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QUIZ # 3 (150 ITEMS) answer 1. Answer C. When obtaining the history of a patient who may be in labor, the nurses highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons. 2. Answer B. During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of patients labor. 3. Answer A. Blurred vision of other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses. 4. Answer B. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects. 5. Answer C. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle is not significant. Breast tenderness and mittelschmerz are not reliable indicators of ovulation. 6. Answer A. An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldnt allow accurate comparison of fetal movement and FHR changes. 7. Answer B. Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. 8. Answer B. Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-feeding after surgery is possible. Still, its good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mothers ability to meet all of her babys nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the clients psychological adaptation to mothering may be dependent on how successfully she breast feeds. 9. Answer B. Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.

10. Answer B. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy. 11. Answer C. Fetal station the relationship of the fetal presenting part to the maternal ischial spines is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as 1, 2, or 3. A presenting part below the ischial spines, as +1, +2, or +3. 12. Answer D. Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby whos smacking his lips isnt well attached and can injure the mothers nipples. 13. Answer D. Ultrasound is used between 18 and 40 weeks gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the third trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 weeks gestation to detect genetic disease. Fetoscopy is done at approximately 18 weeks gestation to observe t he fetus directly and obtain a skin or blood sample. 14. Answer C. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isnt in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isnt within normal limits. 15. Answer C. During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. The type of anesthesia planned doesnt reflect the clients preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes. 16. Answer B. This question requires an understanding of station as part of the intrapartal assessment process. Based on the clients assessment findings, this client is ready for delivery, which is the nurses top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery. 17. Answer A. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the clients position from supine to side-lying may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the womans position and relieve cord compression. 18. Answer A. Hemorrhage jeopardizes the clients oxygen supply the first priority among human physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for infection, Pain, and Urinary retention. 19. Answer A. Lactation is an example of a progressive physiological change that occurs during the postpartum period.

20. Answer B. The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruption placentae. 21. Answer D. For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until 32 weeks gestation and twice a week to assess fetal well-being. 22. Answer A. The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper stimulated neurologic system by interfering with signal transmission at the neuromascular junction. 23. Answer B. The blastocyst takes approximately 1 week to travel to the uterus for implantation. 24. Answer A. An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieves pressure on the rectum. Tearing may still occur. 25. Answer D. The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the clients cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the clients care. 26. Answer B. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccines toxic effects to the fetus. 27. Answer D. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. 28. Answer A. In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids. 29. Answer A. When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the clients statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques. 30. Answer A. Using both hands to assess the fundus is useful for the prevention of uterine inversion. 31. Answer: (C) Country Club Management Country club management style puts concern for the staff as number one priority at the expense of the delivery of services. He/she runs the department just like a country club where every one is happy including the manager. 32. Answer: (C) Servant leader Servant leaders are open-minded, listen deeply, try to fully understand others and not being judgmental 33. Answer: (A) Possesses inspirational quality that makes followers gets attracted of him and regards him with reverence

Charismatic leaders make the followers feel at ease in their presence. They feel that they are in good hands whenever the leader is around. 34. Answer: (C) Assessment of personal traits is a reliable tool for predicting a managers potential. It is not conclusive that certain qualities of a person would make him become a good manager. It can only predict a managers potential of becoming a good one. 35. Answer: (A) Recognizes staff for going beyond expectations by giving them citations Path Goal theory according to House and associates rewards good performance so that others would do the same 36. Answer: (C) Great Man Leaders become leaders because of their birth right. This is also called Genetic theory or the Aristotelian theory 37. Answer: (C) Laissez faire Laissez faire leadership is preferred when the followers know what to do and are experts in the field. This leadership style is relationship-oriented rather than task-centered. 38. Answer: (D) Leadership is shared at the point of care. Shared governance allows the staff nurses to have the authority, responsibility and accountability for their own practice. 39. Answer: (D) Inspires others with vision Inspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit. 40. Answer: (A) Have condescending trust and confidence in their subordinates Benevolent-authoritative managers pretentiously show their trust and confidence to their followers 41. Answer: (A) Call for a staff meeting and take this up in the agenda. This will allow for the participation of every staff in the unit. If they contribute to the solutions of the problem, they will own the solutions; hence the chance for compliance would be greater. 42. Answer: (C) Low morale of staff in her unit Low morale of staff is an internal factor that affects only the unit. All the rest of the options emanate from the top executive or from outside the institution. 43. Answer: (B) Majority rule Majority rule involves dividing the house and the highest vote wins.1/2 + 1 is a majority. 44. Answer: (B) system used to deliver care A system used to deliver care. In the 70s it was termed as methods of patient assignment; in the early 80s it was called modalities of patient care then patterns of nursing care in the 90s until recently authors called it nursing care systems. 45. Answer: (A) Concentrates on tasks and activities Functional nursing is focused on tasks and activities and not on the holistic care of the patients 46. Answer: (A) Psychological and sociological needs are emphasized. When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as tasks to be done 47. Answer: (A) Assessing nursing needs and problems This option follows the framework of the nursing process at the same time applies the management process of planning, organizing, directing and controlling 48. Answer: (B) Preparing a nursing care plan in collaboration with the patient The best source of information about the priority needs of the patient is the patient himself. Hence

using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively. 49. Answer: (D) Patients who need the most care In setting priorities for a group of patients, those who need the most care should be number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care ca be attended to later or even delegated to assistive personnel according to rules on delegation. 50. Answer: (C) Integrate the solutions to his day-to-day activities Integrate the solutions to his day-to-day activities is expected to happen during the third stage of change when the change agent incorporate the selected solutions to his system and begins to create a change. 51. Answer: (C) Focuses on routine tasks Strategic planning involves options A, B and D except C which is attributed to operational planning 52. Answer: (A) The Good Shepherd Medical Center is a trendsetter in tertiary health care in the Philippines in the next five years A vision refers to what the institution wants to become within a particular period of time. 53. Answer: (B) Goal B 54. Answer: (C) Broken line This is a staff relationship hence it is depicted by a broken line in the organizational structure 55. Answer: (C) Unity of command The principle of unity of command means that employees should receive orders coming from only one manager and not from two managers. This averts the possibility of sowing confusion among the members of the organization 56. Answer: (B) Hierarchy Hierarchy refers to the pattern of reporting or the formal line of authority in an organizational structure. 57. Answer: (B) Unity of direction Unity of direction means having one goal or one objective for the team to pursue; hence all members of the organization should put their efforts together towards the attainment of their common goal or objective. 58. Answer: (A) Lets work together in harmony; we need to be supportive of one another The principle of esprit d corps refers to promoting harmony in the workplace, which is essential in maintaining a climate conducive to work. 59. Answer: (A) Increase the patient satisfaction rate Goal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which are aimed at specific end. 60. Answer: (D) Organizational culture An organizational culture refers to the way the members of the organization think together and do things around them together. Its their way of life in that organization 61. Stephanie is a new Staff Educator of a private tertiary hospital. She conducts orientation among new staff nurses in her department. Joseph, one of the new staff nurses, wants to understand the channel of communication, span of control and lines of communication. Which of the following will provide this information? 62. Answer: (A) Organizational structure Organizational structure provides information on the channel of authority, i.e., who reports to whom and with what authority; the number of people who directly reports to the various levels of hierarchy and the lines of communication whether line or staff.

63. Answer: (B) Informal This is usually not published and oftentimes concealed. 64. Answer: (D) Tall organization Tall organizations are highly centralized organizations where decision making is centered on one authority level. 65. Answer: (A) 1 & 2 Centralized organizations are needs only a few managers hence they are less expensive and easier to manage 66. Answer: (C) having legitimate right to act Authority is a legitimate or official right to give command. This is an officially sanctioned responsibility 67. Answer: (B) Provide a pair of hands to other units as needed Providing a pair of hands for other units is not a purpose in doing an effective staffing process. This is a function of a staffing coordinator at a centralized model. 68. Answer: (D) Staff preferences Staff preferences should be the least priority in formulating objectives of nursing care. Individual preferences should be subordinate to the interest of the patients. 69. Answer: (A) Uses visioning as the essence of leadership. Transformational leadership relies heavily on visioning as the core of leadership. 70. Answer: (C) Team management Team management has a high concern for services and high concern for staff. 71. D. An interpreter will enable the nurse to better assess the clients problems and concerns. Nonverbal communication is important; however for the nurse to fully determine the clients problems and concerns, the assistance of an interpreter is essential. The use of symbolic pictures and universal phrases may assist the nurse in understanding the basic needs of the client; however these are insufficient to assess the client with a psychiatric problem. 72. D. Psychoanalytic is based on Freuds beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other. Behavioral cognitive and interpersonal theories do not emphasize unconscious conflicts as the basis for symptomatic behavior. 73. D. By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety. In option A, the nurse is offering an interpretation that may or may not be accurate; the nurse is also asking a question that may be answered by a yes or no response, which is not therapeutic. In option B, the nurse is intervening before accurately assessing the problem. Option C, which also encourages a yes or no response, avoids focusing on the clients anxiety, which is the reason for his pacing. 74. A. A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the clients attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable. The remaining answer choices will increase the clients anxiety and therefore are inappropriate. 75. A. Education and work history would have the least significance in relation to the clients sexual problem. Age, health status, physical attributes and relationship issues have great influence on sexual expression. 76. C. Inpatient treatment of a client with anorexia usually focuses initially on establishing a plan for refeeding to combat the effects of self-induced starvation. Refeeding is accomplished through behavioral therapy, which uses a system of rewards and reinforcements to assist in establishing weight restoration. Emphasizing nutrition and teaching the client about the long-term physical consequences of anorexia maybe appropriate at a later time

in the treatment program. The nurse needs to assess the clients mealtime behavior continually to evaluate treatment effectiveness. 77. A. One of the core issues concerning the family of a client with anorexia is control. The familys acceptance of the clients ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addressed in these responses. 78. D. The client with a somatoform disorder displaces anxiety onto physical symptoms. The ability to express anxiety verbally indicates a positive change toward improved health. The remaining responses do not indicate any positive change toward increased coping with anxiety. 79. C. Directly questioning a client about suicide is important to determine suicide risk. The client may not bring up this subject for several reasons, including guilt regarding suicide, wishing not to be discovered, and his lack of trust in staff. Behavioral cues are important, but direct questioning is essential to determine suicide risk. Indirect questions convey to the client that the nurse is not comfortable with the subject of suicide and, therefore, the client may be reluctant to discuss the topic. 80. C. A client exhibiting flight of ideas typically has a continuous speech flow and jumps from one topic to another. Speaking in coherent sentences is an indicator that the clients concentration has improved and his thoughts are no longer racing. The remaining options do not relate directly to the stated nursing diagnosis. 81. C. The nurse should take any nurse statements indicating suicidal thoughts seriously and further assess for other risk factors. The remaining diagnoses fail to address the seriousness of the clients statement. 82. D. This statement provides accurate information and an element of hope for the family of a schizophrenic client. Although the remaining statements are true, they do not provide the empathic response the family needs after just learning about the diagnosis. These facts can become part of the ongoing teaching. 83. A. A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events. The client with a distorted perception of the environment would not necessarily have impairments affecting hygiene and grooming skills. Although taking medications and participating in unit activities may be appropriate outcomes for nursing intervention, these responses are not related to client perceptions. 84. D. A client with these symptoms would have poor impulse control and would therefore be prone to actingout behavior that may be harmful to either himself or others. All of the remaining nursing diagnoses may apply to the client with mania; however, the priority diagnosis would be risk for violence. 85. C. Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems. None of the remaining defense mechanisms involves making excuses for behaviors. 86. B. Physical aggressiveness, low stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders. Restlessness, short attention span, and hyperactivity are typical behaviors in a client with attention deficit hyperactivity disorder. Deterioration in social functioning, excessive anxiety and worry and bizarre behaviors are typical in schizophrenic disorders. Sadness, poor appetite, sleeplessness, and loss of interest in activities are behaviors commonly seen in depressive disorders. 87. B. Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. There is no evidence to support any of the remaining answer choices. 88. D. Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. The nurse will also need to preserve the clients privacy and identify the extent of injury. However, it is essential that the nurse follow legal and agency guidelines for preserving evidence. Identifying the assailant is the job of law enforcement, not the nurse.

89. D. Socioeconomic status is not a reliable predictor of abuse in the home, so it would be the least important consideration in deciding issues of safety for the victim of family violence. The availability of appropriate community shelters and the ability of the nonabusing caretaker to intervene on the clients behalf are important factors when making safety decisions. The clients response to possible relocation (if the client is a competent adult) would be the most important factor to consider; feelings of empowerment and being treated as a competent person can help a client feel less like a victim. 90. A. In the early stage of Alzheimers disease, complex tasks (such as balancing a checkbook) would be the first cognitive deficit to occur. The loss of self-care ability, problems with relating to family members, and difficulty remembering ones own name are all areas of cognitive decline that occur later in the disease process. 91. C. The client with Alzheimers disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the clients attention. An over stimulating environment may cause the labile mood, which will be difficult for the client to understand. The client with Alzheimers disease loses the cognitive ability to respond to either humor or logic. The client lacks any insight into his or her own behavior and therefore will be unaware of any causative factors. 92. A. A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimers disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimers disease. 93. C. The most important factors to determine in this situations are the clients perception of the crisis event and the availability of support (including family and friends) to provide basic needs. Although the nurse should assess the other factors, they are not as essential as determining why the client considers this a crisis and whether he can meet his present needs. 94. D. Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning. The remaining answer choices are not considered the primary outcome of crisis intervention, although they may occur as a side benefit. 95. B. Increased anxiety and uncertainly characterize the initiation phase in group therapy. Group members are more self-reliant during the working and termination phases. 96. A. As the group progresses into the working phase, group members assume more responsibility for the group. The leader becomes more of a facilitator. Comments about behavior in a group are indicators that the group is active and involved. The remaining answer choices would indicate the group progress has not advanced to the working phase. 97. C. The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium. Concurrent use of any of the remaining medications will not increase the risk of lithium toxicity. 98. D. In a functional family, parents typically do not agree on all issues and problems. Open discussion of thoughts and feeling is healthy, and parental disagreement should not cause system stress. The remaining answer choices are life transitions that are expected to increase family stress. 99. A. Aged cheese and red wines contain the substance tyramine which, when taken with an MAOI, can precipitate a hypertensive crisis. The other foods and beverages do not contain significant amounts of tyramine and, therefore, are not restricted. 100. C. Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the clients blood pressure (lying, sitting, and standing) before administering this drug. If the client had taken the drug previously, the nurse would also need to assess the skin color and sclera for signs of jaundice, a possible drug side affect; however, based on the information given here, there is no evidence that the client has received chlorpromazine before. Although the drug can cause urine retention, asking the client to avoid will not alter this anticholinergic effect.

101. B. The onset of action of the SSRI antidepressant paroxetine occurs around 3 to 4 weeks after drug therapy begins. Therefore, a client will seldom notice improvement before this time. Continuing to take the drug is important for this client. 102. B. Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis. None of the remaining medications will increase the sympathomimetic response and, therefore, are not contraindicated. 103. C. Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem. Adding fiber to ones diet and exercising regularly are measures to counteract another anticholinergic effect, constipation. Depending on the specific medication and how it is prescribed, taking the medication at night may or may not be important. However, it would have nothing to do with urinary retention in this client. 104. B. Coffee contains caffeine, which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam. None of the remaining foods is contraindicated. 105. B. The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety. Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous, the primary purpose is directed toward sobriety of members. 106. C. A therapeutic community is designed to help individuals assume responsibility for themselves, to learn how to respect and communicate with others, and to interact in a positive manner. The remaining answer choices may be outcomes of psychiatric treatment, but the use of a therapeutic community approach is concerned with promotion of self-reliance and cooperative adaptation to being with others. 107. ADCBE. The nurse should remain with the client to provide support and promote safety. Reducing external stimuli, including dimming lights and avoiding crowded areas, will help decrease anxiety. Encouraging the client to use slow, deep breathing will help promote the bodys relaxation response, thereby interrupting stimulation from the autonomic nervous system. Encouraging physical activity will help him to release energy resulting from the heightened anxiety state; this should be done only after the client has brought his breathing under control. Teaching coping measures will help the client learn to handle anxiety; however, this can only be accomplished when the clients panic has dissipated and he is better able to focus. 108. C. Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml 109. C. The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person). The nurse may also assess for confabulation and perseveration in a client with cognitive impairment; but the questions in this situation would not elicit the symptom response. Delirium is a type of cognitive impairment; however, other symptoms are necessary to establish this diagnosis. 110. D. Short words and simple sentence minimize client confusion and enhance communication. Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension. Although pictures and gestures may be helpful, they would not substitute for verbal communication. 111. D. Confabulation is a communication device used by patients with dementia to compensate for memory gaps. The remaining answer choices are incorrect. 112. C. Maintaining a calm approach when intervening with an agitated client is extremely important. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the clients confusion. 113. C. Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The other options are incorrect responses, although all may be seen in this client.

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114. D. Following established activity schedules is a realistic expectation for clients with dementia. All of the remaining outcome statements require a higher level of cognitive ability than can be realistically expected of clients with this disorder. 115. C. The familys perception of the problem is essential because change in any one part of a family system affects all other parts and the system as a whole. Each member of the family has been affected by the current problems related to the school system and the nurse would be interested in the data. The childs performance in school and the teachers attempts to solve the problem are relevant and may be assessed; however, priority would be given to the familys perception of the problem. The famil y education and work history may be relevant, but are not a priority. 116. B. Te parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia. Acknowledging the patients responsibility is neither accurate nor helpful to the parents and would only reinforce their feelings of guilt. Support groups are useful; however, the nurse needs to handle the parents self-blame directly instead of making a referral for this problem. Teaching the parents various ways to change would reinforce the parental assumption of blame; although parents can learn about schizophrenia and what is helpful and not helpful, the approach suggested in this option implies the parents behavior is at fault. 117. A. Family boundaries are parameters that define who is inside and outside the system. The best method of obtaining this information is asking the family directly who they consider to be members. The question asked by the nurse would not elicit information about the familys ethnicity or culture, nor does it address the nature of the family relationship. 118. B. Differentiation is the process of becoming an individual developing autonomy while staying in contact with the family system. Cooperative action among family members does not refer to differentiation, although individuals who have a high level of differentiation would be able to accomplish cooperative action. Incongruent messages in which the recipient is a victim describe double-bind communication. Maintenance of system continuity or equilibrium is homeostasis. 119. D. The nurse who wishes to be helpful to the entire family must remain neutral. Taking sides in a conflict situation in a family will not encourage negotiation, which is important for problem resolution. If the nurse aligned with the adolescent, then the nurse would be blaming the parents for the childs current problem; this would not help the familys situation. Learning to negotiate conflict is a function of a healthy family. Encouraging the parents to adopt more realistic rules or the adolescent to comply with parental rules does not give the family an opportunity to try to resolve problems on their own. 120. C. Enmeshment is a fusion or overinvolvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior. The remaining options are not appropriate to the situation described. 121. Answer C. Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces, resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe. Glycocalyx does not have the effects in options B-D. 122. Answer B. The child can move his extremities and function in a normal fashion. This lessens stress associated with position restriction and promotes normal activity. Fear may not be eliminated. All lines can be dislodged. Even small catheters can be readily seen. 123. Answer C. In patients unable to take oral nutrition, parenteral hyperalimentation is an option for providing nutritional support. High concentrations of dextrose, protein, minerals, vitamins, and trace elements can be provided. Dosing is not affected with options a and d. Crystalloid can provide free water but has very little nutritional benefits. Hyperalimentation can provide free water and considerable nutritional benefits. 124. Answer D. A multilumen catheter contains separate ports and means to administer agents. An agent infusing in one port cannot mix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given in separate ports simultaneously.

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125. Answer A. Occlusion occurs with slow infusion rates and concurrent administration of some medications. Lipid occlusions may be treated with 70 percent ethanol or with 0.1 mmol/mL NaOH. Lipids provide essential fatty acids. It is recommended that approximately 4 percent of daily calories be EFAs. A deficiency can quickly develop. Daily essential fatty acids are necessary for constant prostaglandin production. Lipids are almost isotonic with blood. 126. Answer C. Strict aseptic technique including the use of cap, mask, and sterile gown and gloves is require when placing a central venous line including a PICC. Options A, B, and D are incorrect statements. They increase the risk of infection. 127. Answer C. Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false. Unnecessary pain should be prevented. 128. Answer B. Any air entering the right heart can lead to a pulmonary embolus. All air should be purged from central venous lines; none should enter the patient. 129. Answer A. A special portacath needle is used to access the portacath device. A syringe is attached and the sample is obtained. One of the primary reasons for insertion of a portacath device is the need for frequent or long-term blood sampling. A vacutainer will exert too much suction on the central line resulting in collapse of the line. Only special portacath needles should be used to access the portacath device. 130. Answer B. The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters the subclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection. 131. Answer C. A foreign body in a blood vessel increases the risk of infection. Catheters that come outside the body have an even higher risk of infection. Most infections are caused by skin bacteria. Other infective organisms include yeasts and fungi. Options 1 and 4 are complications of a CVAD but are not the primary problem. Once placed, these lines do not cause pain and discomfort. 132. Answer D. A solution containing heparin is used to reduce catheter clotting and maintain patency. The concentration of heparin used depends on the patients age, comorbidities, and the frequency of catheter access/flushing. Although patients have few complications, the device is not risk free. Patients may develop infection, catheter clots, vascular obstruction, pneumothorax, hemothorax, or mechanical problems (catheter breakage). Strict adherence to protocol enhances the longevity of central access devices. They routinely last weeks to months and sometimes years. The patient will be taught how to perform dressing changes at home. 133. Answer A. Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkins lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA cross-linkage. Alkylating agents are noncell cycle-specific agents. 134. Answer C. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. A well-known estrogen antagonist used in breast cancer therapy is tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs reduces breast cancer recurrence by 30 percent. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history of the disease. Thyroxine is a natural thyroid hormone. It does not treat thyroid cancer. ACTH is an anterior pituitary hormone, which stimulates the adrenal glands to release glucocorticoids. It does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone, which stimulates glycogenolysis and gluconeogenesis. It does not treat pancreatic cancer. 135. Answer D. The time required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cell maturation in the bone marrow becomes evident. Leukopenia is an abnormally low white blood cell count. Answers A-C pertain to red blood cells.

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136. Answer A. Epoetin alfa (Epogen, Procrit) is a recombinant form of endogenous erythropoietin, a hematopoietic growth factor normally produced by the kidney that is used to induce red blood cell production in the bone marrow and reduce the need for blood transfusion. Glucagon is a pancreatic alpha cell hormone, which cause glycogenolysis and gluconeogenesis. Fenofibrate (Tricor) is an antihyperlipidemic agent that lowers plasma triglycerides. Lamotrigine (Lamictal) is an anticonvulsant. 137. Answer A. Prostate tissue is stimulated by androgens and suppressed by estrogens. Androgen antagonists will block testosterone stimulation of prostate carcinoma cells. The types of cancer in options 2-4 are not androgen dependent. 138. Answer A. Chemotherapy often induces vomiting centrally by stimulating the chemoreceptor trigger zone (CTZ) and peripherally by stimulating visceral afferent nerves in the GI tract. Ondansetron (Zofran) is a serotonin antagonist that bocks the effects of serotonin and prevents and treats nausea and vomiting. It is especially useful in single-day highly emetogenic cancer chemotherapy (for example, cisplatin). The agents in options 2-4 are selective serotonin reuptake inhibitors. They increase the available levels of serotonin. 139. Answer C. With intrathecal administration chemotherapy is injected through the theca of the spinal cord and into the subarachnoid space entering into the cerebrospinal fluid surrounding the brain and spinal cord. The methods in options A, B, and D are ineffective because the medication cannot enter the CNS. 140. Answer B. Leucovorin is used to save or "rescue" normal cells from the damaging effects of chemotherapy allowing them to survive while the cancer cells die. Therapy to rapidly reduce the number of cancerous cells is the induction phase. Consolidation therapy seeks to complete or extend the initial remission and often uses a different combination of drugs than that used for induction. Chemotherapy is often administered in intermittent courses called pulse therapy. Pulse therapy allows the bone marrow to recover function before another course of chemotherapy is given. 141. Answer B. Prevent uric acid nephropathy, uric acid lithiasis, and gout during cancer therapy since chemotherapy causes the rapid destruction of cancer cells leading to excessive purine catabolism and uric acid formation. Allopurinol can induce myelosuppression and pancytopenia. Allopurinol does not have this function. 142. Answer B. Medications administered intravesically are instilled into the bladder. Intraventricular administration involves the ventricles of the brain. Intravascular administration involves blood vessels. Intrathecal administration involves the fluid surrounding the brain and spinal cord. 143. Answer C. The overall goal of cancer chemotherapy is to give a dose large enough to be lethal to the cancer cells, but small enough to be tolerable for normal cells. Unfortunately, some normal cells are affected including the bone marrow. Myelosuppression limits the bodys abilit y to prevent and fight infection, produce platelets for clotting, and manufacture red blood cells for oxygen portage. Even though the effects in options a, b, and d are uncomfortable and distressing to the patient, they do not have the potential for lethal outcomes that myelosuppression has. 144. Answer A. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to expulsion of gastric contents. Catecholamine inhibition does not induce vomiting. Chemotherapy does not induce vomiting from autonomic instability. Chemotherapy, especially oral agents, may have an irritating effect on the gastric mucosa, which could result in afferent messages to the solitary tract nucleus, but these pathways do not project to the vomiting center. 145. Answer A. Myelo comes from the Greek word myelos, which means marrow. Ablation comes from the Latin word ablatio, which means removal. Thus, myeloablative chemotherapeurtic agents destroy the bone marrow. This procedure destroys normal bone marrow as well as the cancerous marrow. The patients bone marrow will be replaced with a bone marrow transplant. Myelocytes are not muscle cells Tumors are solid masses typically located in organs. Surgery may be performed to reduce tumor burden and require less chemotherapy afterward. 146. Answer C. Nausea and vomiting (N&V) are common side effects of chemotherapy. Some patients are able to trigger these events prior to actually receiving chemotherapy by anticipating, or expecting, to have these effects. N&V occurring post-chemotherapeutic administration is not an anticipatory event but rather an effect of the drug. N&V occurring during the administration of chemotherapy is an effect of the drug.

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147. Answer C. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Less drug is available if bound to protein. Distribution to receptor sites is irrelevant since the drug bound to protein cannot bind with a receptor site. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again. 148. Answer C. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Hepatic clearance is the amount of drug eliminated by the liver. Total clearance is the sum of all types of clearance including renal, hepatic, and respiratory. First-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of drug making it into circulation. 149. Answer C. Drug B will induce the cytochrome p-450 enzyme system of the liver; thus, increasing the metabolism of Drug A. Therefore, Drug A will be broken down faster and exert decreased therapeutic effects. Drug A will be metabolized faster, thus reducing, not increasing its therapeutic effect. Inducing the cytochrome p-450 system will not increase the adverse effects of Drug B. Drug B induces the cytochrome p-450 system but is not metabolized faster. Thus, the therapeutic effects of Drug B will not be decreased. 150. Answer A. Epinephrine (adrenaline) rapidly affects both alpha and beta adrenergic receptors eliciting a sympathetic (fight or flight) response. Muscarinic receptors are cholinergic receptors and are primarily located at parasympathetic junctions. Cholinergic receptors respond to acetylcholine stimulation. Cholinergic receptors include muscarinic and nicotinic receptors. Nicotinic receptors are cholinergic receptors activated by nicotine and found in autonomic ganglia and somatic neuromuscular junctions.