183) ANSWER

D) A 62-year-old male with chronic renal failure

RATIONALE

Renal failure interferes with excretion of electrolytes, including magnesium. All of the conditions listed in the incorrect options increase the risk of hypomagnesemia by interfering with magnesium absorption in the small intestine. Critical words are hypermagnesemia and risk. Eliminate options 1 and 2, since intake of magnesium is reduced in these conditions. Recall that magnesium is absorbed in the small intestine, and eliminate option 3.

182)Answer

D. Phenylketonuria

Rationale

•In untreated children with phenylketonuria (PKU), the hallmark of the disease is mental retardation. Other characteristics include fair skin, abnormal gait and posture, stunted growth, and urine with a musty odor.

•PKU is an autosomal recessive metabolic disorder. Absence of the liver enzyme phenylalanine hydroxylase prevents conversion of phenylalanine, an essential amino acid, into tyrosine. As a result, excessive phenylalanine builds up in the blood stream and tissues causing permanent damage to brain tissue.

•Branched-chain ketoaciduria, or maple syrup urine disease, causes an inability to break down branched-chain amino acids, leading to a buildup of waste products.

•Celiac disease is an autoimmune disorder in which gluten triggers an inflammatory response in the digestive tract.

•Tay-Sach’s disease causes an inability to break down phospholipids, causing lipid accumulation in the brain and a rapid deterioration of mental and physicial abilities.

181) ANSWER

A) Aminoglycoside antibiotics

RATIONALE

Nephrotoxicity can be caused by aminoglycoside antibiotics. This type of drug accumulates in tubular cells, eventually killing them. Options 2 and 3 are ototoxic, while option 4 is avoided in renal disease. Associate this drug category with nephrotoxicity.

180) Answers

C. Muscle weakness
E. Arrhythmia
F. Bradycardia

Rationale

•Hyperkalemia may result due to the inability of the adrenal gland to secrete aldosterone, a potassium-wasting hormone

•Signs and symptoms of hyperkalemia include muscle weakness, arrhythmias, bradycardia, diarrhea and nausea

•Tremors, hypoventilation, and tachycardia are not common signs of hyperkale

179) ANSWER

A) Chronic elevated blood glucose levels damage cells and causes multiple organ damage.

RATIONALE

Research by the National Institute of Health and the American Diabetes Association demonstrates a strong correlation between chronic hyperglycemia and complications of retinopathy, nephropathy, and neuropathy. Thus, there is damage to the eyes, kidneys, and peripheral nerves, respectively. Lactic acidosis occurs with diabetic ketoacidosis (option 2). Option 3 is a false rationale for the client in the question. Insulin is needed to carry glucose across the cell membrane into the cell, not to be transported in the blood (option 4). Recall knowledge of the long term complications of hyperglycemia.

178) ANSWER

C) Who develops a paralytic ileus after abdominal surgery.

RATIONALE

Intestinal obstructions are mechanical (options 1, 2, 4) or paralytic, in which neurogenic or muscular impairment hinders peristalsis. Early ambulation after surgery usually helps to prevent this. Make the association between paralytic ileus and surgery to identify option 4 as correct.

177) ANSWER

C) Clot binding the wound edges

RATIONALE

The first signs of healing are absence of bleeding and wound edges bound by fibrin in the clot. Inflammation at the wound edges follows the first sign, and then, when the clot diminishes, inflammation decreases, and collagen forms a scar. Eliminate option 2 as not being indicative of healing, and option 4 as being a later stage than is described in the question stem.

176) ANSWER

A) Increased peripheral temperature

RATIONALE

During music therapy, the parasympathetic system will be stimulated, causing vasodilation to the skin, thereby increasing skin temperature. An increased respiratory rate would indicate a sympathetic response. An increased heart rate also would indicate a sympathetic response. An increased blood pressure also would indicate a sympathetic response. An understanding of the pathophysiological effects of music therapy on the body is essential to answer this question correctly.

175) ANSWER

B) If steroid medication is withdrawn suddenly, a client could die of acute adrenal insufficiency.

RATIONALE

Abrupt cessation of long-term steroid therapy can cause acute adrenal insufficiency, which could lead to death. Options 1 and 4 are incorrect statements. Central nervous system symptoms such as confusion and psychosis are adverse effects of steroids such as prednisone (option 3). Recall knowledge of the pathophysiological process of glucocorticoids. Option 2 is the only correct pathophysiological process of the classification. If this was difficult, review the action of glucocorticoids.

174) ANSWER

D) Acetaminophen (Tylenol) 2 tablets PO q4 hours PRN for headache

RATIONALE

The Tylenol order contains all of the pertinent information except the dosage. The prescriber needs to be contacted (option 4). The Digoxin order contains the drug, dosage, route, time interval (option 1). Because all of the components are present, the Ambien order can be implemented (option 2). The Lasix order includes all of the specific information: drug, form, dosage, route, and time period (option 3). Recall that the sequence of noting medication orders includes a complete order along with appropriate components for the specific client.

173) Answer

B. Hot flashes

Rationale

•Tamoxifen is an antineoplastic agent that competes with estrogen for binding sites. Hot flashes occur in over 60% of patients on tamoxifen.

•Side effects include hot flashes, vaginal bleeding, amenorrhea, menstrual changes, nausea, vomiting, rash, pruritus, osteoporosis, bone pain, and fractures.

172) ANSWER

A) Hypothermia.

RATIONALE

Neonates with sepsis may display either hypothermia or hyperthermia, but hypothermia is more common. The other symptoms are not associated with sepsis. Recall that neonates are as likely to demonstrate hypothermia as hyperthermia.

171) ANSWER

D) If client has ingested grapefruit juice with meals

RATIONALE

Grapefruit juice changes the metabolism of the calcium channel blocker drugs and leads to an increase in blood levels of the drug resulting serious signs and symptoms such as dysrhythmia, angina, heart block, bradycardia, and hypotension (option 4). Assessment of respiratory pattern may be important because of the toxicity, but does not address the primary problem directly (option 2). Assessment should focus on the cause. There is no direct relationship between altered body temperature and toxic levels of this drug (option 1). Weight gain is an adverse effect of this drug. The highest priority is insisting the client ingest this drug safely. Identification of the cause of the toxicity takes the highest priority (option 3). Apply knowledge of the primary cause of toxicity in calcium channel blockers.

170) Answer

C. Aortic stenosis

Rationale

•Aortic stenosis is the narrowing of the aortic valve. This causes reduced cardiac output and increased left ventricle pressure.

•With exertion, the heart cannot increase cardiac output because of a narrow aortic valve. This can cause syncope due to insufficient perfusion to the brain. Syncope is a hallmark sign of aortic stenosis.

•Aortic regurgitation and mitral stenosis do not cause syncope.

169) Answer

B. My husband will be fine if he takes a long nap

Rationale

•Allowing the patient with head injury to take a long nap needs further teaching because it could imply that the wife did not fully understand that she must interrupt the patient’s sleep to detect early signs of increased ICP.

•Contusion or hematoma development can cause increase in ICP which disrupts neural function. Head injury, whether it is a concussion, contusion or hemorragic with hematoma formation can result in decreased LOC which can be masked with a long nap. It is important to monitor the patient frequently.

•Vomiting and difficulty talking are signs of increased ICP.

168) ANSWER

B) Dyspnea

RATIONALE

Children with acyanotic heart defects may have a murmur without other symptoms. Dyspnea and tachycardia are early signs of pulmonary edema, which may lead to congestive heart failure. Eliminate all normal findings in a patient with acyanotic heart disease. Weight gain could be a positive growth sign or a sign of impending heart failure. Without additional information, that option is questionable. Dyspnea is a negative finding that should be reported.

167) ANSWER

D) Palpate peripheral pulses q2-4h.

RATIONALE

Pulses are assessed frequently to ensure that adequate circulation is present and an occlusion or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has a comparison point postoperatively. Pulses could be absent for the short-term postoperatively due to vasospasm or hypothermia. Recall that assessment is the first step in the nursing process. Option 4 reflects an assessment.

166) ANSWER

A) the man became nauseated.

RATIONALE

Motion receptors can be stimulated with instillation of large amounts of fluid. Nausea or vomiting would be stimulated. Relief will occur if the irrigation procedure is stopped. The correct choice is the only answer that does not involve the ear or irrigation procedure directly.

165) ANSWER

B) 1-4 weeks

RATIONALE

Sertraline is an antidepressant of the SSRI type. These agents work within 1-4 weeks. Option 1 is an insufficient amount of time, while options 3 and 4 are excessive, as well as similar. Specific knowledge of the time frame in which SSRIs exert an effect is needed to answer this question. Use medication knowledge and the process of elimination to make a selection.

164) ANSWER

A) The intravascular compartment becomes dehydrated.

RATIONALE

Fluid shifts from the intravascular compartment to the interstitial compartment due to damage to the cells' permeability, causing a drop in blood pressure and edema. Option 2 does occur in the beginning, but is not the reason for administering fluids. Notice the question asks about initially; options 3 and 4 would be appropriate rationales for decreasing fluid later on. Be sure both options are correct when choosing answers with more than one item mentioned.

163) ANSWER

D) Calcium.

RATIONALE

The majority of kidney stones are comprised of calcium oxalate or calcium phosphate. Sturvite stones (15 to 20 percent), uric acid (5 to 10 percent) and cystine stones are uncommon. Select the answer that reflects the most common stone component, calcium.

162) Answer

D. High fluid intake

Rationale

•An excessive fluid intake in a patient with cardiac disease would increase the risk of heart failure.

•The postpartum patient with cardiac disease is already at risk for fluid overload due to the extra accumulation of fluid from pregnancy.

•Monitoring input and output of the patient is the top priority of the nurse to prevent risk of fluid overload.

•Vital signs should be monitored every 2-4 hrs to monitor the cardiac condition of the patient.

•High fiber diet is recommended to prevent constipation and straining.

161) ANSWER

A) "My peak flow meter can tell me if an asthma episode might be coming, even though I might still be feeling okay."

RATIONALE

Peak expiratory flow readings over time indicate the child s respiratory ability when she is well. Readings of 50 percent below "personal best" indicate an asthma episode is imminent. The meter does not prevent an attack. Critical words are "understands" and "peak expiratory flow meter." Knowledge of this device and how it helps to manage asthma helps to answer the question.

160) ANSWER

B) The client has adrenal insufficiency.

RATIONALE

In the presence of adrenal insufficiency, metyrapone can cause an adrenal crisis by stopping the synthesis of cortisol. Options 1 and 4 are the opposite of what is occurring with the client. Option 3 is an unrelated finding. Note in the question stem that the client is experiencing an adrenal crisis. Options 1, 2, and 4 can be eliminated because they are the direct opposite of the scenario in the question. Option 2 is the only option that addresses adrenal insufficiency.

159) Answer

C. Familial adenomatous polyposis

Rationale

•All of the options are risk factors of prostate cancer except familial adenomatous polyposis, which refers to an inherited disorder characterized by numerous polyps in the epithelium of the large intestine. Familial adenomatous polyposis increases the risk of colon cancer.

•Prostate cancer is one of the most common cancers in American men. Genetics and age play a role in its development. Other risk factors for prostate cancer include family history, African-American race, increased levels of dihydrotestosterone, and folic acid supplement.

158) ANSWER

D) Use a bulk-forming agent, such as Metamucil.

RATIONALE

Metamucil is a bulk-forming laxative that could aggravate diarrhea. Kaopectate (option 2) is an antidiarrheal agent that is commonly used to manage this health problem, which is usually self-limiting. The client should contact the health care provider again if diarrhea persists (option 3), because diarrhea lasting more than two days requires attention. Dairy products are a food source that can aggravate diarrhea (option 1). Note that the question stem asks for selection of the option that would establish that the client needs further teaching. Note that the words "bulk-forming" are present in option 4. This would lead you to suspect that diarrhea would be aggravated, with more stool produced, if a "bulk-forming" agent were consumed. The other answers all indicate that the client understands management of the illness.

157) ANSWER

B) Antigen-IgE-mast cell interaction.

RATIONALE

Type I hypersensitivity reactions are caused by widespread antigen-antibody reactions such as anaphylaxis. These responses are usually immediate and lead to an antigen-antibody complex that causes the release of histamine. Option 4 is an explanation of what occurs with a blood transfusion reaction. Option 3 is an explanation of a Type IV delayed hypersensitivity. Option 1 is false. This question requires knowledge about hypersensitivity responses.

156) Answer

B. 30 mg per day

Rationale

•During pregnancy, approximately 30 mg of iron is needed per day.

•Non-pregnant women require about 18 mg of iron per day.

•Iron is important in the formation of hemoglobin to carry oxygen throughout the body. Iron will be transferred to the fetus even if maternal iron intake is inadequate, but this causes depletion of the mother’s iron stores.

155) ANSWER

C) Retracting the foreskin.

RATIONALE

Phimosis is a tight foreskin that is unable to be retracted by an age when retraction should take place. Eliminate options 2 and 4 as unrelated to the condition.

154) ANSWER

D) Cardiovascular disease

RATIONALE

Cardiovascular disease is a common cause of death in clients with end-stage renal disease resulting from accelerated atherosclerosis. Hypertension, hyperlipidemia, and glucose intolerance all contribute to the process. All other disorders may be present throughout the uremic stage but are less likely to cause death. Identify option 4 as the condition likely to cause death.

153) ANSWER

C) Keeps airways open.

RATIONALE

In conditions such as emphysema or asthma, where airways are constricted or airflow is limited, pursed-lip breathing keeps the airways open by maintaining positive pressure. The technique is used with clients with emphysema for whom the main problem is keeping airways open.

152) ANSWER

D) Ipsilateral motor loss below lesion

RATIONALE

Hemisection of the anterior and posterior portions of the spinal cord results in loss of position sense (proprioception) on the same side of the body as the trauma, below the level of injury. Option 3 is seen in anterior cord syndrome; option 1 is incorrect. The core issue of the question is knowledge of characteristics of Brown-Séquard syndrome following spinal cord injury. Use nursing knowledge and the process of elimination to make a selection.

151) ANSWER

D) Influenza

RATIONALE

Influenza has been associated with Guillian-Barré syndrome, which causes progressive paralysis. Eliminate options 1, 2, and 3 which have no known association with Guillian-Barré.

150) Answer

C. Nausea

Rationale

•Amantadine (Symmetrel), in addition to its action on the influenza virus, increases the availability of dopamine in certain areas of the brain. Increased dopamine action in the chemoreceptor trigger zone of the brain causes nausea and vomiting.

149) ANSWER

B) 100/60 to 130/76.

RATIONALE

An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for PIH. The blood pressures in each of the other options do not meet the criteria for increase in either the systolic or the diastolic blood pressure reading. Specific knowledge of the criteria for PIH is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. As an alternative, choose option 2 because it has the greatest degree of change in both systolic and diastolic measurements.

148) ANSWER

A) Pain

RATIONALE

Herpetic lesions are very painful, so the first priority is to provide comfort measures for the client. The other diagnoses do not address the client's most immediate concern. Recognize that prioritization is the key to correctly answering this question. The most immediate issue is pain.

147) Answer

C. Albuterol (Ventolin)

Rationale

•Albuterol is a short acting beta agonist administered via nebulizer or metered dose inhaler. Albuterol is the drug of choice for acute bronchospasms and bronchoconstriction.

•Theophylline, salmeterol, and Advair are not indicated for short term bronchospasm or bronchoconstriction relief.

146) ANSWER

A) Swan-neck deformity and ulnar deviation

RATIONALE

Swan-neck deformity occurs at the proximal interphalangeal (PIP) joint and ulnar deviation occurs as a result of joint destruction with disease progression. Heberden’s and Bouchard’s nodes are commonly found in clients with osteoarthritis. Tophi (firm, moveable nodules) are associated with gout. Charcot’s joint is considered a neuropathic disorder that falls under the broader category of rheumatism. It is not specific to RA and is more likely to be seen as a complication in clients with diabetes. The core issue of the question is identification of signs and symptoms of RA. Use nursing knowledge and the process of elimination to make a selection.

145) ANSWER

A) Hot chocolate

D) Spinach salad

RATIONALE

A magnesium level of 2.8 is elevated (normal is 1.4-2.1 mEq/L), most likely as a result of inadequate renal secretion secondary to the chronic renal failure. Foods high in magnesium include whole grains; legumes; oranges; bananas; green, leafy vegetables; and chocolate. First, recognize the magnesium level is elevated. Recall foods high in magnesium to choose options 1 and 4.

144) ANSWER

D) Impaired verbal communication

RATIONALE

At this age, a 1-year-old is beginning speech. This child will have trouble developing language because of the spasticity. Urinary incontinence occurs in all 1-year-old children, as does feeding self-care deficit. Thought processes are difficult to evaluate in a 1-year-old. The core issue of the question is the ability to determine appropriate nursing diagnoses for a client with cerebral palsy while taking into consideration growth and development. Use nursing knowledge and the process of elimination to make a selection.

143) Answer

A. Nausea

Rationale

•Ethosuximide (Zarotin) most commonly causes GI distress, such as nausea, vomiting, abdominal pain, and diarrhea.

•Other side effects include sedation, lethargy, headache, ataxia, and confusion.

142) ANSWER

C) Angiotensin-converting enzyme (ACE) inhibitors

RATIONALE

Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. The effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy. There is only one correct answer to this question. In order to select the correct answer, review the complications of each medication.

141) ANSWER

B) Venous drainage from the brain.

RATIONALE

Keeping the head of the bed elevated to 30 degrees promotes venous drainage, which is important in decreasing ICP. Alignment of the head prevents obstruction of the jugular veins. Obstruction would impede venous drainage. Recall that appropriate drainage is enhanced by gravity. Keeping the head of the bed elevated will promote drainage.

140) ANSWER

A) Whiteheads

RATIONALE

Whiteheads are classified as closed comedones. Blackheads are open comedones. Options 3 and 4 are irrelevant. The core issue of the question is knowledge of various skin eruptions. The wording of the question tells you that the correct response is also a true statement of fact. Use the process of elimination and nursing knowledge to make a selection.

139) ANSWER

C) Eupnea respirations

RATIONALE

The action of theophylline is bronchodilation, which should relax respiratory efforts. Eupnea is normal respirations, which should be a direct result of bronchodilation. Recall that eupnea means normal breathing, which is the goal of therapy.

138) ANSWER

A) Hamburger with enriched bun

RATIONALE

Anemia in pregnancy is often caused by inadequate iron intake. Lean meat and enriched bread are good sources of iron. Knowledge of foods high in iron will help to answer the question correctly. Take time to review these if needed.

137) ANSWER

A) Space interventions and encourage rest periods.

RATIONALE

Activity intolerance in clients with anemia results from the imbalance between oxygen demand and supply. Activities should be planned to intersperse activity with periods of rest to decrease hypoxemic episodes and to decrease tissue demand for oxygen. All the other options are appropriate interventions for a client with anemia, but they do not relate to the nursing diagnosis of activity intolerance. The core issue of the question is knowledge that anemia causes fatigue and that measures to prevent fatigue need to be incorporated in the plan of care. Use this knowledge and the process of elimination to make a selection.

136) Answer

A. Reduces the risk of DVTs

Rationale

•DVTs are prevented with the use of anticoagulation, compression stockings, sequential compression devices, and exercise. Having the head of bed at 15 to 30 degrees will not signigicantly affect the risk of DVTs.

•A patient with an increased intracranial pressure should have their bed elevated to 15-30 degrees. This will help increase venous outflow, which decreases ICP. Elevating the head too much can decrease cerebral perfusion pressure, causes hypoxia and ischemia.

135) ANSWER

A) Casein

D) Whey

RATIONALE

Casein and whey are often used as additives and stabilizers in processed foods. The client with lactose intolerance may have difficulty digesting these additives since they are milk products. Sodium phosphate is a preservative. Lecithin is an emulsifier. Maltodextrin is a sugar. Key term is lactose intolerance, indicating the client has difficulty digesting milk products. Recognize casein and whey as by products of milk.

134)  Answer

D. Acute renal failure

Rationale

•During a AAA repair, a stent graft is placed in the aorta to support the lumen and reduce pressure on the aneurysm sac. If the stent graft is placed wrong, it can block the renal arteries and cause renal failure.

•Hemorrhage is more common before the AAA repair, when the aneurym ruptures.

•Emboli and infection are also complications of a AAA repair, but they are less common than renal failure.

133) ANSWER

a.	breakthrough pain.

RATIONALE

Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

132)ANSWER

d.	Oxygen saturation

RATIONALE

Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

131) ANSWER

c.	Warm, pink, and dry skin

RATIONALE

Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

130) ANSWER

a.	On the left side

RATIONALE

The patient should be positioned with the “good” lung in the dependent position to improve the match between ventilation and perfusion. The obese patient’s abdomen will limit respiratory excursion when sitting in the high-Fowler’s or tripod positions.

129) ANSWER

c.	Auscultate breath sounds.

RATIONALE

Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient’s admission diagnosis.