For an adolescent boy, the main life-stage task is: Developing a sense of trust in others and in his environment. Finalizing his goals and plans for the future. Striving to attain independence and identity. Resolving inner conflicts and turmoil. The adolescent is striving to attain a sense of independence and identity. Trust (Answer 1) is usually developed during infancy and matures as the individual develops. Goals and plans (Answer 2) are made during the adolescent period, but they are rarely finalized realistically until late adulthood. During this period, inner conflicts (Answer 4) are rarely resolved and are usually heightened Know age-appropriate psychosocial tasks. A child lying on the stretcher during admission suddenly complains of nausea and begins to vomit. The nurse should immediately: Turn the child's head to the side. Suction the child's oropharynx. Raise the head of the stretcher. Insert an NG tube. To prevent aspiration, the first and immediate action the nurse should take is to turn the child's head to the side. All of the other actions (Answers 2,3,4) may also prevent aspiration but will take considerably longer and are not effective immediately Patent airway is the primary concern in this question; note the use of the word immediately, meaning an instant action. A woman is in active labor; her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity (PMI) of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. Which action should the nurse take immediately? Examine the woman for signs of a prolapsed cord. Turn the woman on her left side to increase placental perfusion. Take the woman's radial pulse while still auscultating the FHR. Start oxygen by mask to reduce fetal distress. Taking the mother's pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal bradycardia. Answer 1 is wrong because although the cord may prolapse at any time before the oncoming head occludes the cervix, the most common time of occurrence is when the membranes rupture. Answer 2 is wrong because fetal bradycardia has not yet been determined; the nurse needs to differentiate maternal from fetal heart rate. Answer 4 is wrong because if the fetal heart rate is normal, there is no need for supplemental oxygen therapy Think priority, which is to assess and determine if there is a problem with, fetal pulse rate. Differentiate between maternal and fetal pulse rates. Recall normal fetal rate vs. bradycardia. The nurse explains that a flexible sigmoidoscopy involves: Instillation of a radiopaque contrast medium into the lower gastrointestinal tract. Insertion of a fiber-optic scope that allows for direct visual examination of the anal canal, rectum, and sigmoid colon. Insertion of a fiber-optic scope that allows for direct visualization of the sigmoid colon, transverse colon, and ileocecal valve. Surgical removal of polyps and biopsy of suspicious gastrointestinal mucosa. Sigmoidoscopy involves the insertion of a flexible instrument into the anus that allows direct visualization of the anal canal, rectum, and sigmoid colon. The patient is usually prepared for this procedure with enemas. Answer 1 is an example of a lower GI study. Answer 3 describes a colonoscopy, and Answer 4 describes two of the procedures that can be accomplished with a colonoscope Read the choices closely looking for clues. Visualize (oscopy) and think of the anatomy. A viable 7-pound, 12-ounce boy is born. Apgar scores are 7 and 9. In assessing the baby, the nurse notes he appears slightly cyanotic. What should the nurse per form first? 1. Wrap him in another blanket, to reduce heat loss. Stimulate him to cry, to increase oxygenation. Aspirate his mouth and nose with bulb syringe. Elevate his head to promote gravity drainage of secretions. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange. Answer 1 is wrong because the first priority is a patent airway. Answer 2 is wrong because the baby may aspirate mucus, which would occlude the airway. Answer 4 is wrong because gravity drainage is accomplished in head-dependent position -Apply the ABCs: airway first. Review the plan of care for an infant immediately after delivery. Prioritize procedures, and choose the answer you would do first, to maintain a patent airway. A 32-year-old mother of three adolescents has increased her consumption of alcoholic beverages to 24 oz of 80-proof drinks per day. She gets angry with the children very quickly, cries spontaneously several times every day, and complains of headaches constantly. In planning her care, what would be considered the least appropriate nursing intervention? Stimulating her to work at a concrete task. Encouraging her to cry. Providing her with someone to talk to. Isolating her from stimuli. Isolation may lead to withdrawal and depression. She needs positive reinforcement and reassurance to increase her self-esteem. Isolation may also lead to an increase in her drinking and depression. Based on the symptoms she is exhibiting, involving her in simple, concrete tasks (Answer 1) may help her feel useful. Crying (Answer 2) helps her alleviate anxiety through the physical expression of her feelings. Encouraging the verbalization of her feelings (Answer 3) will demonstrate that someone cares for her enough to listen, and may decrease her anxiety level Note key phrase: "least appropriate. The nurse explains to a patient that bronchitis is characterized by: Hypertrophy of the bronchial mucous glands and the production of mucoid sputum sometimes difficult to expectorate. Bronchoconstriction and edema of the wall of the bronchioles. Exudate in the alveoli. Increasing lung stiffness. The basic pathophysiological changes associated with chronic bronchitis are hypertrophy of the mucous glands lining the bronchi and the production of increased amounts of mucus (sometimes thick and difficult to expectorate) that tend to narrow the airway and trap air distal to the mucus. Bronchoconstriction and edema of the bronchial walls (Answer 2) are characteristic of asthma. Exudate in the alveoli (Answer 3) and increasing lung stiffness (Answer 4) are consistent with pneumonia Look for inflammation ("-itis") in the bronchials. Which assessment finding indicates a need for further assessment of a pregnant woman's general health status at 18 weeks of gestation? Rheumatic fever at age 12. Rubella titer negative. Family history of multifetal births. Treatment for chlamydial infection before pregnancy validation. Definitive (30%) increase in blood volume occurs at this point in pregnancy; rising cardiac load imposes stress on the heart valves (e.g., mitral stenosis) affected during the episode of rheumatic fever. Answer 2 is wrong because first-trimester rubella infection presents the greatest hazard to the fetus, and immunization should be planned for the immediate postpartum period. Answer 3 is wrong because diagnosis of multifetal pregnancy would be based not on discussions of general health status but on physical evidence (fundal height, ultrasound). Answer 4 is wrong because once treatment is ended, infection is gone The key is timing; second trimester, not first (2). Recall cardiac risks of rheumatic fever and how pregnancy places a woman at increased risk. Note that the stem asks for general health status; therefore, eliminate specific physical assessment called for in Answer 3, Eliminate Answer 4 because a prior treated infection is not a second-trimester concern. If a child's nasogastric tube is functioning properly after an emergency appendectomy, the nurse should expect to make which observation? There is no drainage on the surgical dressing. The child's abdomen is soft. The child is able to swallow saliva. There are bowel sounds in all four quadrants. The main purpose of a nasogastric tube is to drain fluid and gas from the stomach; if it is functioning properly, the child's abdomen should be soft, and the tube should drain stomach contents, including bile. The nasogastric tube will not affect the drainage on the dressing (Answer 1) or the bowel sounds (Answer 4). The child may complain of a sore throat from this tube, but it should not affect the ability to swallow saliva (Answer 3) What should the nasogastric tube do? What would be the expected outcome? At 38 weeks of gestation, a woman's cervix is dilated 4 cm and effaced 60%. She does not speak English and has no prenatal record. Which nursing diagnosis is least likely to prove a problem during this woman's labor and birth? Pain related to uterine contractions and fear. Impaired verbal communication related to language barrier. Anxiety/fear related to poor communication and labor. Altered nutrition, less than body requirements. Although hydration may be affected by the physiological stress of labor, the duration is insufficient to significantly affect nutritional status. Answer 1 is wrong because discomfort generally does accompany labor. Answer 2 is wrong because the inability to communicate clearly affects nurse-patient relationships and may induce or augment anxiety. Answer 3 is wrong because labor is commonly accompanied by anxiety This question asks for the nursing diagnosis that is least likely to be a problem. First, eliminate the three options that are likely to be a problem at 38 weeks of gestation with a cervix that is 4 cm dilated and 60% effaced. The nurse plans care for an adolescent based on the knowledge that this patient least needs: External control on his or her behavior by adults. Limit setting based on fear and reprimands. Adult role models for identification. Stable relationships and interactions. Limits do need to be set, but they should be based on mutual respect rather than fear. Adult (or external) controls on behavior (Answer 1) are essential and must be consistent. Role models serve to stimulate the identification process (Answer 3) both consciously and unconsciously. Stable relationships (Answer 4) are essential if the adolescent is to mature and develop a sense of trust Key words are least and adolescent-related need. The question asks for what the adolescent does not need. Use a true-false approach, option by option. A patient has been admitted to the hospital with acute rheumatoid arthritis. The hands are painful and edematous, and there is severe pain in the left hip. The temperature is 101°F orally; pulse, 96; respirations, 22. ASA grx qid has been ordered. The nurse can expect this patient's temperature and pulse to be elevated because of: Increased fluid losses. Inflammation of the hand and hip joints. Stress response. Side effect of salicylate therapy. Fever and increased pulse rates occur in rheumatoid arthritis due to the systemic inflammatory process of this dysfunction. If the fever is high or prolonged, increased fluid losses could occur due to insensible water loss (Answer 1); however, the effects on body temperature would be secondary to the primary inflammatory response. Though the stress response (Answer 3) does increase pulse rate, normally it does not significantly affect body temperature. Answer 4 is incorrect because salicylates have an antipyretic effect Look for a choice consistent with an "itis" (inflammation). Which factor should the nurse identify as the most probable cause of a child's lice? The child washes the hair only once a week. The child shares the comb and brush with a friend. The child wears a hat to school every day. The child's hair is long, thick, and curly. Lice are spread by direct or indirect contact: sharing combs and brushes, sharing hats, sleeping together, etc. It is generally unrelated to frequency of hair washing (Answer 1), wearing a hat (Answer 3), or having long hair (Answer 4) Because lice are contagious, the best answer focuses on prevention of spread to others. Only one option involves others. A 45-year-old man is assessed as having an obsessive-compulsive disorder. Which behavior would the nurse least expect him to exhibit? Working 50- to 60-hour weeks. Smoking two packs of cigarettes a day. Showing flexibility in decision making. Exhibiting a low level of concentration. Most obsessive-compulsive individuals are highly inflexible and resist change because change stimulates anxiety and they are unable to cope with stress. Answers 1,2, and 4 are all likely behaviors Note key phrase: "least expect. The nurse knows that a colostomy begins functioning: Immediately. 2-3 days postoperatively. 1 wk postoperatively. 2 wk postoperatively. The stomas will begin to secrete mucus within 48 hours, and the proximal loop should begin to drain fecal material within 72 hours. Ileostomies (Answer 1) begin to drain immediately. Answers 3 and 4 are incorrect because peristalsis generally returns within 48-72 hours postoperatively Know when bowel sounds (peristalsis) return following general anesthesia. A woman is seen in clinic complaining of amenorrhea, fatigue, urinary frequency, and morning nausea. She states that her LMP was 7 weeks ago and that her menses have been normal except for one episode following a spontaneous abortion at 8 weeks of gestation. She states she has a 5-year-old boy and 3-year-old twin girls at home. Which would accurately describe this woman if she is pregnant now? Gravida 4 para 2. Gravida 5 para 3. Gravida 4 para 3. Gravida 3 para 2. History of three pregnancies plus current pregnancy (gravida 4). Parity refers to the number of pregnancies carried to viability, not the number of babies. Two pregnancies were carried past viability (para 2). This formula does not allow for indicating the number of abortions or living children. Answers 2, 3, and 4 are wrong based on the definitions of gravida and parity Be able to determine a woman's obstetric history by defining gravida and para. Use the acronym GTPAL (gravida, term, preterm, abortions, living children). The least appropriate nursing intervention for a client experiencing alcohol withdrawal delirium would be: Reinforcing time, place, and person. Providing consistent and concrete answers to questions. Administering ordered vitamins and glucose. Applying and maintaining physical restraints. The psychological effect of being restrained can be severe. Therefore, any form of restraint should be applied as a last resort. Isolating the client from other clients during the initial adjustment period would serve to decrease stimuli and possibly prevent the need for restraints. Answers 1,2, and 3 are all more appropriate interventions Note key phrase: "least appropriate. The nurse is discussing nutrition in pregnancy with a group of women in the prenatal clinic. Which comment indicates a lack of understanding that requires the nurse's intervention? I'll be drinking six to eight glasses (1500-2000 mL) of water, milk, and juices every day. Since I am overweight, I am maintaining a weight gain of two-thirds of a pound a week during the last 6 months of pregnancy. Since our nutrient needs can't be met through dietary sources, I am taking plenty of vitamin and mineral supplements. Since I am a vegetarian, I am working with a registered dietitian to plan meals with complementary protein combinations. The nurse should find out what "plenty of vitamins and mineral supplements" means. Hypervitaminosis has an adverse effect on the woman's immune system response and fetal development. Answer 1 is not the answer because 1500-2000 mL of fluids per day is recommended. Answer 2 is not the answer because the recommended weight gain, with a good diet, is two-thirds of a pound per week for the last 6 months of pregnancy. Answer 4 is not the answer because a registered dietitian is recommended to assist vegetarian women with complementary protein combinations When a question asks for the answer that requires further teaching because of a lack of understanding on the patient's part, look for the incorrect answer. Review basic nutrient and fluid needs in pregnancy and lactation. Following above-the-knee amputation, a patient verbalizes feelings of decreased self-worth and of being less of a person. Acceptance of the surgery is largely dependent on: What the doctor says. How the patient's family is reacting. How the nursing staff reacts and responds to the patient's behavior. The patient's ability to grieve. The loss of a limb is significant. The patient facing the amputation must deal with self-perception, incorporate the changes in body image, and be allowed to grieve. The nurse must be sensitive to the patient's stage of grieving and provide information as asked for, at a level consistent with the patient's ability to comprehend. Although the attending physician (Answer 1), family (Answer 2), and nursing staff (Answer 3) may affect the patient's perception of a situation, the work of grieving is primarily personal, with movement both forward and backward as the patient progresses through the stages Focus on the patient's needs first. After being in a community mental health day treatment center for 3 weeks, an adolescent client has become apathetic and withdrawn. The client generally sits alone and stares into space. The most appropriate nursing intervention would include: Selecting a group activity for the client to participate in. Stimulating self-growth by providing challenging activities for the client. Allowing the client to spend at least 3 hours a day in the room, for inner reflection. Encouraging staff members to sit with the client during group activities until there is voluntary socialization. The adolescent initially needs the staff's help in one-to- one socialization. The client next must be stimulated by the staff to participate in minimally demanding group activities (Answer 1). Allowing a minimum of 3 hours of isolated behavior (Answer 3) will probably increase the withdrawal. Perhaps the nurse could establish a behavior-modification program involving a trade-off of 15 minutes alone for every 45 minutes spent socializing and interacting with others. If activities are too challenging (Answer 2), the client may become frustrated and feel incompetent, which would lead to a decrease in self-esteem Note key phrase: "most appropriate. The nurse recognizes that the pattern of pulmonary dysfunction reflected by increased total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) is characteristic of: Restrictive lung disease. Obstructive lung disease. Vascular lung disease. A combination of restrictive and obstructive lung disease. Increased lung volumes (TLC, FRC, RV) and decreased airflow—vital capacity (VC) and forced expiratory volume in 1 second (FFV,)—are functional problems consistent with obstructive lung disease. In restrictive lung disease (Answer 1), volumes generally are decreased. Vascular lung disease (Answer 3) has no effect on ventilatory capacity but directly affects diffusion of gases; that is, pulmonary infarction decreases blood flow to the lungs, so some alveoli that are ventilated are no longer perfused. Restrictive lung disease is incorrect (Answer 4) Visualize a lung with increased capacities: hyperinflated, trapped air (COPD). A 15-year-old girl is seen in clinic with complaints of severe vulvovaginal itching, burning on urination, and thin, watery vaginal discharge for the past 4 days. During the history and physical examination, she appears very embarrassed and upset. Looking at the floor, she admits to being sexually active. She says, "Do you think I'm pregnant, or have something awful? How can I tell my mother?" Which nursing diagnosis is least likely to apply in this situation? Anxiety/fear related to the perceived possibility of diagnosis of pregnancy or sexually transmitted disease. Ineffective individual coping related to situational crisis. Self-esteem disturbance related to inability to reconcile expectations of peers and family; situational crisis. Powerlessness related to lifestyle of helplessness. Adolescents rarely demonstrate a lifestyle characterized by helplessness; rather, they are striving to gain control over their own lives. Answer 1 is wrong because the teenager has verbalized anxiety and fear over possible diagnoses. Answer 2 is wrong because the threat of adolescent pregnancy evidently presents a situational crisis for her. Answer 3 is wrong because either diagnosis will provide her with evidence that she failed to meet family expectations, and precipitates situational crisis Pay attention to key phrase: "least likely." A patient, age 25, has been scheduled for surgery to remove the lesions at the footplate of the stapes, associated with otosclerosis. A patient who is scheduled for a stapedectomy should be told to expect: Tinnitus for several weeks after surgery. Rhinitis as the edema from surgery resolves. The hearing loss to continue for a while. Showering and swimming not to be permitted. Stapedectomy is the surgical procedure for the treatment of otosclerosis. Its success cannot be determined in the immediate postoperative period. The patient must be told that hearing is affected for a while after surgery because of edema. Tinnitus (Answer 1) is a postoperative complication that must be reported, but is not expected. The resolution of postoperative edema (Answer 2) does not result in rhinitis. Once the ear has healed, normal activities are permitted, including showering and swimming (Answer 4). With an upper respiratory infection, deep-sea diving and flying are usually restricted Use a process of elimination. Ringing in the ears is never normal, which leaves short-term hearing impairment, given the surgery. A 16-year-old hospitalized in a psychiatric unit for 10 days disappears from the hospital after an argument with a staff member. The client is found walking about a mile from the hospital grounds. In planning care for this client after this incident, the nurse would consider which factor most significant? The client's need to: Be reprimanded for deviant behavior. Re medicated to calm down. Be listened to in order to identify feelings. Understand the consequences of his or her actions. The adolescent client is probably very frightened and angry. The client needs to feel that his side will be considered in order to cope effectively with these feelings and with this behavior. Answers 1,2, and 4 are all staff oriented and provide little psychological support for the client as an individual striving for independence Choose the "most significant" need. The physician orders prednisone, 10 mg every morning, for a patient with rheumatoid arthritis. Which precaution should the nurse advise the patient of during pre-discharge teaching? Take oral preparations of prednisone before meals. Never stop or change the amount of the medication without medical advice. Have periodic complete blood counts while on the medication. Wear sunglasses if exposed to bright light for an extended period of time. In preparing the patient for discharge on prednisone therapy, the nurse should caution him or her to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) never stop or change the amount of medication without medical advice; and (d) store the medication in a light-resistant container. Answer 1 is incorrect because prednisone, as well as other medications given in rheumatoid arthritis therapy, is irritating to the GI tract and should be taken after meals. Answer 3 is incorrect because although fluid, electrolyte, and serum-glucose levels need frequent evaluation during prednisone therapy, CBCs need regular checking if the patient is on phenylbutazone (Butazolidin), oxyphenbuta- zone (Tandearil), or ibuprofen (Motrin) therapy. Answer 4 is a precaution given to patients on hydroxychloroquine S04 (Plaquenil) or chloroquine (Aralen) therapy Think patient safety. The greatest risk is discontinuing or altering dose. External fetal monitor tracings show consistent fetal decelerations of uniform shape, which begin with the contraction and return to baseline as the contraction subsides. What is the correct interpretation of these data? Acute fetal distress. Uteroplacental insufficiency. Umbilical cord compression. Physiological fetal bradycardia. Early decelerations represent the normal fetal response to head compressions during contractions. Answer 1 is wrong because head compression does not cause fetal distress. Answers 2 and 3 are wrong because there are no signs of late or variable decelerations First, decide if this is OK or not OK. Note the word "physiological," which implies an anticipated outcome. You can eliminate options with "insufficiency" and "distress," which mean there is a problem. A woman with active tuberculosis (TB) wants to become pregnant. The nurse knows that further teaching is necessary when the woman states: Pulmonary TB may jeopardize my pregnancy. Spontaneous abortion may occur in one out of five women who are infected. I can get pregnant after I have been free of TB for 6 months. I know that I may not be able to have close contact with my baby until contagion is no longer a problem. Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2 years after she is declared to be free of TB before she should attempt pregnancy. Answer 1 is not the answer because pregnancy may be jeopardized by TB. Answer 2 is not the answer because spontaneous abortion does occur in one of five women who are infected. Answer 4 is not the answer because she will not have close contact with her baby until contagion is no longer a problem The focus of the best answer is not what may occur, but when. The time period is the problem here. The nurse can increase the ventilatory efficiency of a patient with COPD by positioning the patient as follows: High Fowler's. Prone. Sitting up and leaning slightly forward. Trendelenburg. The position that allows for the greatest amount of lung expansion is sitting up and leaning slightly forward. This position can be facilitated by allowing the patient to rest his or her arms on a bedside table. The position that also facilitates lung expansion, but not to the same degree, is high Fowler's (Answer 1). Both the prone position (Answer 2) and the Trendelenburg position (Answer 4) tend to decrease full lung expansion due to increased pressure of abdominal contents on the diaphragm When two options are plausible, choose the most comprehensive (two actions instead of just one). During the adolescent period, the least important task to complete is: Developing an individualized personality. Attaining adequate defense mechanisms. Establishing an ego identity. Refining and stabilizing the superego. The superego may never be completely refined or stabilized. Some individuals may achieve an optimal level of functioning some time in late adulthood; however, rarely will the superego become stabilized during adolescence. As stated in Answer 1, the individual does strive to develop an independent and unique personality during adolescence. To maintain a steady state of functioning, the adolescent must learn to use defense mechanisms (Answer 2) in an appropriate manner. Developing a positive ego identity (Answer 3) is one of the major goals of adolescence Key words: "least important," means eliminate the three options that are age related. The nurse would position a patient with ruptured appendix in: Semi-Fowler's. Trendelenburg. Left Sims'. Dorsal recumbent. The patient is placed in a semi-Fowler's position to promote the flow of drainage to the pelvic region, where a localized abscess can be drained or be resolved by the body's normal defenses. The elevated position also keeps the infection from spreading upward in the peritoneal cavity. Answers 2,3, and 4 are incorrect because none of them elevates the trunk of the body Look for a pattern. Only one choice has the patient sitting up. A woman wants to breastfeed her baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution? Estrogen. Progesterone. Relaxin. Oxytocin. Contraction of the milk ducts and the let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland. Answers 1,2, and 3 are wrong because these hormones have no effect on the let-down reflex or uterine involution Know the hormones responsible for initiation and continuation of lactation. You can also select the correct answer by recalling the hormone involved in uterine involution (also included in the question). A 7-year-old is admitted to the burn unit in serious condition with deep partial-thickness burns over the head, face, neck, and anterior chest. On the first night in the hospital, the nurse enters the room and finds the child crying softly and moaning in pain. Recognizing the extent of the injuries, the nurse should: Do nothing at this time. Offer two acetaminophen (Tylenol) pills as ordered and a glass of warm milk. Give an 1M injection of 40 mg of meperidine HC1 (Demerol) as ordered. Inject 25 mg of meperidine HC1 (Demerol) as ordered via central IV line. The nurse should know that deep partial-thickness (second-degree) burns cause severe pain. The nurse should also know that during the first 48-72 hours after a serious burn, there is a very poor peripheral circulation due to hypovolemia; therefore, medications should be given via the IV route. PO (Answer 2) and IM (Answer 3) medications are generally contraindicated during this time. To do nothing (Answer 1) would be inappropriate, given the nature and extent of the injuries Think impaired peripheral circulation; think IV, not IM; eliminate PO due to burns on face and neck. Suddenly, during a labor contraction, a woman's water breaks. Which assessment finding indicates a deviation from normal labor patterns? Dark-colored amniotic fluid. The woman complains of nausea and vomits. Fetal bradycardia with contractions. The woman becomes diaphoretic and irritable. Normal amniotic fluid is essentially colorless; any color may signify fetal or maternal problems. For example, green amniotic fluid indicates meconium released due to fetal hypoxia; bloody amniotic fluid may indicate abruptio placentae. Answer 2 is wrong because nausea with or without emesis is common in labor, due to physiological stress. Answer 3 is wrong because fetal bradycardia commonly manifests at contraction acme, due to head compression. Answer 4 is wrong because diaphoresis and irritability are signs of transitional phase of labor Choose the answer here that is not normal. Know normal and expected findings (2,3,4), and then identify the one that is not normal. The most important nursing intervention in planning care for a client with increasing symptoms of depression and alcoholism would include: Referring to an alcohol rehabilitation program. Identifying how the client has coped with anxiety in the past. Arranging for inpatient hospitalization. Requesting a prescription for an antidepressant. Past coping mechanisms are important in assessing the client's ability to return to a steady state of functioning. Strengths and weaknesses in the client's ability to rationally assess and cope with feelings need to be explored. Referrals may need to be made (Answer 1), but an initial assessment of the client needs to be completed first. Inpatient hospitalization may be needed (Answer 3); however, the assessment of ability to cope with the situation may assist in identifying whether hospitalization is needed. Obtaining a prescription for an antidepressant at this time (Answer 4) may prove to be detrimental. Even if the client does not decide to over dose, medication without psychological support is generally ineffective Choose an assessment intervention as a most important priority (e.g., "identifying"). What should the nurse recognize as an inappropriate method of treating hyperthyroidism? Subtotal thyroidectomy. Administration of propylthiouracil. Radioiodine therapy. Administration of thyroglobulin. Thyroglobulin (Proloid) is a purified extract of pig thyroid and is used in the treatment of hypothyroidism. Answers 1,2, and 3 are current methods for treating Graves' disease, or hyperthyroidism Key word is "inappropriate," which means select the wrong treatment. Another key term is hyperthyroidism, not hypothyroidism. A pregnant woman returns for a routine visit at 12 weeks of gestation. Which nursing assessment could the nurse use to verify the EDB and estimate uterine/fetal growth? Leopold's maneuvers. Weight-gain pattern. Vital signs and fetal heart tones. Height of the fundus. At 12 weeks of gestation, fundus should be palpable at the pubic symphysis. Answer 1 is wrong because of inability to palpate due to current uterine size and position. Answer 2 is wrong because weight-gain patterns provide no information regarding uterine or fetal growth. Answer 3 is wrong because maternal vital signs are not diagnostic of gestational age or uterine growth, and fetal heart tones may be heard with a Doppler as early as 9-6 weeks Key terms: timing (12 wk gestation) and uterine and fetal growth. Eliminate Answer 1 because it is too early to do; eliminate Answers 2 and 3 because they do not give information about gestation and fetal growth. A teenager has a history of setting fires. These arson attempts may exhibit which behavior? Acting out. Depression. Paranoia. Mania. Acting out is the expression through behavior (rather than through words) of emotions that occur when the client relives or reproduces the feelings, wishes, or conflicts that are operating unconsciously. The client may be feeling frustrated, angry, ambivalent, etc., for numerous reasons, such as conflict between self and parents, a reaction to parents' marital conflicts, sibling rivalry, or frustration due to poor self-esteem. By definition, Answers 2,3, and 4 are incorrect Review definition of acting out. Which statement by the nurse correctly describes a wheeze? A high-pitched musical sound produced by airflow in narrowed bronchioles. Rarely considered pathological. A medium-pitched sonorous sound produced by airflow in obstructed bronchi. A high-pitched crowing sound produced by edema in the trachea. A wheeze is a high-pitched, musical chest sound produced by airflow in narrowed bronchioles. It is primarily an expiratory sound and is always, not rarely (Answer 2), considered pathological. Rhonchi are medium-pitched sonorous sounds (Answer 3) produced by airflow obstruction in larger airways. Stridor is a high-pitched crowing sound (Answer 4) on inspiration and is due to an upper-airway obstruction, such as edema, adhesions, or tracheal hypertrophy Think "wheeze" is a "squeeze"—only v one choice includes narrowing. A 32-year-old client is diagnosed as having a mood disorder. What drug is usually administered in treating such disorders? Lithium (lithium carbonate). Librium (chlordiazepoxide HC1). Prolixin (fluphenazine hydrochloride). Mellaril (thioridazine). Lithium is used to treat affective disorders. Thioridazine (Mellaril) (Answer 4) is a major tranquilizer used to treat schizophrenia. Thioridazine has been used to treat the manic phase of bipolar affective disorders, but it is not the primary drug. Chlordiazepoxide HC1 (Librium) (Answer 2) is a minor tranquilizer used to relieve the mild or moderate anxiety usually associated with affective and somatoform disorders. Fluphenazine HC1 (Prolixin) (Answer 3) is along-acting psychotropic used primarily to treat schizophrenia. It can be administered biweekly in an injection for a long-term effect Review types of common medications for each psychiatric disorder. The primary purpose of the nurse performing passive range-of-motion exercises to an acute rheumatoid arthritis patient's affected limbs is to: Prevent contractures and limited range of motion. Continually evaluate the patient's functional abilities. Assess the patient's pain tolerance. Evaluate the effectiveness of drug therapy. The primary purpose of passive range-of-motion exercises is to prevent contractures and decreased range of motion. Secondarily, passive range-of-motion exercises assist the nurse in evaluating functional abilities (Answer 2), pain tolerance (Answer 3), and the effectiveness of drug therapy (Answer 4) The stem asks for a purpose (goal). Three of the options are nursing actions. A pregnant woman's last menstrual period began on April 3. Which is an accurate estimate of her EDB? January 3. January 10. January 27. December 10. By calculation of EDB using Nagele’ s rule of counting back 3 months and adding 7 days to the date of LMP: 4th month — 3 months = 1st month (January); third day plus 7 days = tenth day; January 6 is her EDB. Answer 1 is wrong because of failure to add 7 days to LMR Answer 3 is wrong because 7 days were subtracted from date of LMR Answer 4 is wrong because of counting back 4 months instead of 3 Mathematical accuracy is the key to the right answer, using Nagele’s rule. Use the formula for calculating the EDB. After 24 hours of hospitalization for a suicide attempt, the client begins to verbalize more and has interacted with other clients on the inpatient psychiatric unit. The nurse should realize that this increase in energy level may indicate that the client: Needs less individual attention. Needs more individual attention. Needs a decrease in antidepressant medications. Is presently motivated to get well. An increase in the client's energy level may provide enough motivation to make another suicide attempt. Gener ally, depressed clients do not kill themselves because their energy level is very low. Therefore, the one-to-one relationship needs to be maintained and stressed at this time. Answers 1,3, and 4 are dangerous assumptions at this time Focus on two contradictory options (less attention vs. more attention); select "more attention. The appropriate nursing action with a patient experiencing expressive aphasia following a CVA would be: Help the patient and family accept this permanent disability. Associate words with physical objects. Wait indefinitely for the patient to verbalize. Tell the family that the patient cannot communicate. The patient needs an opportunity to receive word images. Point to the object and clearly enunciate its name, e.g., "spoon." Also, the patient with expressive aphasia needs the chance to practice repeating words. Begin with simple words, such as yes and no, and then progress to complete phrases. Recovery from aphasia depends on the area of the brain involved and the extent of damage. There may be spontaneous recovery or improvement with speech therapy 2 years after the stroke. To consider the impairment permanent (Answer 1) would be premature. Answer 3 is incorrect because waiting may increase the patient's frustration. Try to anticipate the patient's needs to reduce feelings of helplessness. The nurse plays an important part in showing the family members how to communicate and in not discouraging communication (Answer 4) Only one option shows "action" to improve patient communication. Which action by the nurse would be most helpful in preparing a 5-year-old for cardiac catheterization? Describe the procedure in very simple terms. Take the child to the lab to observe such a procedure. Answer only those questions the child asks. Use puppets to dramatize the procedure for the child. A preschooler would probably respond best to the use of puppets to dramatize the procedure. Any description of the procedure alone (Answer 1), no matter how simple, would probably not be enough to enable most preschoolers to understand what will happen to them. Taking a patient to the operating room or the catheterization lab (Answer 2) would probably be unnecessarily frightening for any patient, especially a child. The child may not ask any questions him self or herself (Answer 3), and if the child does not, the nurse would be unable to do any teaching 3 stage at preschool calls for therapeutic play (i.e., dramatic). Cognitive input is not age appropriate. The number of first-time pregnancies in women between ages 35 and 40 years has increased by 40%. The nurse conducting a parent education class for these women, in the last trimester of pregnancy, should include discussion of: Energy and stamina to meet demands of parenting. Feeling troubled by pregnancy and being less adjusted during the last trimester of pregnancy. The longer labor experienced by older mothers. The greater number of labor/birth complications experienced by older mothers. The nurse needs to address the amount of energy and stamina needed to meet the demands of parenting. Older women have commented that the lack of energy and stamina came as a surprise. Answer 2 is incorrect because older women tend to be less troubled by pregnancy and remain better adjusted during the last trimester. Older mothers, as a group, do not have longer labor (Answer 3), nor, with good prenatal care, do they show a greater number of labor/birth complications (Answer 4) Focus on the general expected concerns for this age group and this trimester. You can eliminate options that focus on "troubled" feelings, "longer labor," "greater number of... complications. The nurse explains to a patient that the colostomy appliance for a double barrel colostomy should be changed: Every day. When drainage leaks through the seal. Once a week. At a time selected by the visiting nurse. Appliance should be changed every 2-3 days or as soon as there is leakage. Drainage can excoriate the skin; therefore, a new appliance needs to be applied as soon as leakage appears. Answer 1 is wrong because every day is too often; there will be damage to the skin from pulling the appliance off so often. Answer 3 is wrong because 1 week is too long for the skin to go without being examined and cleansed. Answer 4 is incorrect; the visiting nurse does not determine when the appliance should be changed Look for a choice that reflects individual differences and patient control. A woman in labor expresses concern about her baby's status. If the nurse identifies the presence of early decelerations, which intervention should be instituted? Elevate the woman's hips, and start oxygen by mask. Lower the head of the bed, and place the woman in supine position. Mark the tracing in red, and check for dislodged electrode. Reassure the woman that this represents a normal tracing. Early decelerations represent the normal fetal response to contractions. Answer 1 is wrong because this action would be taken to relieve possible cord compression. Answer 2 is wrong because use of the Trendelenburg position is not necessary. Answer 3 is an inaccurate interpretation of the assessment data First decide if this is OK or not OK. Because it is OK, choose psychosocial rather than repositioning (1,2) or looking for a problem (3, dislodged electrode). Review the differences and nursing interventions between early, late, and variable decelerations of the FHR. Know expected outcomes and risks of each, and choose appropriate interventions. A patient is scheduled for a temporary colostomy due to severe diverticulitis. Preoperative preparation of this patient includes administration of neomycin S04. The nurse expects that this antibiotic will: Combat postoperative wound infection. Decrease bacterial count of the colon. Reduce the size of the suspected tumor before surgery. Stimulate peristalsis and facilitate action of cleansing enemas. Neomycin sulfate is used preoperatively because it is poorly absorbed in the intestinal tract and acts to decrease the bacteria count in the colon. As the result of this action, postoperative infection is reduced (Answer 1). Neomycin does not reduce tumor size (Answer 3) or directly affect peristalsis (Answer 4) Timing is important (preop) and purpose of drug classification—antibiotic. A 35-year-old person takes an overdose of sleeping pills and alcohol, and is brought to the emergency department in an ambulance called by a neighbor, who discovered the person unconscious on the living room sofa. On admission, the client is unconscious. Vital signs are TPR 98-60-10 and BP 90/50. Reflexes are dull. The emergency department nurse's initial response should include: Administering a central nervous system stimulant. Paging the resident on call. Maintaining a patent airway. Assessing the patient's neurological signs. The first priority with any client who is unconscious is to maintain a patent airway. The nurse would need a physician's order to administer any medication or stimulant (Answer 1), which may not be appropriate in this situation. The emergency department nurse would see that the attending resident was paged (Answer 2), but this task could be delegated while the nurse administered primary care. Monitoring neurological signs (Answer 4) is also essential but can be done after ensuring that the client can breathe Remember the ABCs: airway first. After nebulizer treatment with isoproterenol (Isuprel), the following pulmonary function data were obtained: <br> TLC FRC RV VC FEV, <br> Before treatment 7000 5000 4200 2800 2000 <br> After treatment 7000 4000 3000 3800 2500 <br> The nurse would conclude that the change in lung volumes indicates: Improvement. Deterioration. No change. Data inadequate to decide. Treatment with bronchodilators such as isoproterenol will decrease bronchoconstriction, improving the movement of air in and out of the lungs. Answers 2,3, and 4 are incorrect because these pulmonary function studies indicate that the patient has been able to increase inspiratory capacity by 600 mL (VC 2800-3800) and expiratory capacity (RV decreased, FRC decreased, and FEV, increased) Know vital capacity (VC)—the amount of air in a breath. A vaginal examination disclosed several painful red papules on the inner surfaces of the labia minora and in the vagina. Lesions were extremely painful on gentle touch with an applicator. Discharge had a very foul odor. Inflammatory regional lymph nodes were easily palpated. With which infectious organism are these assessment findings associated? Trichomonas vaginalis. Candida albicans. Herpesvirus type 2. Neisseria gonorrhoeae. Painful, red, papular lesions associated with foul-smelling vaginal discharge are characteristic of herpesvirus type 2 infection. Answer 1 is wrong because discrete lesions do not accompany trichomonal infections; discharge usually is thin, frothy, and gray or yellow-green and usually has a foul odor (like rotting fish). Answer 2 is wrong because monilial vaginal infections produce a characteristic white, cheesy discharge. Answer 4 is wrong because gonorrhea in women is often totally asymptomatic or may produce a purulent vaginal discharge Only by knowing signs and symptom (especially color of discharge) for each infectious lesion will you be able to identify the organism involved. Review causes and treatments for herpesvirus type 2. Know the potential risks during pregnancy and delivery for the fetus/newborn. A 15-year-old in a day treatment center begins to mutilate the forearms with lighted cigarettes and scratch the wrists with thumbtacks and staples found on the unit. What is the least appropriate nursing goal? Supervising closely. Avoiding confrontations regarding this behavior. Removing all items that could be used for destructive purposes. Assisting the teenager to increase self-esteem. Confrontation could help the 15-year-old client identify the inappropriateness of mutilation and other destructive behaviors as attention-getting devices. Answers 1,3, and 4 are all appropriate interventions Note the key phrase: "least appropriate. A woman asks the nurse what makes a pregnancy test "turn positive." The nurse's best response is based on the knowledge that the biological marker for pregnancy tests is: Human placental lactogen. Human chorionic gonadotropin. Luteinizing hormone. Alpha-fetoprotein. Human chorionic gonadotropin (HCG) is the biological marker used in pregnancy tests. This hormone is produced by the fertilized ovum and the chorionic villi and maintains the corpus luteum’ s production of estrogen and progesterone for the first 8-6 weeks of pregnancy. The hormone reaches maximum level at 50-70 days. Answer 1 is incorrect because human placental lactogen is produced by the placenta. Luteinizing hormone (Answer 3) is the primary anterior pituitary hormone during the second "half" of the menstrual cycle. Alpha-fetoprotein (Answer 4) is a biological marker for assessing for open neural tube defects in the fetus Because the HCG is produced by the fertilized ovum; it is the marker for a positive pregnancy. A woman who does not speak English is in active labor, with moderate to strong contractions every 2-3 minutes, lasting 45 seconds. She appears very frightened, By which modality can the nurse convey caring and allay anxiety? Asking her husband to translate all interactions. Touching, smiling, and speaking in a calm, assured voice. Speaking slowly, loudly, and clearly, to facilitate her understanding. Offering to notify the doctor on call. Touch, facial expression, and tone of voice may be used effectively to reduce anxiety, apprehensions, and fear in situations where verbal communication is inhibited by language barriers. Answer 1 is wrong because the continual use of an intermediary (her husband) may impede establishing the rapport necessary for a successful labor experience. Answer 3 is wrong because incomprehensible words become no more understandable if spoken slowly or distinctly; loud voices are disconcerting during labor. Answer 4 is inappropriate because the nurse, not the MD, is there to provide ongoing care and allay anxiety Because she is not verbal (in English), use nonverbal communication. After an adolescent has been in a mental health day treatment center for a year and a half, the professional staff are considering discharging this client. The client asks the nurse whether other people must be told about the time spent in a mental health center. The most appropriate response the nurse could make would be: Yes, especially to all future school officials. Yes, especially to all prospective employers. No, this is an individual decision. No, there is no specific requirement. Although there are several specific forms that elicit disclosure of this information, there is no law that mandates disclosure (Answer 4). The client has to make this decision independently. The nurse should provide therapeutic support for whatever decision. Answers 1 and 2 are untrue statements Note the key phrase "most appropriate"; it provides therapeutic support for patient's decision. A peripheral iridectomy is the surgical procedure of choice following an acute episode of closed-angle glaucoma. Which nursing measure is inappropriate for a patient who has had an iridectomy'? Instill eyedrops to mobilize the affected pupil by alternate dilation and constriction. Ambulate the patient as soon as possible after the surgery. Reinforce the surgical dressing as needed to prevent infection. If ordered, instruct the patient to massage the affected eye. An iridectomy is performed in the upper segment of the iris and is covered by the upper eyelid, as normally. The excision in the iris is occluded, which decreases discomfort. Infection is less likely because bacteria are carried in the tears, by gravity, to the lower cul-de-sac. The need for a dressing is usually indicated, to decrease infection or eye movement. Because infection is nut likely and mobilization of the eye (Answer 1) is desirable to prevent posterior synechiae (adhesion of iris to cornea or lens), no dressing is needed. Answers 2 and 4 are appropriate actions. Massage of the eye, if ordered, encourages continuous flow of fluids through the surgical opening The key word is inappropriate. Although dressings prevent infection, reinforcing the dressing would be necessary for bleeding, which is not indicated. A woman who is pregnant complains of constipation. What should the nurse recommend to relieve her symptoms of constipation? Regular bedtime use of mild laxatives such as mineral oil. Limit fluid intake to 1000 mL daily. Increase dietary intake of fresh fruit and salads. Begin Kegel exercises to increase tone. Increased dietary bulk and adequate fluids relieve symptoms of constipation naturally, by stimulating peristalsis. Answer 1 is wrong because regular use of laxatives reduces normal bowel functions; mineral oil contributes to loss of fat-soluble vitamins A, D, and E. Answer 2 is wrong because adequate fluid intake is needed to avoid dry, packed stools associated with constipation. Answer 4 is wrong because Kegel exercises increase sphincter control and do not encourage defecation Think diet, not laxatives or Kegel exercises. In monitoring the postop course of an adolescent who has had surgery for a ruptured appendix, the nurse would be most correct in expecting that this patient will: Have severe pain for 24 hours. Be discharged within 48 hours. Make a slow, steady recovery. Make a fairly rapid and complete recovery. Adolescents who have had an appendectomy are expected to make a complete, rapid recovery; they should have minimal to moderate pain during the first 24 hours (Answer 1). Discharge time frame varies, not necessarily within 48 hours, or after a slow recovery (Answers 2,3). Consider age-appropriate expected outcome. An adolescent may exhibit depression differently from an adult. An adolescent who is depressed is most likely to exhibit which behavior? Withdrawal. Apathy. Violence. Regression. Hostility and aggression are considered the underlying factors in the psychogenesis and psychodynamics of depression. The adolescent is in a stage of development in which he or she experiences extensive anger due to frustration. The adolescent has a greater energy level because of the increased libidinal energy available in his or her system. To expend this energy, many adolescents act out their feelings of depression in violent ways rather than become withdrawn, apathetic, or regressive (Answers 1,2,4) Choose the option that is different: violence is different from withdrawal, apathy, and regression. The nurse needs to know that the woman likely to be at highest risk for pelvic inflammatory disease (PID) is one who: Uses an intrauterine device (IUD) for contraception. Acquired gonorrhea from a fomite. Has had multiple sex partners. Drinks one alcoholic beverage per day (e.g., glass of wine). PID is more common in women who have multiple sex partners. Answer 1 is incorrect because there is an increased incidence of infection (not PID) in women during the first month after insertion of an IUD. Gonorrhea (Answer 2) can cause PID whether it is acquired through skin-to-skin contact or from a fomite (a fomite is a nonliving material on which disease-producing organisms can be conveyed, e.g., bed linens or washcloths). Answer 4 is incorrect because a pattern of heavy alcohol consumption is associated with certain nutritional deficiencies (e.g., vitamin B complex) that decrease a person's immune responsiveness to vaccines and depress the cell-mediated and humoral lymphocytic activity Think inflamed pelvis from multiple sex partners. Nursing actions that will facilitate a COPD patient's medical therapy include: Limiting fluid intake to prevent volume overload and right-sided heart failure. Oral and endotracheal suctioning as necessary. Instructing the patient in deep breathing and coughing techniques and pursed-lip exhalations. Maintenance of bed rest and activity restrictions to reduce acidosis. Deep breathing, coughing, and pursed-lip exhalations are all techniques that the nurse can teach the patient to improve ventilation. Adequate fluid intake (Answer 1) is essential for keeping sputum liquefied; however, very hot and very cold drinks should be avoided because they may cause bronchospasm. Patients with COPD also need to be taught to avoid exposure to infections, early signs of infection, and the need to seek medical intervention promptly should symptoms occur. Answers 2 and 4 are not indicated in this patient's therapy Look for an option that makes the patient an active participant in the care. When a newborn is nearly 24 hours old, a nursing assessment notes that the infant's skin is dry and flaking and that there are several areas of an apparent macular rash. The nurse charts this as: Erythema toxicum. Milia. Icterus neonatorum. Multiple hemangiomas. Erythema toxicum is the normal, non-pathological macular newborn rash. Answer 2 is wrong because milia are small white nodules due to clogged sebaceous glands. Answer 3 is wrong because icterus neonatorum is the term for normal physiological jaundice of the newborn, which occurs 4R—72 hours after birth. Answer 4 is wrong because hemangiomas are small elevated clusters of capillaries ("stork bites"). The clue to the correct answer is time (24 hours old) and type of rash (macular), not yellow (3) or white (2). What is a reliable index of the exercise tolerance of a patient who has rheumatoid arthritis? Pulse and respiratory rate. Occurrence and duration of pain in the affected joint. Mobility of joints. Decreased redness and swelling of joints. Patients should not be encouraged to do exercises to the point of unusual pain, and pain should not last longer than one-half hour after exercise. If pain lasts longer than this, the exercises are too strenuous. Answer 1 is incorrect because pulse and respiratory rates are affected not only by physical stress but also by emotional and psychological stress. Answers 3 and 4 indicate that therapy has been effective Read the choices. Look for an indication that the exercise was appropriate or excessive. In planning nursing care for a hospitalized client who is suicidal, what is the least appropriate nursing action? Searching personal effects for toxic agents. Removing straps from clothing. Placing the client in small groups for observation. Removing sharp objects from the environment. The client should be placed under one-to-one, not group, observation to ensure effective protection against suicidal behaviors. Answers 1,2, and 4 are all appropriate actions. Note the key phrase: "least appropriate. In positioning a child with burns of the head, face, neck, and anterior chest during recovery, the nurse should: Avoid head flexion. Keep the child as still as possible. Avoid sitting the child up in a chair. Place two firm pillows under the child's head. In positioning the child during recovery, the nurse should avoid those positions in which contractures and flexion deformities may occur. With burns on the neck, the nurse should keep the neck extended and help the child avoid flexing the neck (Answer 4). Keeping the child still (Answer 2) will predispose him or her to complications of immobility. There is no reason why the child cannot sit in a chair (with help as needed) during recovery (Answer 3) Burned tissue should always be positioned in either neutral or extended position for healing, never flexed. A woman in labor, with an interest in using Lamaze for labor and birth, appears lired, tense, and uncomfortable. She complains that her back aches, the monitor "bothers" her, and she wants people to leave her alone and let her rest. Which nursing intervention, implemented by the nurse, demonstrates proper nursing judgment? Offer to get an order for some pain medication. Reposition the woman and apply sacral pressure. Turn monitor off audible reading. Darken room and leave her alone for 5 minutes. The woman is demonstrating signs of beginning transition. Sacral pressure and back rubs assist in reducing her discomfort at this time. Answer 1 is wrong because assessment indicates irritability, not pain. Further, she has expressed a desire to use Lamaze for labor and birth. Answer 3 is wrong because it is important to maintain continual assessment of fetal status during the transitional stage. Answer 4 is wrong because the woman should be attended continually during transition First, you need to recognize the symptoms of transition; therefore, positioning is the best answer. Eliminate the three other options because pain medication is not used as a first intervention when she wants to use "natural childbirth" (i.e., Lamaze). Answers 3 and 4 are contraindicated during transition. A patient's arterial blood gases reveal: pH 7.38, Po2 65, Pco2 55, HCO, 32. The nurse's interpretation of this patient's blood gases is that he or she has: Uncompensated respiratory acidosis. Compensated respiratory acidosis. Uncompensated metabolic alkalosis. Compensated metabolic alkalosis. To read blood gases, first note the pH. In this case, pH is 7.38, which is within the normal range (7.35-7.45) but is on the acidotic side. Next, look at the Pco2 and HCO, to see which one is causing the shift to acidosis. In this case the Pco2 is 55 (acidosis) and the HCO_, is 32 (alkalosis). Therefore, the patient has compensated respiratory acidosis because the kidneys have been able to conserve enough bicarbonate to keep pH within normal range. In this case a pH below 7.35 would indicate uncompensated respiratory acidosis (Answer 1). If the patient had uncompensated metabolic alkalosis (Answer 3), pH would be above 7.45. If the patient had compensated metabolic alkalosis (Answer 4), pH would be between 7.41 and 7.45 Look at each component to determine normal, increased, or decreased. If pH is normal, it has to be compensated. Below 7.4 = acidosis; above 7.4 = alkalosis. An adolescent's parents have decided that they would rather have their child placed outside of the home when discharged from the mental health day treatment center. The most appropriate intervention the nurse could make would include: Asking the parents to reassess their feelings about this decision. Suggesting that the parents discuss this decision with the entire family. Referring the parents to a social worker to assist in finding an alternative placement. Assisting the parents in finding an appropriate discharge placement. Although the adolescent's parents may perceive this as a parental decision, it is important for the entire family to be included in the decision-making process because the entire family system will be affected by this change. Asking the parents to reassess their feelings (Answer 1) may help them evaluate the situation, but it avoids facing the issue as a family decision. A referral may be appropriate (Answers 3,4); however, all parties involved in the decision must be listened to before making a referral or searching for an alternative placement Key phrase: "most appropriate." It is most appropriate to involve the family system in decision making related to an adolescent. Which laboratory test result or parameter(s) would be increased on assessment of a patient with acute rheumatoid arthritis? Hemoglobin and hematocrit. Sedimentation rate and C-reactive protein. Wasserman test result. Platelet count. In rheumatoid arthritis both the erythrocyte sedimentation rate and C-reactive protein levels are increased. Anemia is common, so hemoglobin and hematocrit are usually decreased, not increased (Answer 1). The Wasserman test result (Answer 3) is normally negative. The platelet count (Answer 4) is not affected Only one option measures inflammation. Know appropriate lab tests. Anticipatory guidance may be indicated to help expectant parents achieve the normal develop mental tasks of the beginning family. What is least likely to cause anxiety and stress at 18 weeks of gestation? Economic demands of having a child. Change in intrafamily relationships. Increasing awareness of the need to be responsible for another individual (the baby). Feelings of having to "compete" for attention. During pregnancy, attention is focused on the expectant parents; feelings of competition for attention with the baby arise during the postpartum period. Answer 1 is wrong because pressures of present and anticipated expenses associated with childbearing do impose stress on the family. Answer 2 is wrong because both expectant parents must adjust to changing relationships between themselves and their extended families. Answer 3 is wrong because both parents may experience stress on recognizing the need to be totally responsible for the health and development of a baby and the concomitant need to change their lifestyle to meet those obligations The key is timing: 18 weeks of gestation. Review the normal developmental tasks of pregnancy by trimester, especially the adjustments of the family. The question asks for the hast likely cause, so choose an incorrect answer because these feelings would occur in the postpartum period, not at 18 weeks. The teaching plan for a patient with COPD should emphasize: Smoking and alcohol restrictions. Nutrition, fluid balance, and ways to stop smoking. Vocational rehabilitation programs available in the community. Activity restrictions and pulmonary physiology. Although it is not possible to make a patient stop smoking, the patient should be presented with information about methods used by other people who were successful in stopping. Although most people are aware of the deleterious effects of smoking, patients need to be reminded of the relationship between smoking and their present condition. Fluid intake and nutrition should be discussed and adapted to individual needs. Patients should be able to identify drugs, giving the name, correct dosage, timing, and potential side effects. Alcohol in moderation is not restricted (Answer 1). Vocational rehabilitation should be present as an option but not emphasized (Answer 3). Activities should be encouraged to tolerance (Answer 4) Look for the option that is broadest and encompasses the most areas for teaching. To establish a relationship with a 14-year-old boy who is hospitalized in a private, coed, inpatient mental hospital unit, what would be inappropriate for the nurse to consider? Boys in early adolescence feel threatened by women authority figures. Enforced inactivity will deprive the adolescent of a major avenue for relieving frustration. Impulse control is a major problem for men. Fear and ambivalence will usually dissipate with the passage of time. The passage of time will not help him cope effectively with his feelings of fear and ambivalence. These feelings are a normal part of the maturation process, and only with effective limit setting and psychological support will the adolescent's ability to cope be strengthened. In early adolescence boys generally are intolerant of women authority figures (Answer 1). They perceive these women as a threat to their emerging masculine identity. Adolescents need physical activity to alleviate tension (Answer 2). Men in general have problems dealing with impulse control (Answer 3) and need consistent limits set on their behaviors Note the word "inappropriate" and think of the four options in this question as true or false. It is false that with passage of time, fear and ambivalence will dissipate. When a woman uses Norplant implants for contraception, it is essential for the nurse to discuss the fact that she: Is likely to have breakthrough bleeding. Is not protected against most sexually transmitted diseases. Will be more at risk for endometrial cancer. Is likely to experience some weight loss. Norplant implants do not provide protection against sexually transmitted diseases. Couples should also receive information about the need to use condoms for prevention of transmission of STDs. Answer 1 is incorrect because some women may experience breakthrough bleeding, but many will not. If they do, it usually is only temporary. Answer 3 is incorrect because there is no correlation between use of long-acting Progestin implants and endometrial cancer. Answer 4 is incorrect because women may experience weight gain, usually not weight loss Choose the answer that is the most critical to know about so that she can use protection. Eliminate Answers 3 and 4 because they are theoretically incorrect. A woman who is pregnant states, "I don't feel like myself lately." Further assessment identifies feelings of discomfort due to mood swings, tingling, tender breasts, and fluctuating sexual desire. Which nursing diagnosis is most appropriate? Body image disturbance related to second trimester physiological and psychological adaptations. Altered nutrition, less than body requirements, related to increased need for vitamin B6 during pregnancy. Ineffective individual coping related to perceived need to alter lifestyle, role change. Personal identity disturbance related to introspection and self-focusing. This woman's behavior typifies patterns expressed during the second trimester. Answer 2 is wrong because her symptoms are related both to fluctuating hormone levels and to psychological reevaluation of self and marriage. Answers 3 and 4 are wrong because of the physiological component of her symptoms Look for the expected body image changes related to second-trimester pregnancy, covering both physiological and psychological components. An adolescent client in a mental health day treatment center for depression exhibits frequent outbursts of maladaptive behavior. This client started hitting other clients and even struck a nurse. In assessing this client's behavior, the nurse should consider which fact to be most relevant? Hitting others makes the client feel satisfied because the client is then in control of the situation. Hitting others provides an escape from feelings of hopelessness. Hitting others is a mechanism for alleviating anxiety. Hitting others allows this client to instill fear in others. Hitting others provides the adolescent with an outlet for feelings of hopelessness and despair. Although this behavior may not make a person feel happy or satisfied, it does provide a defense against feeling unhappy. Answers 1,3, and 4 are not primary motivations of this behavior Note the phrase "most relevant" and turn this question into a "true or false." Note a relationship between depression in the stem and hopelessness in Answer 2. Chronic obstructive pulmonary disease can progress to respiratory failure. A patient with emphysema be comes increasingly drowsy, tachypneic, and tachycardia. The nurse should first: Prepare IV aminophylline. Position the patient in high Fowler's. Give 2 liters of 02 per nasal cannula. Administer 60% 02 via mask. Position the conscious patient sitting upright in a supported, forward-leaning position (high Fowler's, orthopneic) to improve ventilation and oxygenation. A calm and reassuring approach will decrease hyperactivity of the patient and oxygen need. Acute respiratory failure is a medical emergency. Aminophylline (Answer 1) is indicated to combat bronchospasm, but it is not an independent nursing action. Low-flow oxygen (2 L) is also administered to the patient in respiratory failure; however, nasal cannulas (Answer 3) do not provide predictable 02 concentrations. A Venturi mask would be more appropriate. Answer 4 is incorrect because the higher concentration of 02 (60%) may lead to respiratory depression unless the patient is maintained on controlled mechanical ventilation Focus on the patient first, then the equipment. A woman who is pregnant complains her nausea is very "bothersome" in the morning, when she must prepare breakfast for her family. Which action should the nurse recommend? Avoid eating before retiring. Drink a glass of fruit juice immediately on rising. Eat one or two soda crackers before rising. Make and eat her breakfast first. Dry soda crackers absorb gastric juices and increase blood sugar, thereby reducing nausea. Answer 1 is wrong because eating before retiring has no effect on morning nausea. Answer 2 is wrong because drinking fruit juice on an empty stomach may increase nausea. Answer 4 is wrong because demands of physical activity may increase nausea Narrow your focus to the two options for what, not when, to eat/drink. One item is a dry food (crackers), the other is liquid (but acidic). Eliminate the acidic liquid because it can be a gastric irritant. A child is to have daily debridement and whirlpool therapy for burns. In cleansing the burns, the nurse would be most correct in selecting sterile: 1.4X4 gauze pads. Cotton balls. Washcloths. Telfa pads. The best topical cleansing material to use in debriding burns are sterile 4X4 gauze pads. Cotton balls (Answer 2) may pull and stick to burned tissue. Washcloths (Answer 3) are too harsh and may damage new healing tissue. Telfa pads (Answer 4) are too smooth and will not cleanse the area as well as gauze pads Think of the most effective texture and eliminate cotton, terrycloth, Telfa. A patient with a history of alcohol abuse is hospitalized after an overdose of sleeping pills. The nurse should be aware that in the first 72 hours following admission to the hospital the patient is most likely to exhibit: Withdrawal delirium. Suspiciousness. Mood swings. The use of coping mechanisms such as reaction formation. Individuals who have used alcohol habitually over an extended time period usually exhibit symptoms of withdrawal delirium when the alcohol intake is severely decreased or curtailed. Answers 2,3, and 4 are less likely reactions Note the phrase "most likely to exhibit" and review signs and symptoms of alcohol withdrawal. A patient has a smoking history of 25 years and a recent episode of 5 days of increased breathlessness. On physical examination, the patient is found to have a barrel chest, medium-pitched crackles, and wheezes in the right upper lobe and both lower lung lobes. The nurse observes that this patient demonstrates the "increased work of breathing" during this acute period by: Increasing the rate and depth of respirations. Increasing diaphragmatic excursion. Using pursed-lip exhalations. Using accessory muscles for ventilation. Indications of respiratory distress and the increased work of breathing in this patient arc characterized by the use of the accessory muscles of respiration, the sternocleidomastoid and trapezius muscles. Using these muscles enables the patient to increase the size of the thorax, thus allowing air to move in. Patients with chronic bronchitis and air trapping generally are not able to increase the depth of breathing (Answer 1) by increasing diaphragmatic excursion (Answer 2). Some patients may be using pursed-lip exhalations (Answer 3), but these help maintain open airways for the expulsion of gases Visualize the patient. If the patient was "working" to take in a breath, what would you see? A woman who is pregnant complains of severe "charley horses" during the night. Which action should the nurse recommend to provide symptomatic relief? Drink a glass of milk at bedtime. Extend affected leg and dorsiflex the foot. Increase dietary intake of vitamin C. Mild exercise every evening, such as walking. Charley horse pain (cramp in gastrocnemius muscle) is due to sudden spasm and acute flexion of leg muscles; it is relieved by dorsiflexing the foot, which reduces the muscle spasm. Answer 1 is wrong because such action will not eliminate the possibility of muscle spasm during pregnancy. Answer 3 is wrong because the actions of vitamin C do not affect muscle spasms. Answer 4 is wrong because exercise does not prevent muscle spasm Key concept is timing. Choose the option that can produce on-the-spot symptomatic relief (key words in the item). Two days before above-the-knee amputation, an adult patient expresses a desire to learn more about the surgery and outcome. Preoperative teaching is directed toward: Discussing the possibility of another vocation. Learning crutch walking. Instruction in postoperative exercises. Encouraging the patient to verbalize fears and concerns. Although the patient expresses a willingness to learn, apprehension will limit the ability to assimilate much. The patient must be taught specific arm and leg exercises, including frequent repositioning onto the abdomen to prevent contracture. Before discharge, alternative vocational pursuits (Answer 1) may be discussed, as indicated. In the postoperative period the focus changes to crutch walking (Answer 2). Encouraging the patient to verbalize fears and concerns (Answer 4) is not a specific teaching strategy but rather an intervention designed to give support, as well as identify potential problems The stem says "learn;" therefore something to teach before surgery is the best choice. A 14-year-old boy with a history of setting fires has developed a homosexual relationship with a 16-year-old boy. In planning care, the nurse should primarily: Avoid confronting him about attention-getting behavior. Validate his rationale for establishing the relationship. Explore his thoughts, feelings, and attitudes. Enforce limits on interactions between the two patients. His thoughts, feelings, and attitudes toward sexual relationships need to be explored to assess his level of maturity in deciding his sexual preference. Confrontation, rather than avoidance of confrontation (Answer 1), could help him identify his use of homosexual behavior as an attention-seeking device. Validation of his rationale for seeking homosexual relationships (Answer 2) may be identified more appropriately through exploring his thoughts, feelings, and attitudes regarding his sexual orientation. Enforcing limits on his relationships (Answer 4) will only make him angry and is in any case an invasion of his right to privacy and freedom of choice. As long as neither client is forcing himself on the other, their relationship should not be interfered with. However, if it is determined that for some appropriate reason this relationship is detrimental to either individual's optimal level of functioning, limits should be set Focus on the phrase "primary concern," which calls for exploring thoughts, feelings, and attitudes. A male adolescent (age 15) complains of having nothing to do while he is recovering from an appendectomy. The nurse should: Ask him to place routine lab slips in the charts. Refer him to the tutor and arrange for him to get his school books and homework. Bring in several board games, and encourage him and his 14-year-old roommate to start playing with one of them. Introduce him to the two 15-year-old girls in the room next door. A male adolescent will most likely prefer the companionship of another boy close to his age. Although he may be interested in girls (Answer 4), being introduced to them would not necessarily prove helpful for him. Adolescents cannot be relied on to place materials into hospital charts (Answer 1). Because his recovery is expected to be rapid and complete, he will miss little school, and there is no need to get him involved with in-hospital tutoring (Answer 2); he can easily catch up with his schoolwork when he gets home Remember age-relevant 3 stage: socialization with peers is the most important social influence for the adolescent. Health teaching for a woman infected with herpes simplex 2 should include: Abstain from intercourse until lesions heal. Penicillin is the drug of choice for treatment. Therapy is curative. The organism is associated with later development of hydatidiform mole. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one's sexual partner. Answer 2 is wrong because the current drug of choice is acyclovir (Zovirax). Answer 3 is wrong because currently available therapy is only palliative; the virus remains in the body after symptoms subside. Answer 4 is wrong because hydatidiform mole has a genetic basis Look for the option that reduces chances of transmission of herpes simplex 2. Which statement by the nurse correctly describes a double-barrel colostomy? It is the least common type of colostomy, and it discharges liquid or unformed stool. A single loop of the transverse colon is exteriorized and supported by a glass rod. There are two openings, a proximal loop and a distal loop. It has two stomas. A proximal loop discharges feces, and a distal loop discharges mucus. It is most often permanent and is done to treat disorders of the sigmoid colon. A double-barrel colostomy has two stomas that may or may not be separated by skin. The proximal loop discharges feces, and the distal loop discharges mucus. The closure of this temporary colostomy usually occurs in approximately 6 months. Answer 1 is an example of an ascending colostomy, Answer 2 describes a transverse loop colostomy, and Answer 4 describes a descending colostomy Visualize two gun barrels. Which option describes two round openings? When administering lithium to a client with a mood disorder, what is the least relevant consideration? If the client's urinary output decreases significantly, diuretics should be ordered. The client must be given a complete physical examination before administering the drug. If the client experiences nausea, vomiting, and muscle weakness, the dosage may require regulating. If the client exhibits symptoms of mania during the first 10 days of receiving the drug, haloperidol (Haldol) may also be administered. Lithium is excreted through the kidneys. Consequently, the kidneys must function adequately to avoid lithium toxicity. Diuretics should not be given concurrently with lithium because they may potentiate sodium and fluid depletion, which may lead to lithium toxicity. Haloperidol (Haldol) (Answer 4) is a major tranquilizer that is sometimes administered simultaneously with lithium during the first week to 10 days to control manic symptoms. Nausea, vomiting, and muscle weakness (Answer 3) are all possible side effects of lithium. They indicate a need for close observation and regulation of the drug if they disrupt the person's level of functioning. Every client should be screened before the administration of any medication (Answer 2). However, because lithium is a drug that is taken over a long period of time, blood levels must be consistently regulated and physical examinations routinely scheduled (every 3 months initially, then every 6 months once the client appears to be regulated) Note the phrase "least relevant" and turn this into a "true or false" question. Know that lithium is a salt depleter; therefore, diuretics should not be given. A woman in labor suddenly screams and shouts in Spanish. Her husband translates that she has a "terrible pain in her calf," a charley horse. What should the nurse do immediately? Inform the doctor that the woman has signs of abruptio placentae. Administer oxygen by mask to expedite conversion of muscle lactic acid. Straighten the woman's knee and dorsiflex her foot. Turn the woman on her left side to increase placental perfusion. Sudden spasm and extreme flexion of the calf muscles are relieved by forcibly extending the muscle by hyperextension of the knee and dorsiflexion of the foot. Answer 1 is wrong because her complaint is due to muscle spasm. Answer 2 is wrong because relief is accomplished by stretching the muscle; the pain is not due to lowered levels of oxygen in the muscle. Answer 4 is wrong because increasing placental perfusion will be ineffective in relieving the muscle spasm Because the complaint is the leg, the best answer is an intervention that deals with the leg, for immediate symptom relief. A 7-year-old child is fitted for a pressure stockinette to cover her head, face, and neck to minimize scarring as her burns are healing. To help the child cope with her injuries, treatment, and recuperation, die nurse should ask her parents to bring: Her favorite toys and stuffed animals. Some of her friends for a short visit. Her favorite foods, including pizza and ice cream. Colorful scarves and hats. To help the child cope with body image changes associated with her burns, the nurse should work with her parents to help her with her physical appearance. Colorful scarves and hats will cover her hairless scalp and pressure stockinette, making her look more like other school-age children. It may also boost her morale. Stuffed animals (Answer 1) may harbor bacteria and be a possible source of infection. Her friends (Answer 2) will probably not be allowed to visit in the hospital, especially in the burn unit, which is a frightening place for most children. They can call her or send cards and pictures instead; they can visit her when she returns home. Favorite foods (Answer 3) will not specifically help the child cope with her injuries and treatment; therefore, this is not a good choice Think body image concerns that are age typical for school-age children, who are influenced by their peers and usually want to "fit in. A 14-year-old boy is likely to experience several biological and psychosocial changes at this time. Which behavior would the nurse expect to see? An increase in imaginative thinking. An increased ability to learn by rote. An increase in academic achievement. An increased ability to cope with frustration. Adolescents are preoccupied with their changing bodies, their relationships, and their fantasies. Although they have difficulty with rote learning (Answer 2), they have an increased potential for imaginative thinking. During this period they are less able to concentrate on their academic work (Answer 3), which leads to increased feelings of frustration that are usually not accompanied by an increased ability to cope (Answer 4) Know age-appropriate behavior. The nursing goal for a non English speaking woman who has just given birth is demonstration of confidence and competence in caring for her newborn. Which modality will be most effective in facilitating and evaluating her achievement of this goal? Giving her a booklet in her language, describing basic techniques of baby care. Discussing the pattern and procedure of basic newborn care with her. Demonstrating basic baby care procedures and having her perform them with her husband. Referring her to the public health department nurses in her community. Assisting the mother to develop basic skills in infant care under comfortable professional supervision is the most effective way of increasing a woman's confidence and competence in caring for her infant. Answer 1 is wrong because although the booklet is a helpful adjunct to teaching, skills are most effectively gained by actual experience. Note: Always sensitively assess her ability to read. Answer 2 is wrong because clear, meaningful communication is inhibited by the language barrier, and actual experience in providing care will be of most assistance to her. Answer 4 is wrong because basic infant care techniques should be mastered before the mother leaves the hospital with her newborn Note the use of the word "demonstration" in the stem and in the correct option (3). The best answer is a nonverbal, hands-on activity. The nurse identifies methods to reduce flatus and odor for a patient with a double-barrel colostomy. What would be the least effective method to achieve this? Avoid eating broccoli and cabbage. Use Banish deodorant drops in bottom of appliance. Put pinhole in appliance to let flatus escape. Empty feces and gas from appliance as necessary. Putting a pinhole in the appliance is the least effective method because it allows flatus to escape immediately and the patient has no control. Answer 1 is incorrect because foods that cause increased flatus, such as cabbage and broccoli, should be avoided. Answer 2 is incorrect because any deodorant that is safe for mucous membranes can be used, or the patient can purchase appliances that have an odor barrier. Answer 4 is incorrect because emptying the appliance does protect the seal in that extra weight from a full pouch will pull at a seal; once the seal is broken, odor can escape The stem says "least" effective; one option does not reduce the gas problem, it just releases the gas. A woman in labor says, "I can't stand it any longer. I have to push." On vaginal examination, her cervix has dilated to S cm and the head is at station 0. For which reason should the nurse encourage this woman to pant, or breathe naturally, with her contractions? Pushing now could cause the cord to prolapse. She should increase her oxygen level before completion of the first stage. Pushing before complete dilation may cause cervical edema and may prolong labor. Panting will speed cervical dilation. Pushing on an incompletely dilated cervix may contribute to development of cervical edema and/or or lacerations. Answer 1 is wrong because an engaged head occludes the cervix. Neither panting nor normal breathing increases oxygen level (Answer 2). Answer 4 is wrong because breathing patterns do not affect cervical dilation Key information in the stem: head at station 0 (eliminates 1) and 8 cm dilation (incomplete dilation; same as "before complete dilation" in the correct option 3). Focus on "normal"; focus on the time element (first trimester). Pulmonary function data were collected on a patient. The results were: <br> TLC FRC RV VC FEV, <br> Predicted 6000 3000 2000 4000 3000 <br> Observed 7000 5000 4200 2800 2000 <br> The nurse's analysis of these data reveals: Hyperinflation. Hyperventilation. Hyperpnea. Hypercapnia. The observed total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) are all increased over expected values. These values indicate that the patient is hyperinflated, a common phenomenon with air obstruction and air trapping. Hyperventilation is characterized by an increase in Po, and pH (Answer 2). Hyperpnea is simply an increase in respiratory rate (Answer 3). Hypercapnia is identified when Pco2 is elevated (Answer 4) Look at the total capacity (TLC). Visualize a balloon—hyperinflated. The nurse should teach the parents of a child with lice that to prevent other members of the family from getting lice: The child should sleep alone and in her or his own bed. All family members should get a very short haircut. The child should wear a hair net for a few days. All family members should comb their hair with a fine-toothed comb after regular shampooing. Lice are spread by direct or indirect contact; the child should sleep alone to prevent other family members from also getting lice. In addition, the family should be taught to wash the linens in hot soapy water to kill any lice that are on them. Having the family all get short haircuts (Answer 2) or use a fine-toothed comb (Answer 4), or having the child wear a hair net (Answer 3), would not necessarily prevent the other family members from getting lice The focus is on what the child needs to do to prevent the spread, not the unaffected family members. An 18-year-old with acting-out behaviors has been living in a group home for the past 2 months. The patient has asked permission to visit a friend in the psychiatric hospital. The nurse should: Allow the patient to visit. Assess the patient's motives. Ask parents' permission. Consult with the hospital staff. The 18-year-old may have valid reasons for wanting to visit a friend, but allowing the patient to visit without assessing motives (Answer 1) may prove detrimental to the patient, to the friend, and to the staff. The parents (Answer 3) essentially relinquished their decision-making authority by allowing their child to live in the group home. The hospital staff would have to be consulted before the visit, regardless of the patient's motive. However, Answer 4 is too vague, in that it does not specify what issues would be covered in the consultation Key word: "assess," the first step of the nursing process. Which nursing intervention should be implemented to reduce a pregnant woman's stress in the first trimester regarding her feelings about mood swings, tingling, tender breasts, and fluctuating sexual desire? Validate normalcy of emotional lability. Recommend high-protein, high-vitamin diet. Refer her to a psychologist for counseling. Reinforce positive feelings about the pregnancy. Understanding the reasons for disconcerting symptoms and receiving assurance of their normalcy assist in coping. Answer 2 is wrong because although diet may improve the general sense of well-being, diet will not affect feelings generated by the developmental tasks of pregnancy. Answer 3 is wrong because the woman is demonstrating normal behavioral changes associated with the first trimester of pregnancy. Answer 4 is wrong because it does not address the problem Because these are normal physiological and psychological changes that are expected during the first trimester of pregnancy, choose the answer that says these are normal. A complication of chronic obstructive pulmonary disease is the possible rupture of an emphysematous bleb. The nurse suspects that the patient has a right tension pneumothorax. What signs would the nurse expect to see? Flushed appearance from elevated blood pressure. Tracheal deviation to the unaffected side. Hypo resonance on the affected side. Medial shift of the heart. Indications of mediastinal shift and tension pneumothorax include cyanosis, severe dyspnea, and deviation of the trachea and larynx from the normal midline position toward the side of the chest opposite the pneumothorax (the unaffected side). Because no blood is available for cardiac output, the blood pressure is absent, not elevated (Answer 1). Answer 3 is incorrect because the lung has collapsed on the affected side, resulting in tympany on percussion, reduced or absent breath sounds, and hyperresonance. With a right tension pneumothorax, the heart will shift laterally from the normal midclavicular line. If the left lung were involved, the heart would shift medially (Answer 4) Define the key problem: pneumo (air) thorax (chest cavity)—pushing on left lung. What would deviate? A 15-year-old's behavior is becoming increasingly combative. The teenager hits other clients and the nursing staff at least once or twice each day. What is an inappropriate nursing goal? Help the teenager: Develop impulse control. Manage feelings appropriately. Learn socially acceptable behavior. Internalize feelings. It is important for the client who is angry to express feelings overtly. Internalizing them would cause increased feelings of frustration and anxiety and would therefore be counterproductive. Answers 1, 2, and 3 are all appropriate goals The question asks for an inappropriate nursing goal. To reduce symptoms of early morning stiffness in a patient who has rheumatoid arthritis, the nurse can encourage the patient to: Take a hot tub bath or shower in the morning. Put joints through passive ROM before trying to move them actively. Sleep with a hot pad. Take two aspirins before arising, and wait 15 minutes before attempting locomotion. A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some patients state that cold decreases localized pain, particularly during acute attacks. Passive ROM exercises (Answer 2) may be helpful, but this is not the response of choice because they cannot be done by the patient. Sleeping with a hot pad (Answer 3) may cause localized injury. Some patients, however, have found electric blankets helpful in reducing early morning stiffness. Taking salicylates on an empty stomach (Answer 4) may increase gastric irritation and distress Look for nonpharmacological actions that address the immediate need.