- (Topic 7)
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:

1. A. The test is inconclusive and should be repeated
2. B. Further testing is needed
3. C. The test is normal and the fetus is reacting appropriately
4. D. The fetus is distressed

Correct Answer: C
(A) The test results were normal, so there would be no need to repeat to determine results.
(B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.

- (Topic 4)
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

1. A. The delirious client is capable of returning to his previous level of functioning.
2. B. The delirious client is incapable of returning to his previous level of functioning.
3. C. Delirium entails progressive intellectual and behavioral deterioration.
4. D. Delirium is an insidious process.

Correct Answer: A
(A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.

- (Topic 7)
A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

1. A. Hematocrit, hemoglobin, and white blood cell (WBC) count
2. B. Blood urea nitrogen, electrolytes, and creatinine
3. C. Glucose, glucose tolerance test, and random blood sugar
4. D. X-rays, electroencephalogram, and electrocardiogram(ECG)

Correct Answer: B
(A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning.

- (Topic 4)
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?

1. A. High protein and high calorie
2. B. High calorie and high carbohydrate
3. C. Low-fat 2-g sodium diet
4. D. High protein and high fat

Correct Answer: B
(A) A high-protein diet is contraindicated in hepatic disease. (B) High carbohydrates provide high-caloric content to prevent tissue catabolism. (C) A low-fat 2-g sodium diet is a cardiac diet; however, a low-fat diet would be beneficial. (D) A high-protein and high-fat diet is contraindicated in hepatic disease.

- (Topic 4)
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?

1. A. Exudate
2. B. Crust
3. C. Edema
4. D. Erythema

Correct Answer: B
(A) Exudate (moist, active drainage) is a clinical sign of wound infection. (B) Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. (C) Edema (swelling) is a clinical sign of wound infection. (D) Erythema (redness) is a clinical sign of wound infection.