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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Safe and Effective Care Environment | 17–33% | - Safety and Infection Control - Management of Care |
| Topic 2: Psychosocial Integrity | 6–12% | |
| Topic 3: Physiological Integrity | 43–67% | - Basic Care and Comfort - Physiological Adaptation - Pharmacological and Parenteral Therapies - Reduction of Risk Potential |
| Topic 4: Health Promotion and Maintenance | 6–12% |
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NEW QUESTION # 368
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?
Answer: C
Explanation:
(A) If awakened first, the child will know that nothing painful will be done without the child being alerted. (B) The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. (C) The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. (D) The parent will be able to offer support and comfort during and after the injection.
NEW QUESTION # 369
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.
NEW QUESTION # 370
A 32-year-old female client is being treated for Guillain-Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.
NEW QUESTION # 371
A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
NEW QUESTION # 372
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:
Answer: C
Explanation:
Explanation
(A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. (B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. (C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.
NEW QUESTION # 373
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