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Questions 158

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Question 1 of 5

A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is:

Correct Answer: D

Rationale: Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.

Question 2 of 5

A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?

Correct Answer: A

Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.

Question 3 of 5

The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?

Correct Answer: C

Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.

Question 4 of 5

The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?

Correct Answer: A

Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (
B) is for rectal exams, prone (
C) for back surgeries, and Trendelenburg (
D) for shock or upper abdominal access.

Question 5 of 5

A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this 'psych stuff.' When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:

Correct Answer: D

Rationale: Repressed anger is associated with psychophysiological disorders like a bleeding ulcer, as stress and unexpressed emotions contribute to physical symptoms.

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