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Questions with Approved Answers
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A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain.
The nurse attempts to comfort the child by explaining that:
A) The pain is a normal, temporary condition Correct
B) The pain occurs because nerves have been cut
C) This pain will go away once a prosthesis is used
D) Pain medication may be needed for life to alleviate the discomfort - Answer -Answer: A
Rationale: Phantom limb pain is a temporary condition that some people who undergo amputation
experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the
client. The child should be reassured that the condition is normal. Numerous pharmacological agents are
available to help ease postoperative neurogenic pain. Pain medication is not needed for life. The
incorrect options will not provide comfort to the child.
A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following
interventions does the nurse immediately implement?
A) Elevating the foot of the bed 6 inches
B) Placing ice packs on and under the right leg
C) Documenting the need for hourly calf measurements
D) Performing passive range-of-motion exercises of the right leg - Answer -Answer: A
Rationale: Standard therapy for DVT consists of bed rest, leg elevation, and application of warm, moist
heat to the affected leg. Elevation of the legs decreases venous pressure, which in turn relieves edema
and pain. The client may have calf measurements prescribed once per shift or once per day, but they
would not be obtained hourly. Placing ice packs on and under the right leg is incorrect, because heat, not
cold, is usually prescribed. Passive range-of-motion exercises of the right leg would be dangerous to the
client because activity after clot formation can cause pulmonary embolus.
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
A) Ineffective coping skills
B) Perceptual disturbances
,C) Chronic low self-esteem
D) Risk for self-directed violence - Answer -Answer: D
Rationale: The altered perceptions and cognitive distortions experienced by the client with schizophrenia
put the client at risk for self-harm. A fundamental responsibility of the nurse is to provide a safe
environment for this client and others. Although ineffective coping skills, disturbed perceptual ability,
and low self-esteem may be appropriate concerns, the risk for self-directed violence is the priority.
A client in a manic state emerges from her room and quickly enters the dayroom. She announces to the
group that she is the star of a burlesque show and will begin her performance shortly. The priority
nursing action is to:
A) Ask the client to go to her room and to change her clothes
B) Tell the client firmly that burlesque shows are not allowed in the nursing unit
C) Tell the client that her bathroom privileges are being suspended because of her behavior
D) Quietly and firmly assist the client to her room and help her dress in appropriate clothes -
Answer -Answer: D
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and
is highly excitable. The nurse must take control without creating increased stress or anxiety in the client.
Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her
dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client's
bathroom privileges because of behavior, having the client change her clothes and telling the client that
burlesque shows are not allowed in the nursing unit will all increase the client's anxiety.
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump through a
subclavian central line. The client calls the nurse and complains of difficulty breathing and chest pain.
The nurse notes that the client's pulse rate is increased, the blood pressure has dropped, and oxygen
saturation is 89%. Use the number 1 to denote the first action and the number 4 the last.
~ Placing the client in lateral Trendelenburg position on the left side
~ Clamping the PN infusion catheter
~ Obtaining an electrocardiogram (ECG)
~ Notifying the physician - Answer -The correct order is:
1) Clamping the PN infusion catheter
2) Placing the client in lateral Trendelenburg position on the left side
3) Notifying the physician
4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian central line insertion
is embolism, air or thrombus. Signs and symptoms include chest pain, dyspnea, hypoxia, anxiety,
tachycardia, and hypotension. On auscultation, the nurse would hear a loud churning sound over the
pericardium. If this sign is detected, the PN infusion catheter is immediately clamped and the client
, placed in a lateral Trendelenburg position on the left side, which helps trap the air in the apex of the
ventricle and prevents its ejection into the pulmonary arterial system. The physician would be notified.
An ECG may be obtained, but this would not be the immediate action.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'"
D) "Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." - Answer -Answer: B
Rationale: A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or
sarcasm because of the fear associated with such illnesses. It is important for the nurse to convey an
accepting attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed
at learning that you have asthma" paraphrases the client's words and focuses on the client's feelings.
"Do you think that having asthma will kill you?" reflects and paraphrases the client's words but is
somewhat sarcastic. "Asthma is a very treatable condition, but it's important to learn how to properly
administer your medications. Let's practice with your inhalant" lectures the client and does not deal
directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge
rather than as a 'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the client's
words.
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the
nurse respond to the client?
A) "No one is going to kill you."
B) "Your medication is making you feel like this."
C) "Are you worried that people are trying to hurt you?"
D) "What makes you think that terrorists were sent to hurt you?" - Answer -Answer: C
Rationale: It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing
with delusions may make the client more defensive and cause the client to cling to the delusions even
more strongly. Medication may be prescribed to reduce the occurrence of delusions, but it does not
cause the delusions. Encouraging discussion regarding the delusion is inappropriate.
A client who was recently sexually assaulted is self-contained and calm. The client says to the nurse, "It
doesn't seem real." Which defense mechanism is the client using?
A) Denial
B) Projection
C) Rationalization
