Hurst Readiness Exam 1
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse
recognizes that teaching was
... [Show More] successful when the women identify which hormone as causing amenorrhea?
1. Progesterone
2. Estrogen
3. Follicle-stimulating hormone (FSH)
4. Human chorionic gonadotropin (hCG)
Rationale 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for
fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone
present in urine for pregnancy test
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest
wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect?
1. Mediastinal shift
2. Tension pneumothorax
3. Flail chest
4. Pulmonary contusion
Rationale 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a
see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A closed or open tension pneumothorax
results from the lung collapsing and air entering into the pleural cavity. This results in pressure shifting toward
the unaffected pleural cavity. 2. Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the
pleural cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A pulmonary contusion usually
results from blunt trauma. Bruising of lung would be demonstrated by pain but not paradoxical chest wall movement.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to
receive a new admit?
1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure
disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history
of mild heart failure prescribed one unit of packed red blood cells for anemia.
Rationale
2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with a seizure
disorder, because they care for clients who have eclampsia (seizures). 1. Incorrect: This client might have
tuberculosis (TB) and is not a good choice to move to the OB floor, because of the risk for transmission of an
infectious disease. 3. Incorrect: This client is not the best one to be transferred to the OB floor, because these
nurses do not routinely care for clients with a new pacemaker. The client is also likely to remain on a cardiac
monitor until discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history of
heart failure and would require close monitoring while receiving a blood transfusion.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet.
What points should the nurse include?
1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes
with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.
Rationale
1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails
rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too
thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time
30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to
moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of
lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus
and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary
healthcare provider first.
When caring for young adult clients, which developmental tasks would the nurse expect to see?
1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing
meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be
given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.
Rationale
3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy
relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect:
Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus
Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect:
During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity
versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment
can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to
support others.
What symptoms does the nurse expect to see in a client with bulimia nervosa?
1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4.
Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
Rationale
2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent
inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced
vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is
found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive
exercise is found in bulimia nervosa as a means to compensate for the binge eating.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory
studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing
cause of the pain?
1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally
is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4.
Side lying position in the operating room generated pressure damage.
Rationale
2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is
used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If
the CO2 irritates the phrenic nerve, it radiates to the shoulder. 1. Incorrect: Surgical cannulation of the bile
duct is not performed during a laparoscopic cholecystectomy. 3. Incorrect: Large abdominal retractors are not
used during this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The client
is turned in several directions during the procedure to prevent damage to the abdominal viscera.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T
99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse
determines that this client is in what acid/base imbalance?
1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
Rationale
2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection,
fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not
acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since
the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance
since the HCO3 is in normal range.
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge
nurse. Which statement by the UAP indicates that further teaching is needed? [Show Less]