Which phenomena is defined as "a subjective human experience that is what the client says it is, exists when the client says it is present, and it alerts humans to actual or potential bodily tissue damage"?

A. Anxiety

B. Pain

C. Fear

D. Perception

Choice B is correct. Pain is defined as a subjective human experience that is what the client says it is, exists when the client says it is present, and alerts humans to actual or potential bodily tissue damage. It is an unpleasant and distressing experience that has both physical and emotional components.

Choice A is incorrect. Anxiety is a psychological and emotional response to an anticipated threat to self that leads to unpleasant feelings such as feelings of dread.

Choice C is incorrect. Fear is defined as the emotional response to actual and present danger.

Choice D is incorrect. Perception is defined as the human being’s ability to interpret the environment exterior to the person as interpreted by the person’s senses, including hearing, vision, and tactile sensation.

225) ANSWER

A) Tinea corporals

RATIONALE

Tinea corporals are a fungal infection of the body called ringworm. The most common lesions are large, circular patches with raised, red borders of vesicles, papules, or pustules. This question requires knowledge of tinea.

224) ANSWER

B) High Risk for Deficient Fluid Volume

RATIONALE

The client with DIC is at risk for hemorrhage, which takes priority over the non-life-threatening options 1 and 4. The client could experience bruising or other areas of local bleeding from the disorder, but hypovolemia from hemorrhage takes priority over risk for injury (option 3). The issue of the question is knowledge of complications of DIC, specifically hemorrhage and loss of circulating volume. With this in mind, focus on physiologically based nursing diagnoses, and eliminate options 1 and 4. Choose option 2 because it addresses a greater and more specific physiological risk.

223) Answer

B. B. With 15 minute intervals, the nurse begins to position patient into high-fowler’s, then instructs her to dangle her feet at the bedside, after this, she assists her to move from the bed to the chair and then, walk with her around the room.

Rationale

•Early walking after surgery prevents the development of complications. The nurse facilitates proper ambulation when she instructs the patient to perform leg exercises while in bed and positions her to high-Fowlers.

•Then, the patient is instructed to dangle her feet at the bedside. The patient may feel dizzy, nauseated, or faint so it must be performed slowly and with long intervals in between. Then, the patient is moved from the bed to the chair and should be assisted to walk around the room.

•Other options show inappropriate ambulation because the procedure was done too quickly and non-systematically.

222) Answer

B. Avoiding contact with people who have upper respiratory infections

Rationale

•Acute otitis media generally follows a respiratory infection, it is important to avoid contact with people having upper respiratory infections.

•Inflammation of the middle ear is the most prevalent disease of childhood after respiratory infections.

•There is a higher incidence of acute otitis media in formula-fed infants than those who are breast-fed because of the more slanted position that formula-fed infants are held in while feeding. This allows milk to enter the Eustachian tube.

•Most cases of acute otitis media are caused by bacteria and treated with antibiotics such as amoxicillin. If the infection is viral, antivirals are reserved for severe cases only.

221) Answer
B. Urine concentration

Rationale
•ADH concentrates the urine by reabsorbing water in the renal tubule aquaporins.
•Sodium reabsorption and potassium excretion is the responsibility of aldosterone.v

220) Answer
A. Administering I.V. therapy


Rationale
•Administering I.V. fluids and medication is USUALLY beyond the scope of an LPN. The LPN must have special training in order to administer I.V. fluids.
•The other options are all within the scope of an LPN.

219) Answer
B. Check the PCA pump to verify that the settings are correct

Rationale
•After stabilizing the patient from opioid toxicity, the nurse should verify that the patient was receiving the correct dosage. The ordered dosage was safe for an adult patient, so the error may have been programming the PCA pump.
•Requesting that the PCA be discontinued or that the dosage be lowered is not appropriate until the nurse investigates the reason for opioid toxicity.

218) ANSWER
A) Cefoxitan (Mefoxin)

RATIONALE
A disulfiram-like effect is associated with certain drugs, including metronidazole (Flagyl). Onset is usually within 15-30 minutes of ingestion of alcohol, but can occur up to 72 hours after Flagyl has been discontinued. The reaction lasts approximately 20-30 minutes but can remain up to 24 hours. The core issue of the question is knowledge of which drugs can cause a disulfiram-like reaction when used with alcohol. Use specific nursing knowledge and the process of elimination to make a selection.

217) ANSWER
C) Sodium bicarbonate, to make the client alkalotic so the potassium will shift into the ECF

RATIONALE
Sodium bicarbonate will temporarily alkalinize the plasma, causing the potassium to move into the cells. NS is an isotonic solution, and therefore will not cause fluid or electrolyte shifting. Calcium gluconate is given to blunt the effects on the myocardium; it does not decrease the serum K level. Insulin and dextrose are given to decrease K levels by increasing K uptake at the cellular level. A critical word is acidosis. Recall that potassium is increased in acidosis to direct you to option 3, in which alkalosis is the goal of treatment.

216) ANSWER
C) Chronic impairment of brain functioning

RATIONALE
The behaviors described in this situation are characteristic of clients with dementia, which is a possible late consequence of AIDS. The nurse should understand that the occurrence of symptoms indicates progression of the AIDS illness and that care should be planned accordingly. Option 1 is incorrect because an individual can live with dementia for some time before death occurs, either from AIDS or another cause. Option 2 is incorrect because the situation describes behaviors that are characteristic of the chronic progressive decline that is seen in persons with dementia. Option 4 is incorrect because the particular pattern of behaviors that is described are not particularly associated with the side effect profile of drugs used to control AIDS. Review usual progression patterns of AIDS. Recognize that the client and significant others have a right to know what is happening.

215) ANSWER
B) ST elevations

RATIONALE
ST elevations indicate immediate myocardial injury; ST depressions indicate myocardial ischemia; a Q wave forms several days after a myocardial infarction; a U wave is a sign of hypokalemia. Omit options 3 and 4 as not reflective of the acute phase of myocardial injury. Recall that ST elevations reflect injury.

214) ANSWER
C) Isoproterenol (Isuprel)

RATIONALE
Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol stimulates beta 1 and beta 2 receptors, and therefore should not be used with clients with tachydysrhythmias. In order to answer this question, recall knowledge of beta 1 and beta 2 stimulants and their effects on the heart. Use the process of elimination, and exclude those medications of the same category, to be led to the correct choice.

213) ANSWER
D) Acetaminophen (Tylenol)



RATIONALE
Medications such as acetaminophen (Tylenol) are highly metabolized by the liver and should be avoided. Other such drugs are barbiturates and sedatives. Options 1 and 2 are ordered to decrease the ammonia level, and option 3 may be ordered for pain. Omit options 1 and 2 as these are commonly used to reduce ammonia. Demerol is the better option for pain.

212) ANSWER
A) The signs and symptoms of pulmonary edema

RATIONALE
Medications used to treat symptoms of multiple sclerosis have been noted to increase pulmonary edema, leading to chest pain and shortness of breath. Option 2 could increase risk of urinary tract infection. Option 3 is useful to avoid infection, but does not specifically relate to medication teaching. Option 4 could increase fatigue, if done to excess, and lead to exacerbation of symptoms. The core issue of the question is knowledge of essential teaching points for a client being treated with drug therapy for multiple sclerosis. Use specific nursing knowledge and the process of elimination to make a selection.

211) ANSWER
A) Gestational trophoblastic disease


RATIONALE
The client has three risk factors of molar pregnancy: Japanese background, brownish, "prune juice" vaginal bleeding, and the severe nausea and vomiting associated with excessive hCG found in trophoblastic disease. The client has only one symptom of hyperemesis; placenta previa presents with bright red bleeding; and there is no information suggestive of psychosis. The core issue of this question is a cluster of symptoms. Eliminate options 2 and 3 because they are characterized by one main symptom. Eliminate option 4 because no psychological symptoms are presented.

210) ANSWER
C) Vitamins A and D

RATIONALE
Clients who are taking cholestyramine (which is a bile resin) should be monitored for fat-soluble vitamin deficiencies (Vitamins A, D, E, and K), as the gastrointestinal side effects of the medication can lead to reduced absorption. Niacin, thiamine, folic acid, cyanocobalamin, and Vitamin C (options 1, 2, and 4) are all examples of water-soluble vitamins. The core issue of the question is knowledge that cholestyramine places the client at risk for deficiency of fat-soluble vitamins. Use the process of elimination and reason that this answer is correct because the action of cholestyramine is to bind onto cholesterol (fat) and prevent its absorption into the GI tract.

209) ANSWER
C) Ask him to choose a face on the Wong FACES pain rating scale.

RATIONALE
Pain management is a high priority following gastric surgery, and the nurse should use age-appropriate tools to assess for pain, such as the Wong FACES rating scale. A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain gastric decompression. The child is kept NPO until bowel function returns. The use of a pH probe to measure gastric acidity is not necessary. The core issue of the question is knowledge of appropriate interventions in the first 24 hours following gastric surgery. Use knowledge that the gastric tube should not be manipulated or used for feeding to eliminate some options. Use nursing knowledge of routine postoperative care and the process of elimination to make a final selection.

208) 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.

207) ANSWER
C) Risk for injury related to disease state

RATIONALE
Because of their very fragile bones, children with OI experience countless fractures, and the prevention of injury takes highest priority in this child’s care. Pain would be important if a fracture actually occurs, but the key is prevention of fractures, making risk for injury more appropriate. Skin integrity impairment would also not be a concern unless a fracture actually occurred. Option 4 can be eliminated as the child is 4 years old and body image is not a great concern. Of the three remaining, choose the option that would be a concern throughout the care of this child.