November 2008 NLE Practice IV

November 2008 NLE Practice IV - CARE OF THE CLIENT WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS – PART B NURSING PRACTICE IV – CARE OF THE CLIENT WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS – PART B Situation 1: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponges and instrument count. 1. Counting is performed thrice: during the pre-incision phase, the operative phase and closing phase. Who counts the sponges, needle and instruments? a. The scrub nurse only b. The circulating nurse only c. The surgeon and the assistant surgeon d. The scrub nurse and the circulating nurse 2. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest layer. 1. Fascia 2. Muscle 3. Peritoneum 4. Subcutaneous/fat 5. Skin a. 5,4,3,2,1 b. 5,4,2,1,3 c. 5,4,1,3,2 d. 5,4,1,2,3 3. When is the first sponge instrument count reported? a. Before closing the subcutaneous layer b. Before peritoneum is closed c. Before closing the skin d. Before the fascia is sutured 4. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted? a. Anesthesiologist b. Surgeon

c. OR nurse supervisor d. Circulating nurse 5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing? a. MRI and incidence report b. CT Scan, MRI, Incidence report c. XRAY and incidence report d. CT Scan and incidence report Situation 2: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills. 6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urine specimen for culture and sensitivity? a. Clamp tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine b. Drain urine from the drainage bag into the sterile container c. Disconnect the tubing from the urinary catheter and let urine flow into a sterile container d. Wipe the self sealing aspiration port with antiseptic solution and insert a sterile needle into the self sealing port 7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? a. Upon waking up, cough deeply and expectorate into container b. Cough after pursed lip breathing c. Save sputum for two days in covered container d. After respiratory treatment, expectorate into a container 8. The best time for collecting the sputum specimen for culture is a. Before retiring at night b. Upon waking up in the morning c. Anytime of the day d. Before meals 9. When suctioning the endotracheal tube, the nurse should a. Explain procedure to patient. Insert catheter gently applying suction. Withdraw using twisting motion b. Insert catheter until resistance is met then withdraw slightly, applying suction c. Hyperoxygenate client. Insert catheter using back and forth motion d. Insert suction catheter four inches into the tube. Suction 30 seconds using twisting motion as catheter is withdrawn. 10. The purpose of NGT IMMEDIATELY after an operation is: a. For feeding or gavage b. For gastric decompression c. For lavage, or the cleansing of stomach content

d. For the rapid return of peristalsis Situation 3: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems liles scantly urination, hematuria and dysuria. 11. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as follows: a. Urethra, kidney, bladder, urethra b. Urethra, bladder wall, trigone, ureteral opening c. Bladder wall, uterine wall, and urethral opening d. Urethral opening, ureteral opening bladder 12. In the OR, you will position Mr. Santos who is undergoing cystoscopy in: a. Supine b. Lithotomy c. Semi-fowler d. Trendelenburg 13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him? a. “Cystoscopy is direct visualization and examination by urologist.” b. “cystoscopy is done by x-ray visualization of the urinary tract.” c. “Cystoscopy is done by using lasers on the urinary tract.” d. “Cystoscopy is an endoscopic procedure of the urinary tract.” 14. Withing 24-48 hours post cystoscopy, it is normal to observe one of the following: a. Pink-tinged urine b. Distended bladder c. Signs of infection d. Prolonged hematuria 15. Leg cramps are NOT uncommon post-cystoscopy. Nursing intervention includes: a. Bed rest b. Warm moist soak c. Early ambulation d. Hot sitz bath Situation 4: Mang Felix, a 79 year old man who is brought to the surgical unit form PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3 way indwelling urinary catheter for continuous fast drip bladder irritation which is connected to a straight drainage. 16. Immediately after surgery, what would you expect his urine to be? a. Light yellow b. Amber c. Bright red d. Pinkish to red

17. The purpose of the continuous bladder irrigation is to: a. Allow continuous monitoring of the fluid output status b. Provide continuous flushing of clots and debris from the bladder c. Allow for proper exchange of electrolytes and fluid d. Ensure accurate monitoring of intake and output 18. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be your most appropriate action? a. Remove his catheter then allow him to void on his own b. Irrigate his catheter c. Tell him to “go ahead and void. You have an indwelling catheter.” d. Assess color and rate of outflow if there is a change, refer to urologist for possible irrigation 19. You decided to check on Mang Felix’s IV fluid infusion. You noticed a change in flow rae, pallor and coldness around the insertion site. What is your assessment finding? a. Phlebitis b. Infiltration to subcutaneous tissue c. Pyrogenic rection d. Air embolism 20. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during first post operative day, which of the following is the LEAST relevant to document in the case of Mang Felix? a. Chest pain and vital signs b. Intravenous infusion rate c. Amount, color, and consistency of bladder irrigation drainage d. Activities of daily living started Situation 5: Melamine contamination in milk has brought worldwide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient’s needs. 21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewelry box covers due to its fire retardant properties. Milk and food manufacturers add melamine in order to: a. It has a bacteriostatic property leading to increase food and milk life as a way of preserving the foods b. Gives a glazy and more edible look on foods c. Make milks tasty and creamy d. Create an illusion of a high protein content on their product 22. Most of the milks contaminated by Melamine came from which country? a. India b. China c. Philippines d. Korea

23. Which government agency is responsible for testing the melamine content of foods and food products? a. DOH b. MMDA c. NBI d. BFAD 24. Infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine poisoning? a. Irritability, back ache, urolithiasis b. High blood pressure, fever c. Anuria, oliguria or hematuria d. Fever, irritability and large output of diluted urine 25. What kind of renal failure does melanin poising cause? a. Chronic, pre-renal b. Acute, post-renal c. Chronic, intrarenal d. Actue, pre-renal Situation 6: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15. 26. The survival rate for Acute Lymphoid Leukemia is approximately a. 25% b. 40% c. 75% d. 95% 27. Whereas acute non-lymphoid leukemia has a survival rate of a. 25% b. 40% c. 75% d. 95% 28. The three main consequence of leukemia that causes the most danger is: a. Neutropenia causing infection, anemia causing impaired oxygenation, and thrombocytopenia leading to bleeding tendencies b. Central nervous system infiltration, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies c. Splenomegaly, hepatomegaly, fractures d. Invasion by the leukemia cells to the bone causing severe bone pain 29. Gold standard in the diagnosis of leukemia is by which of the following? a. Blood culture and sensitivity b. Bone marrow biopsy c. Blood biopsy 30. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the

client for long term therapy. One common side effect, especially of adriamycin is alopecia. The child asks: “Will I get my hair back once again?” The nurse best response is by saying: a. “Don’t be silly, of course you will get your hair back.” b. “We are not sure, let’s hope it’ll grow.” c. “This side effect is usually permanent, but I will get the doctor to discuss it for you.” d. “Your hair will regrow in 3 to 6 months but of different color, usually darker and of different texture.” Situation 7: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in woman. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer. 31. All of the following are factors that said to contribute to the development of breast cancer except: a. Prolonged exposure to estrogen such as an early menarche or late menopause, nulliparity, and childbirth after age 30. b. Genetics c. Increasing age d. Prolonged intake of tamoxifen (Nolvadex) 32. Protective factors for the development of breast cancer includes which of the following except: a. Exercise b. Prophylactic tamoxifen c. Breast feeding d. Alcohol intake 33. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patient that the lumpectomy with radiation a. Reduces the fear and anxiety that accompanies the diagnosis and treatment of cancer b. Has about the same 10-year survival rate as the modified radical mastectomy c. Provides a shorter treatment period with a fewer long term complications d. Preserves the normal appearance and sensitivity of the breast 34. Carmen, who is asking the nurse the most appropriate time of the month to do her self-examination of the breast. The MOST appropriate reply by the nurse would be: a. The 26th days of the menstrual cycle b. 7 to 8 days after conclusion of the menstrual period c. During her menstruation d. The same day each month 35. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy?

a. Cover the areas with thick clothing materials b. Apply a heating pad to the site c. Wash skin with water after the therapy d. Avoid applying creams and powders to the area 36. Based on DOH and World Health Organization (WHO) guidelines, the mainstay for early protection method for breast cancer that is recommended for developing countries is a. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE) b. an annual hormone receptor assay c. an annual mammogram d. a physician conduct a breast clinical examination every 2 years 37. the purpose of performing the breast self examination (BSE) regularly is to discover a. fibrocystic masses b. cancerous lungs c. areas of thickness or fullness d. changes from previous BSE 38. If you are to instruct a post-menopausal woman about BSE, when would you tell her to do BSE? a. On the same day of each month b. Right after the menstrual period c. On the first day of her menstruation d. On the last day of her menstruation 39. During breast self-examination, the purpose of standing in front of the mirror is to observe the breast for a. Thickening of the tissue b. Axillary lymphnodes c. Lumps in the breast tissue d. Change in size and contour 40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client’s left shoulder is to a. Bring the breast closer to the examiner’s right hand b. Tense the pectoral muscle c. Balance the breast tissue more evenly on the chest wall d. Facilitate lateral positioning of the breast Situation 8: Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management, you have important responsibilities as nurse. 41. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert? a. Tell him that sometimes these feelings can be psychogenic

b. Refer him to the physician c. Reassure him that these feelings are normal d. Help him plan his activities 42. Immediately following the radiation teletherapy, Albert is a. Considered radioactive for 24 hours b. Given an complete bath c. Placed on isolation for 6 hours d. Free from radiation 43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse, you should observe the following symptoms: a. Petechiae, ecchymosis, epistaxis b. Weakness, easy fatigability, pallor c. Headache, dizziness, blurred vision d. Severe sore throat, bacteremia, hepatomegaly 44. What nursing diagnosis should be of highest priority? a. Knowledge deficit regarding thrombocytopenia precautions b. Activity intolerance c. Impaired tissue integrity d. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal 45. What intervention should you include in your care plan? a. Inspect his skin for petechiae, bruising, GI bleeding regularly b. Place Albert on strict isolation precautions c. Provide rest in between activities d. Administer antipyretics if his temperature exceeds 38C Situation 9: Burns are caused by transfer of heat source to the body. It can be thermal, electrical, radiation or chemical. 46. A burn characterized by pale white appearance, charred or with fat exposed and painlessness is a. Superficial partial thickness burn b. Deep partial thickness burn c. Full thickness burn d. Deep full thickness burn 47. Which of the following BEST describes superficial partial thickness burn or first degree burn? a. Structures beneath the skin are damaged b. Dermis is partially damaged c. Epidermis and dermis are both damaged d. Epidermis is damaged 48. A burn that is said to be “WEEPING” is classified as a. Superficial partial thickness burn b. Deep partial thickness burn

c. Full thickness burn d. Deep full thickness burn 49. During the acute phase of the burn injury, which of the following is a priority? a. Wound healing b. Reconstructive surgery c. Emotional support d. Fluid resuscitation 50. While in the emergent phase, the nurse knows that the priority is to: a. prevent infection b. control pain c. prevent deformities and contractures d. return the hemodynamic stability via fluid resuscitation 51. The MOST effective method of delivering pain medication during the emergent phase is a. Intramuscularly b. Subcutaneously c. Orally d. Intravenously 52. When a client accidentally splashes chemicals to his eyes, the initial priority care following the chemical burn is to a. Irrigate with normal saline for 1 to 15 minutes b. Transport a physician immediately c. Irrigate with water for 15 minutes or longer d. Cover the eyes with a sterile gauze 53. Which of the following can be a fatal complication of upper airway burns? a. Stress ulcers b. Hemorrhage c. Shock d. Laryngeal spasms and swelling 54. When a client will rush towards you and he has burning clothes on, it is your priority to do which of the following first? a. Log roll on the grass/ground b. Slap the flames with his hands c. Try to remove the burning clothes d. Splash the client with 1 bucket of cool water 55. Once the flames are extinguished, it is most important to a. Cover client with a warm blanket b. Give him sips of water c. Calculate the extent of his burns d. Assess Sergio’s breathing 56. During the first 24 hours after the thermal injury, you should assess Sergio

for a. Hypokalemia and hypernatremia b. Hypokalemia and hyponatremia c. Hyperkalemia and hyponatremia d. Hyperkalemia and hypernatremia 57. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. You recognize that this most likely indicates that the client is developing a. Cerebral hypoxia b. Hypervolemia c. Metabolic acidosis d. Renal failure 58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, right and left arm, and at the anterior part of chest sparing the abdominal area. He also has superficial partial thickness burn at the posterior trunk and at the half upper portion of the left leg. He is in the emergent phase of burn. Using the parkland’s formula, you know that during the first 8 hours of burn, the amount of fluid will be given is: a. 5,400 ml b. 10,600 ml c. 9,450 ml d. 6,750 ml 59. The doctor incorporated insulin on the client’s fluid during the emergent phase. The nurse knows that insulin is given because a. Clients with burn also develops metabolic acidosis b. Clients with burn also develops hyperglycemia c. Insulin is needed for additional energy and glucose burning after the stressful incident to hasten wound healing, regain of consciousness and rapid return of hemodynamic stability d. For hyperkalemia 60. The IV fluid of choice for burn as well as dehydration is: a. 0.45% Na CL b. NSS c. Sterile water d. D5LR SITUATION 10: Enterostomal Therapy is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. 61. You plan to teach Fermin how to irrigate the colostomy when a. The perineal wound heals and Fermin can sit comfortable on the commode b. Fermin can lie on the side comfortable, about the 3rd post-operative day c. The abdominal incision is closed and contamination is no longer a danger d. The stools starts to become formed around the 7th post-operative day 62. When preparing to teach Fermin how to irrigate colostomy, you should plan

to do the procedure: a. When Fermin would have normal bowel movement b. At least 2 hours before visiting hours c. Prior to breakfast and morning care d. After Fermin accepts alteration in body image 63. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin a. Lubricates the tip of the catheter prior to inserting into the stoma b. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion c. Discontinues the insertion of fluid after 500 ml of fluid has been instilled d. Clamps off the flow of fluid when feeling uncomfortable 64. You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my physician and report: a. If I have any difficulty inserting the irrigating tube into the stoma.” b. If I noticed a loss of sensation to touch in the stoma tissue.” c. The expulsion of flatus while the irrigating fluid is running out.” d. When mucus is passed from the stoma between the irrigation.” 65. You would know after teaching Fermin that dietary instruction for him is effective when he states, “it is important that I eat: a. Soft food that is easily digested and absorbed by the large intestines.” b. Bland food so that my intestines do not become irritated.” c. Food low in fiber so that there are fewer stools.” d. Everything that I ate before the operation, while avoiding foods that cause gas.” Situation 11: Based on studies of nurses working in special units like the intensive care unit and coronary care unit, it is important for nurses to gather as much information to be able to address their needs for nursing care. 66. Critically ill patients frequently complain about which of the following when hospitalized? a. Hospital food b. Lack of blankets c. Lack of privacy d. Inadequate nursing staff 67. Who of the following is at greatest risk of developing sensory problem? a. Female patient b. Adolescent c. Transplant patient d. Unresponsive patient 68. Which of the following factors may inhibit learning in critically ill patients? a. Gender b. Medication c. Educational level

d. Previous knowledge of illness 69. Which of the following statements does not apply to critically ill patients? a. Majority need extensive rehabilitation b. All have been hospitalized previously c. Are physically unstable d. Most have chronic illness 70. Families of critically ill patients desire which of the following needs to be met first by the nurse? a. Provision of comfortable space b. Emotional support c. Updated information on client’s status d. Spiritual counseling Situation 12: Johnny sough consultation to the hospital because of irritability, jittery and he has been experiencing these signs and symptoms for several months. 71. His diagnosis was hyperthyroidism. The following are expected symptoms except a. Anorexia b. Palpitation c. Fine tremors of the hands d. Hyperalertness 72. She has to take drugs to treat her hyperthyroidism. Which of the following will you NOT expect that the doctor will prescribe? a. Colace (Docusate) b. Cytomel (llothyronine) c. Tapazole 73. The nurse knows that Tapazole has which of the following side effects that will warrant immediate withholding of the medication? a. Death b. Sore throat c. Hyperthermia d. Thrombocytosis 74. You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess the evidence of a. Thyroid storm b. Mediastinal shift c. Damage to the laryngeal nerve d. Hypocalcemia tetany 75. Should you check for hemorrhage, you will a. Slip you hand under the nape of the neck b. Check for hypotension

c. Apply neck collar to prevent hemorrhage d. Observe the dressing if it is soaked with blood 76. Basal metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the standard procedure, you need to tell Johnny that: a. Obstructing his vision b. Restraining his upper and lower extremities c. Obstructing his hearing d. Obstructing his nostrils with a clamp 77. The BMR is based on the measurement that: a. Rate of respiration under different condition of activities and rest b. Amount of oxygen consumption under resting condition over a measured period of time c. Amount of oxygen consumption under stressed condition over a measured period of time d. Ration of respiration to pulse rate over a measured period of time 78. Her physician ordered lugol’s solution in order to a. decrease the vascularity and size of the thyroid gland b. decrease the size of the thyroid gland only c. increase the vascularity and size of the thyroid gland d. increase the size of the thyroid gland only 79. Which of the following is a side effect of Lugol’s solution? a. Hypokalemia b. Nystagmus c. Enlargement of the thyroid gland d. Excessive salivation 80. In administering Lugol’s solution, the precautionary measure should include: a. Administer with glass only b. Dilute with juice and administer with a straw c. Administer it with milk and drink it d. Follow it with milk of magnesia Situation 13: Pharmacological treatment was not effective for Johnny’s hyperthyroidism and now, he is scheduled for thyroidectomy. 81. Instruments in the surgical suite for surgery are classified as either CRITICAL, SEMI-CRITICAL and NON-CRITICAL. If the instrument is introduced directly into the blood stream or into any normally sterile cavity or area of the body, it is classified as: a. Critical b. Semi critical c. Non-critical d. Ultra critical 82. Instruments that do not touch the paitnet or have contact only to intact skin

is classified as: a. Critical b. Semi critical c. Non critical d. Ultra critical 83. If an instrument is classified as semi critical, an acceptable method of making the instrument ready for surgery is through a. Sterilization b. Decontamination c. Disinfection d. Cleaning 84. While critical items should be a. Clean b. Decontaminated c. Sterilized d. Disinfected 85. As a nurse, you know that intact skin acts as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin or mucus membranes should be a. Disinfected b. Sterile c. Clean d. Alcoholized 86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of diagnosis of thyroid cancer. Prior to total thyroidectomy, you should instruct Johnny to a. Perform range and motion exercise on the head and neck b. Apply gentle pressure against the incision when swallowing c. Cough and deep breath every 2 hours d. Support head with the hands when changing position 87. As Johnny’s nurse, you plan to set up an emergency equipment at the bedside following thyroidectiomy. You should include a. An airway and rebreathing tube b. A tracheostomy set and oxygen c. A crush chart with bed board d. Two ampoules of sodium bicarbonate 88. Which of the following nursing interventions is appropriate after a total thyroidectomy? a. Place pillows under your patient’s shoulders b. Raise the knee gatch to 30 degrees c. Keep your patient in a high-fowler’s position d. Support the patient’s head and neck with pillows and sandbags 89. If there is an accidental injury to the parathyroid gland during a

thyroidectomy, which of the following might Leda develop post-operatively? a. Cardiac arrest b. Dyspnea c. Respiratory failure d. Tetany 90. After surgery, Johnny develops peripheral numbness, tingling and muscle twitching, and spasm. What would you anticipate to administer? a. Magnesium sulfate b. Calcium gluconate c. Potassium iodides d. Potassium chloride Situation 14: Budgeting is an important part of a nurse managerial activity. The correct allocation and distribution of resources is vital in the harmonious operation of the financial balance of the agency. 91. Which of the following best defines budget? a. Plan for the allocation of resources for future use b. The process of allocating resources for future use c. Estimate cost and expense d. Continuous process in seeing that the goals and objectives of the agency is met 92. Which of the following best defines Capital Budget? a. Budgeting estimates the cost of direct labor, number of staff to be hired, and necessary number of workers to meet the general patient’s needs b. Includes the monthly and daily expenses and expected revenue and expenses c. These are related to long term planning and includes major replacement of expenses of the plant, major equipments and inventories d. These are expenses that are not dependent of the level of production or sales. These tend to be time-related, such as salaries or rents being paid per month 93. Which of the following best describes Operational Budget? a. Budget to estimate the cost of direct labor, number of staff to be hired and necessary number of workers to meet the general patient needs b. Includes the monthly and daily expenses and expected revenue and expenses c. These are related long term planning and includes major replacement or expenses of the plant, major equipments and inventories d. These are expenses that are not dependent on the level of production or sales. These tend to be time related, such as salaries or rents being paid per month 94. Which of the following accurately describes Fixed Cost in budgeting? a. These are usually the raw materials and labor salaries that depend on the production or sales b. These are expenses that change in proportion to the activity of a business c. These are expenses that are not dependent on the level of production or sales. They tend to be time-related, such as rent d. This is the summation of the Variable Cost and the fixed cost

95. Which of the following accurately describes Variable cost in budgeting? a. These are related to long term planning and include major replacement or expansion of the plant, major equipment and inventories b. These are expenses that change in proportion to the activity of a business c. These are expenses that are not dependent on the level of production or sales. They tend to be time related such as rent d. This is the summation of variable cost and the fixed cost. Situation 15: Andrea is admitted to the ER following an assault where she was hit in the face and head. She was brought to the ER by a policewoman. Emergency measures were started. 96. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as a. Biot’s b. Kussmaul’s c. Cheyne stokes d. Eupnea 97. What do you call the triad of sign and symptoms seen in a client with increasing ICP? a. Virchow’s triad b. The Chinese triad c. Cushing’s triad d. Charcot’s triad 98. Which of the following is true with the Triad seed in the head injuries? a. Narrowing of pulse pressure, cheyne stokes respiration, tachycardia b. Widening pulse pressure, irregular respiration, bradycardia c. Hypertension, kussmaul’s respiration, tachycardia d. Hypotension, irregular respiration, bradycardia 99. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis? a. Ineffective airway clearance b. Ineffective breathing pattern c. Impaired gas exchange d. Activity intolerance 100. You know that apnea is seen in client with Cheyne Stokes respiration, APNEA is defined as: a. Inability to breath in a supine position so the patient sits up in bed to breathe b. The patient is dead, the breathing stops c. There is an absence of breathing for a period of time, usually 15 seconds or more d. A period of hypercapnea and hypoxia due to the cessation of respiratory effort in spite of normal respiratory functioning

ANSWER KEY: 1. D 2. D 3. B 4. B 5. C 6. D 7. A 8. B 9. B 10. B 11. B 12. B 13. D 14. A 15. B 16. D 17. B 18. D 19. B 20. D 21. D 22. B 23. D 24. D 25. B 26. C 27. B 28. A 29. B 30. D 31. D 32. D 33. D 34. B 35. D 36. A 37.B 38. A 39. A 40. C 41. D 42. D 43. A 44. C 45. A 46. C 47. B

48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97.

B A D D C D A D C A A D D D A B A D C D B B B A A B C A D B A D B A C C C A D B D D B A C B C B C C

98. B 99. B 100. C