngitis.

ANSWER: Blurred vision ; RATIONALE: Cataracts lead to progressive worsening and blurring of vision. Eye pain and redness, common with glaucoma, are not present with cataracts. Floaters are characteristics of retinal detachment.

ANSWER: 4 mcg/mL. ; RATIONALE: The therapeutic serum level for Dilantin is 10 – 20 mcg/mL. A level of 4 mcg/mL is subtherapeutic and may be caused by patient non-compliance or increased metabolism of the drug. A level of 15 mcg/mL is therapeutic. Choices C and D are expressed in mcg/dL, which is the incorrect unit of measurement.

ANSWER: Severe pain in the right lower arm. ; RATIONALE: Impaired perfusion to the right lower arm as a result of a closed cast may cause neurovascular compromise and severe pain, requiring immediate cast removal. Itching under the cast is common and fairly benign. Neurovascular compromise in the arm would not cause pain in the shoulder, as perfusion there would not be affected. Impaired perfusion would cause the fingers to be cool and pale. Increased warmth would indicate increased blood flow or infection.

ANSWER: Developmental readiness of the child ; RATIONALE: If the child isn’t developmentally ready, child and parent will become frustrated. Consistency is important once toilet training has already started. The mother’s positive attitude is important when the child is ready. Developmental levels of children are individualized and comparison to peers isn’t useful.

ANSWER: The patient should limit fatty foods. ; RATIONALE: Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.

ANSWER: Documenting the care provided during her shift ; RATIONALE: Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. The other three options would be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t take priority over documentation.

ANSWER: Green vegetables and liver ; RATIONALE: Green vegetables and liver are a great source of folic acid.

ANSWER: Acetaminophen ; RATIONALE: Because the discomfort is typically mild after surgery to repair a detached retina, a mild analgesic such as acetaminophen would be used. Codeine is constipating and may lead to straining and increased intraocular pressure (IOP). Meperidine often causes nausea and vomiting, further adding to the client’s level of discomfort, and vomiting may lead to increased IOP. Morphine causes nausea, vomiting, and constipation, which should be avoided after surgery.

ANSWER: Worsening dyspnea ; RATIONALE: Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit.

ANSWER: Oily skin ; RATIONALE: The skin would be dry and not oily.

ANSWER: The foster mother ; RATIONALE: When children are minors and aren’t emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social workers, the nurse, and the nurse-manager have no legal rights to give consent in this scenario.

ANSWER: Cough following bronchodilator utilization ; RATIONALE: The bronchodilator will allow a more productive cough.

ANSWER: Check for signs of bleeding, including examination of urine and stool for blood. ; RATIONALE: A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Transfusion of red cells is indicated for severe anemia.

ANSWER: Prophylactic antibiotic therapy prior to anticipated exposure to ticks. ; RATIONALE: Prophylactic use of antibiotics is not indicated to prevent Lyme disease. Antibiotics are used only when symptoms develop following a tick bite. Insect repellant should be used on skin and clothing when exposure is anticipated. Clothing should be designed to cover as much exposed area as possible to provide an effective barrier. Close examination of skin and hair can reveal the presence of a tick before a bite occurs.

ANSWER: In 48 to 72 hours ; RATIONALE: Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction should appear in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible.

ANSWER: Plugged feeling in the ear and reverberation of the client’s own voice. ; RATIONALE: Serous otitis media is manifested by a plugged feeling in the ear, reverberation of the client’s own voice, and hearing loss. A bright red, bulging or retracted tympanic membrane and fever suggest suppurative otitis media. Inflammation of the external ear and crust formation on the auditory canal suggest external otitis media. Sensorineural hearing loss and tinnitus indicate otosclerosis.

ANSWER: Hepatic damage. ; RATIONALE: Acetaminophen in even moderately large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N-acetylcysteine administration as an antidote. Tinnitus is associated with aspirin overdose, not acetaminophen. Diarrhea and hypertension are not associated with acetaminophen.

ANSWER: Prevent accidents ; RATIONALE: Accidents are the major cause of death and disability during the school-age years. Therefore, accident prevention should take priority when teaching parents of school-age children. Preschool (not school-age) children are afraid of the dark, have fears concerning body integrity, and should be encouraged to dress without help (with the exception of tying shoes).

ANSWER: Assess the child’s current developmental level and plan care accordingly ; RATIONALE: Nursing care plan should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially a child with mild limitations.

ANSWER: A fiery red pharyngeal membrane and fever ; RATIONALE: Strep throat, or acute pharyngitis, results in a red throat, edematous lymphoid tissues, enlarged lymph nodes, fever, and sore throat. Pain over the sinus area and purulent nasal secretions would be evident with sinusitis. Foul-smelling breath and respirations indicate adenoiditis. A weak cough and high-pitched noisy respirations are associated with foreign-body aspiration.

ANSWER: Provide a secure environment for the patient. ; RATIONALE: This patient’s safety is your primary concern.

ANSWER: The patient has a pacemaker. ; RATIONALE: The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Psychiatric medication is not a contraindication to MRI scanning.

ANSWER: No treatment is necessary; the fluid is reabsorbing normally. ; RATIONALE: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

ANSWER: Careful assessment of vital signs. ; RATIONALE: The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

ANSWER: 10% glucose ; RATIONALE: The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement, although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous access.