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ANSWERS & RATIONALES COMPRE 1-C Question 1.

Which initial assessment is essential for the nurse to make when a client is admitted for treatment of a left CVA? 1. Strength of hand grasps 2. Presence of breath sounds 3. Response to verbal stimulation 4. Presence of peripheral pulses Looking for answers(s):3 Explanation: A is INCORRECT because, although assessing muscle strength and symmetry is important, the priority assessment is level of consciousness. B is INCORRECT because, although physical assessment is important, the priority assessment is level of consciousness. C is CORRECT because assessing level of consciousness is the first priority. D is INCORRECT because, although peripheral vascular assessment is important, the priority assessment is level of consciousness. Question 2. Following a carotid endarterectomy, the nurse notes that the client is having difficulty managing saliva, and the tongue appears to deviate to one side. These findings would indicate damage to which cranial nerves? 1. Facial and vagus 2. Hypoglossal and spinal accessory 3. Spinal accessory and facial 4. Hypoglossal and facial Looking for answers(s):4 Explanation: A is INCORRECT because vagus nerve (CN X) damage results in an ineffective cough and weak, hoarse voice. B is INCORRECT because damage to the spinal accessory nerve (CN XI) results in drooping of the shoulder and muscle atrophy. C is INCORRECT because damage to the spinal accessory nerve (CN XI) results in drooping of the shoulder and muscle atrophy. D is CORRECT because the hypoglossal (CN XII) nerve controls the tongue. Facial (CN VII) nerve damage results in inability to close the eyelid, drooling, and difficulty swallowing. All of the cranial nerves listed may be potentially damaged by the surgery. Question 3. Following a surgical repair of a fractured hip, for which common complication should the nurse observe? 1. Peripheral arterial occlusion 2. Hypostatic pneumonia 3. Paralytic ileus 4. Thromboembolism Looking for answers(s):4 Explanation: A is INCORRECT because the vascular problem is venous, not arterial.

B is INCORRECT because even though most of the clients are elderly and have impaired physical mobility, pneumonia is not the most common complication following hip surgery. C is INCORRECT because even though general anesthesia is used for the surgery, the incidence of paralytic ileus is not increased with hip surgery. D is CORRECT because thromboembolism, specifically deep vein thrombosis, may occur in as many as 4060 percent of hip fracture clients following surgery. Both the surgery and immobility contribute to the incidence. Question 4. Nursing care to prevent autonomic dysreflexia in a client with a spinal cord injury includes: 1. Small daily doses of an antihypertensive medication 2. Inserting an indwelling urinary catheter regardless of level of injury 3. Positioning the client in high-Fowlers while awake 4. Using topical anesthetic if manual rectal (digital) stimulation is used Looking for answers(s):4 Explanation: A is INCORRECT because antihypertensive meds are used to treat autonomic dysreflexia, not prevent it. B is INCORRECT because, while monitoring and ensuring output is important for clients with spinal cord injury, an indwelling urinary catheter is not appropriate for all clients and increases their risk for urinary tract infection. C is INCORRECT because positioning the client in high-Fowlers is used to treat an episode of autonomic dysreflexia, not prevent it. The client with spinal cord injury should be repositioned frequently to prevent skin breakdown, not positioned solely in highFowlers. D is CORRECT because digital stimulation of the rectum can trigger autonomic dysreflexia, as can a full bowel. Using topical anesthetic when performing digital stimulation can prevent a dysreflexic episode. Question 5. Following a spinal anesthetic, the nurse should ensure that the client receives adequate fluids, to prevent which complication? 1. Spinal fluid loss 2. Dehydration 3. Spinal headache 4. Urinary retention Looking for answers(s):3 Explanation: A is INCORRECT because it may be impossible to prevent leakage. Keeping the client flat, and well hydrated will lessen the effects of any leakage. B is INCORRECT because the purpose of fluids is to prevent a drop in cerebral pressure. Any leakage from the puncture site is not enough to cause dehydration. C is CORRECT because there can be leakage of cerebrospinal fluid from the puncture site, causing a drop in cerebral pressure and a headache. Keeping the client flat and providing sufficient fluids will avoid this preventable problem. D is INCORRECT because giving fluids will not prevent urinary retention; if retention is present, fluids will cause more discomfort.

Question 6. A client with a casted fracture of the lower leg complains that the pain medication is not working. The nurse assesses that the toes are cool and pale, and when the limb is elevated, there is increased pain. The nurse should suspect what potential complication? 1. Thrombophlebitis 2. Compartment syndrome 3. Fat emboli 4. Gas gangrene infection Looking for answers(s):2 Explanation: A is INCORRECT because the pain of thrombophlebitis would not be aggravated with elevation. Analgesia is not used with thrombophlebitis. B is CORRECT because the clinical manifestations are consistent with compartment syndrome, due to fluid accumulation, increased pressure and tissue hypoxia within the limb compartment. Tissue ischemia and necrosis may develop. The nurse should monitor neurovascular status of the extremity, remove any restrictive dressings, and should not elevate the limb. C is INCORRECT because fat emboli cause respiratory distress, fever, and petechiae. D is INCORRECT because with gangrene, there would be a sudden drop in Hgb, rapid pulse, puffiness of the limb, and a foul smell. Question 7. Which neurological response would the nurse expect to be affected by a lumbar injury? 1. Pupillary response 2. Romberg test 3. Patellar reflex 4. Abdominal reflex Looking for answers(s):3 Explanation: with intracerebral problems such as a subdural hematoma. B is INCORRECT because the Romberg test is a balance test measuring cerebellar function. The client stands, feet together, first with eyes open, then with eyes closed. There should be no loss of balance and minimal swaying. C is CORRECT because the patellar reflex is a deep tendon reflex, which tests the function of muscles innervated by nerves found in the lumbar 2 4 region. D is INCORRECT because the abdominal reflex is a superficial (cutaneous) reflex, which tests nerves in the thoracic 712 region. Stroking the upper, middle or lower abdominal region toward the umbilicus causes the umbilicus to move toward the stimulus. Question 8. For what sign of metabolic alkalosis should the nurse observe? 1. Ankle edema 2. Confusion 3. Hyperventilation 4. Diarrhea Looking for answers(s):2 Explanation: A is INCORRECT because metabolic alkalosis occurs from conditions

which cause a loss of fluids and acid, such as vomiting or use of diuretics. Ankle edema indicates fluid excess. B is CORRECT because apathy, confusion, and stupor are signs of metabolic alkalosis. There is an attempt by the body to compensate for the acid-base imbalance by decreasing alveolar ventilation. Low potassium usually accompanies alkalosis. C is INCORRECT because hyperventilation is the compensatory response for metabolic acidosis. With metabolic alkalosis, the respiratory systems would attempt to conserve carbon dioxide; so there would be hypoventilation. D is INCORRECT because frequently metabolic alkalosis is precipitated by the loss of fluid from vomiting, which would most likely result in an absence of stool. Question 9. A client has been admitted to ICU with a severe head injury. The clients intracranial pressure is being monitored. Which signs would alert the nurse that the clients intracranial pressure is rising? -SELECT ALL THAT APPLY1. Increased pulse rate 2. Decreased pulse rate 3. Widening pulse pressure 4. Change in respiratory pattern 5. Increased respiratory rate 234 Explanation: Increased intracranial pressure can manifest in many ways. Typical changes that occur as pressure increases include decreased pulse rate (B), increased systolic pressure which results in widening pulse pressure (C), changes in the respiratory pattern (D), and pupils may initially be equal but sluggish to respond. A is INCORRECT because pulse rate decreases with increased intracranial pressure due to increased pressure on the thalamus, hypothalamus, pons, and medulla. E is INCORRECT because initial changes in respirations include a change in pattern, followed by a decrease in respiratory rate as the intracranial pressure increases, not an increase in rate. Question 10. Which snack should the nurse suggest as the best nutritional choice when a client with a slow healing wound is discharged home? 1. Lemon Jello 2. Graham crackers 3. Applesauce 4. Hard boiled egg Looking for answers(s):4 Explanation: A is INCORRECT because, although gelatin is a protein source, it is not a complete protein, and it does not provide the essential amino acids of an egg. B is INCORRECT because wound healing requires protein; graham crackers are largely fat. C is INCORRECT because applesauce is a carbohydrate, and would not promote a positive nitrogen balance needed for wound healing. D is CORRECT because an egg is a complete protein, and contains the essential amino acids needed for positive nitrogen balance and healing. An egg also has the greatest biological value.

Question 11. Which measure should be included in client teaching to prevent constipation? 1. Drinking 1000 mL of apple juice daily 2. Eating high-residue foods 3. Using glycerin suppositories daily 4. Taking a mild cathartic at bedtime Looking for answers(s):2 Explanation: A is INCORRECT because apple juice would be high in pectin, which may contribute to constipation. Sufficient oral fluids are important though, particularly water. B is CORRECT because high residue or high fiber is important for normal elimination. C is INCORRECT because regular use of suppositories will diminish the normal sphincter tone. (The question asks about prevention). D is INCORRECT because regular use of a laxative will diminish the normal sphincter tone. (The question asks about prevention). Question 12. Following a partial gastrectomy, dumping syndrome may occur. To avoid dumping syndrome, the nurse should teach the importance of: 1. Following a low fat diet 2. Avoiding concentrated carbohydrates 3. Increasing fluids with meals 4. Walking after meals Looking for answers(s):2 Explanation: A is INCORRECT because fats slow gastric emptying, and should, therefore, be increased with dumping syndrome. B is CORRECT because carbohydrates accelerate gastric emptying, as do fluids taken during meals. Moderate fat and high protein are encouraged to slow gastric emptying; rest also delays emptying. C is INCORRECT because liquids with meals increase gastric emptying; liquids should be taken after eating. D is INCORRECT because resting for 20 30 minutes after eating, while lying on the left side, is advised to slow gastric emptying. Question 13. Dietary health teaching should include which condiment on a low sodium diet? 1. Barbecue sauce 2. Mayonnaise 3. Vinegar 4. Prepared mustard Looking for answers(s):3 Explanation: A is INCORRECT because barbecue sauce, catsup, chili sauce and soy sauce are all high in sodium. B is INCORRECT because commercial salad dressings and mayonnaise are high in added sodium.

C is CORRECT because condiments such as vinegar, lemon juice and wine are low in sodium. D is INCORRECT because prepared mustard is high in sodium. Dried mustard or mustard seeds are low in sodium. Question 14. The nurse tells the client that withholding food before surgery prevents which complication? 1. Gastric distention postoperatively 2. Vomiting and aspiration during surgery 3. Nausea and paralytic ileus after surgery 4. A food-drug interaction with anesthesia Looking for answers(s):2 Explanation: A is INCORRECT because gastric distention is caused by reduced peristalsis due to general anesthesia, not the presence of food. B is CORRECT because an empty stomach lessens the risk of aspiration of stomach contents during general anesthesia, which leads to aspiration pneumonia. C is INCORRECT because general anesthesia, not the food itself, can cause nausea and paralytic ileus. D is INCORRECT because there are no known food-drug interactions with anesthesia. Question 15. The nurse is counseling a client who has lactose intolerance. What type of diet would the nurse recommend? 1. Restricted protein and sodium 2. Low fat 3. Avoid nuts, whole grains, seeds, raw vegetables, celery, and corn 4. Avoid dairy products Looking for answers(s):4 Explanation: A is INCORRECT because restricted protein and sodium is recommended for clients with renal failure. B is INCORRECT because a low fat diet is recommended for many clients including those with gall bladder disease and obesity, but it is not a recommendation for clients with lactose intolerance. C is INCORRECT because avoiding nuts, whole grains, seeds, raw vegetables, celery, and corn is recommended to prevent intestinal obstruction in clients with new ileostomies. D is CORRECT because lactose intolerance means that the client has a deficiency of the enzyme lactase, which breaks down dairy products into simpler sugars. Question 16. The client had a knee repair and the physician ordered: no weight bearing on the affected leg. What method of ambulation will the nurse teach the client? 1. Use of a 4-prong cane 2. Crutch walking using a 3-point gait 3. Crutch walking using a 4-point gait 4. Use of a walker

Looking for answers(s):2 Explanation: A is INCORRECT because use of a 4-prong cane requires weight bearing on both legs. B is CORRECT because the affected leg does not touch the ground during the 3-point gait. C is INCORRECT because the 4-point gait requires weight bearing on both legs. D is INCORRECT because a walker requires weight bearing on both legs. Question 17. Which food would be permitted on a full liquid diet? 1. Pureed squash 2. Mashed potatoes 3. Vanilla ice cream 4. Creamed corn Looking for answers(s):3 Explanation: A is INCORRECT because pureed vegetables are not considered liquid. B is INCORRECT because mashed vegetables are not considered liquid. C is CORRECT because when ice cream melts, it is liquid like a milk shake. (If this were a clear liquid diet, ice cream would not be permitted). D is INCORRECT because creamed vegetables are not considered liquid. Question 18. The client is experiencing right-sided hemiplegia following a stroke. What would the nurse report to the MD as an improvement in the clients condition? 1. Inattention to the right hand 2. Outbursts of laughing and crying 3. Shrugging shoulders bilaterally 4. Grimacing and resisting passive ROM Looking for answers(s):4 Explanation: A is INCORRECT because unilateral neglect or inattention to the right hand would not indicate improvement. B is INCORRECT because emotional lability, which frequently occurs, has nothing to do with the hemiplegia. C is INCORRECT because shrugging uses large muscle masses, yet the numbness and paralysis may still be present. D is CORRECT because it appears the client is experiencing pain and purposeful resistance. Question 19. To replace potassium lost while taking furosemide (Lasix), the client should be guided to select what high potassium food? 1. Tangerines 2. Cottage cheese 3. Cranberry salad 4. 7-grain bread Looking for answers(s):1 Explanation: A is CORRECT because most fruits, whole or juiced, are good sources of potassium. They are also low in sodium (except for the dried fruits).

B is INCORRECT because hard or soft cheeses are not recommended sources of potassium. The fat content may also be a concern for the client. C is INCORRECT because cranberries are one of the few fruits not considered a source of potassium. D is INCORRECT because grains are not considered a source of potassium. Legumes are good sources of potassium. Question 20. The nurse would know that the client understands the restriction for the 2 gm sodium-restricted diet when the client identifies which food is high in sodium? 1. Cottage cheese 2. Gelatin 3. Aged cheddar cheese 4. Sherbet Looking for answers(s):3 Explanation: A is INCORRECT because cottage cheese, as well as skim milk and cream cheese, are allowed on a low-sodium diet. B is INCORRECT because gelatin is an acceptable dessert on a sodium-restricted diet. C is CORRECT because aged, hard cheese and processed cheese are high in sodium and should be avoided. D is INCORRECT because sherbet is an acceptable dessert on a sodium-restricted diet. Question 21. The nurse would conclude the client has a dislocated hip rather than a fractured hip if the limb is: 1. Shorter and externally rotated 2. Partially immobilized with diminished pulses 3. Discolored and swollen 4. Numb and deformed Looking for answers(s):2 Explanation: A is INCORRECT because the leg will be shortened and externally rotated with a hip fracture. B is CORRECT because a dislocation limits mobility, whereas a fracture typically allows for abnormally free movement of the limb. Pulses may be absent or diminished due to disruption of the blood supply. C is INCORRECT because bleeding into the capsule, and swelling may not be present with all dislocations. D is INCORRECT because there may be no visible deformity, and although there may be decreased sensations, numbness does not occur with all dislocations. Question 22. In addition to excitability, the nurse should monitor a client with hyperthyroidism for: 1. Ankle edema, skin discoloration, and drowsiness 2. Tremors, sweating, and rapid pulse 3. Difficulty breathing, jaundice, and hirsutism 4. Slow breathing, flat affect, and cool skin

Looking for answers(s):2 Explanation: A is INCORRECT because these symptoms are not consistent with hyperthyroidism. Ankle edema is common with CHF. Skin color changes may indicate Addisons or hypoadrenalism. Many conditions cause drowsiness. B is CORRECT because hyperthyroidism is a state of an accelerated metabolic rate, resulting in muscle tremors, sweating, and tachycardia. C is INCORRECT because these symptoms may occur with numerous cardiac or respiratory problems, liver disease, or hyperadrenalism (Cushings). D is INCORRECT because these symptoms might be seen with hypothyroidism or myxedema, which is a potentially dangerous slowing of the metabolism. Question 23. A client with severe pain in both hands from rheumatoid arthritis needs to gain weight. What would be the best nursing approach to increase intake? 1. Offer to feed the client 2. Offer utensils 3. Offer favorite foods 4. Offer finger foods Looking for answers(s):4 Explanation: A is INCORRECT because feeding the client does not promote self-care ability. B is INCORRECT because utensils, unless specially designed, would require gripping, which would be more painful and difficult to manage. C is INCORRECT because favorite foods do not deal with the clients pain and difficulty eating. D is CORRECT because even with pain in the hands, finger foods require the least amount of joint mobility and promote self-care. Question 24. A client has had a craniotomy involving the frontal lobe. During the immediate postop period, what is the most important responsibility of the nurse? 1. Keep the client flat in bed 2. Prevent head movement with sandbags 3. Assess the clients level of consciousness 4. Encourage coughing and deep breathing Looking for answers(s):3 Explanation: A is INCORRECT because the optimum positioning following supratentorial surgery is 30 degrees, to promote venous outflow. B is INCORRECT because sandbags are not routinely used to prevent head movement. C is CORRECT because changes in level of consciousness may alert the nurse to dangerously high levels of intracranial pressure. D is INCORRECT because coughing and deep breathing would increase intracranial pressure. Question 25. What is the most important nursing measure for a client placed in Bucks extension traction before surgery to repair a fractured hip?

1. Turning every 2 hours to unaffected side 2. Elevating the head of the bed to maintain alignment 3. Checking skin condition regularly 4. Teaching isometric exercises to prevent muscle atrophy Looking for answers(s):3 Explanation: A is INCORRECT because the purpose of the traction is to keep the fractured hip aligned before surgery, so the client is not positioned on the unaffected side. The hip on the unaffected side may be raised slightly with a pillow while maintaining alignment. B is INCORRECT because raising the head of the bed may cause the client to slide down in bed. C is CORRECT because Bucks extension is a skin traction, and skin breakdown or circulation impairment may occur if the wraps are too tight. D is INCORRECT because the traction will not be applied long enough to cause muscle atrophy. After surgery, the client will receive physical therapy and eventually ambulate. Question 26. Which nursing action is indicated if the weights of Bucks extension traction are almost touching the floor? 1. Remove a few weights from the traction 2. Slide the client up in bed 3. Shorten the rope length of the weights 4. Elevate the affected leg on a pillow Looking for answers(s):2 Explanation: A is INCORRECT because removing the weights is not a nursing action, and will decrease the amount of traction. B is CORRECT because the weights may pull the client down in bed. C is INCORRECT because adjusting the rope lengths is not a nursing action. D is INCORRECT because elevating the leg will not prevent the client from sliding down in bed. The foot of the bed may be elevated to exert a counterbalance. Question 27. The nurse explains that treatment for Parkinsons disease may include which intervention? 1. Hormonal replacement 2. Dopamine supplement 3. Myelin stimulation 4. Genetic counseling Looking for answers(s):2 Explanation: A is INCORRECT because, although the cause of Parkinsons is not clearly known, the deficiency is with the neurotransmitter dopamine. B is CORRECT because one category of drugs used to treat Parkinsons is dopamine agonists. An example is levodopa (Dopar, Sinemet, Larodopa). The drug is converted to dopamine, which serves as the neurotransmitter to relieve the tremors and rigidity of Parkinsons. C is INCORRECT because Parkinsons is not a demyelinating process like multiple sclerosis. D is INCORRECT because Parkinsons is not thought to be hereditary.

Question 28. When transferring the client from the bed to a chair following a right total hip replacement, where should the chair be placed? 1. In front of the client who sits on the edge of the bed 2. On the clients left side, with the opening of the chair facing the client, and the side up against the bed 3. On the clients right side, with the opening of the chair facing the client, and the side up against the bed 4. On either side of the client, depending on whether the client is right or left handed Looking for answers(s):2 Explanation: A is INCORRECT because this position would require the client to pivot further than would be safe. B is CORRECT because there should be no weight bearing on the affected right hip. The chair should be on the clients left, so the client can pivot on the unaffected left leg. C is INCORRECT because this would place the affected leg closest to the chair, and it would be hard to keep from standing on the limb. D is INCORRECT because the position is determined by which hip has been replaced, not by the clients dominant side. Question 29. In dietary health teaching, which food should the nurse teach the client to avoid in a low sodium diet? 1. Halibut steak 2. Corned beef brisket 3. Chicken breast 4. Pork roast Looking for answers(s):2 Explanation: A is INCORRECT because halibut would be permitted on a low sodium diet. B is CORRECT because corned beef is a processed cut of beef and is high in added sodium. C is INCORRECT because chicken breast would be permitted on a low sodium diet. D is INCORRECT because pork roast would be permitted on a low sodium diet. Salted pork, smoked meats, or bacon would not be allowed. Question 30. Which change in laboratory data would the nurse expect for a client with Addisons disease? 1. Increased potassium, decreased sodium and glucose 2. Decreased potassium, increased sodium and glucose 3. Increased potassium, sodium and hematocrit 4. Decreased potassium, sodium and hematocrit Looking for answers(s):1 Explanation: A is CORRECT because Addisons disease is hypoadrenalism. The symptoms are the opposite of Cushings disease. Normal adrenal function increases the glucocorticoids (glucose) and mineralocorticoids, which increase sodium levels and eliminate potassium.

B is INCORRECT because these changes would be seen with hyperadrenalism, or Cushings disease. C is INCORRECT because sodium and potassium go in opposite directions with adrenal disease; if one goes up, the other goes down. Changes in the hematocrit are seen with liver disease, bleeding problems or fluid imbalances. D is INCORRECT because sodium and potassium go in opposite directions with adrenal disease; if one goes up, the other goes down. Changes in the hematocrit are seen with liver disease, bleeding problems or fluid imbalances. Question 31. The nurse would recommend a diet low in phosphorus for a client with: 1. Diverticulosis 2. Hepatic failure 3. Chronic renal failure 4. Hyperthyroidism Looking for answers(s):3 Explanation: A is INCORRECT because a high fiber diet would be recommended for a client with diverticulosis. B is INCORRECT because the client with hepatic failure will be on a low-protein to noprotein diet, as well as sodium restriction. C is CORRECT because, in chronic renal failure, the kidney is unable to excrete phosphorus, or phosphate (PO4), therefore the levels rise. D is INCORRECT because a diet high in protein, calories, vitamins, and minerals is recommended for clients with hyperthyroidism or other hypermetabolic states. Question 32. The nurse would know that the client understands the teaching about a low cholesterol diet when the client selects: 1. Crab legs 2. Baked chicken 3. Broiled hamburger 4. Cream of broccoli soup Looking for answers(s):2 Explanation: A is INCORRECT because shellfish is not low in cholesterol, and should be limited in a restricted fat and cholesterol diet. B is CORRECT because baked chicken is the lowest in fat and cholesterol. C is INCORRECT because red meat is higher in fat and cholesterol than poultry. D is INCORRECT because cream soups, unless made with non-fat milk, are high in fat and cholesterol. Question 33. A client on a liquid diet has finished lunch: pint of milk; 4 oz of apple juice; 6 oz of broth, and 6 Tbs. of Jello. The nurse would calculate the total oral intake for this meal to be: 1. 450 ml 2. 630 ml 3. 750 ml 4. 900 ml

Looking for answers(s):2 Explanation: A is INCORRECT because this amount is too low. To arrive at the correct answer, use 30 mL per ounce, and 15 mL per tablespoon. B is CORRECT because the client consumed 18 oz of juice and broth, combined (30 mL per oz), which is 540 mL, plus 6 Tbs. (3 tsp/Tbs.; 5 mL/tsp), which is 90 mL, for a total of 630 mL. C is INCORRECT because this amount is too high. To arrive at the correct answer, use 30 mL per ounce, and 15 mL per tablespoon. D is INCORRECT because this amount is too high. To arrive at the correct answer, use 30 mL per ounce, and 15 mL per tablespoon. Question 34. The nurse is developing a plan for rehabilitation for a client with a C7 spinal cord injury. The nurse should expect that the client will be: 1. Ventilator dependent 2. Able to independently use a wheelchair 3. Able to drive a car using hand controls 4. Able to stand and walk with leg braces Looking for answers(s):2 Explanation: A is INCORRECT because a client with an injury at level C4 or higher would be ventilator-dependent. B is CORRECT because the client with a C7 spinal cord injury would be expected to have triceps function with elbow extension, along with finger extensors and flexors, and a good grasp. This level of function will allow the client to independently use a wheelchair. Sometimes a client with a C7 injury can drive a car with hand controls, but this is not usual. C is INCORRECT because a client with an injury at level T1-6 will most likely be able to drive a car using hand controls. D is INCORRECT because a client with an injury at L4 or below will likely be able to stand and walk using leg braces and canes. Question 35. Which food should the nurse suggest that the client choose when on a low fat diet? 1. Peanut butter 2. Oatmeal raisin cookies 3. Angel food cake 4. Butterscotch pudding Looking for answers(s):3 Explanation: A is INCORRECT because peanut butter, even if reduced in fat, still contains 6 gm of fat in 1 Tbs. B is INCORRECT because unless specified, the cookies most likely contain butter and eggs, with 8 gm of fat in 4 cookies. C is CORRECT because angel food cake is made with egg whites, and would be the lowest in fat. There is 1 gm of fat in the whole cake. D is INCORRECT because unless specified to be made low, or fat-free, the pudding would contain at least 78 gm of fat.

Question 36. In the early stages of treatment, which nursing diagnosis is a priority for a client with hyperthyroidism? 1. Hypothermia 2. Altered nutrition 3. Colonic constipation 4. Altered tissue perfusion Looking for answers(s):2 Explanation: A is INCORRECT because a client usually experiences heat intolerance, not a low temperature. The skin is warm and smooth from increased circulation. B is CORRECT because the metabolism is accelerated with hyperthyroidism. Negative nitrogen balance and weight loss occur despite a ravenous appetite. C is INCORRECT because the client generally experiences diarrhea and increased peristaltic activity from the accelerated metabolic rate, not constipation. D is INCORRECT because the initial priority is the metabolic rate. The client will be tachycardic; if this is not controlled, it may then result in heart failure and altered perfusion. Question 37. Which snack would be best for a client on a low-protein diet? 1. Lemon Jello (1 cup) 2. Ice cream (1 cup) 3. Vanilla yogurt (1 cup) 4. Rice pudding (1 cup) Looking for answers(s):1 Explanation: A is CORRECT because 1 cup of a gelatin dessert contains only 4 gm of protein; of the snacks listed, this has the least amount of protein. (An even better snack would be sherbet, which has even less protein). B is INCORRECT because 1 cup of ice cream has 5 gm of protein. C is INCORRECT because 1 cup of yogurt contains 12 gm of protein. D is INCORRECT because 1 cup of rice pudding would supply at least 10 gm of protein since it contains three sources of protein: egg, milk, and rice. Question 38. The nurse should advise a client with AIDS to eat snacks high in potassium, such as bananas, because: 1. Potassium is lost through night sweats 2. The diarrhea lowers the serum potassium 3. Infection destroys cellular potassium 4. Fatigue will improve with potassium Looking for answers(s):2 Explanation: A is INCORRECT because more sodium and water would be lost through sweating. B is CORRECT because diarrhea is present in the advanced stages of AIDS, and potassium will be lost in the liquid stool. C is INCORRECT because a severe infection, such as septicemia, actually causes an increase in serum potassium.

D is INCORRECT because low potassium causes muscle weakness, but increasing potassium will not necessarily improve fatigue. Question 39. Which finding would first alert the nurse to increasing intracranial pressure (ICP)? 1. Falling blood pressure 2. Irregular breathing rhythm 3. Presence of Babinski reflex 4. Decorticate posturing Looking for answers(s):2 Explanation: A is INCORRECT because the pulse pressure will increase, with an increase in the systolic and eventually a drop in the diastolic pressure. B is CORRECT because Biots breathing, an irregular breathing pattern, will be seen with increasing ICP. C is INCORRECT because a Babinski reflex indicates upper motor neuron damage, which may be present without increased ICP. D is INCORRECT because, before decorticate posturing (flexion of arms) occurs, which indicates cortical involvement, there would have been vital sign changes, or a change in level of consciousness. Question 40. In which position would the nurse expect the intracranial pressure of client with a head injury to be the lowest? 1. Semi-Fowlers 2. Dorsal recumbent 3. Supine 4. High-Fowlers Looking for answers(s):1 Explanation: A is CORRECT because a 30-degree elevation (semi-Fowlers), is the optimum position. Cerebral venous outflow is greatest in this position. B is INCORRECT because ICP will increase in this position, which is flat. C is INCORRECT because supine does not necessarily indicate head elevation. D is INCORRECT because the elevation in high-Fowlers is greater than the highest optimum elevation, which is 30 degrees. Question 41. Which change after discharge should the nurse teach the client with Parkinsons disease to make? 1. Avoiding time spent in sunlight 2. Discontinuing volunteer services at church 3. Hiring someone to do housekeeping 4. Removing loose rugs from floors in the house Looking for answers(s):4 Explanation: A is INCORRECT because there is no photosensitivity with Parkinsons. Clients with systemic lupus need to avoid sunlight. B is INCORRECT because there is no indication that the client will not be able to continue involvement in volunteer activities.

C is INCORRECT because it is impossible to determine whether the client will need assistance with housekeeping without more data. D is CORRECT because the presence of scatter rugs, or loose throw rugs, will be a safety hazard with the abnormal gait of a client with Parkinsons. Question 42. Which meal selection would have the most positive effect on tissue healing? 1. Beef broth 2. Sliced peaches 3. Flavored gelatin 4. Egg custard Looking for answers(s):4 Explanation: A is INCORRECT because the amount of protein in broth is minimal. Broth is also high in sodium, unless specified as low sodium broth. B is INCORRECT because fruit is a carbohydrate; healing is most influenced by protein. C is INCORRECT because gelatin does not have the most protein for the most positive effect on tissue healing. D is CORRECT because custard contains the greatest amount of protein. There are two sources of proteineggs and milk. Question 43. The nurse would know that a client who is experiencing an acute episode of diverticulitis understands the health teaching that was done when the client selects: 1. Cream of Wheat cereal 2. Oat bran cereal 3. Sliced bananas and orange wedges 4. Fresh spinach salad Looking for answers(s):1 Explanation: A is CORRECT because a low fiber, low-residue diet is appropriate during an acute episode of diverticulitis, after the client is no longer NPO. This diet includes foods that reduce stool bulk and slow transit time, such as refined cereals, thus allowing inflamed bowel to rest. B is INCORRECT because bran is a water-soluble fiber and is appropriate for uncomplicated diverticulosis, but not acute diverticulitis. C is INCORRECT because fresh fruits are high in fiber (although very ripe bananas are permitted on a low fiber diet) and are appropriate for uncomplicated diverticulosis, but not acute diverticulitis. D is INCORRECT because those vegetables which are allowed when the client is no longer NPO, need to be canned, cooked or strained, or in the form of strained juice. Thus prepared, spinach is allowed for resolving diverticulitis, as are beets, acorn squash, green beans, and pumpkin. Question 44. The client receiving TPN is at greatest risk of initially developing which imbalance? 1. Metabolic Alkalosis 2. Metabolic Acidosis

3. Hyperglycemia 4. Septicimia Looking for answers(s):3 Explanation: A is INCORRECT because this is not the initial imbalance. If a more common imbalance is left untreated, it could progress to metabolic acidosis rather than alkalosis. B is INCORRECT because, before becoming acidotic, the client would experience another, more common imbalance. C is CORRECT because TPN is a hyperosmolar solution made up of at least 10% glucose. The client may experience several of these imbalances, but hyperglycemia is the most common. D is INCORRECT because septicemia is not the greatest risk; however, the solution is a medium for growth of bacteria, and if aseptic technique is not maintained, septicemia might result. Question 45. Which food should a client on a low-cholesterol diet be instructed to avoid? 1. Liver 2. Turkey 3. Ham 4. Beef Looking for answers(s):1 Explanation: A is CORRECT because organ meats and egg yolks contain the greatest amount of cholesterol. B is INCORRECT because poultry is permitted on a low-cholesterol diet. C is INCORRECT because pork, particularly processed pork, is high in sodium and fat (saturated and unsaturated). D is INCORRECT because beef is permitted in moderation on a low-cholesterol diet. Question 46. The nurse observes clear drainage on the pillow of a client with a head injury. What should be the first nursing action? 1. Culture the drainage 2. Clean the nose with normal saline 3. Apply a sterile dressing 4. Test the drainage for glucose Looking for answers(s):4 Explanation: A is INCORRECT because the drainage is usually not infected; therefore, a culture is not a priority action. B is INCORRECT because determining the source of the drainage is most important. Gentle wiping may be done, but no special solutions are necessary. C is INCORRECT because determining the source of the drainage is most important. A dressing may then be applied to absorb the drainage. D is CORRECT because the clear drainage is most likely cerebral spinal fluid and will be positive for glucose.

Question 47. What is the most important consideration in planning the diet for a client admitted with an acute flare-up of rheumatoid arthritis? 1. Three regular meals with increased dairy products 2. Six smaller meals with protein, fruits, and vegetables 3. Soft consistency, well-balanced until inflammation subsides 4. Low calorie, low fat to assist in weight loss Looking for answers(s):2 Explanation: A is INCORRECT because the larger meals may be more fatiguing, and dairy products are not the best source of protein. B is CORRECT because during an acute inflammation, the client will be anorexic and weak, and will fatigue easily. Protein is needed for healing; six smaller meals will avoid fatigue; and complex carbohydrates will provide energy. Fats are avoided because weight gain would further traumatize the joints. C is INCORRECT because chewing is not the problem. Well-balanced may seem like a good choice; however, with the fatigue and inflammation, the diet should be high in protein and complex carbohydrates. D is INCORRECT because weight loss is not the priority during an acute inflammation. Protein is needed for healing, and carbohydrate for a quick and easily digested energy source. Question 48. What assessment data would indicate to the nurse that the clients hyperthyroid state was returning to normal? 1. Pulse rate increased 2. Serum thyroxin level was normal 3. Thyroid gland was palpable 4. Hair became coarse and dry Looking for answers(s):2 Explanation: A is INCORRECT because tachycardia is a symptom of hyperthyroidism. B is CORRECT because as the client enters a euthyroid state, the serum thyroxin level will return to normal. C is INCORRECT because an enlarged thyroid is a sign of hyperthyroidism. D is INCORRECT because the changes in hair are seen with hypothyroidism. Question 49. When supine, what is the best position for the paralyzed upper extremity of a client who had a stroke? 1. Arm adducted to side, hand extended, finger flexed 2. Elbow flexed, fingers grasping a hand roll 3. Abducted arm, forearm and wrist on pillows by head 4. Arm resting on chest, hand and fingers extended Looking for answers(s):3 Explanation: A is INCORRECT because adduction will lead to contractures of the shoulder; conversely, abduction provides some external rotation of the shoulder which is necessary to raise the arm above the head without pain. Hand and fingers should be in a functional position, which is slight supination; fingers slightly flexed and thumb in opposition.

B is INCORRECT because this option is not complete; it does not address the shoulder positioning, which is important. The elbow and hand positioning are partially correct. C is CORRECT because the arm should be abducted at least 60 degrees, the elbow on a pillow, hand toward the head of the bed, and the wrist elevated even higher than the elbow, palmar side up. This is called a modified Statue of Liberty position. It stretches the internal rotators of the shoulder, and prevents edema. The hand should grip a roll. D is INCORRECT because the hand is not in a functional position, and the shoulder would be adducted. Question 50. The client has chronic congestive heart failure and is on a 2 Gm sodium diet. The nurse has been successful in teaching when the client eliminates which foods from the diet? -SELECT ALL THAT APPLY1. Lean, roasted ham 2. Cooked cereal 3. Tomato juice 4. Tuna, canned, water pack 5. Frozen vegetables 134 Explanation: A is CORRECT because lean, roasted ham, while it may be lower in fat, still has about 1 Gm of sodium in 3 ounces. C is CORRECT because 3/4 cup of canned tomato juice has 820 mg of sodium. D is CORRECT because canned tuna, water pack, has 250-350 mg of sodium in 3 ounces. The client can switch to tuna with no added salt. B is INCORRECT because cooked cereal has only 0-5 mg of sodium, if cooked without salt. E is INCORRECT because frozen vegetables contain only 1-70 mg of sodium, if they are cooked without salt.

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