Practice Test Questions
1. When assessing a patient for the potential development of hypovolemic shock, which of the following manifestations would the nurse most likely see first?
A. nervousness and apprehension
B. decreased urinary output
C. systolic blood pressure below 90mm Hg
D. hypoventilation and tachycardia
2. A psychiatric patient continues to disrupt the unit milieu by pacing up and down the hall. The nurse responds by placing the patient in the seclusion room. As a result or her actions, the nurse may be held responsible for which of the following legal implications?
A. false imprisonment
C. invasion of privacy
D. defamation of character
3. An eight-year-old child has cerebral palsy, a tracheostomy, and is oxygen (O2) dependent. During an initial visit to the home, the nurse would include which of the following questions in an environmental safety assessment?
A. “Are there drafts or air leaks in the home?”
B. “Are there other children in the home?”
C. “Does anyone smoke in the home?”
D. “Are there pets in the home?”
1. Key: A Client Need: Physiological Adaptation
A. Early hypoxic and hypocapnic changes result in restlessness, confusion, anxiousness, apprehension, agitation, lethargy and mental cloudiness.
B. Decreased urinary output is a clinical manifestation of hypovolemic shock, but occurs later than nervousness and apprehension.
C. During the compensatory stage of shock, the blood pressure is adequate to perfuse the vital organs. The systolic blood pressure does not drop to below 90 mm Hg until the progressive stage of shock.
D. The heart rate is increased and the depth of ventilation is increased in the early stages of shock to compensate for the lactic acid produced due to anaerobic metabolism.
2. Key: A Client Need: Psychosocial Adaptation
A. There is no indication for the use of seclusion with this patient. The use of seclusion or restraint that is not defensible as being necessary and in the client’s best interest may result in false imprisonment of the client and liability for the nurse.
B. Battery is harmful or offensive touching of another person. This is not present in the scenario.
C. Invasion of privacy would involve sharing of information or discussion of the client’s case without permission. There is no evidence that his occurred.
D. Charges of defamation can be brought if information regarding the client is divulged and that information ultimately harms the client’s reputation.
3. Key: C Client Need: Safety and Infection Control
C. The child is being discharged to home and is oxygen dependent. Oxygen may be administered in the home. Home Oxygen therapy requires that a number of safety features should be in place. Because oxygen is highly flammable gas, precautions must be taken to ensure the safety of the patient and family. Assessing the home for potential fire hazards is necessary. There should be no open flames, electrical sparks or flammable materials present. Smoking in the home by any person when oxygen is in use is contraindicated.
A. Drafts or air leaks in the home may affect the environmental temperature but would have no direct impact on the care or safety of the child at home who requires oxygen therapy.
B. Other children in the home do not pose any direct threat to the child who is at home on oxygen. Returning the child to home will reduce the amount of developmental delay or social handicap related to prolonged hospitalization.
D. Pets in the home could be a potential problem if they shed fine hire. Small particles, such as dust and fine hair, could potentially cause obstruction of the tracheostomy. Keeping the child separate from the family pet should be sufficient to maintain a clear airway.