GCC 576 - 600

The definition of "family" has evolved as society has changed. The most comprehensive definition of the term includes:

• A unit of people related by birth or adoption or by marriage
• Two or more emotionally involved people
• Related people who live in close proximity to each other
• A changing group of people
• -

Answer explanation

Option 1: A unit of people related by birth or adoption or by marriage

Option 2: Two or more emotionally involved people

Option 3: Related people who live in close proximity to each other

Option 4: A changing group of people

Option 5: -

Correct Option: Option 2 – Two or more emotionally involved people

Explanation: Significant others who may be related or bonded to the client by friendship are considered "family." In our society, even pets can be considered family members because of the emotional bond between client and animal. Related people living in close proximity was a previous definition of family, which has since evolved to be more inclusive. A changing group of people is not a specific classification, and is therefore an incorrect answer choice.

The nurse is caring for a client who is nauseated and in danger of aspiration. Which action would the nurse take first?

• Administer an ordered antiemetic medication
• Obtain an ice bag and apply to the client's throat
• Turn the client to one side
• Notify the physician
• -

Answer explanation

Option 1: Administer an ordered antiemetic medication

Option 2: Obtain an ice bag and apply to the client's throat

Option 3: Turn the client to one side

Option 4: Notify the physician

Option 5: -

Correct Option: Option 3 – Turn the client to one side

Explanation: Turning the client to the side will allow any vomit to drain from the mouth and decrease the risk for aspiration. Answers A, B, and D are all appropriate as nursing interventions, but a patent airway and prevention of aspiration is the priority.

A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy?

• Positive
• Probable
• Presumptive
• Diagnostic
• -

Answer explanation

Option 1: Positive

Option 2: Probable

Option 3: Presumptive

Option 4: Diagnostic

Option 5: -

Correct Option: Option 2 – Probable

Explanation: The plan of care should reflect that this woman is experiencing probable signs of pregnancy. She may be pregnant but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease processes as well as pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound confirmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word "diagnostic" is not used to describe the condition of pregnancy.

A client had cardiothoracic surgery. After a long stay in the cardiovascular recovery unit (CVRU), the client has not yet been out of bed. The client's medical history reveals that the client lives in a one-story home alone and drives a car. The nurse notes that the client has been lethargic, unwilling to participate in basic ADL, and needs one-on-one encouragement to eat. What is the most logical rationale for the client's unwillingness to participate in self-care, and what is the best plan of care for the nurse to follow to promote independence?

• The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.
• The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should allow the client plenty of quiet time, isolated and alone, to reflect and to grieve. The nurse should promote proper hygiene by performing all ADL activities for the client.
• The client is experiencing "ICU syndrome." The nurse should notify the physician of the nurse's observations and request antianxiety medication. The nurse should then monitor the client closely.
• The client is experiencing "ICU syndrome." The nurse should notify the physician of the nurse's observations and request antianxiety medication. The nurse should then encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.
• -

Answer explanation

Option 1: The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.

Option 2: The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should allow the client plenty of quiet time, isolated and alone, to reflect and to grieve. The nurse should promote proper hygiene by performing all ADL activities for the client.

Option 3: The client is experiencing "ICU syndrome." The nurse should notify the physician of the nurse's observations and request antianxiety medication. The nurse should then monitor the client closely.

Option 4: The client is experiencing "ICU syndrome." The nurse should notify the physician of the nurse's observations and request antianxiety medication. The nurse should then encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.

Option 5: -

Correct Option: Option 1 – The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.

Explanation: The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence. Extended immobility may lead to grief, withdrawal, and fear. The client should not be isolated for reflection. The client should be encouraged to perform ADL as independently as possible. The client is not experiencing "ICU syndrome."

A client who is rushed to the emergency department is diagnosed with a ruptured aortic aneurysm. Which intervention should the nurse expect for this client?

• Administration of beta-blockers.
• Administration of antihypertensives.
• Arteriogram.
• Surgical repair.
• -

Answer explanation

Option 1: Administration of beta-blockers.

Option 2: Administration of antihypertensives.

Option 3: Arteriogram.

Option 4: Surgical repair.

Option 5: -

Correct Option: Option 4 – Surgical repair.

Explanation: Surgical repair is the only treatment for a ruptured aneurysm. Administration of drugs could prevent rupture. An arteriogram is used to detect an aneurysm.

A patient, age 76, is transferred to the medical-surgical unit from the emergency department (ED) with a diagnosis of left-sided stroke in evolution. On admission to the unit, he has a blood pressure of 150/90 mm Hg, an apical pulse of 78 beats/minute and regular, a respiratory rate of 20 breaths/minute, and a rectal temperature of 100º F (37.8º C). The practitioner orders oxygen by nasal cannula at 2 L/minute; vital sign assessment every hour for the first 4 hours, every 2 hours for the next 4 hours, and then every 4 hours; I.V. D5W in half-normal saline solution at a rate of 100 ml/hour, and no oral intake. When helping to transfer the patient to his bed, the nurse notices a snoring quality to his respirations. Which nursing action is the highest priority at this time?

• Place the patient in Fowler's position
• Assess the patient's ability to communicate his needs
• Position the patient on his side, with the head of the bed elevated slightly
• Place items the patient may need to the left side of the bed
• -

Answer explanation

Option 1: Place the patient in Fowler's position

Option 2: Assess the patient's ability to communicate his needs

Option 3: Position the patient on his side, with the head of the bed elevated slightly

Option 4: Place items the patient may need to the left side of the bed

Option 5: -

Correct Option: Option 3 – Position the patient on his side, with the head of the bed elevated slightly

Explanation: Stroke in evolution refers to continuing neurologic changes over 24 to 48 hours. The patient should be placed on his side because leaving a patient on his back may cause the tongue to fall backward as well as the aspiration of secretions, resulting in airway obstruction that in turn may induce atelectasis and pneumonia. Option A is inappropriate for this patient because weakness on the right side (resulting from his left-sided lesion) would make him unable to maintain this position. Options B and D aren't priorities.

The nurse is assessing a client who has undergone a right lobectomy. Which assessment should alert the nurse to the possibility of internal bleeding?

• Urinary output of 200mL during the past 3 hours
• Sanguineous chest tube drainage at a rate of 50mL per hour for the past 3 hours
• Restless and shortness of breath
• Decreased pulse rate and decreased respirations
• -

Answer explanation

Option 1: Urinary output of 200mL during the past 3 hours

Option 2: Sanguineous chest tube drainage at a rate of 50mL per hour for the past 3 hours

Option 3: Restless and shortness of breath

Option 4: Decreased pulse rate and decreased respirations

Option 5: -

Correct Option: Option 3 – Restless and shortness of breath

Explanation: Signs of possible internal bleeding include restless and shortness of breath. Answer A is incorrect because the urinary output is within normal limits. Answer B is incorrect because the color and rate of chest tube drainage is within the expected range following a lobectomy. Answer D is incorrect because the pulse rate and respiratory rate would be increased with internal bleeding.

After instructing participants in a childbirth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which of the following?

• Biofeedback
• Effleurage
• Guided imagery
• Pelvic tilt exercises
• -

Answer explanation

Option 1: Biofeedback

Option 2: Effleurage

Option 3: Guided imagery

Option 4: Pelvic tilt exercises

Option 5: -

Correct Option: Option 4 – Pelvic tilt exercises

Explanation: Pelvic tilt exercises are useful to alleviate backache during pregnancy and labor but are not useful for the pain from contractions. Biofeedback (a conscious effort to control the response to pain), effleurage (light uterine massage), and guided imagery (focusing on a pleasant scene) are appropriate pain relief techniques to practice before labor begins. Various breathing exercises also can help to alleviate the discomfort from contraction pain.

A client has a nasogastric (NG) tube placed after abdominal surgery. Which finding indicates the NG tube may be removed?

• Drainage volume decreases
• The client experiences flatus
• The client no longer feels nauseous
• The client is burping
• -

Answer explanation

Option 1: Drainage volume decreases

Option 2: The client experiences flatus

Option 3: The client no longer feels nauseous

Option 4: The client is burping

Option 5: -

Correct Option: Option 2 – The client experiences flatus

Explanation: NG tubes are placed after abdominal surgery to prevent distension secondary to decreased peristalsis and retention of gas in the bowel. Passing flatus indicates that the bowel has returned to its normal functioning at which point the NG tube can be removed.

A client is receiving Theodur. The nurse monitors the theophylline blood level and assesses that the level is within therapeutic range when it is at what level?

• 5ug/mL
• 8ug/mL
• 15ug/mL
• 25ug/mL
• -

Answer explanation

Option 1: 5ug/mL

Option 2: 8ug/mL

Option 3: 15ug/mL

Option 4: 25ug/mL

Option 5: -

Correct Option: Option 3 – 15ug/mL

Explanation: A level of 15ug/mL is within the normal theophylline therapeutic range of 10-20ug/mL. Answers A, B, and D are not within the therapeutic range.