- (Topic 3)
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, ??This is too much trouble. I would rather just have a Foley.???? An appropriate response for the RN teaching him would be:
Correct Answer:A
(A) This response acknowledges the client??s feelings, gives him factual information, and acknowledges that the final decision is his. (B) This response is judgmental and discourages the client from expressing his feelings about the procedure. (C) Catheterization is a procedure thattakes time to learn, but which, for the spinal cord–injured client, can significantly reduce the incidence of urinary tract infections. A young client with a T-4 injury has the hand function to learn this procedure fairly easily. (D) The final decision about bladder elimination management ultimately rests with the client and not the physician.
- (Topic 5)
A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
Correct Answer:A
(A) Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. (B) Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. (C) The limb has been immobilized already by the cast, and therefore immobilization is not a concern. (D) Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.
- (Topic 1)
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
Correct Answer:D
(A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
- (Topic 3)
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
Correct Answer:A
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.
- (Topic 3)
A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?
Correct Answer:B
(A) Anger is an emotion that is not necessarily present in schizophrenia. (B) Lack of response to or involvement with environment and distancing are characteristic of schizophrenia. (C) Euphoria is more characteristic of manic-depressive disorder (bipolar disorder). (D) Hostility is an emotion that is not necessarily present in schizophrenia.