A 25-year-old client was admitted yesterday after a motor vehicle collision.

A 25-year-old client was admitted yesterday after a motor vehicle collision.Neurodiagnostic studies showed a basal skull fracture in the middle fossa.Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?

Rationale:

Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature (B), because the fracture leaves the meninges open to bacterial invasion. Clients may experience (C and D), but these findings do not pose as great a life-threatening risk as infection. Jugular distention (A) is not a typical complication of basal skull fractures.A.Bilateral jugular venous distention B.Oral temperature 102° F C.Intermittent focal motor seizures D.Intractable pain in the cervical region Submit

Incorrect | Correct Answer: B

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

Rationale:

Thin, nonelastic skin (C), is an important factor in decubitus formation. Proportion of body fat to lean mass increases with age (A), and might help decrease ulcer tendency. (B) results in gray hair. (D) can contribute to broken bones, but it is probably not a factor in decubitus formation.A.16% increase in overall body fat B.Reduced melanin production C.Thinning of the skin with loss of elasticity D.Calcium loss in the bones Submit

Incorrect | Correct Answer: C

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

Rationale:

Thin, nonelastic skin (C), is an important factor in decubitus formation. Proportion of body fat to lean mass increases with age (A), and might help decrease ulcer tendency. (B) results in gray hair. (D) can contribute to broken bones, but it is probably not a factor in decubitus formation.A.16% increase in overall body fat B.Reduced melanin production C.Thinning of the skin with loss of elasticity D.Calcium loss in the bones Submit

Incorrect | Correct Answer: C

Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?1

MED-SURG NCLEX QUESTIONS AND ANSWERS

Rationale:

Microalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end stage renal disease caused by diabetic nephropathy. (C) may be elevated in end stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA).A.Hypokalemia B.Microalbuminuria C.Elevated serum lipids D.Ketonuria Submit

Incorrect | Correct Answer: B

When preparing a male client who has had a total laryngectomy for discharge, what instruction would be most important for the nurse to include in the discharge teaching?

Rationale:

It is imperative that total neck breathers carry a medical alert card (C) that notifies healthcare personnel of the need to use mouth-to-stoma breathing in the event of a cardiac arrest in this client. Mouth-to-mouth resuscitation will not establish a patent airway. (A and D) are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence upon writing messages (B) is probably the least effective.A.Recommend that the client carry suction equipment at all times.B.Instruct the client to have writing materials with him at all times.C.Tell the client to carry a medic alert card that explains his condition.D.Caution the client not to travel outside of the United States alone.Submit

Correct | Correct Answer: C

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?

Rationale:

Weight-bearing exercise is an important measure to reduce the risk of osteoporosis.Of the activities listed, cross-country skiing (A) includes the most weight-bearing, while (B, C, and D) involve less.A.Cross-country skiing B.Scuba diving C.Horseback riding D.Kayaking Submit

Incorrect | Correct Answer: A

An antacid (Maalox) is prescribed for a client with peptic ulcer disease. What is the therapeutic action of this medication which is effective in treating the client's ulcer?2

Rationale:

The objective of antacids is to neutralize gastric acids and keep a pH of 3.5 or above (C) which is necessary for pepsinogen inactivity. (A) is the therapeutic effect of H2 receptor antagonists, such as ranitidine (Zantac). (B) is the therapeutic effect of sucralfate (Carafate). (D) is the therapeutic effect of anticholinergic drugs such as propantheline bromide (Pro-Banthine) used as adjunctive therapy with antacids.A.Decrease in the production of gastric secretions B.Production of an adherent barrier over the ulcer C.Maintenance of a gastric pH of 3.5 or above D.Decrease in the gastric motor activity Submit

Correct | Correct Answer: C

A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection?

Rationale:

(A) is at greatest risk for developing sexually transmitted diseases, including HIV, because the greater the number of sexual partners one has, the greater the risk for contracting STDs. (B) comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. (C), who free-bases, would not be sharing needles, so contracting STDs is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV, as long as both partners are monogamous and neither is infected (D).A.A 17-year-old who is sexually active with numerous partners B.A 45-year-old lesbian who has been sexually active with two partners in the past year C.A 30-year-old cocaine user who inhales the drug and works in a topless bar D.A 34-year-old male homosexual who is in a monogamous relationship Submit

Incorrect | Correct Answer: A

A female practical nurse (PN) who is a valued employee tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident.She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?

Rationale:

Temporary reassignment (D) is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. (A) is not the best option, because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination (B). Implying that the PN is somehow creating the situation is inappropriate until further evaluation is conducted (C).A.Notify the family that the resident will have to be discharged if his behavior does not improve.B.Notify administration of the PN's insubordination and need for counseling about her statements.C.Ask the PN what she has done to encourage the resident to 3

believe that she is his daughter.D.Reassign the PN until the resident can be assessed more completely for reality orientation.Submit

Incorrect | Correct Answer: D

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?

Rationale:

A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are 2 to 5 times higher than the normal value (A). Severe, boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the immediate importance that a positive Trousseau sign has.A.The client's amylase level is three times higher than the normal level.B.While the nurse is taking the client's blood pressure, he has a carpal spasm.C.On a 1 to 10 scale the client tells the nurse that his epigastric pain is at 7.D.The client states that he will continue to drink alcohol after going home.Submit

Incorrect | Correct Answer: B

The nurse is receiving report from PACU about a client with a Penrose drain who is to be admitted to the surgical nursing unit. Before choosing a room for this client, which information is most important for the nurse to obtain?

Rationale:

The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected (D). Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require (A).Although (B) is helpful information, it does not have the priority of (D). A Hemovac® (C) is used to drain fluid from a dead space and is not a determinant for the room assignment.A.If suctioning will be needed for drainage of the wound B.If the family would prefer a private or semiprivate room C.If the client also has a Hemovac® in place D.If the client's wound is infected Submit

Correct | Correct Answer: D

A client with non–insulin-dependent diabetes mellitus (NIDDM) takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates the use of which approach to best manage the client's diabetes while the client is NPO during the perioperative period?4