31. Key: C Client Need: Reduction of Risk Potential
C. Because of the location of the incision site, drainage tends to run down the sides of the patient’s neck and pool behind the neck.
A. Behind the patient’s neck is the most accurate assessment.
B. Sputum would not be affected.
D. While blood may show on the dressing, post-operative bleeding is best assessed for behind the patient’s neck.
32. Key: B Client Need: Physiologic Adaptation
B. Client needs more information about the benefits of exercise.
A. Annual flu shots are recommended for clients with chronic diseases such as asthma.
C. Medication should remain with the client rather than in a suitcase when traveling.
D. Animal dander and shedding may aggravate asthma.
33. Key: C Client Need: Management of Care
C. Parkinson’s disease is a degenerative disorder of the central nervous system that often impairs the sufferer’s motor skills and speech, as well as other functions; however, the client usually learns to live within the limitations of the disease. The client’s actions my indicate depression and lowered self-esteem and, because of the possibility of suicide, should be addressed as a priority.
A. The client may have impaired verbal communication but the nursing diagnosis does not address the client’s lack of participation in his care.
B. The client may have sleep pattern disturbances but the nursing diagnosis does not address the client’s lack of participation in his care.
D. This nursing diagnosis is not a priority at this time.
34. Key: A Client Need: Safety and Infection Control
A. A patient who is admitted to the emergency department with a sudden onset of abdominal pain should be kept npo (nothing by mouth) until the suspected cause is determined and the need for surgery ruled out. Administering an oral pain medication or anything by mouth would not be appropriate, and should be questioned.
B. An x-ray for abdominal pain would be an appropriate intervention for this patient. The nurse would not question this order as it will aid in the diagnosis.
C. An IV should be kept in place for a patient with abdominal pain as an access for medication and as a means to keep the patient hydrated while npo. This order would not be questioned.
D. Keeping the patient npo would be a standard intervention for someone with abdominal pain. The nurse would not question this order.
35. Key: D Client Need: Health Promotion and Maintenance
D. A cephalohematoma generally disappears without treatment in 2 weeks to 3 months.
A. Head circumference measurement is usually performed to assess for hydrocephalus.
B. Applying warm compresses is not a required nursing action.
C. Neurological status is evaluated• but arousing the infant hourly is not necessary.
36. Key: A Client Need: Psychosocial Integrity
A. Protection of self and others is central to care.
B. The right to vote is maintained unless the patient is actively psychotic.
C. Phone privileges are maintained.
D. Day passes require approval of the primary care provider in consultation with the team.
37. Key: A Client Need: Basic Care and Comfort
A. Alcohol can cause irritation and inflammation of the pancreas.
B. The diet for pancreatitis is high in carbohydrates and low in fat.
C. Meats often are high in fat and should be decreased.
D. High levels of blood fats can cause chronic pancreatitis.
38. Key: B Client Need: Pharmacological and Parenteral Therapies
B. Both vinegar and cough syrup contain alcohol, which react with the Antabuse. Consuming any source of alcohol while on Antabuse can cause severe nausea and vomiting.
A. There is no need to avoid canned meats. Aged cheese should be avoided when taking monoamine oxidase (MAO) inhibitors.
C. Milk and milk products do not interfere with the functioning of Antabuse.
D. There is no need to avoid spicy foods and coffee. Spicy foods and coffee should be avoided if the patient has gastritis.
39. Key: B Client Need: Reduction of Risk Potential
B. All jewelry should be removed prior to an MRI.
A. The patient does not need to be fasting for an MRI.
C. Dye is not used during an MRI.
D. Radiation exposure is not a side effect of an MRI.
40. Key: A Client Need: Physiologic Adaptation
A. A symptom of Ménière’s syndrome is vertigo. The client should avoid driving.
B. This action by the client may cause vertigo.
C. Hearing loss is not a manifestation of Ménière’s syndrome.
D. Exposure to cold does not trigger symptoms.
41. Key: A Client Need: Management of Care
A. Goals of care for a client who has second-stage Alzheimer’s disease are client safety and helping the client to live comfortably.
B. Client goal is not realistic. A client in the second stage of Alzheimer’s disease would exhibit increased forgetfulness making it difficult to function at work, to remember directions, and to even make it through the day without difficulty. The person may be restless and unable to sleep at night.
C. Client goal is not realistic. Forgetfulness and memory deficits prevent working through issues from the past.
D. Client goal is not realistic. As the Alzheimer’s progresses in the second stage, the individual has difficulty articulating feelings or making requests.
42. Key: B Client Need: Safety and Infection Control
B. Thin fluids are the most difficult to control for a patient with a swallowing problem. Thin fluids can be thickened in order to enhance swallowing and to decrease the chance of aspiration. Fluids can be thickened with powders made especially for this problem, or the dietician can add things such as yogurt or pudding.
A. Food should be served according to the patient’s preference, and whatever temperature stimulates sensory perception to the patient. Serving food that is either too warm or too cold may interfere with the patient’s ability to swallow and may decrease the desire to eat.
C. The patient should be in a high-Fowler’s position in order to maintain a straight GI tract and enhance motility through the tract.
D. Food should be placed in the unaffected side of the mouth when the patient has suffered a stroke. Placing food too far back in the mouth may cause the patient to choke. Food should be placed no further back than midway.
43. Key: B Client Need: Health Promotion and Maintenance
B. Chickenpox is contagious from about 2 days before the rash appears and lasts until all the blisters are crusted over. The nurse should elicit more information about the brother’s illness.
A & C. Normal 4-year-old behavior.
D. Parents often stay with their child when the child is hospitalized.
44. Key: B Client Need: Psychosocial Integrity
B. This response provides the patient’s understanding of the situation and helps the nurse to determine if it is realistic.
A. This is a closed-ended comment, which does not encourage the patient to describe what he saw.
C. The nurse cannot say this with certainty.
D. There is no indication that the other patients are avoiding him.
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