Pre-Board Nursing Exam for November 2014 NLE [SATA]

ANSWER: Increasing self-awareness ; Improving interpersonal relationships ; Dealing with particular stressors ; RATIONALE: The purposes of group therapy are: • Increasing self-awareness • Improving interpersonal relationships • Dealing with particular stressors • Make changes in behavior

ANSWER: Surgery ; Aging process ; Obesity ; RATIONALE: Sliding hiatal hernia is caused by muscle weakness in the esophageal hiatus which is precipitated by 1, 2 and 3.

ANSWER: Decreasing heart rate ; Decreasing BP ; Decreasing myocardial contractility ; Decreasing calcium output ; RATIONALE: Beta-adrenergic blocking agents decrease myocardial oxygen demand by: • Decreasing heart rate • Decreasing BP • Decreasing myocardial contractility • Decreasing calcium output

ANSWER: Fatty foods ; Alcohol ; Chocolate ; RATIONALE: The client should avoid the following foods: • Fatty foods • Cola beverages • Coffee • Tea • Chocolate • Alcohol * These foods decrease LES pressure.

ANSWER: Dysuria ; Nausea and vomiting ; Body malaise ; RATIONALE: There is urinary urgency and frequency in UTI. Pain is in the suprapubic area and at the lower back. Fever not hypothermia is noted in infection.

ANSWER: Measuring I and O ; Staying with the client during meals ; Weighing the client 3 times a week at the same time ; RATIONALE: The client should be accompanied to the bathroom or anywhere in the room for at least a half hour after eating to prevent self-induced vomiting. The focus should be on the client not on the food.

ANSWER: Aesthetic needs ; Self-fulfillment ; Creativity ; Spirituality ; RATIONALE: • Aesthetic needs – self-actualization • Freedom from sense of worthlessness – self-esteem • Oxygen – physiologic • Freedom from anxiety – safety • Self-fulfillment – self-actualization • Creativity – self- actualization • Spirituality – self-actualization • Protection – safety

ANSWER: Removes debris ; Relieves pain ; Improves muscle tone ; RATIONALE: Hydrotherapy purposes: • Removes debris • Relieves pain • Improves muscle tone • Improves circulation • Relieves pain • Promotes healing • Prevents contractions

ANSWER: Assess for claustrophobia ; Secure written consent ; Instruct the client to remain still during the procedure ; RATIONALE: • Inform the client that the MRI unit is very quiet, thus, she must not make any loud noises – the MRI unit makes a loud, knocking noise • Assess for claustrophobia – the client will be placed in a tunnel-like device • Secure written consent – needed to be done before the procedure • Instruct the client to remain still during the procedure – necessary during the procedure • Recently implanted clips or wires implanted to the client should be removed before the client undergoes MRI – clients with prosthetics/pacemakers or those who have recently implanted clips/wired are not eligible for MRI scans

ANSWER: Promoting family function ; Resolving family issues and conflicts ; Improving relationship among family members ; RATIONALE: • Promoting family function – purpose of family therapy • Self-understanding – goal of group therapy • Resolving family issues and conflicts – purpose of family therapy • Discussing the member’s involvement in the issue/problem – process involved in family therapy • Improving relationship among family members – purpose of family therapy

ANSWER: Specific gravity ; WBC ; RBC ; RATIONALE: BUN and Serum sodium are components of blood studies not routine urinalysis.

ANSWER: No eye contact or facial responsiveness noted in the infant ; Ritualistic changes ; Labile moods ; RATIONALE: • No eye contact or facial responsiveness noted in the infant • Ritualistic changes • Labile moods • Infant not responsive to cuddling • Impaired or nor verbal communication • Inability to tolerate change • Fascination with movement and spinning objects • Unresponsive or overresponsive to stimuli

ANSWER: To administer medications ; To relieve flatulence ; RATIONALE: Purposes of administering enemas: • To administer medications • To relieve flatulence • To relive constipation • To lower body temperature • To evacuate feces in preparation for diagnostic procedure or surgery

ANSWER: The main purpose of CABG is myocardial revascularization. ; It is recommended if severe narrowing of one or more branches of the coronary arteries exist. ; RATIONALE: • It is the mechanical dilatation of the coronary vessel wall by compressing the atheromatous plaque. – percutaneous transluminal coronary angioplasty (PTCA) • The main purpose of CABG is myocardial revascularization. - CABG • It is recommended for clients with single-vessel coronary artery disease. - percutaneous transluminal coronary angioplasty (PTCA) • It is recommended if severe narrowing of one or more branches of the coronary arteries exist. – CABG

ANSWER: Low sodium diet ; Low fat diet ; High fiber diet ; RATIONALE: The cleint’s diet should be low in Na, low fat and low cholesterol and high in fiber. Avoid saturated fats and always read labels before buying prepared foods.

ANSWER: It occurs at about 80% of the cases ; The child may be able to become self-supporting ; RATIONALE: Mild mental retardation occurs about 80% of all cases of MR. the child is educable until the 6th grade and is able to become self-supporting.

ANSWER: Binge eating ; Fatty foods ; Large quantities of milk ; RATIONALE: Bland diet is deal for clients with PUD. Antacids are used for neutralizing HCL in PUD. Only 400 ml/day of milk is allowed in clients with PUD.

ANSWER: Increase fluid intake ; Administer laxatives ; RATIONALE: The stool of the client is white for only 24-72 hours. The patient can be assisted to any comfortable position after the procedure.

ANSWER: GI intubation ; NGT insertion ; Total parenteral nutrition ; RATIONALE: Ultrasonography, MRI and colonoscopy are diagnostic/laboartory tests for GI system not a GI intervention.

ANSWER: Speak in a pleasant tone ; Do not lie about something you cannot keep ; Explain what you are going to do and give reasons for it ; RATIONALE: The child’s progress should not be compared to anyone else. When talking to children bend down to meet the child on own level.

ANSWER: Bleeding ; Hematoma ; Infection ; RATIONALE: The risks of performing a renal biopsy are bleeding, hematoma and infection.

ANSWER: Reduces coronary vasospasm ; Inhibits calcium ion transportation ; RATIONALE: Calcium channel blockers have vasodilation effects.

ANSWER: Allergy ; Pericarditis ; Sickle cell disease ; RATIONALE: Corticosteroid and diuretics are used in the treatment of nephrotic syndrome. Possible causes of this condition are: • Allergy • Circulation problems (CHF, Pericarditis) • Systemic diseases (DM, Sickle cell disease) • Infections (herpes zoster)

ANSWER: Memory impairment ; May be temporary or progressive memory loss ; Exaggeration of former character traits ; Inability to perform basic ADL ; RATIONALE: • Occurs postoperatively or usually following head injury – delirium • Memory impairment – dementia • May be temporary or progressive memory loss – dementia • Exaggeration of former character traits – dementia • Reduced awareness of environment – delirium • Speech and attention deficits – delirium • Inability to perform basic ADL – dementia

ANSWER: Control and regulate instinctual drive ; Operates on reality principle ; RATIONALE: • Present at birth – id • Develops as the person unconsciously incorporates standards and restrictions – superego • Control and regulate instinctual drive – ego • Operates on pleasure principle – id • The aggressive energy – id • Operates on reality principle – ego

ANSWER: It uses an ultrasound to assess cardiac structure and mobility ; No special preparations is required ; It is painless and takes approximately 30-60 minutes to complete ; The client has to remain still, in supine position slightly turned to the left side, with HOB elevated to 15-20 degrees. ; RATIONALE: • It uses an ultrasound to assess cardiac structure and mobility – Echocardiography • It is a continuous ECG monitoring – holter monitoring • The portable monitoring system is called the telemetry unit – holter monitoring • No special preparations is required – Echocardiography • It is painless and takes approximately 30-60 minutes to complete – Echocardiography • The client has to remain still, in supine position slightly turned to the left side, with HOB elevated to 15-20 degrees. – Echocardiography

ANSWER: Panic reaction ; Disorders of perception ; Nausea and vomiting ; RATIONALE: • Panic reaction – cannabis overdose • Disorders of perception - cannabis overdose • Nausea and vomiting - cannabis overdose • Respiratory arrest – PCP overdose • Delirium - PCP overdose • Suicide - PCP overdose • Violent behavior - PCP overdose

ANSWER: Elevate HOB 6-12 inches when sleeping ; 1-2 hours before and after eating the client should assume an upright position ; Dinner should be taken 4 hours before bedtime ; RATIONALE: The client should have a small frequent feedings (about 4-6 meals) throughout the day. No evening snacks are allowed to these patients and dinner should be taken at least 3 hours before bedtime.

ANSWER: Use sterile NSS to irrigate the area ; Strict asepsis ; Reverse/protective isolation ; RATIONALE: Administration of morphine and avoiding draft exposure is used to relieve pain and promote comfort for patients with burn.

ANSWER: Streptokinase ; Tissue plasminogen activator (PTA) ; Urokinase ; RATIONALE: • Morphine Sulfate – for pain relief • Streptokinase - To disintegrate blood clot by activating the fibrinolytic process • Lidocaine – for pain relief • Tissue plasminogen activator (PTA) - To disintegrate blood clot by activating the fibrinolytic process • Urokinase - To disintegrate blood clot by activating the fibrinolytic process

ANSWER: Cinoxacin (Cinobac) ; Nalidixic Acid (NegGram) ; Metheramine Mandelate (Mandelamine) ; RATIONALE: • Cinoxacin (Cinobac) - Urinary antiseptic • Co-trimoxazole (Bactrim) - Sulfonamide • Nalidixic Acid (NegGram) - Urinary antiseptic • Sulfisoxazole (Gantrisin) - Sulfonamide • Metheramine Mandelate (Mandelamine) - Urinary antiseptic

ANSWER: NGT ; Chest tube ; RATIONALE: NGT and Chest are the possible post-op contraptions following a gastric wrap-around.

ANSWER: Severe malnutrition ; Severe GI side effects of chemotherapy ; Severe burns ; RATIONALE: Indications of TPN are: • Major GI diseases: fistulas/inflammatory diseases • Severe burns/trauma • Need for extensive support for an extended period • Severe GI side effects of chemotherapy

ANSWER: Heavy lifting ; Crossing legs ; Long trips ; RATIONALE: To prevent bleeding and thrombophlebitis after retropubic prostatectomy, the client should avoid: • Heavy lifting • Sexual intercourse 3 weeks after discharge • Driving 2 weeks after discharge • Crossing legs • Long trips • Vigorous exercise • Straining with defecation

ANSWER: Levin tube ; Cantor tube ; RATIONALE: • Salem-sump tube – double-lumen • Miller-abott tube – double-lumen • Levin tube – single-lumen • Cantor tube – single-lumen • Sengstaken Blakemore tube – triple-lumen

ANSWER: Steroids ; Indomethacin ; Colchicines ; RATIONALE: For 48 hours the client should withhold steroids, indomethacin and colchicines because these drugs may cause GI irritation thereby, bleeding. Fiber should be increased in the diet.

ANSWER: Continuous bladder irrigation is done postop ; No incontinence is noted after the procedure ; RATIONALE: In TURP there is no incision done. No incontinence and impotence is noted postoperatively.

ANSWER: Administering the drug with food ; Withholding drug if bradycardia is present ; RATIONALE: • Assuming a sitting or supine position when taking the drug – for Nitrogylcerine • Administering the drug with food – the drug may cause GI upset, hence, this must be done • Instructing the patient to gradually change his or her position – for Nitrogylcerine • Withholding drug if bradycardia is present – assess PR before administration of the drug

ANSWER: Chest pain of longer duration ; Chest pain may occur at rest ; The attacks tend to occur in the early hours of the day ; May result from coronary artery spasm ; RATIONALE: • Chest pain of longer duration – variant angina • Chest pain may occur at rest - variant angina • Attacks during nighttime only – nocturnal angina • The attacks tend to occur in the early hours of the day - variant angina • Associated with rapid eye movement sleep - nocturnal angina • May result from coronary artery spasm - variant angina

ANSWER: Nausea and vomiting ; Epigastric pain ; RATIONALE: S/S of gastritis: • Fever • Painless GI bleeding • Nausea and vomiting • Diarrhea, abdominal cramping • Epigastric pain • Anorexia

ANSWER: Securing written consent ; Inform on discomfort of the procedure ; Assess for allergy to the dye ; RATIONALE: Interventions listed in 1 and 4 are appropriate after the procedure. Epinephrine should be prepared not Lidocaine to combat anaphylactic shock.

ANSWER: Erotic attachment to parent of opposite sex is noted ; Pleasure through genitals ; RATIONALE: • Pleasure is through the mouth – 0-18 months: ORAL • Erotic attachment to parent of opposite sex is noted – 3-6 years: PHALLIC • Concern with cleanliness or being dirty – 18months-3 years: ANAL • Pleasure through genitals – 3-6 years: PHALLIC • Energy is used to gain new skills in social relationships and knowledge: 6-12 years: LATENCY

ANSWER: Drug therapy ; Early case finding ; RATIONALE: • Drug therapy – secondary • Health teaching about stress and its management – primary • Early case finding – secondary • Identifying persons at risk of certain diseases – primary • Facilitate return of client to home by use of social agencies – tertiary

ANSWER: Radiates down one or both arms, left shoulder, jaw, neck and back ; Precipitated by activity ; RATIONALE: • Crushing and severe – MI • Radiates down one or both arms, left shoulder, jaw, neck and back – Angina • Relieved by rest and morphine – Angina is relieved by rest and nitroglycerine • Precipitated by activity – angina • Characterized by Levine’s sign – MI

ANSWER: Assist the client in focusing on a topic ; Be accepting of hostile statements ; Use distraction to divert client from behaviors that are harmful to self or others ; RATIONALE: In a manic episode of bipolar disorder the nurse should determine what the client is attempting to tell and use an ACTIVE form of listening. Therapeutic touch should never be provided but rather maintaining a certain distance from the client would prevent the nurse from getting hurt while not leaving the client unattended.

ANSWER: U-wave ; Depressed ST segment ; Short T wave ; RATIONALE: • U-wave – hypokalemia • Peaked T-wave – hyperkalemia • Depressed ST segment – hypokalemia • Short T wave – hypokalemia • Elevated ST segment – hyperkalemia • Peaked T wave – hyperkalemia • Pathologic Q wave – MI • Inverted T wave – MI

ANSWER: Diazepam ; Anticholinergics ; Ca-channel blockers ; RATIONALE: Drugs listed in these numbers lower the LES (lower esophageal sphincter) pressure.

ANSWER: Navane ; Mellaril ; RATIONALE: • Librium – antianxiety • Navane – antipsychotic • Mellaril – antipsychotic • Valium – antianxiety • Sinequan – antidepressant • Artane – anticholinergic

ANSWER: Ultrasound ; Renal Pyelogram (RPG) ; Urinalysis ; RATIONALE: To assess/diagnose renal calculi the following can be done: • Ultrasound • Renal Pyelogram (RPG) • Urinalysis • Cystoscopy • Intravenous pyelography

ANSWER: Chronic cystitis ; Use of cyclophosphamide ; Bladder calculi ; RATIONALE: Risk factors of bladder cancer: • Chronic cystitis • Use of cyclophosphamide • Bladder calculi • Exposure to cigarette smoke • Pelvic radiation • Schistosomiasis • Large phenacetin intake

ANSWER: Hematocrit ; Hemoglobin ; Platelet count ; RATIONALE: • Hematocrit – assessment parameter of hematopoietic system problems in chronic renal failure • Hemoglobin - assessment parameter of hematopoietic system problems in chronic renal failure • Level of orientation - assessment parameter of neurologic system problems in chronic renal failure • Reflexes - assessment parameter of neurologic system problems in chronic renal failure • Platelet count - assessment parameter of hematopoietic system problems in chronic renal failure • Serum calcium - assessment parameter of skeletal system problems in chronic renal failure • Assess for joint pain - assessment parameter of skeletal system problems in chronic renal failure

ANSWER: Alcoholics ; Elderly ; Terminally ill ; Adolescents ; RATIONALE: Groups at increased risk for suicide: • Alcoholics • Elderly • Terminally ill • Adolescents • Persons who have experienced loss • Depressed people • Minority groups

ANSWER: Small frequent feedings are advised ; Carbohydrates should be limited and simple sugars should be eliminated in the diet ; Fluids should be given after meals ; RATIONALE: • Instruct the client to elevate the head of bed after meals – after meals the client should lie down (on the left side) • Foods from the refrigerator are allowed – very hot and cold foods should be avoided

ANSWER: Bending ; Straining ; Heavy lifting ; RATIONALE: Factors that increase intraabdominal pressure are: • Use of constrictive clothing • Straining • Heavy lifting • Bending, stooping • Coughing

ANSWER: BUN: 30 mg/dl ; Serum Creatinine: 3 mg/dl ; Protein in urine: +1 ; RATIONALE: • BUN: 30 mg/dl – normal range: 10-20 mg/dl • Serum Creatinine: 3 mg/dl – normal range: 0.4-1.2 mg/dl • Hct: 38% - normal value: 38-54% • Serum Chloride: 108 mEq/L – normal range: 98-108 mEq/L • Protein in urine: +1 – absent in urine

ANSWER: Ability to use abstraction ; Short and long term memory ; Attention and concentration ; RATIONALE: • Ability to use abstraction – intellect • Amount, volume and clarity of speech – speech • Short and long term memory – intellect • Loose associations – thoughts • Content of thoughts and clarity – thoughts • Attention and concentration – intellect

ANSWER: Sexual activity ; Eating a heavy meal ; Exposure to cold ; Excitement ; RATIONALE: Precipitating events of angina are: E – Exertion: vigorous exercise done very sporadically E – Emotions: excitement, sexual activity E – Eating a heavy meal E – Environment: exposure to cold

ANSWER: Oliguria ; Azotemia ; RATIONALE: Inability of the kidneys to excrete metabolic waste products of protein through urine formation would result to: • Oliguria • Azotemia • Uniferous odor of breath • Stomatitis and GI bleeding – urea is converted back into ammonia which irritates mucous membrane • Destruction of rbc, wbc and platelets • Renal encephalopathy

ANSWER: Increased BP ; Delusions ; Hallucinations ; Agitation ; RATIONALE: Signs of delirium tremens include tachycardia, increased BP, agitation, delusions and hallucinations.

ANSWER: Approving ; Agreeing ; Probing ; RATIONALE: • Focusing – therapeutic • Approving – non-therapeutic • Agreeing – non -therapeutic • Probing – non-therapeutic • Exploring – therapeutic • Clarification – therapeutic

ANSWER: Dipyridamole (Persatin) ; Ticlopidine (Ticlid) ; RATIONALE: • Dipyridamole (Persatin) – platelet aggregator inhibitor • Diltiazem (Cardizem) – calcium channel blocker • Ticlopidine (Ticlid) - platelet aggregator inhibitor • Verapamil (Calan) - calcium channel blocker • Heparin Sodium – anticoagulant

ANSWER: Heroin ; Morphine ; Methadone ; RATIONALE: • Some appetite suppressant - amphetamine • LSD – Hallucinogen • Heroin – opioid (narcotic) • Morphine - opioid (narcotic) • Methadone - opioid (narcotic) • Mescaline – Hallucinogen

ANSWER: Pharyngeal bleeding ; Cardiac dysrhythmias ; Transient hypoxemia ; RATIONALE: After TEE the nurse should observe for signs and symptoms of complications such as pharyngeal bleeding, cardiac dysrhythmias, vasovagal reaction and transient hypoxemia.

ANSWER: Encourage ambulation ; Increase fluids in the diet ; RATIONALE: Demerol is used for pain control if renal calculi are already present. Dairy products should be limited to decrease the risk of having Ca stones. Allopurinol is used to decrease uric acid in renal calculi.

ANSWER: Steroids ; ASA ; NSAIDs ; RATIONALE: Drugs that can cause PUD are those listed in 3, 4 and 5. Caffeine and alcohol (beer) can also predispose a client to having a PUD but the question’s criteria is “drugs” thus, 1 and 2 are incorrect.

ANSWER: Assess for signs and symptoms of bleeding ; Monitor prothrombin time ; Coumadin is an anticoagulant and should never be given with ASA. Green leafy vegetable should be minimized in the diet as these foods contain Vitamin K. Vitamin K is the antidote of Coumadin.

ANSWER: High intake of refined carbohydrates ; Obstruction of fecalith or foreign bodies, bacteria and toxins in the appendix ; RATIONALE: Inflammation of vermiform appendix is caused by either of the following: • Low fiber diet • High intake of refined carbohydrates • Obstruction of fecalith or foreign bodies, bacteria and toxins in the appendix

ANSWER: Instruct the client not to take cough preparations ; Teach the client to always carry an identification card in case of accidental alcohol ingestion ; Monitoring the effects of antianxiety drugs if being taken at the same time ; RATIONALE: Disulfiram produces unpleasant reactions when taken with alcohol including cough medicine and foods prepared with alcohol. In case of accidental alcohol ingestion, teach the client to always carry an identification card. If Disulfiram is taken with antianxiety drugs and oral anticoagulants, thus, taking Disulfiram with these drugs at the same time should be monitored.

ANSWER: Blood uric acid level of 6 mg/dl ; Trigycerides: 200 mg/dl ; CK-MB in a female client: 250 mu/ml ; RATIONALE: • Blood uric acid level of 6 mg/dl – normal range: 2.5-8 mg/dl • Trigycerides: 200 mg/dl – normal range: 140-200 mg/dl • AST: 55 mu/ml – normal range: 7-40 mu/ml • Calcium: 2.5 mEq/L – normal range 4.5-5.5 mEq/L • LDH: 325 mu/ml – normal range: 100-225 mu/ml • CK-MB in a female client: 250 mu/ml – normal range: 50-250 mu/ml

ANSWER: Bleeding ; Crepitus ; Fever ; RATIONALE: After UGI endoscopy, the nurse should assess the patient for the following: • Bleeding • Crepitus (neck) • Fever • Neck/throat pain • Dyspnea • Dysphagia • Back/shoulder pain

ANSWER: Abdominal distention ; Constipation ; Aspiration ; Vomiting ; RATIONALE: Common problems of tube feedings are the following: • Abdominal distention • Constipation • Aspiration • Vomiting • Hyperglycemia

ANSWER: Apply pressure dressing and a small ice bag or ice over the punctured area ; Immobilize affected extremity ; Monitor ECG ; RATIONALE: • Have the client void – before procedure • Assess for allergy to iodine/seafoods – before procedure • Apply pressure dressing and a small ice bag or ice over the punctured area – to prevent bleeding • Immobilize affected extremity – to promote adequate circulation • Elevate HOB to 30-45 degrees – do not elevate HOB to more than 30 degrees if the femoral site was used • Monitor ECG – note for dysrhythmias

ANSWER: Elevated Ck-MB ; Inverted T wave ; Enlargement of Q wave ; RATIONALE: In MI there is elevated Ck-MB, elevated AST and LDH. The T wave is inverted and Q wave is enlarged.

ANSWER: Hypocalcemia ; Renal osteodystrophy ; Hyperphosphatemia ; RATIONALE: If the kidneys are unable to metabolize Vitamin D, the following will be noted: • Hypocalcemia • Renal osteodystrophy • Hyperphosphatemia

ANSWER: Signs of infection ; Prolonged or excessive hematoma ; RATIONALE: The nurse should observe the client for: • Urine retention • Signs of infection • Prolonged or excessive hematoma

ANSWER: Thallium 201 scintigraphy ; First-pass cardiac study ; Dipyridamole-thallium-201 test ; RATIONALE: • Thallium 201 scintigraphy • First-pass cardiac study • Dipyridamole-thallium-201 test • Technitium 99m ventriculography

ANSWER: Introduce group members ; Setting limits ; Encouraging participation ; Promote group cohesiveness ; RATIONALE: The role of the nurse in a group therapy are: • Introduce group members • Setting limits • Encouraging participation • Promote group cohesiveness • Explain purpose and rules of group • Focus on problems of group and group process • Facilitate communication

ANSWER: For decompression ; Stomach irrigation ; Administer medications ; RATIONALE: Purposes of NGT insertion: • For decompression • Stomach irrigation • Administer medications • To provide feeding • Administer supplemental fluids

ANSWER: Pacemakers ; Aneurysm clips ; Orthopedic screws ; RATIONALE: MRI is contraindicated to the client with an implanted: • Pacemakers • Aneurysm clips • Orthopedic screws

ANSWER: Aortic regurgitation ; Diabetes mellitus ; Polycythemia vera ; RATIONALE: Causes of angina are: atherosclerosis, hypertension, diabetes mellitus, thromboangitis obliterans, polycythemia vera and aortic regurgitation.

ANSWER: Avoid aspirin products ; Encourage use of soft toothbrush ; Provide meticulous skin care ; RATIONALE: Interventions listed in 2, 5 and 6 promote patient comfort but does not prevent infection and injury.

ANSWER: Comfortable and loose-fitting clothes should be worn by the client during the test ; Rest is imperative to be done after the test ; The night before the sleep, the client should get an adequate sleep ; RATIONALE: • Instruct the patient to avoid tea, coffee and alcohol 1 week before the test – these items should be avoided on the day of the test • Comfortable and loose-fitting clothes should be worn by the client during the test – should be instructed to the client • Rest is imperative to be done after the test - should be instructed to the client • Nitroglycerine should be taken 2 hours before the test – this medication should NOT be taken 2 hours before the test • The night before the sleep, the client should get an adequate sleep - should be instructed to the client

ANSWER: Plan for a regular activity program ; Encourage slower activity or shorter periods of activity with more rest periods ; RATIONALE: • Administer nitroglycerine – for pain relief • Plan for a regular activity program – for activity and rest promotion • Encourage slower activity or shorter periods of activity with more rest periods - for activity and rest promotion • Facilitate reduction in the client’s present level of anxiety – to decrease anxiety and promote feeling of well-being

ANSWER: Acidosis ; Red macular rash ; High fever ; RATIONALE: Assessment findings in toxic shock syndrome: • Acidosis • Red macular rash • High fever • Hypotension • Diarrhea • Vomiting

ANSWER: Loss of interest in activities ; Social withdrawal ; Normal moods for a period of weeks, followed by depression ; Insomnia ; RATIONALE: • Depression worst in the morning – depression with melancholia • Loss of interest in activities – dysthymic disorder • Excessive guilt - depression with melancholia • Social withdrawal - dysthymic disorder • Normal moods for a period of weeks, followed by depression - dysthymic disorder • Weight loss - depression with melancholia • Insomnia - dysthymic disorder

ANSWER: Coronary thrombosis ; Hemorrhage and shock ; Direct trauma ; RATIONALE: • Coronary thrombosis – MI • Hemorrhage and shock – MI • Diabetes Mellitus – angina • Hypertension – angina • Direct trauma – MI • Aortic regurgitation – angina

ANSWER: Nausea ; Weakness ; Pallor ; RATIONALE: Tachycardia is noted in dumping syndrome not bradycardia. There is diarrhea (explosive), abdominal cramps not constipation. Hypoglycemia is a late sign of dumping syndrome.

ANSWER: Side rails up at all times ; Perform frequent client checks ; RATIONALE: • Side rails up at all times – safety measure • Continue to address the client by name – maintaining reality orientation • Do not force the client to remember things – reality orientation • Perform frequent client checks – safety measure • Arrange for necessary assistive devices – assisting with ADLs

ANSWER: Propanolol (Inderal) ; Pindolol (Visken) ; RATIONALE: Propanolol (Inderal) and Pindolol (Visken) are beta-adrenergic blocking agents.

ANSWER: Termination of relationship is introduced ; Developing a plan of care based on appropriate nursing diagnosis ; RATIONALE: • Client’s needs and problems are identified. – working phase • Summarization of relationship growth and progress – termination • Termination of relationship is introduced – orientation • Developing a plan of care based on appropriate nursing diagnosis – orientation • Employing therapeutic techniques – working • Goal evaluation – working

ANSWER: Monitor for signs and symptoms of infection ; Practice aseptic technique ; Cleanse the site with antiseptic solution ; RATIONALE: Care of the catheter insertion site include: • Monitor for signs and symptoms of infection • Practice aseptic technique • Change the sterile dressings every day • Cleanse the site with antiseptic solution

ANSWER: Organ meat ; Shellfish ; Gravy ; RATIONALE: If uric acid stones are the problem, foods containing purine should be avoided such as: • Organ meat • Shellfish • Gravy • Meat soups • Legumes • Salted anchovies • Mushroom • Sardines

ANSWER: Osmosis ; Diffusion ; Ultrafiltration ; RATIONALE: Osmosis, diffusion and ultrafiltration are physiologic principles of dialysis.

ANSWER: Providing nutritional support – TPN ; Provide psychosocial support ; RATIONALE: Interventions listed in 1, 4 and 5 are appropriate during the post-op period.

ANSWER: Protect the client from injury ; Minimize the client’s fear or anxiety ; Retain the client’s optimal cognitive function ; RATIONALE: Organic Mental disorders such as delirium, dementia and organic brain syndrome should be cared for with the following goals to keep in mind: • Client will be protected from injury • Fear or anxiety is reduced • Retain the client’s optimal cognitive function and self-care abilities

ANSWER: Vitamin B12 supplement ; Fluid-electrolyte replacement ; Antacid administration ; RATIONALE: • High fiber diet until pain resolves – bland or liquid diet until pain resolves • Vitamin B12 - if pernicious anemia occurs - • Avoid overeating – not a medical management but a health teaching • Fluid-electrolyte replacement – to replace loss fluids and electrolytes • Antacid administration – histamine blocker can also be administered • Avoid alcohol - not a medical management but a health teaching

ANSWER: No prostatic fluid ; Short urethra ; RATIONALE: Females are more prone to urinary tract infection because of: • No prostatic fluid • Short urethra

ANSWER: Encourage the client to void ; NPO for 4-6 hours ; Remove dentures/prosthetics ; RATIONALE: • Encourage the client to cough – after TEE • Offer throat lozenges or rinses – after TEE • Place the client in a lateral or semi-fowler’s position – after TEE • Encourage the client to void – before TEE • NPO for 4-6 hours - before TEE • Remove dentures/prosthetics - before TEE

ANSWER: Offer support in resolving crisis ; Assessing the client’s perception of problem ; Work with client as crisis resolves ; RATIONALE: The nurse’s role in crisis intervention: • Offer support in resolving crisis • Assessing the client’s perception of problem • Work with client as crisis resolves • Determine situational supports • Explore previous coping behaviors of the client • Enlisting help of situational supports • Encourage use of new and more effective coping behaviors • Convey hope to client that crisis can be resolved

ANSWER: Petechiae ; Bleeding at IV sites ; RATIONALE: The nurse should observe the client for the following and immediately report to the physician: • Petechiae • Bleeding at IV sites • Hematoma • Cyanosis *diarrhea and high fever are expected assessment findings not complications that must be reported to the physician immediately.