86) ANSWER

D) Coffee

RATIONALE

Caffeine in coffee or tea can have an additive effect with theophylline, and therefore coffee should be eliminated from the meal tray. Peas (option 1), beans (option 2), and milk (option 3) are not problematic because they do not contain caffeine. Recall knowledge of the side effect of theophylline, vasodilation, to be led to the correct answer. By eliminating caffeine from the client s food tray, the additional additive effect of caffeine can be avoided.

85) ANSWER

C) Enuresis

RATIONALE

Childhood disorders that appear to be genetically transmitted include enuresis, autism, mental retardation, some language disorders, Tourette's syndrome, and attention-deficit hyperactivity disorder (ADHD). Of these, autism is the more pervasive disorder. Anxiety (option 1), sleepwalking (option 2), and oppositional defiance disorder (option 4) do not appear to be genetically transmitted. Notice that autism is a more pervasive problem than the other three options. Recall statistics about childhood mental health disorders to make a selection.

84) ANSWER

1. Left occipital anterior (LOA).

RATIONALE

1. The nurse’s findings upon performing

Leopold’s maneuvers indicate that the

fetus is in the left occiput anterior position

(LOA)—that is, the fetal back is felt

on the mother’s left side, the small parts

are felt on her right side, the buttocks

are felt in the fundal region, and the

head is felt above her symphysis.

2. The findings after the nurse performs

Leopold’s maneuvers do not indicate that

the fetus is in the left sacral posterior (LSP)

position; in that position, the fetus’s buttocks

(S or sacrum) are facing toward the mother’s

left posterior (LP), a hard round mass is felt

in the fundal region, and a soft round mass is

felt above the symphysis.

3. The findings after the nurse performs

Leopold’s maneuvers do not indicate that

the fetus is in the right mentum anterior

(RMA) position; in that position, the fetus’s

face (M or mentum) is facing toward themother’s right anterior (RA) and small

objects are felt on the right of the mother’s

abdomen with a flat area felt on the mother’s

left side.

4. The findings after the nurse performs

Leopold’s maneuvers do not indicate that

the fetus is in the right sacral posterior

(RSP) position; in that position, the fetus’s

sacrum (S) is facing the mother’s right posterior

(RP) and a hard round mass is felt in

the fundal region while a soft round mass is

felt above the symphysis.

83) ANSWER

 C)  Urinary output

RATIONALE

Calcium EDTA is toxic to the kidneys. Urine output must be measured to monitor renal function. 

82) ANSWER

B)  Eyes

RATIONALE

Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch. 

81) ANSWER

C)  Decreased potassium

RATIONALE

In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. 

80) ANSWER

A)  Hourly urine output

RATIONALE

Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition.