- (Topic 5)
During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:
Correct Answer:
A
(A) The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. (B) Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. (C) Echopraxia is mimicking the movements of another person. (D) Echolalia is mimicking the speech of another person.
- (Topic 4)
The most frequent cause of early postpartum hemorrhage is:
Correct Answer:
C
(A) Hematomas, which are the result of damage to a vessel wall without laceration of the tissue, are a cause, though not the most frequent cause. (B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less common. (C) The most frequent causes of hemorrhage in the postpartal period are related to an interference with involution of the uterus. Uterine atony is the most frequent cause, occurring in the first 24 hours after delivery. (D) Retained placental fragments are also a cause, although these bleeds usually occur 7–14 days after delivery.
- (Topic 4)
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
Correct Answer:
D
(A) Respiratory rate is not directly affected by digoxin therapy. (B) A radial pulse is not as accurate as an apical pulse. Dysrhythmias may not be detected. (C) A radial pulse is not as accurate as an apical pulse, regardless of assessment time. (D) Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
- (Topic 4)
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
Correct Answer:
B
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
- (Topic 5)
At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
Correct Answer:
B
(A) Bradycardia of 50–70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. (B) The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. (C) Re- establishment of normal bowel function is delayed into the first postpartum week. (D) A postpartum woman??s oral temperature may go as high as 100.4_F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.
