1. Lisa is newly diagnosed with asthma and is being discharged from the hospital after 7.

7. The nurse teaching the client about behavioral changes, which can affect
an episode of status asthmaticus. Discharge teaching should include which of the development of atherosclerosis, should discuss which of the following as a non-
following: modifiable risk factor for atherosclerosis?

A. Limitations in sports that will be imposed by the illness A. cigarette smoking

B. Specific instructions on staying cal during an attack B. hyperlipidemia
C. The relationship of symptoms and a specific trigger such as physical exercise C. female over 55 years of age
D. Incidence of status asthmaticus in children and teens D. sedentary lifestyle
2. Which of the following symptoms is most characteristic of a client with a cancer of 8. A 76 year old man enters the ER with complaints of back pain and feeling fatigued.
the lung? Upon examination, his blood pressure is 190/100, pulse is 118, and hematocrit and
hemoglobin are both low. The nurse palpates the abdomen which is soft, non-tender
A. air hunger and auscultates an abdominal pulse. The most likely diagnosis is:
B. exertional dyspnea
C. cough with night sweats A. Buerger’s disease
D. persistent changing cough B. CHF
3. The client has ST segment depression on his 12-lead ECG. The nurse determines C. Secondary hypertension
that this would indicate the following: D. Aneurysm
9. Nurse Fiona is caring a patient with Raynaud’s disease. Which of the following
A. necrosis outcomes concerning medication regimen is of highest priority?
B. injury
C. ischemia A. Controlling the pain once vasospasm occur
D. nothing significant B. Relaxing smooth muscle to avoid vasospasms
4. Red has just returned from the postanesthesia care unit (PACU) from a C. Preventing major disabilities that may occur
hemorrhidectomy. His postoperative orders include sitz baths every morning. The D. Avoiding lesions on the feet
nurse understands that sitz bath is use for: 10. Mr. Roberto Robles complains of a severe headache and is extremely anxious. The
nurse checks his vital signs and finds him to have a heart rate of 57 bpm and a blood
A. promote healing pressure of 230/110 mmHg. The nurse should also assess for?
B. relive tension
C. lower body temperature A. presence of bowel sounds
D. cause swelling B. presence of babinski reflex
5. Trousseau’s sign is associated with which electrolyte imbalance? C. fecal incontinence
D. urinary catheter patency
A. hyponatremia 11. A 40n year old male patient is complaining of chronic progressive and mental
B. hypocalcemia deterioration is admitted to the unit. The nurse recognizes that these characteristics
C. hypernatremia indicate a disease that results in degeneration of the basal ganglia and cerebral
D. hypercalcemia cortex. The disease is called:
6. A 36 year old female complains of headache and neck pain. The nurse’s
assessments reveal painful flexion of the neck to the chest. The nurse understands A. multiple sclerosis
that nuchal rigidity is associated with: B. myasthenia gravis
C. Huntington’s disease
A. brain tumor D. Guillain-Barre syndrome
B. CVA
C. meningitis
D. subdural hematoma
 12. Dianne Hizon is a 27 year old woman who has been admitted to the ER due to 18. Elsa Santos is a 18 year old student admitted to the ward with a diagnosis of
severe vomiting. Her ABG values are pH= 7.50, PaCO2= 85, HCO3= 31, and SaO2= epilepsy. She tells the nurse that she is experiencing a generalized tingling sensation
93%. The nurse interpretation of this ABG analysis is: and is “smelling roses”. The nurse understands that Esla is probably experiencing:

A. respiratory acidosis A. an acute alcohol withdrawal

B. respiratory alkalosis B. an acute CVA
C. metabolic acidosis C. an aura
D. metabolic alkalosis D. an olfactory hallucination
13. Mr. Perkson has a parkinson’s disease and he finds the resting tremor he is 19. Mr. Lucas, a 63 year old, went to the clinic complaining of hoarseness of voice and
experiencing in his right hand very frustrating. The nurse advises him to: a cough. His wife states that his voice has changed in the last few months. The nurse
interprets that Mr. Lucas’s symptoms are consistent with which of the following
A. take a warm bath disorders:
B. hold an object
C. practice deep breathing A. chronic sinusitis
D. take diazepam as needed B. laryngeal cancer
14. A shuffling gait is typically associated with the patient who has: C. gastroesophageal reflux disease
D. coronary artery disease
A. Parkinson’s disease 20. Sarah complains of a nursing sensation, cramping pain in the top part of her
B. Multiple sclerosis abdomen that becomes worse in the afternoon and sometimes awakes her at night.
C. Raynaud’s disease She reports that when she eats, it helps the pain go away but that pain is now
D. Myasthenia gravis becoming more intense. Which of the following is the best condition for the nurse to
15. The priority in preparing the room for a client with a C7 spinal cord injury is draw:
having:
A. these symptoms are consistent with an ulcer
A. the halo brace device B. The client probably has indigestion
B. a catheterization tray C. A snack before going to bed should be advised
C. a ventilator on stand by D. The client probably developing cholelithiasis
D. the spinal kinetic bed 21. Nurse Cynthia is providing a discharge teaching to a client with chronic cirrhosis.
16. A 47 year old man with liver failure who has developed ascites. The nurse His wife asks her to explain why there is so much emphasis on bleeding precautions.
understands that ascites is due to: Which of the following provides the most appropriate response?

A. dehydration A. “The low protein diet will result in reduced clotting.”

B. protein deficiency B. “The increased production of bile decreases clotting factors.”
C. bleeding disorders C. “The liver affected by cirrhosis is unable to produce clotting factors.”
D. vitamin deficiency D. “The required medications reduce clotting factors.”
17. A client with rheumatoid arthritis may reveal which of the following assessment 22. Betty Lee is a 58 year old woman who is being admitted to the medical ward with
data: trigeminal neuralgia. The nurse anticipates that Mr. Lee will demonstrate which of the
following major complaints?
A. Heberden’s nodes
B. Morning stiffness no longer than 30 minutes A. excruciating, intermittent, paroxysmal facial pain
C. Asymmetric joint swelling B. unilateral facial droop
D. Swan neck deformities C. painless eye spasm
D. mildly painful unilateral eye twitching
 23. A 38 year old woman returns from a subtotal thryroidectomy for the treatment of
hyperthyroidism. Upon assessment, the immediate priority that the nurse would
include is:

A. Assess for pain

B. Assess for neurological status
C. Assess fluid volume status
D. Assess for respiratory distress
24. Nurse Shiela is teaching self-care to a client with psoriasis. The nurse should
encourage which of the following for his scaled lesion?

A. Importance of follow-up appointments

B. Emollients and moisturizers to soften scales
C. Keep occlusive dressings on the lesions 24 hours a day
D. Use of a clean razor blade each time he shaves
25. A 48 year old woman presents to the hospital complaining of chest pain,
tachycardia and dyspnea. On exam, heart sounds are muffled. Which of the following
assessment findings would support a diagnosis of cardiac tamponade?

A. A deviated trachea
B. Absent breath sounds to the lower lobes
C. Pulse 40 with inspiration
D. Blood pressure 140/80
 Answers and Rationales
1. C. The relationship of symptoms and a specific trigger such as physical
exercise. COPD clients have low oxygen and high carbon dioxide levels. Therefore,
hypoxia is the main stimulus for ventilation is persons with chronic hypercapnea.
Increasing the level of oxygen would decrease the stimulus to breathe.
2. D. persistent changing cough. The most common sign of lung cancer is a
persistent cough that changes. Other signs are dyspnea, bloody sputum and long
term pulmonary infection. Option A is common with asthma, option B is common with
COPD and option C is common with TB.
3. C. ischemia. Depressed ST segment and inverted T-waves represent myocardial
ischemia. Injury has a ST segment elevation.
4. A. promote healing. Sitz bath provides moist heat to the perineal and anal area to
clean, promote healing and drainage and reduce soreness to the area. Sitz bath helps
healing with cleaning action and promotion of circulation, thereby reducing swelling.
Sitz bath usually has no therapeutic value in lowering body temperature. Although
relief of tension can occur, this effect is secondary to the promotion of healing.
5. B. hypocalcemia. Trousseau’s sign is a carpal pedal spasm elicited when a blood
pressure cuff is inflated on the arm of a patient with hypocalcemia.
6. C. meningitis. A patient with meningitis will exhibit signs that include photophobia
and nuchal rigidity, which is pain on the flexion of the chin to chest.
7. C. female over 55 years of age. Lifestyle, cigarette smoking and hyperlipidemia
can be changed by changing behaviors.
8. D. Aneurysm. The symptoms exhibited by the client are typical of an abdominal
aortic aneurysm. The most significant sign is the audible pulse in the abdominal area.
If hemorrhage were present, the abdomen would be tender and firm.
9. B. Relaxing smooth muscle to avoid vasospasms. The major task of the health
care team is to medicate the client drugs that produce smooth muscle relaxation,
which will decrease the vasospasm and increase the arterial flow to the affected part.
The drugs used are calcium antagonists.
10. D. urinary catheter patency. The patient is complaining of symptoms of autonomic
dysreflexia, which consists of the triad of hypertension, bradycardia and a headache.
Major causes of autonomic dysreflexia include urinary bladder distention and fecal
impaction. Checking the patency of the urinary catheter will check for bladder
distention.
11. C. Huntington’s disease. Huntington’s disease is a hereditary disease in which
degeneration of the basal ganglia and cerebral cortex causes chronic progressive
chorea (muscle twitching) and mental deterioration, ending in dementia. Huntington’s
disease usually strikes people ages 25 to 55.
12. D. metabolic alkalosis. Ms. Hizon’s pH is above 7.45, which makes it alkalatic, and
her bicarbonate is high which is also makes it basic. Thus, the diagnosis is metabolic
alkalosis.
13. B. hold an object. The resting or non-intentional tremor may be controlled with
purposeful movement such as holding an object. A warm bath, deep breathing and
diazepam will promote relaxation but are not specific interventions for tremor.
14. A. Parkinson’s disease. A shuffling gait from the musculoskeletal rigidity of the
patient with Parkinson’s disease is common. Patients experiencing a stroke usually
exhibit loss of voluntary control over motor movements associated with generalized
weakness; a shuffling gait is usually not observed in stroke patient.
15. C. a ventilator on stand by. Although a ventilator is not required for injury below
C3, the innervation of intercostal muscles is affected. Hemorrhage and cord swelling
extends the level of injury making it likely that this client will need a ventilator.
16. B. protein deficiency. Protein deficiency allows fluid to leak out of the vascular
system and third space into the tissues and spaces in the body such as the peritoneal
space. Bleeding tendencies, dehydration and vitamin deficiency can occur but don’t
cause ascites.
17. D. Swan neck deformities. Swan neck deformities of the hand are classic
deformities associated with rheumatoid arthritis secondary to the presence of fibrous
connective tissue within the joint space. Clients with RA do experience morning
stiffness, but it can last from 30 minutes up to several hours. RA is characterized by
symmetrical joint movement, and heberden’s nodes are characteristic of osteoarthritis.
18. C. an aura. An aura frequently precedes an epileptic seizure and may manifest as
vague physic discomfort or specific aromas. Patients experiencing auras aren’t having
a CVA, substance withdrawal or hallucination.
19. B. laryngeal cancer. These symptoms, along with dysphagia, foul-smelling breath,
and pain when drinking hot or acidic, are common signs of laryngeal cancer.
20. A. these symptoms are consistent with an ulcer. The description of pain is
consistent with ulcer pain. The pain is epigastric and is worse when the stomach is
empty and is relived by food.
21. C. “The liver affected by cirrhosis is unable to produce clotting
factors.” When bile production is reduced, the body has reduced ability to absorb fat-
soluble vitamins. Without adequate Vitamin K absorption, clotting factors II, VII, IX,
and X are not produced in sufficient amounts.
22. A. excruciating, intermittent, paroxysmal facial pain. Trigeminal neuralgia is a
syndrome of excruciating, intermittent, paroxysmal facial pain. It manifests as intense,
periodic pain in the lips, gums, teeth or chin. The other symptoms aren’t characteristic
of trigeminal neuralgia.
23. D. Assess for respiratory distress. Though fluid volume status, neurological status
and pain are all important assessment, the immediate priority for postoperative is the
airway management. Respiratory distress may result from hemorrhage, edema,
laryngeal damage or tetany.
24. B. Emollients and moisturizers to soften scales. Emollients will ease dry skin
that increases pruritus and causes psoriasis to be worse. Washing and drying the skin
with rough linens or pressure may cause excoriation. Constant occlusion may increase
the effects of the medication and increase the risk of infection.
25. C. Pulse 40 with inspiration. Paradoxical pulse is a hallmark symptom of cardiac
tamponade. As pressure is exerted on the left ventricle from fluid, the natural increase
in pressure from the right ventricle during inspiration creates even more pressure,
diminishing cardiac output.
 of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of
the following assessment findings would concern the nurse most?

A. Temperature of 102 degrees F and productive cough

B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
C. Trachea deviating to the right
D. Barrel-chested appearance
4. The proper way to open an envelop-wrapped sterile package after removing the
outer package or tape is to open the first position of the wrapper:

A. away from the body

B. to the left of the body
C. to the right of the body
D. toward the body
5. Assessment of a client with possible thrombophlebitis to the left leg and a deep
vein thrombosis is done by pulling up on the toes while gently holding down on the
knee. The client complains of extreme pain in the calf. This should be documented as:

A. positive tourniquet test

B. positive homan’s sign
C. negative homan’s sign
D. negative tourniquet test
6. Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia.
The doctor orders a series of laboratory tests to determine whether Mr. Elison’s
dementia is treatable. The nurse understands that the most common cause of
dementia in this population is:

A. AIDS
1. A patient is admitted to the medical surgical unit following surgery. Four days after
B. Alzheimer’s disease
surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet,
C. Brain tumors
productive cough. The nurse assesses the patient with understanding that an infection
D. Vascular disease
that is acquired during hospitalization is known as:

A. a community acquired infection

7. Which of the following nursing interventions is contraindicated in the care of a
B. an iatrogenic infection
client with acute osteomyelitis?
C. a nosocomial infection
D. an opportunistic infection
2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing A. Apply heat compress to the affected area
symptoms of cerebral tissue hypoxia. Which of the following nursing interventions B. Immobilize the affected area
would be most important in providing care? C. Administer narcotic analgesics for pain
D. Administer OTC analgesics for pain
8. A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. Prior
A. Providing rest periods throughout the day
to giving the medication, the nurse checks the digoxin level which is therapeutic and
B. Instituting energy conservation techniques
ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse
C. Assisting in ambulation to the bathroom
should:
D. Checking temperature of water prior to bathing
3. A client was involved in a motor vehicular accident in which the seat belt was not
worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains A. Hold the Lanoxin
B. Give the half dose now, wait an hour and give the other half
C. Call the physician D. hypophosphatenia
D. Give the Lanoxin as ordered 15. What laboratory test is a common measure of the renal function?
9. Nurse Marian is caring for a client with haital hernia, which of the following should
be included in her teaching plan regarding causes: A. CBC
B. BUN/Crea
A. To avoid heavy lifting C. Glucose
B. A dietary plan based on soft foods D. Alanine amino transferase (ALT)
C. Its prevalence in young adults 16. Nurse Edward is performing discharge teaching for a newly diagnosed diabetic
D. Its prevalence in fair-skinned individuals patient scheduled for a fasting blood glucose test. The nurse explains to the patient
10. Joseph has been diagnosed with hepatic encephalopathy. The nurse observes that hyperglycemia is defined as a blood glucose level above:
flapping tremors. The nurse understands that flapping tremors associated with hepatic
encephalopathy are also known as: A. 100 mg/dl
B. 120 mg/dl
A. aphasia C. 130 mg/dl
B. ascites D. 150 mg/dl
C. astacia 17. Mang Edison is on bed rest has developed an ulcer that is full thickness and is
D. asterixis penetrating the subcutaneous tissue. The nurse documents that this ulcer is in which
11. Hyperkalemia can be treated with administration of 50% dextrose and insulin. The of the following stages?
50% dextrose:
A. Stage 1
A. causes potassium to be excreted B. Stage 2
B. causes potassium to move into the cell C. Stage 3
C. causes potassium to move into the serum D. Stage 4
D. counteracts the effects of insulin 18. A 24 year old male patient comes to the clinic after contracting genital herpes.
12. Which of the following findings would strongly indicate the possibility of cirrhosis? Which of the following intervention would be most appropriate?

A. dry skin A. Encourage him to maintain bed rest for several days
B. hepatomegaly B. Monitor temperature every 4 hours
C. peripheral edema C. Instruct him to avoid sexual contact during acute phases of illness
D. pruritus D. Encourage him to use antifungal agents regularly
13. Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma. 19. An 8 year old boy is brought to the trauma unit with a chemical burn to the face.
The nurse assesses the client for which of the following common presenting Priority assessment would include which of the following?
symptoms of the disorder?
A. Skin integrity
A. halo vision B. BP and pulse
B. dull eye pain C. Patency of airway
C. severe eye and face pain D. Amount of pain
D. impaired night vision 20. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which of
the following complaints would be indicative of tissue hypoxia related to anemia?

A. dizziness
B. fatigue relieved by rest
14. Chvostek’s sign is associated with which electrolyte impabalnce? C. skin that is warm and dry to the touch
D. apathy
A. hypoclacemia
B. hypokalemia
C. hyponatremia
 21. Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and Answers and Rationales
loss of radial pulses. The nurse suspects that Mrs. Murray may have: 1. C. a nosocomial infection. Nosocomial, or hospital-acquired are infections acquired
during hospitalization for which the patient isn’t being primarily treated. Community
A. Acute MI acquired or opportunistic infections may not be acquired during hospitalization. An
B. CVA iatrogenic infection is caused by the doctor or by medical therapy. And an
C. Dissecting abdominal aorta opportunistic infection affects a compromised host.
D. Dissecting thoracic aneurysm 2. C. Assisting in ambulation to the bathroom. Cerebral tissue hypoxia is commonly
22. Nurse Alexandra is establishing a plan of care for a client newly admitted with associated with dizziness. The greatest potential risk to the client with dizziness is
SIADH. The priority diagnosis for this client would be which of the following? injury, especially with changes in position. Planning for periods of rest and conserving
energy are important with someone with anemia because of his or her fatigue level
A. Fluid volume deficit but most important is safety.
B. Anxiety related to disease process 3. C. Trachea deviating to the right. A mediastinal shift is indicative of a tension
C. Fluid volume excess pneumothorax along with the other symptoms in the question. Since the individual
D. Risk for injury was involved in a MVA, assessment would be targeted at acute traumatic injuries to
23. Nursing management of the client with a UTI should include: the lungs, heart or chest wall rather than other conditions indicated in the other
answers. Option A is common with pneumonia; values in option B are not alarming;
and option D is typical of someone with COPD.
A. Taking medication until feeling better
4. A. away from the body. When opening an envelop-wrapped sterile package,
B. Restricting fluids
reaching across the package and using the first motion to open the top cover away
C. Decreasing caffeine drinks and alcohol
from the body eliminates the need to later reach across the steri9le field while
D. Douching daily
opening the package. To remove equipment from the package, opening the first
24. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The
portion of the package toward, to the left, or to the right of the body would require
nurse understands that a postoperative patient who’s maintained on bed rest is at
reaching across a sterile field.
high risk for developing:
5. B. positive homan’s sign. Pain in the calf while pulling up on the toes is abnormal
and indicates a positive test. If the client feels nothing or just feels like the calf muscle
A. angina is stretching, it is considered negative. A tourniquet test is used to measure for
B. arterial bleeding varicose veins.
C. deep vein thrombosis (DVT) 6. B. Alzheimer’s disease. Alzheimer’s disease is the most common cause of dementia
D. dehiscence of the wound in the elderly population. AIDS, brain tumors and vascular disease are all less common
25. Which of the following statement is true regarding the visual changes associated causes of progressive loss of mental function in elderly patients.
with cataracts? 7. A. Apply heat compress to the affected area. Options B, C and D are appropriate
nursing interventions when caring for a client diagnosed with osteomyelitis. The
A. Both eyes typically cataracts at the same time application of heat can increase edema and pain in the affected area and spread
B. The loss of vision is experienced as a painless, gradual blurring bacteria through vasodilation.
C. The patient is suddenly blind 8. D. Give the Lanoxin as ordered. The Lanoxin should be held for a pulse of 60
D. The patient is typically experiences a painful, sudden blurring of vision. bpm. Nurses cannot arbitrarily give half of a dose without a physician’s order. Unless
specific parameters are given concerning pulse rate, most resources identify 60 as the
reference pulse.
9. A. To avoid heavy lifting. Heavy lifting is one factor that leads to development of a
hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to soft
foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned
individuals are not prone to this condition.
10. D. asterixis. Flapping tremors associated with hepatic encephalophaty are asterixis.
Aphasia is the inability to speak. Ascites is an accumulation of fluid in the peritoneal
cavity. Astacia is the inability to stand or sit still.
11. D. counteracts the effects of insulin. The 50% dextrose is given to counteract the
effects of insulin. Insulin drives the potassium into the cell, thereby lowering the
 serum potassium levels. The dextrose doesn’t directly cause potassium excretion or 24. C. deep vein thrombosis (DVT). DVT, is the most probable complication for
any movement of potassium. postoperative patients on bed rest. Options A, B and D aren’t likely complications of
12. B. hepatomegaly. Although option D is correct, it is not a strong indicator of the post operative period.
cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid 25. B. The loss of vision is experienced as a painless, gradual blurring. Typically,
accumulations is usually in the form of ascites in the abdomen. Hepatomegaly is an a patient with cataracts experiences painless, gradual loss of vision. Although both
enlarged liver, which is correct. The spleen may also be enlarged. eyes may develop at different rates.
13. C. severe eye and face pain. Narrow-angle glaucoma develops abruptly and
manifests with acute face and eye pain and is a medial emergency. Halo vision, dull
eye pain and impaired night vision are symptoms associated with open-angle
glaucoma.
14. A. hypoclacemia. Chvostek’s sign is a spasm of the facial muscles elicited by tapping
the facial nerve and is associated with hypocalcemia. Clinical signs of hypokalemia are
muscle weakness, leg cramps, fatigue, nausea and vomiting. Muscle cramps,
anorexia, nausea and vomiting are clinical signs of hyponatremia. Clinical
manifestations associated with hypophosphatemia include muscle pain, confusion,
seizures and coma.
15. B. BUN/Crea. The BUN is primarily used as indicator of kidney function because
most renal diseases interfere with its excretion and cause blood vessels to rise.
Creatinine is produced in relatively constant amounts, according to the amount of
muscle mass and is excreted entirely by the kidneys making it a good indicator of
renal function.
16. B. 120 mg/dl. Hyperglycemia is defined as a blood glucose level greater than 120
mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered
hyperglycemic. A blood glucose of 100 mg/dl is normal.
17. C. Stage 3. A stage 3 ulcer is full thickness involving the subcutaneous tissue. A
stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A
stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through the
skin and exhibit tissue necrosis and muscle or bone involvement.
18. C. Instruct him to avoid sexual contact during acute phases of
illness. Herpes is a virus and is spread through direct contact. An antifungal would
not be useful; bed rest and temperature measurement are usually not necessary.
19. C. Patency of airway. A burn face, neck or chest may cause airway closure because
of the edema that occurs within hours. Remember the ABC’s: airway, breathing and
circulation. Airway always comes first, even before pain. The nurse will also assess
options B and D, but these are not the highest priority assessments.
20. A. dizziness. Central tissue hypoxia is commonly associated with dizziness.
Recognition of cerebral hypoxia is critical since the body will attempt to shunt
oxygenated blood to vital organs.
21. D. Dissecting thoracic aneurysm. A dissecting thoracic aneurysm may cause loss
of radical pulses and severe chest and back pain. An MI typically doesn’t cause loss of
radial pulses or severe back pain. CVA and dissecting abdominal aneurysm are
incorrect responses.
22. C. Fluid volume excess. SIADH results in fluid retention and hyponatremia.
Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for
injury should be addressed following fluid volume excess.
23. C. Decreasing caffeine drinks and alcohol. Caffeine and alcohol can increase
bladder spasms and mucosal irritation, thus increase the signs and symptoms of UTI.
All antibiotics should be taken completely to prevent resistant strains of organisms.