Correct Answer: A.

Pain on flexion of the hip and knee

Kernig’s sign is positive if pain occurs on flexion of the hip and knee. Kernig’s sign
is one of the physically demonstrable symptoms of meningitis. Severe stiffness of
the hamstrings causes an inability to straighten the leg when the hip is flexed to
90 degrees.
 Option B: The Brudzinski reflex is positive if pain occurs on flexion of the
head and neck onto the chest. Brudzinski’s sign is one of the physically
demonstrable symptoms of meningitis. Severe neck stiffness causes a
patient’s hips and knees to flex when the neck is flexed. Brudzinski’s sign is
used to diagnose meningitis.
 Option C: A tension headache may cause pain on the left side and behind
the eyes, and may be linked to stress. Tension headaches account for up to
42 percent of headaches worldwide. They may occur on one side so could
be the cause of a headache on the left side.
 Option D: Benign paroxysmal positional vertigo (BPPV) is one of the most
common causes of vertigo — the sudden sensation that you’re spinning or
that the inside of your head is spinning. BPPV causes brief episodes of mild
to intense dizziness. It is usually triggered by specific changes in the head’s
position. This might occur when one tips their head up or down, when the
client lies down, or when he turns over or sits up in bed.
Correct Answer: A. Agnosia
Agnosia is the term used to describe the loss of the ability to recognize what
objects are and what they are used for. For an instance, a person with agnosia
might try to use a fork instead of a spoon, a shoe instead of a cup or a knife
instead of a pencil etc. With regard to people, this might involve failing to
recognize who people are, not due to memory loss but rather as a result of the
brain not working out the identity of a person on the basis of the information
supplied by the eyes.
 Option B: Apraxia is the term used to describe the failure to carry out
voluntary and purposeful movements notwithstanding the fact that
muscular power, sensibility, and coordination are intact. In everyday terms,
this might involve the inability to tie shoelaces, turn a tap on, fasten
buttons or switch on a radio.
 Option C: Aphasia is the term used to describe a difficulty or loss of the
ability to speak or understand spoken, written or sign language as a result
of damage to the corresponding nervous center. This can become apparent
in a number of ways. It might involve exchanging a word which is linked by
meaning (e.g. time instead of clock), using the wrong word but one which
sounds alike (e.g. boat instead of coat) or using a totally different word with
no apparent connection. When accompanied by echolalia (the involuntary
repetition of words or phrases spoken by another person) and the constant
repetition of a word or phrase, the result can be a form of speech which is
difficult for others to understand or a kind of jargon.
 Option D: Anomia is a form of aphasia in which the patient is unable to
recall the names of everyday objects. Anomic aphasia is a language
disorder that leads to trouble naming objects when speaking and writing.
Brain damage caused by stroke, traumatic injury, or tumors can lead to
anomic aphasia.
Correct Answer: C. Sundowning
Increased confusion at night is known as “sundowning” syndrome. This increased
confusion occurs when the sun begins to set and continues during the night. The
term “sundowning” refers to a state of confusion occurring in the late afternoon
and spanning into the night. Sundowning can cause a variety of behaviors, such
as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead
to pacing or wandering.
 Option A: Fatigue is not necessarily present. Sundowning isn’t a disease,
but a group of symptoms that occur at a specific time of the day that may
affect people with dementia, such as Alzheimer’s disease. The exact cause
of this behavior is unknown.
  Option B: Increased confusion at night is not part of normal aging. Some
research suggests that a low dose of melatonin — a naturally occurring
hormone that induces sleepiness — alone or in combination with exposure
to bright light during the day may help ease sundowning.
 Option D: A delusion is a firm, fixed belief. Delusions are defined as fixed,
false beliefs that conflict with reality. Despite contrary evidence, a person in
a delusional state can’t let go of their convictions. Delusions are often
reinforced by the misinterpretation of events. Many delusions also involve
some level of paranoia. For example, someone might contend that the
government is controlling our every move via radio waves despite evidence
to the contrary.
Correct Answer: C. “I’ll get you some juice and toast. Would you like
something else?”
The client who is confused might forget that he ate earlier. Don’t argue with the
client. Simply get him something to eat that will satisfy him until lunch. Avoid
challenging illogical thinking. Challenges to the patient’s thinking can be
perceived as threatening and result in a defensive reaction. Maintain normal fluid
and electrolyte balance; establish/maintain normal nutrition, body temperature,
oxygenation (if patients experience low oxygen saturation treat with
supplemental oxygen), blood glucose levels, blood pressure.
 Option A: Orient patient to surroundings, staff, necessary activities as
needed. Present reality concisely and briefly. Avoid challenging illogical
thinking—defensive reactions may result. Increased orientation ensures a
greater degree of safety for the patient.
 Option B: This statement is validating the delusion. Encourage
family/SO(s) to participate in reorientation as well as providing ongoing
input (e.g., current news and family happenings). The confused patient may
not completely understand what is happening. The presence of family and
significant others may enhance the patient’s level of comfort.
 Option D: Communicate patient’s status, cognition, and behavioral
manifestations to all necessary providers. Recognize that a patient’s
fluctuating cognition and behavior is a hallmark for delirium and is not to be
construed as a patient preference for caregivers.
Correct Answer: D. Nausea
Nausea and gastrointestinal upset are very common in clients taking
acetylcholinesterase inhibitors such as Exelon. Other side effects include liver
toxicity, dizziness, unsteadiness, and clumsiness. The main adverse effects
associated with the use of rivastigmine are gastrointestinal. The primary
symptoms are nausea and vomiting. These acute effects primarily occur during
the initial dose-escalation phase of therapy upward dose titration of the drug to
achieve a therapeutic dose. These events can be minimized by using a slow
titration schedule and taking the medication with food if prescribing an oral
formulation.
 Option A: Toxicity to the drug, while rare, should be carefully monitored.
Common manifestations of toxicity include the presence of severe
gastrointestinal reactions, allergic cutaneous reactions, as well as central
nervous system effects. Classic manifestations of a patient in crisis can be
remembered by the mnemonic DUMBELS – diarrhea, urination, miosis,
bradycardia, excitability, lacrimation, salivation/excessive sweating prior to
treatment.
 Option B: The client might already be experiencing urinary incontinence or
headaches, but they are not necessarily associated. Patients that are
experiencing a cholinergic crisis should have atropine followed by
pralidoxime to reverse the anticholinergic effects of rivastigmine. While the
usual treatment of the crisis involves giving atropine before pralidoxime, a
case study done in 2009 showed a successful reversal of cholinergic crisis
with just pralidoxime without atropine pretreatment.
 Option C: The client with Alzheimer’s disease is already confused. With its
approval by the FDA, rivastigmine is indicated to treat mild to moderate
 dementia of the Alzheimer’s type. Its indications also include the treatment
of mild to moderate dementia that is associated with Parkinson’s disease.
Correct Answer: B. Report the finding to the doctor
Any lesion should be reported to the doctor. This can indicate a herpes lesion.
Clients with open lesions related to herpes are delivered by Cesarean section
because there is a possibility of transmission of the infection to the fetus with
direct contact to lesions. During pregnancy there is a higher risk of perinatal
transmission with primary HSV infection than with recurrent infection. If a primary
HSV outbreak is diagnosed in pregnancy, oral antiviral treatment may be
administered to help reduce the duration and severity of symptoms and viral
shedding.
 Option A: It is not enough to document the finding. Viral or serologic
testing should be performed to confirm suspected HSV infections; the basic
groups of tests used are viral and antibody detection techniques. For viral
detection, the primary testing techniques are viral culture and HSV antigen
detection by polymerase chain reaction.
 Option C: The physician must make the decision to perform a C-section.
Cesarean delivery is recommended to prevent perinatal HSV transmission
in women with active genital lesions or prodromal symptoms, but it is not
recommended for women with HSV lesions found only on nongenital areas,
such as the back, thigh, or buttock.
 Option D: It is not enough to continue primary care. Antiviral agents
commonly used to treat HSV infections are acyclovir (Zovirax), famciclovir
(Famvir), and valacyclovir (Valtrex), which are all U.S. Food and Drug
Administration pregnancy category B medications. For patients with more
severe HSV infection, oral treatment can be used for more than 10 days if
the lesions have not healed completely.
Correct Answer: B. Cervical cancer
The client with HPV is at higher risk for cervical and vaginal cancer related to this
STI. The Human Papillomavirus (HPV) is the initiating force behind multiple
epithelial lesions and cancers, predominantly of cutaneous and mucosal surfaces.
Today, HPV has been implicated as a cause of laryngeal, oral, lung and anogenital
cancer. Subtypes 6 and 11 are low risk and usually present with the formation of
condylomata and low-grade precancerous lesions. HPV subtypes 16 and 18 are
high risk and are responsible for high-grade intraepithelial lesions that progress to
malignancies.
 Option A: It is important to understand that HPV alone does not cause
cancer but requires triggers like smoking, folate deficiency, exposure to UV
light, immunosuppression, and pregnancy. Long-term follow-up is essential
as recurrence of warts is common. In addition, all treatments for warts have
side effects that need to be monitored.
 Option C: The prognosis after an HPV infection is good but recurrences are
common. Even though there are many treatments for warts, none works
well and most patients require repeated treatments. The HPV infection can
also result in vulvar intraepithelial dysplasia, cervical dysplasia, and cervical
cancer.
 Option D: Some women remain at high risk for developing vaginal and
anal cancer. The risk of malignant transformation is highest in
immunocompromised individuals. Finally, when a patient has been
diagnosed with HPV infection, there is a 5-20% risk of also having other
STDs like gonorrhea and/or chlamydia.
Correct Answer: B. Herpes
A lesion that is painful is most likely a herpetic lesion. Herpes genitalis can be
caused by the herpes simplex virus type 1 or type 2 and manifests as either a
primary or recurrent infection. Most commonly, viral replication occurs in
epithelial tissue and establishes dormancy in sensory neurons, reactivating
periodically as localized recurrent lesions. It remains one of the most common
sexually transmitted infections (STI) but continues to be underestimated, given
the vague presentation of its symptoms.
  Option A: A chancre lesion associated with syphilis is not painful. The
classic primary syphilis presentation is a solitary non-tender genital chancre
in response to invasion by the T. pallidum. However, patients can have
multiple non-genital chancres, such as digits, nipples, tonsils, and oral
mucosa. These lesions can occur at any site of direct contact with the
infected lesion and are accompanied by tender or nontender
lymphadenopathy.
 Option C: Gonorrhea does not present as a lesion, but is exhibited by a
yellow discharge. Although many females, more than 50%, will not manifest
symptoms of their gonococcal cervix infections, most males, more than
90%, will manifest urogenital gonorrhea symptomatically. The most
common clinical manifestations of gonococcal disease in males include
penile purulent discharge, dysuria, and testicular discomfort.
 Option D: Condylomata lesions are painless warts, so answer D is
incorrect. Patients will generally be concerned about the appearance of the
lesions, as they often cause psychological and psychosexual distress.
Condyloma acuminata may also be found incidentally during routine female
gynecological examinations.
Correct Answer: C. Fluorescent treponemal antibody (FTA)
Fluorescent treponemal antibody (FTA) is the test for treponema pallidum. The
fluorescent treponemal antibody absorption (FTA-ABS) test is a blood test that
checks for the presence of antibodies to Treponema pallidum bacteria. These
bacteria cause syphilis. Syphilis is a sexually transmitted infection (STI) that’s
spread through direct contact with syphilitic sores.
 Option A: The venereal disease research laboratory (VDRL) test is
designed to assess whether you have syphilis, a sexually transmitted
infection (STI). Syphilis is caused by the bacterium Treponema pallidum.
The bacterium infects by penetrating into the lining of the mouth or genital
area. The VDRL test doesn’t look for the bacteria that cause syphilis.
Instead, it checks for the antibodies your body makes in response to
antigens produced by cells damaged by the bacteria. Antibodies are a type
of protein produced by your immune system to fight off invaders like
bacteria or toxins. Testing for these antibodies can let your doctors know
whether you have syphilis.
 Option B: The rapid plasma reagin (RPR) test is a blood test that looks for
antibodies to syphilis. Syphilis is a sexually transmitted infection (STI) that
first causes symptoms seen with many other illnesses. Early symptoms
include rash, fever, swollen glands, muscle aches, and sore throat. The RPR
test looks for antibodies that react to syphilis in the blood. This means the
test doesn’t detect the actual bacteria that cause syphilis. Instead, it looks
for antibodies against substances given off by cells that have been harmed
by the bacteria.
 Option D: The Thayer-Martin culture is done for gonorrhea. It is used for
culturing and primarily isolating pathogenic Neisseria bacteria, including
Neisseria gonorrhoeae and Neisseria meningitidis, as the medium inhibits
the growth of most other microorganisms.
Correct Answer: D. Elevated hepatic enzymes
The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet
count. The syndrome of hemolysis, elevated liver enzymes, and low platelets,
otherwise referred to as HELLP syndrome, has historically been classified as a
complication or progression of severe preeclampsia. Genetic analysis of the
inheritability of predisposition for preeclampsia and/or HELLP syndrome in
pregnancy has also been explored. Results show both genetic and immunological
factors that play a role in pathogenesis.
 Option A: An elevated blood glucose level is not associated with HELLP.
One of the features of HELLP syndrome is microangiopathic hemolytic
anemia. Schistocytes or helmet cells, present on a peripheral blood smear
is diagnostic of microangiopathic hemolytic anemia, making peripheral
smears useful in the workup for HELLP syndrome.
  Option B: Platelets are decreased, not elevated, in HELLP syndrome. The
coagulation cascade is activated by adhesion of platelets on the activated
and damaged endothelium. Platelets release thromboxane A and serotonin,
causing vasospasm, platelet aggregation, and further endothelial damage.
The cascade only terminates with the delivery of the fetus. This causes the
usage of platelets and hence, thrombocytopenia.
 Option C: The creatinine levels are elevated in renal disease and are not
associated with HELLP syndrome. In the liver, intravascular fibrin deposits
give rise to sinusoidal obstruction, intrahepatic vascular congestion,
increased hepatic pressures leading to hepatic necrosis. This may
eventually result in intraparenchymal or subcapsular hemorrhage and
capsular rupture.
Correct Answer: A. The nurse places her thumb on the muscle inset in
the antecubital space and taps the thumb briskly with the reflex
hammer.
The biceps reflex is elicited by placing your thumb on the biceps tendon and
striking the thumb with the reflex hammer and observing the arm movement.
Repeat and compare with the other arm. Using a reflex hammer, deep tendon
reflexes are elicited in all 4 extremities. Note the extent or power of the reflex,
both visually and by palpation of the tendon or muscle in question.
 Option B: This elicits the triceps reflex. The triceps reflex is measured by
striking the triceps tendon directly with the hammer while holding the
patient’s arm with your other hand. Repeat and compare to the other arm.
The triceps reflex is mediated by the C6 and C7 nerve roots, predominantly
by C7.
 Option C: This elicits the patellar reflex. The patellar reflex is a deep
tendon reflex, mediated by the spinal nerves from the levels L2, L3, and L4
in the spinal cord, predominantly in the root L4. The patellar reflex test is
performed to determine the integrity of the neurological function, which is
accomplished by hitting the patellar tendon below the knee cap with a test
hammer
 Option D: This elicits the radial nerve. For the testing of the brachioradialis
reflex, the examiner places the patient in a seated position. From there, the
clinician uses his or her forearm to support the patient’s forearm in a
slightly pronated position. The physician supports the patient’s forearm
rather than asking the patient to maintain the position to achieve relaxation
of the muscle. Once in position, the physician delivers a series of quick hits
to the area of the styloid process of the radius at the point of brachioradialis
insertion.
Correct Answer: B. Brethine 10 mcg IV
Brethine is used cautiously because it raises the blood glucose levels. Terbutaline
can cause a temporary increase in the baby’s heart rate and blood sugar levels.
These side effects usually aren’t serious and are easy to treat after delivery if
they occur. There are concerns about long term use of this drug because the
incidence of danger to the baby increases.
 Option A: Magnesium sulfate is indicated to prevent seizures associated
with pre-eclampsia, and for control of seizures with eclampsia. Magnesium
levels must be monitored frequently by checking serum levels every 6 to 8
hours or clinically by following patellar reflexes or urinary output. If serum
concentration levels are low, a proper dose of magnesium sulfate can be
given parenterally to replete low serum concentrations with recommended
follow up laboratory testing.
 Option C: Stadol is indicated for labor pain in full-term (37 weeks gestation
or more) women without fetal distress in early labor. This medication is
used to treat moderate to severe pain, including pain from surgery, muscle
pain, and migraine headaches. Butorphanol is an opioid pain reliever similar
to morphine. It acts on certain centers in the brain to give pain relief.
 Option D: Ancef is generally acceptable for pregnant women. Controlled
studies in pregnant women show no evidence of fetal risk. Cefazolin is an
 antibiotic used to treat a wide variety of bacterial infections. It may also be
used before and during certain surgeries to help prevent infection. This
medication is known as a cephalosporin antibiotic. It works by stopping the
growth of bacteria.
Correct Answer: C. The infant is at high risk for respiratory distress
syndrome.
When the L/S ratio reaches 2:1, the lungs are considered to be mature. The
Lecithin-to-Sphingomyelin Ratio (L/S ratio) is one of several methods for clinicians
to assess fetal lung maturation. This biochemical test was first introduced in the
1970s, where a sample of amniotic fluid was collected via amniocentesis to
determine the risk of the neonate developing respiratory distress syndrome
(RDS). The sample was then evaluated, utilizing thin-layer chromatography to
assess the size of lecithin relative to sphingomyelin.
 Option A: The L/S ratio does not indicate congenital anomalies. Based on
new guidelines, these indications no longer warrant testing the L/S ratio or
performing other fetal lung testing modalities. One possible exception
relates to inaccurate dating of the gestational age. If there is poor dating of
the pregnancy and the delivery is to be planned between 32 to 39 weeks
gestation, the clinician may consider testing for fetal lung maturity.
 Option B: The infant is not at risk for intrauterine growth retardation. The
main focus of testing the L/S ratio is to determine fetal lung maturity in an
effort to decrease the risk of delivering a neonate with respiratory distress
syndrome (RDS). RDS predominantly occurs in preterm infants less than 39
weeks gestation with increased risk with lesser gestational age.
 Option D: The infant will most likely be small for gestational age and will
not be at risk for birth trauma. The normal L/S ratio is 2.0 to 2.5 and is
significant for appropriate fetal lung development. An L/S ratio of less than
2.0 is significant for immature fetal lung development. For patients who
have poorly controlled diabetes, there was a discussion for the L/S ratio to
be 3.0 due to elevated maternal glucose impacting the maturity of the
developing fetal lungs.
Correct Answer: C. Jitteriness
Jitteriness is a sign of seizure in the neonate. For infants presenting with clinical
signs compatible with hypoglycemia, like apnoea, hypotonia, jitteriness, apathy,
hypothermia, tremors and seizures, treatment must ensure that blood glucose
levels remain above 0.45 g/L (2.5 mmol/L). An IV bolus dose of glucose (150-200
mg/kg) should be administered urgently, followed by a constant rate infusion.
 Option A: It’s normal for a baby to cry for 2–3 hours a day for the first 6
weeks. During the first 3 months of life, they cry more than at any other
time. New parents often are low on sleep and getting used to life with their
little one.
 Option B: Generally, newborns sleep a total of about 8 to 9 hours in the
daytime and a total of about 8 hours at night. But because they have a
small stomach, they must wake every few hours to eat. Most babies don’t
start sleeping through the night (6 to 8 hours) until at least 3 months of
age. But this can vary a lot. Some babies don’t sleep through the night until
closer to 1 year.
 Option D: It is also common for newborns to hiccup, sneeze, yawn, spit up,
burp, and gurgle. Sometimes newborns cry for no reason at all. If this
happens, try comforting the baby by rocking, singing, talking softly, or
wrapping him or her in a blanket.
Correct Answer: B. Hypersomnolence
The client is expected to become sleepy, have hot flashes, and be lethargic.
Patients most commonly complain of minor facial flushing and warmth with the
administration; however, symptoms typically resolve spontaneously. In patients
with neuromuscular disease, such as in myasthenia gravis, the neuromuscular
function may become worse at lower concentrations of medication.
 Option A: Magnesium levels must be monitored frequently by checking
serum levels every 6 to 8 hours or clinically by following patellar reflexes or
 urinary output. If serum concentration levels are low, a proper dose of
magnesium sulfate can be given parenterally to replete low serum
concentrations with recommended follow up laboratory testing.
 Option C: If the patient is on a continuous magnesium sulfate infusion,
serum levels must be accounted for as symptoms related to
hypermagnesemia may become clinically evident. At supratherapeutic
serum concentrations, absent reflexes, abnormal cardiac conduction, and
muscle weakness may occur.
 Option D: Decreased respirations indicate a magnesium sulfate toxicity. If
patients exhibit signs and symptoms of hypermagnesemia, the
recommendation is to discontinue magnesium sulfate products
immediately. If the patient consumed magnesium sulfate orally, then the
use of magnesium-free enemas or cathartics can be useful in removing
excess magnesium from the GI tract.
Correct Answer: D. Increase the rate of the IV infusion
If the client experiences hypotension after an injection of epidural anesthetic, the
nurse should turn her to the left side, apply oxygen by mask, and speed the IV
infusion. If the blood pressure does not return to normal, the physician should be
contacted. Epinephrine should be kept for emergency administration.
 Option A: Placing the client in Trendelenburg position (head down) will
allow the anesthesia to move up above the respiratory center, thereby
decreasing the diaphragm’s ability to move up and down and ventilate the
client.
 Option B: The IV rate should be increased, not decreased. Monitoring the
patient hemodynamic status during the procedure is very important. The
minimum monitors required are pulse oximeter for pulse and oxygen
saturation as well as blood pressure cuff and continuous EKG to assess
cardiovascular status.
 Option C: The oxygen should be applied by mask, not cannula. Epidural
anesthesia is achievable using either the classic epidural, the combined
spinal-epidural (CSE) technique, or dural puncture epidural (DPE). CSE and
DPE include an additional step consisting of delivering a spinal dose of LA
and co adjuvants (CSE) or only puncturing the dura mater (DPE) using a
spinal needle.
Correct Answer: A. Alteration in nutrition
Cancer of the pancreas frequently leads to severe nausea and vomiting and
altered nutrition. Weight loss occurs in about 90% of patients. Abdominal pain
occurs in about 75% of patients. Weakness, pruritus from bile salts in the skin,
anorexia, palpable, non-tender, distended gallbladder, acholic stools, and dark
urine.
 Option B: Patients with adenocarcinoma of pancreas typically present with
painless jaundice (70%) usually due to obstruction of the common bile duct
from the pancreatic head tumor. Lab findings will include elevation in liver
function tests, direct and total bilirubin levels, elevated amylase and lipase,
and elevated pancreatic tumor markers (CA 19-9 and CEA).
 Option C: Neoadjuvant first approach in resectable pancreatic
adenocarcinoma is implemented more and more frequently at high-volume
centers nationwide and internationally. The rational behind neoadjuvant
first approach is that the patient is in their best shape to receive
chemotherapy and at best odds of completing chemotherapy for 4-6
months. In addition, tissue is thought to be still well-oxygenated having not
gone through a large procedure such as the Whipple.
 Option D: For patients with metastatic, stage IV, pancreatic cancer,
discussions with the patient regarding treatment are essential. One can
receive chemotherapy. However, the life prolongation will be at best
months, yet affect the toxicity and effects of the chemotherapy. It is
important to keep nutrition on the forefront of the patient’s care as nutrition
can affect wound healing.
Correct Answer: C. Daily measurement of abdominal girth
Measuring with a paper tape measure and marking the area that is measured is
the most objective method of estimating ascites. Ascites is the pathologic
accumulation of fluid within the peritoneal cavity. It is the most common
complication of cirrhosis and occurs in about 50% of the patient with
decompensated cirrhosis in 10 years. The development of ascites denotes the
transition from compensated to decompensated cirrhosis.
 Option A: The initial tests that should be performed on the ascitic fluid
include a blood cell count, with both a total nucleated cell count and
polymorphonuclear neutrophils (PMN) count, and a bacterial culture by
bedside inoculation of blood culture bottles. Ascitic fluid protein and
albumin are measured simultaneously with the serum albumin level to
calculate the serum-ascites albumin gradient (SAAG).
 Option B: Palpation of the liver will not determine the amount of ascites.
The first abnormality that develops is portal hypertension in the case of
cirrhosis. Portal pressure increases above a critical threshold and circulating
nitric oxide levels increase, leading to vasodilation. As the state of
vasodilatation becomes worse, the plasma levels of vasoconstrictor sodium-
retentive hormones elevate, renal function declines, and ascitic fluid forms,
resulting in hepatic decompensation.
 Option D: Inspecting and checking for fluid waves are more subjective.
Patients typically report progressive abdominal distension that may be
painless or associated with abdominal discomfort, weight gain, early
satiety, shortness of breath, and dyspnea resulting from fluid accumulation
and increased abdominal pressure. Symptoms such as fever, abdominal
tenderness, and confusion can be seen in spontaneous bacterial peritonitis.
Correct Answer: B. Fluid volume deficit
The vital signs indicate hypovolemic shock. Monitor and document vital signs
especially BP and HR. Decrease in circulating blood volume can cause
hypotension and tachycardia. Alteration in HR is a compensatory mechanism to
maintain cardiac output. Usually, the pulse is weak and may be irregular if
electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.
 Option A: The oxygen and nutrients subsequently diffuse from the blood
into the interstitial fluid and then into the body cells. Insufficient arterial
blood flow causes decreased nutrition and oxygenation at the cellular level.
Decreased tissue perfusion can be temporary, with few or minimal
consequences to the health of the patient, or it can be more acute or
protracted, with potentially destructive effects on the patient.
 Option C: Ineffective airway clearance is the inability to clear secretions or
obstructions from the respiratory tract to maintain a clear airway.
Appropriate management is vital to prevent potentially life-threatening
hypovolemic shock. Older patients are more likely to develop fluid
imbalances. The goals of management are to treat the underlying disorder
and return the extracellular fluid compartment to normal, to restore fluid
volume, and to correct any electrolyte imbalances.
 Option D: Alterations sensory / perceptual (visual, auditory, kinesthetic,
gustatory, tactile, olfactory) State in which an individual experiences a
change in the amount or type of stimuli received, accompanied decrease
towards exaggeration or disorder of the response to such stimuli.
Correct Answer: A. Likes to play football
The client with osteogenesis imperfecta is at risk for pathological fractures and is
likely to experience these fractures if he participates in contact sports. The client
might experience symptoms of hypoxia if he becomes dehydrated or
deoxygenated; extreme exercise, especially in warm weather, can exacerbate the
condition.
 Option B: Osteogenesis imperfecta (OI) is a genetic disorder of connective
tissues caused by an abnormality in the synthesis or processing of type I
collagen. It is also called brittle bone disease. It is characterized by an
increased susceptibility to bone fractures and decreased bone density.
Other manifestations include blue sclerae, dentinogenesis imperfecta, short
 stature, as well as deafness in adulthood. There are also reports of valvular
insufficiencies and aortic root dilation.
 Option C: Osteogenesis imperfecta is a rare genetic disease. In the
majority of cases, it occurs secondary to mutations in the COL1A1 and
COL1A2 genes. More recently, there has been the identification of diverse
mutations related to OI.
 Option D: Milder manifestations include generalized laxity, easy bruising,
hernias, and excess sweating. Clinical manifestations range from mild with
a nearly asymptomatic form to most severe forms (involving infants
presenting with crumpled ribs, fragile cranium, and long bone fractures
incompatible with life) resulting in perinatal mortality.
Correct Answer: D. Tell the family members to take the fruit home
The client with neutropenia should not have fresh fruit because it should be
peeled and/or cooked before eating. He should also not eat foods grown on or in
the ground or eat from the salad bar. The nurse should remove potted or cut
flowers from the room as well. Any source of bacteria should be eliminated, if
possible.
 Option A: Educate clients and SO about appropriate methods for cleaning,
disinfecting, and sterilizing items. Knowledge of ways to reduce or eliminate
germs reduces the likelihood of transmission.
 Option B: Perform measures to break the chain of infection and prevent
infection. Assist clients in carrying out appropriate skin and oral hygiene.
Instruct clients to perform hand hygiene when handling food or eating.
 Option C: Place the patient in protective isolation if the patient is at high
risk of infection. Protective isolation is set when the WBC indicates
neutropenia. Wear personal protective equipment (PPE) properly.
Correct Answer: B. Increase the infusion of Dextrose in normal saline
Dextrose in normal saline is indicated as a source of water, electrolytes, and
calories. Early complications after total laryngectomy are bleeding, postoperative
edema, and airway compromise, these, especially in the immediate
postoperative, should be carefully monitored.
 Option A: In clients who have not had surgery to the face or neck,
however, in this situation, this could further interfere with the airway.
Increasing the infusion and placing the client in supine position would be
better.
 Option C: Administration of atropine IV is not necessary at this time and
could cause hyponatremia and further hypotension. Administration of
corticosteroids is recommended to minimize postoperative edema and
airway compromise, hematoma or seroma, that should be prompt surgically
evacuated, wound infection related to the perioperative exposure of the
wound to bacteria, it could be minimized using a broad-spectrum antibiotic
coverage and pharyngocutaneous fistula; total laryngectomy patients are at
risk for pharyngeal suture line dehiscence with a resultant
pharyngocutaneous fistula.
 Option D: Moving the emergency cart at the bedside is not necessary at
this time. The primary goal for the treatment of laryngeal cancer is the
control of the disease. Preservation of speech, swallowing functions, and
avoidance of the tracheostomy are secondary goals. Traditionally the
treatment of laryngeal carcinomas has been radiotherapy or surgery or a
combination of both.
Correct Answer: C. Cover the insertion site with a Vaseline gauze
If the client pulls the chest tube out of the chest, the nurse’s first action should be
to cover the insertion site with an occlusive dressing. Afterward, the nurse should
call the doctor, who will order a chest x-ray and possibly reinsert the tube. A chest
tube may be inserted at the bedside, in the procedure room, or in the surgical
suite. Health care providers often assist physicians in the insertion and removal of
a closed chest tube drainage system.
 Option A: A chest tube falling out is an emergency. Immediately apply
pressure to the chest tube insertion site and apply sterile gauze or place a
 sterile Jelonet gauze and dry dressing over the insertion site and ensure
tight seal. Apply dressing when the patient exhales. If a patient goes into
respiratory distress, call a code. Notify primary health care providers to
reinsert new chest tube drainage systems.
 Option B: A chest tube drainage system disconnecting from the chest tube
inside the patient is an emergency. Immediately clamp the tube and place
the end of the chest tube in sterile water or NS. The two ends will need to
be swabbed with alcohol and reconnected.
 Option D: After initial insertion of a chest tube drainage system, assess the
patient every 15 minutes to 1 hour. Once the patient is stable, and
depending on the condition of the patient and the amount of drainage,
monitoring may be less frequent. If the patient is stable (vital signs within
normal limits; drainage amount, colour, or consistency is within normal
limits; the patient is not experiencing any respiratory distress or pain),
assessment may be completed every 4 hours. Always follow hospital policy
for frequency of monitoring a patient with a chest tube.
Correct Answer: A. Assess for signs of abnormal bleeding
The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an
extremely prolonged Protime and can result in a spontaneous bleeding episode.
Patients receiving treatment with warfarin should have close monitoring to ensure
the safety and efficacy of the medication. Periodic blood testing is the
recommendation to assess the patient’s prothrombin time (PT) and the
international normalized ratio (INR).
 Option B: The laboratory parameter utilized to monitor warfarin therapy is
the PT/INR. The PT is the number of seconds it takes the blood to clot, and
the INR allows for the standardization of the PT measurement depending on
the thromboplastin reagent used by a laboratory. Therefore, monitoring a
patient’s INR while on warfarin is strongly preferable over PT because it
allows for a standardized measurement without variations due to different
laboratory sites.
 Option C: When managing warfarin toxicity, the initial step would be to
discontinue warfarin and then administer vitamin K (phytonadione). The
vitamin K may administration can be either via the oral, intravenous, or
subcutaneous route. However, the initial administration of oral vitamin K is
often preferable in patients without major bleeding or extremely elevated
INR.
 Option D: Patients also require close monitoring for signs and symptoms of
active bleeding throughout their treatment. Close monitoring for signs and
symptoms of bleeding, such as dark tarry stools, nosebleeds, and
hematomas, is necessary. The patient’s hemoglobin and hematocrit level
should undergo an assessment before initiating warfarin and approximately
every six months while on therapy.
Correct Answer: C. A cup of yogurt
The food with the most calcium is the yogurt, which has approximately 400 mg of
calcium. A growing baby needs a considerable amount of calcium to develop. If
the mother does not consume enough calcium to sustain the needs of the
developing baby, the body will take calcium from the bones, decreasing bone
mass and putting the mother at risk for osteoporosis. Osteoporosis causes
dramatic thinning of the bone, resulting in weak, brittle bones that can easily be
broken.
 Option A: Eat a variety of foods to get all the nutrients you need.
Recommended daily servings include 6-11 servings of breads and grains,
two to four servings of fruit, four or more servings of vegetables, four
servings of dairy products, and three servings of protein sources (meat,
poultry, fish, eggs or nuts).Consume fats and sweets sparingly.
 Option B: Choose foods high in fiber that are enriched, such as whole-grain
breads, cereals, beans, pasta and rice, as well as fruits and vegetables.
Although it’s best to get fiber from foods, taking a fiber supplement can
help get the necessary amount.
  Option D: A glass of fruit juice is mainly rich in vitamin C and fiber. Choose
at least one good source of vitamin C every day, such as oranges,
grapefruits, strawberries, honeydew, papaya, broccoli, cauliflower, Brussels
sprouts, green peppers, tomatoes, and mustard greens. Pregnant women
need 80 – 85 mg of vitamin C a day.
Correct Answer: C. The nurse inserts a Foley catheter.
The client receiving magnesium sulfate should have a Foley catheter in place, and
hourly intake and output should be checked. Strict intake and output will be
assessed throughout the magnesium sulfate infusion. Record urinary output at
least every 1 hour if Foley catheter is in place. Otherwise, measure and record all
voids. Urine output should be at least 30 mL/hour while administering magnesium
sulfate. If less, notify the provider of decreased urine output.
 Option A: There is no need to refrain from checking the blood pressure in
the right arm. Before beginning any infusion of magnesium sulfate, the
primary RN will obtain baseline vital signs (temperature, pulse, respirations,
blood pressure, and O2 saturation). Baseline fetal heart rate (FHR), deep
tendon reflexes (DTRs), clonus, bilateral breath sounds, urinary output, and
activity will be assessed and documented in the Electronic Health Record
(EHR).
 Option B: A padded tongue blade should be kept in the room at the
bedside, just in case of a seizure, but this is not related to the magnesium
sulfate infusion. Temperature is assessed every 4 hours, unless rupture of
membranes. Once membranes have ruptured, temperature will be assessed
every 2 hours. If febrile (? 100.4) provider will be notified and temperature
will be assessed hourly thereafter.
 Option D: Darkening the room is unnecessary. Inform staff and visitors of
the need to maintain a quiet environment, and avoidance of excessive
visitation and environmental stimulation. Include assessment of epigastric
pain, visual disturbances, edema, headache, level of consciousness, and
lung auscultation prior to start of infusion and every 2 hours throughout
infusion or more frequently as condition indicates.
Correct Answer: D. Notify the physician of the mother’s refusal
If the client’s mother refuses the blood transfusion, the doctor should be notified.
Because the client is a minor, the court might order treatment. Appropriate
management of such patients entails understanding of ethical and legal issues
involved, providing meticulous medical management, use of prohemostatic
agents, essential interventions and techniques to reduce blood loss and hence,
reduce the risk of subsequent need for blood transfusion.
 Option A: It is inappropriate to ask the mother to leave during blood
transfusion, especially as she has not consented to it. Respect for patient’s
autonomy and human rights require obtaining informed consent before any
medical intervention. This is fundamental to good medical practice. The
rejection of blood transfusions causes an ethical dilemma between the
patient’s freedom to accept or to reject a medical treatment even unto
death (i.e., autonomy), and the physician’s duty to provide optimal
treatment.
 Option B: It is better to discuss with patients the specifics of blood
transfusion refusal, if possible. A mentally competent individual has an
absolute moral and legal right to refuse or reject the consent for medical
treatment or transfusion except when he has diminished decision-making
capacity or a legal intervention mandates treatment.
 Option C: It is the physician’s primary responsibility to explain the
consequences to the mother and try to encourage her to consent for the
procedure. It is important to convince that every attempt will be made to
avoid blood, but also convey that a doctor would not allow a child to let die
for lack of blood transfusion. In the UK, children under 16 years of age can
legally give consent if they can understand the issues involved (Gillick
Competence).
Correct Answer: B. Laryngeal edema
 The nurse should be most concerned with laryngeal edema because of the area of
burn. For burns classified as severe (> 20% TBSA), fluid resuscitation should be
initiated to maintain urine output > 0.5 mL/kg/hour. One commonly used fluid
resuscitation formula is the Parkland formula. The total amount of fluid to be
given during the initial 24 hours = 4 ml of LR × patient’s weight (kg) × % TBSA.
 Option A: Severe burns cause not only significant injury at the local burn
site but also a systemic response throughout the body. Inflammatory and
vasoactive mediators such as histamines, prostaglandins, and cytokines are
released causing a systemic capillary leak, intravascular fluid loss, and
large fluid shifts. These responses occur mostly over the first 24 hours
peaking at around six to eight hours after injury. This response, along with
decreased cardiac output and increased vascular resistance, can lead to
marked hypovolemia and hypoperfusion called “burn shock.”
 Option C: Patient’s vital signs, mental status, capillary refill and urine
output must be monitored and fluid rates adjusted accordingly. Urine
output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in
children less than 30kg is a good target for adequate fluid resuscitation.
Recent literature has raised concerns about complications from over-
resuscitation described as “fluid creep.” Again, adequate fluid resuscitation
is the goal.
 Option D: The primary survey assesses the A.B.C.s for life-threats. In the
burn patient, attention should focus on the airway looking for oral burns
that might cause swelling and obstruction, breathing problems from smoke
inhalation or lung injury, and bleeding or circulation problems by looking for
life-threatening bleeding and checking blood pressure, heart rate, and
pulses. The next step would be resuscitation and immediate intervention for
life-threats.
Correct Answer: D. The client gains weight.
The client with anorexia shows the most improvement by weight gain. Expect
weight gain of about 1 lb (0.5 kg) per week to see the effectiveness of the
treatment regimen. Establish a minimum weight goal and daily nutritional
requirements. Malnutrition is a mood-altering condition, leading to depression and
agitation and affecting cognitive function and decision making. Improved
nutritional status enhances thinking ability, allowing initiation of psychological
work.
 Option A: Selecting a balanced diet does little good if the client will not
eat. Make a selective menu available, and allow the patient to control
choices as much as possible. Patient who gains confidence in herself and
feels in control of the environment is more likely to eat preferred foods.
 Option B: The hematocrit might improve by several means, such as blood
transfusion, but that does not indicate improvement in the anorexic
condition. Use a consistent approach. Sit with the patient while eating;
present and remove food without persuasion and comment. Promote a
pleasant environment and record intake. Patient detects urgency and may
react to pressure. Any comment that might be seen as coercion provides
focus on food. When staff responds in a consistent manner, the patient can
begin to trust staff responses. The single area in which the patient has
exercised power and control is food or eating, and he or she may
experience guilt or rebellion if forced to eat. Structuring meals and
decreasing discussions about food will decrease power struggles with the
patient and avoid manipulative games.
 Option C: The tissue turgor indicates fluid stasis, not an improvement of
anorexia. Maintain a regular weighing schedule, such as Monday and Friday
before breakfast in the same attire, and graph results. Provides an accurate
ongoing record of weight loss or gain. Also diminishes obsessing about
changes in weight.
.
 Correct Answer: D. Paresthesia of the toes

Paresthesia is not normal and might indicate compartment syndrome. Acute

compartment syndrome occurs when there is increased pressure within a closed
osteofascial compartment, resulting in impaired local circulation. Acute
compartment syndrome is considered a surgical emergency since, without proper
treatment, it can lead to ischemia and eventually necrosis.

.
 Option A: At this time, pain beneath the cast is normal. Pain is typically
severe, out of proportion to the injury. Early on, pain may only be present
with passive stretching. However, this symptom may be absent in advanced
acute compartment syndrome. In the initial stages, pain may be
characterized as a burning sensation or as a deep ache of the involved
compartment.
 Option B: Classically, the presentation of acute compartment syndrome
has been remembered by “The Five P’s”: pain, pulselessness, paresthesia,
paralysis, and pallor. However, aside from paresthesia, which may occur
earlier in the course of the condition, these are typically late findings.
 Option C: Pulses should be present. Beware that the presence or absence
of a palpable arterial pulse may not accurately indicate relative tissue
pressure or predict the risk for compartment syndrome. In some patients, a
pulse is still present, even in a severely compromised extremity.