45. Key: A Client Need: Basic Care and Comfort
A. Back pain, perineal pain, mild dysuria and urinary frequency occur with chronic prostatitis. Rarely, prostatic abscesses can occur. Management includes daily sitz baths and administration of antibiotics.
B. Cold scrotal compresses will not decrease inflammation and will also be uncomfortable.
C. With chronic prostatitis, long-term antibiotics are necessary. They usually last 30 days.
D. Activities that drain the prostate are encouraged. This includes sexual intercourse and prostatic massage.
46. Key: A Client Need: Pharmacological and Parenteral Therapies
A. In congestive heart failure, the patient generally sleeps on two or three pillows to facilitate breathing. Being able to sleep supine without difficulty indicates improvement.
B. A productive cough could be an indication of worsening of CHF.
C. Patients with CHF usually do not have a fever.
D. An increased heart rate could indicate a worsening of CHF.
47. Key: B Client Need: Reduction of Risk Potential
B. Direct pressure is applied to the catheter insertion site for at least 15–20 minutes after catheter removal to prevent bleeding. The patient is monitored afterwards for signs of bleeding.
A. The patient may be on bed rest for several hours but not for 12 hours.
C. The extremity should be flat.
D. The patient should be supine.
48. Key: D Client Need: Physiologic Adaptation
D. Increased fiber will assist with the movement of food through the GI tract.
A. The patient may eat three large meals a day as tolerated.
B. The patient should drink at least 2 liters of fluid per day.
C. The recumbent position after eating is not necessary.
49. Key: B Client Need: Management of Care
B. Oral feedings should be stopped and the infant hydrated by other means, since the infant is unable to tolerate oral feedings.
A. The infant would be weighed daily but it is not the priority action in this case.
C. Oral fluids should be stopped and the infant hydrated by other means.
D. Checking the stool for reducing substances is not a priority action.
50. Key: A Client Need: Safety and Infection Control
A. Chemotherapeutic agents cause bone marrow suppression. This results in decreased leukocytes, erythrocytes and platelets. Decreased white cells cause immunosuppression, which can lead to infection, sepsis and death. Loss of red blood cells and platelets may result in fatigue and bleeding (GI bleeding and hypovolemic shock). The effects of bone marrow suppression can be life threatening.
B. Chemotherapy can lead to malnutrition due to nausea, vomiting and stomatitis. Nutrition is important but not the number one priority.
C. Breast cancer impacts on a woman’s sexuality and self-image. This is especially important in women who are surgically treated for breast cancer. Nursing care for mastectomy clients should involve supporting the woman as she copes with her changed body image. Support should also be provided to the woman’s significant other. This is an important part of care but not the priority for women receiving chemotherapy for breast cancer treatment.
D. Impaired physical mobility is usually not a result of chemotherapy. Fatigue due to bone marrow suppression can negatively affect one’s activity level and ability to complete activities of daily living.
51. Key: C Client Need: Health Promotion and Maintenance
C. Facial edema may be indicative of pre eclampsia and should be reported immediately.
A. This is an anticipated finding because the expanding uterus puts pressure on the stomach. The finding does not require immediate intervention.
B. The pressure of the growing fetus can interfere with normal bowel function. The finding does not require immediate intervention.
D. Afternoon fatigue is anticipated in the third trimester.
52. Key: D Client Need: Psychosocial Integrity
D. A contract, which the patient signs, is designed to let the patient know what behaviors are unacceptable and the consequences of engaging in those behaviors. By signing the contract the patient agrees not to engage in the behavior.
A. Medication may be necessary if the patient becomes combative• but will not necessarily prevent assaultive behavior.
B. This action will not prevent assaultive behavior.
C. The staff should be aware that the patient has been re-admitted but this will not prevent assaultive behavior by the patient.
53. Key: D Client Need: Pharmacological and Parenteral Therapies
D. Patients with cirrhosis of the liver often develop hepatic encephalopathy due to the ammonia released by nitrogenous waste in the intestine. Lactulose leads to less ammonia production by inhibiting bacterial urea degradation. It also reduces colonic transit time, thus reducing the time available for ammonia production and expediting ammonia elimination.
A & B. These findings do not indicate effectiveness of lactulose therapy.
C. Lactulose is a laxative that reduces colon transit time.
54. Key: D Client Need: Reduction of Risk Potential
D. Bleeding within the pericardial sac will muffle heart sounds.
A. Bleeding/fluid accumulation is in the pericardial sac rather than the chest.
B. Blood pressure decreases rather than increases.
C. Pulse becomes thready rather than bounding.
55. Key: C Client Need: Physiologic Adaptation
C. Salmonella is a type of bacteria usually found in poultry, eggs, unprocessed milk, meat and water.
A. Manifestations suggest ingestion of a contaminated food substance.
B. Shellfish poisoning, rather than salmonella, can occur from ingesting raw shellfish.
D. Manifestations suggest ingestion of a contaminated food substance.
56. Key: B Client Need: Management of Care
B. Statement assumes the patient has control over the depression, which the patient does not. The nurse should intervene.
A. A non-judgmental comment; however, the comment asks for insight that the patient may not have.
C. Non-judgmental comment; however, the focus should not be on what the aide experienced.
D. Comment is centered on the aide’s thoughts and feelings rather than the patient’s. However, the comment, while non-therapeutic, is not judgmental.
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