Select All That Apply Practice Exam Flashcards

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

Answer: Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.

Heart failure results in the heart's inability to pump sufficient blood to meet the body's metabolic demands, leading to decreased cardiac output. This reduced pumping efficiency directly causes decreased blood flow to peripheral tissues, resulting in 'Ineffective tissue perfusion.' This diagnosis accurately reflects a major physiological consequence of heart failure.

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.

Answer: Verify patency of the line by the presence of a blood return at regular intervals.

When administering chemotherapy via a central venous line, verifying patency and inspecting the insertion site are critical safety measures. A blood return confirms the catheter is correctly positioned within the vein, preventing extravasation of vesicant drugs. If blood return is absent, repositioning the client or encouraging a cough may help, but if patency remains questionable, the healthcare provider must be contacted to verify placement before proceeding with administration.

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Answer: Impulsiveness

Borderline Personality Disorder (BPD) is characterized by a pervasive pattern of instability in relationships, self-image, and emotions, along with marked impulsivity. Key features include impulsive behaviors (e.g., spending, substance abuse), rapid and intense shifts in mood (lability of mood), and self-destructive actions like self-mutilation or suicidal gestures. These symptoms contribute to the chaotic and unpredictable nature of the disorder.

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

Answer: The client functions well in other areas of his life.

Impulse control disorders, such as Intermittent Explosive Disorder, are characterized by recurrent aggressive outbursts that are grossly out of proportion to any provocation. Individuals often function well in other areas of their lives between episodes, but these outbursts are typically followed by distress, regret, or embarrassment. A history of parental alcoholism and chaotic, abusive family life are common risk factors contributing to the development of these disorders.

Which of the following nursing interventions are written correctly? (Select all that apply.)

Answer: Elevate head of bed 30 degrees before meals.

A correctly written nursing intervention should be specific, measurable, achievable, relevant, and time-bound (SMART). 'Elevate head of bed 30 degrees before meals' clearly specifies the action (elevate HOB), the degree (30 degrees), and the timing (before meals), making it a precise and actionable instruction. The other options lack sufficient detail regarding frequency, specific parameters, or timing.

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take.

Answer: Place the client in good body alignment

If peritoneal dialysis outflow is less than inflow, the nurse should first troubleshoot potential mechanical issues. Placing the client in good body alignment, repositioning them to their side, and checking for kinks in the tubing can help facilitate drainage by moving the catheter or resolving obstructions. Additionally, ensuring the drainage bag is below the client's abdomen utilizes gravity to promote outflow before escalating to physician notification.

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

Answer: Excess Fluid Volume

Chronic renal failure significantly impairs the kidneys' ability to excrete fluid and waste products. This leads to common issues such as 'Excess Fluid Volume' due to fluid retention, 'Imbalanced Nutrition; Less than Body Requirements' due to anorexia and dietary restrictions, and 'Activity Intolerance' resulting from anemia and the accumulation of toxins. These diagnoses directly reflect the physiological consequences and client responses to impaired kidney function.

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

Answer: Head tilt

Brain tumors in children often lead to increased intracranial pressure (ICP) and focal neurological deficits. Signs of increased ICP include vomiting (often projectile and without nausea) and lethargy. A head tilt can indicate cerebellar involvement or an attempt to compensate for visual disturbances or balance issues caused by the tumor.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Answer: Elevate the HOB to 90 degrees

Autonomic Dysreflexia is a medical emergency in clients with spinal cord injury at T6 or above, characterized by severe hypertension and a pounding headache. The priority interventions include elevating the head of the bed to lower blood pressure and identifying/removing the noxious stimulus, such as loosening constrictive clothing or assessing for bladder distention or bowel impaction. If these measures are insufficient, antihypertensive medication may be necessary to prevent complications like stroke.

A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:

Answer: Low self-esteem

Grandiose delusions, such as believing one is the Son of God, often serve as a psychological defense mechanism. These beliefs can compensate for profound feelings of inadequacy, worthlessness, or low self-esteem. By adopting an identity of immense power and importance, the individual attempts to escape painful realities about their own perceived deficiencies.

A client with a bowel resection and anastomosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?

Answer: The client’s abdomen is soft.

After a bowel resection with an NG tube to intermittent suction, the primary goal is to decompress the gastrointestinal tract and prevent distention. A soft abdomen indicates that the NG tube is effectively removing gas and fluid, preventing accumulation and reducing pressure on the surgical site. This is a key sign that the suction is working properly and achieving its therapeutic effect.

The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?

Answer: Tremulousness

Hypoglycemia, or low blood sugar, triggers the release of stress hormones like epinephrine, leading to characteristic adrenergic symptoms. Tremulousness (shaking or trembling) is a classic and early sign of hypoglycemia, along with palpitations, anxiety, and sweating. These symptoms serve as important warning signals for the client to intervene.

Which of the following symptoms is associated with exacerbation of multiple sclerosis?

Answer: Diplopia

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system, and its exacerbations involve new or worsening neurological symptoms. Diplopia, or double vision, is a very common symptom during MS exacerbations, resulting from demyelination of the cranial nerves that control eye movement. It often indicates an acute inflammatory attack affecting the visual pathways.

Which of the following conditions is most likely related to the development of renal calculi?

Answer: Gout

Gout is a metabolic disorder characterized by elevated levels of uric acid in the blood. High uric acid concentrations can lead to the formation of uric acid crystals, which can precipitate in the kidneys and form renal calculi (kidney stones). Therefore, gout is a significant risk factor for developing uric acid kidney stones.

A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?

Answer: Providing small, frequent meals

Clients with AIDS experiencing wasting syndrome often have limited intestinal absorptive capability due to the disease process and opportunistic infections. Providing small, frequent meals helps to maximize nutrient absorption by reducing the volume of food presented to the compromised digestive system at any one time. This approach also helps maintain consistent caloric intake and reduces gastrointestinal distress.

The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetidine. The purpose of the cimetidine is to:

Answer: Prevent a common side effect of prednisone

Prednisone, a corticosteroid, is known to increase the risk of gastric irritation and peptic ulcer formation as a common side effect. Cimetidine is an H2 receptor antagonist that reduces stomach acid production. Therefore, cimetidine is administered concurrently with prednisone to prevent or mitigate these gastrointestinal side effects, protecting the client's gastric lining.