Nokea
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:
- A. Takes more time to remove
- B. Has a greater risk of becoming reoccluded
- C. Is smaller in diameter
- D. Has too many valves
Correct Answer: A
Rationale: It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it.
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A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.'
- B. If I have any side effects from my medicines, I will take an extra dose of Cogentin.'
- C. When I get home, I should be able to taper myself off the Haldol because the voices are gone now.'
- D. As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway.'
Correct Answer: A
Rationale: The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. This statement reflects lack of insight into the importance of compliance. This statement reflects no insight into his illness or his responsibility in health maintenance.
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Lactose-restricted diet
- B. Gluten-restricted diet
- C. Phenylalanine-restricted diet
- D. Fat-restricted diet
Correct Answer: B
Rationale: A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. A gluten-restricted diet is the diet for children with celiac disease. A phenylalanine-restricted diet is prescribed for children with phenylketonuria. A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
- A. Stage 2, latent phase
- B. Stage 1, active phase
- C. Stage 3, transition phase
- D. Stage 1, latent phase
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
The nurse asks a patient about current medications. Which one of the patient's medications is most likely to cause abdominal pain?
- A. Norco (hydrocodone/APAP)
- B. Erythrocin (erythromycin)
- C. Zyrtec (cetirizine)
- D. Aldactone (spironolactone)
Correct Answer: B
Rationale: Erythromycin commonly causes gastrointestinal side effects, including abdominal pain, due to its motility-stimulating effects. Norco may cause constipation, Zyrtec is less likely to affect the GI tract, and Aldactone’s side effects are primarily electrolyte-related.
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
- A. Adhering to a strict schedule of diet, exercise, and wound care
- B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- D. Allowing him to plan, assist in, and perform his own care whenever possible
Correct Answer: D
Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.