Question 1

A nurse is assessing the living arrangement of a client with Alzheimer's disease. The client is currently living with his daughter's family. Which of the following indicates a good adjustment to the living arrangement?

Accepted Answer

Hoping that the client can live on his own soon and stating that he has more lucid moments now demonstrates an understanding of the client's condition. This shows that the daughter is doing a good job adjusting to the living arrangements. Options A, C, and D are statements that demonstrate poor adjustment and caregiver role strain.

Question 2

A 27-year-old woman has died after falling from a ladder and hitting her head on the floor. The nurse is providing grief support to the client's husband and four-year-old daughter. When observing the child, the nurse should be aware that this child may react by:

Accepted Answer

Children aged 2-5 years may see death as reversible; the child may be concerned about who will take care of her. Regressive behavior may be noted in response to grief. Adolescents may express a strong emotional reaction to death, sometimes acting out or rebelling. School-aged children may feel responsible for the death and may experience problems at school due to difficulty focusing. Screaming and withdrawing are coping mechanisms of toddlers.

Question 3

A group of physicians attending a patient with hepatic cirrhosis are discussing possible treatments for variceal bleeding. The physicians were planning to give a sclerosant. The nurse, a part of the health care team, knows that the immediate complication involved with this drug is:

Accepted Answer

The immediate complication of sclerosant therapy is substernal chest pain, which is usually transient and resolves spontaneously. Other immediate complications are dysphagia, low grade fever, and pleural effusion. On the other hand, delayed complications that rarely occur include esophageal strictures, perforation, ARDS, pneumothorax, pericarditis, mediastinitis, fistulas, and pleural effusion. Mucosal ulceration is a delayed complication that occurs in almost 90% of patients.

Question 4

Johnny, a 39-year-old bartender, is admitted because of a growing tumor in the larynx. A nurse is preparing him for a hemilaryngectomy. When planning care, the nurse recognizes which of the following as the procedure's most common post-op complication?

Accepted Answer

A common complication of hemilaryngectomy is aspiration. During this procedure, the thyroid cartilage is separated at the midline to remove the tumor. The nurse must expect to see a tracheostomy tube and NG tube in place post-operatively. Change in voice quality cannot be prevented after this type of surgery.

Question 5

A client admitted for treatment of pressure ulcers on the left heel is being assessed by the nurse. The nurse documents that the wound is red, soft and bleeds easily, indicating second intention of wound healing. This wound type is managed by:

Accepted Answer

This type of wound is packed with sterile wet dressing and covered with dry sterile dressing to allow the drainage to adhere to the wet dressing. Second intention healing or granulation occurs when a wound is soft and red. The necrotic tissue fragments and what is left is a soft, reddish tissue that easily bleeds. The nurse must take care not to disturb the granulation by using dry and abrasive dressings. A dry dressing is more suitable for wounds that are closed by first intention healing or suturing.

Question 6

A nurse reviews the laboratory results of a client admitted due to crushing left-sided substernal chest pain. The nurse determines that which of the following findings supports a diagnosis of acute myocardial infarction?

Accepted Answer

Total creatine kinase rises within 24 hours after damage of cardiac tissue. The level of LDH rises after the first 24 hours, whereas myoglobin level increases within 2 to 3 hours and is expected to return to normal within 24 to 36 hours. CK-MB rises about 3 to 4 hours after the onset of chest pain.

Question 7

A nurse is caring for an elderly female with a right-sided weakness. The client is immobile and bed-bound for most of the day. The nurse implements which intervention for the prevention of skin breakdown and development of pressure ulcers in the elderly?

Accepted Answer

A layer of cornstarch on the sheet can help avoid trauma to the skin. The nurse should keep the surface smooth and free from wrinkles. The client is encouraged to increase her intake of protein for building muscles and other tissues. Alcohol and antibacterial soap are irritating to the skin. The client is instructed to use products containing mild and non-drying chemicals.

Question 8

A staff nurse recognizes that the dose prescribed for a client is higher than the safe dosage for the client. The medication is scheduled to be administered, but the nurse is unable to reach the physician. The most appropriate nursing action is to:

Accepted Answer

If a nurse has questions regarding a physician's order, the nurse should contact or locate the physician for clarification. If the nurse is unable to reach the physician or if the order stays the same after talking to the physician, it is best to contact the nursing supervisor for further clarification. The hospital pharmacist is also an excellent resource.

Question 9

A client diagnosed with acquired immune deficiency syndrome is admitted for pneumocystis carinii pneumonia. In which of the following situations should the nurse intervene?

Accepted Answer

The risk for contact with blood and bodily fluids is low when taking a client's blood pressure; therefore, wearing of mask and gloves are not necessary. Options A, B, and D are appropriate.

Question 10

A client is evaluated for seizures for the first time. The nurse expects which of the following diagnostic procedures to be ordered first?

Accepted Answer

Electroencephalography records the activity of the brain, specifically, the superficial layers of the cerebral cortex. A computed tomography scan is used to detect intracranial bleeding, cerebral edema, and alterations of the brain's structures. Magnetic resonance imaging is similar to the computed tomography scan, but it provides more details. Skull radiography is used to identify skull fractures.

Question 11

A nurse is reviewing the clients' records. The nurse determines that which of the following clients would require airborne precautions?

Accepted Answer

The nurse initiates airborne precautions for a client suspected of chicken pox. Impetigo is transmitted by direct skin contact, whereas meningitis is transmitted by respiratory droplets. Pneumocystis carinii is a common complication of HIV, which is transmitted from an infected person to another through blood, vaginal secretions, semen and breast milk.

Question 12

A client had a purified protein derivative test 48 hours ago after his roommate tested positive for tuberculosis. On assessment, a 3 millimeter reddened and raised area is noted by the nurse. The nurse determines that the finding is which of the following?

Accepted Answer

A 3 mm raised and reddened area indicates the client is positive for tuberculosis. The test would be classified as negative if there had been no recent contact with an infected individual.

Question 13

A registered nurse is admitting a male client suspected of active tuberculosis. As the health care team waits for the results of the tests, the nurse assigns the client to which room?

Accepted Answer

The nurse assigns the client in a single room maintained under negative pressure. A minimum of six to twelve exchanges per hour is recommended by most facilities. If tuberculosis is suspected but not verified, the client must be placed in a single room. The client should stay in this room until the diagnosis is verified.

Question 14

A nurse is planning a health teaching program for accident prevention in the community. The main targets of the program are mothers with young children. What is considered as an undesirable outcome after the health teaching?

Accepted Answer

Desired outcomes of the health teaching program should include the ability to identify safety hazards at home and in the community. Safety practices should be applied to the appropriate age group. Parents of newborns and infants should buy cribs that are lead-free and have slats which measure no more 2 3/8 inches apart. The newborn's head might slip in between the slats if the slats are not close enough together. A nine-month-old can crawl and stick his or her fingers in electrical outlets. Preschool and school aged-children should be taught about the dangers of playing in the street or near the railroad tracks.

Quiz 1: American Association of Colleges of Nursing (AACN) Clinical Nurse Specialist