- (Topic 4)
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

1. A. Depression
2. B. Agitation
3. C. Psychotic ideation
4. D. Anhedonia

Correct Answer: B
(A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. (B) These clinical features are classic signs of agitation. (C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. (D) Anhedonia is the inability to experience pleasure.

- (Topic 4)
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

1. A. Must use the least restrictive measure possible to control the behavior
2. B. Should put the client in seclusion until he promises to behave appropriately
3. C. Should apply full restraints until the behavior is under control
4. D. Should allow other clients to observe the acting out so that they can learn from the experience

Correct Answer: A
(A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take ??time-out?? before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.

- (Topic 6)
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

1. A. Blood pressure increase from 100/80 to 115/85 after lunch
2. B. Headache that is unresponsive to acetaminophen (Tylenol)
3. C. Pulse rate ranges between 68 bpm and 76 bpm
4. D. Temperature rise to 102_F rectally

Correct Answer: D
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.

- (Topic 1)
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

1. A. Pass a nasogastric tube through the left nostril
2. B. Place a 4 X 4 gauze in the nares to impede the flow
3. C. Gently suction the nasal drainage to protect the airway
4. D. Perform a halo test and glucose level on the drainage

Correct Answer: D
(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses.
(B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.

- (Topic 4)
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge.
Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?

1. A. ??I will not drive but ride in the front seat of the car with a seat belt on for my first doctor??s appointment.??
2. B. ??When I bathe tomorrow morning, I will be very careful not to get soap on my incision.??
3. C. ??I am allowed to exercise by walking for short periods.??
4. D. ??Teach my husband about the die
5. E. He??ll be doing all the cooking now.??

Correct Answer: C
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.