1. In a child with suspected coarctation of the aorta, the nurse would expect to find
The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)
2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by
The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.
3. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.
4. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?
The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.
5. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness. Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.
6. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be
The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.
7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggests altered thinking processes.
8. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?
The correct answer is B: Flexion of the hip and knees with passive flexion of the neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis.
9. Post-procedure nursing interventions for electroconvulsive therapy include
The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care.
10. The nurse is talking to parents about nutrition in school aged children. Which of the following is the
The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.
11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home
The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.
12. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.
13. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.
14. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should
The correct answer is C: Give the client simple information about what she will be doing. The distressed disoriented client should be gently oriented to reduce fear and increase the sense of safety and security. Environmental changes provoke stress and fear.
15. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?
The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.
16. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?
The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help you to reinforce the need for daily management of the disease whether or not the patient "feels better".
17. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is
The correct answer is B: "Your child has less red blood cells that carry oxygen." The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.
18. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
The correct answer is B: When the client threatens self-harm and harm to others. Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public.
19. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8 months.
20. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?
The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.
21. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.
22. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?
The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent''s pregnancies will result in a child with systic fibrosis.
23. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent?
The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.
24. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
The correct answer is C: Clothing has become tight around the waist
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.
25. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?
The correct answer is D: Occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.
26. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to
The correct answer is A: Ask the client about the refusal of certain pain medications. Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.
27. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.
28. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client??"
The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.
29. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?
The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss.
30. Which type of accidental poisoning would the nurse expect to occur in children under age 6?
The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.
31. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.
32. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
The correct answer is B: Twenty month-old who has just learned to climb stairs. Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.
33. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.
34. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?
The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia. Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.
35. A nurse is caring for a client with multiple myeloma. Which of the following should be included in the plan of care?
The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, client’s are at high risk for pathological fractures.
36. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
A) Reading
The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention.
37. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture and active and passive range of motion exercises important interventions for maintaining function of affected joints.
38. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?
The correct answer is C: Provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.
39. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?
The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
40. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
The correct answer is D: Note patterns of increased blood pressure
Hypertension is a key assessment in the course of the disease.
41. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alchohol intake.
42. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child?
The correct answer is B: Explain the surgery 1 week prior to the procedure
A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.
43. During the evaluation phase for a client, the nurse should focus on
The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation. Evaluation process of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care.
44. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
The correct answer is A: Review the medications the client is receiving
Antibiotics and medications containing sorbitol may induce diarrhea.
45. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?
The correct answer is D: Thiocyanate
Thiocyanate levels rise with the metabolism if nitroprusside and can cause cyanide toxicity.
46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates
The correct answer is C: Flight of ideas
Flight of ideas - defines nearly continuous flow of speech, jumping from 1 topic to another.
47. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?
The correct answer is B: Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood.
48. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to
The correct answer is B: Ask the client what foods are acceptable
Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.
49. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
The correct answer is B: Decreased colloidal osmotic pressure in the capillaries. The increased glomerular permeability to protein causes a decrease in serum albumin which results in decreased colloidal osmotic pressure.
50. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?
The correct answer is C: Bilirubin
In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.
51. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
The correct answer is C: 15 minutes
Frequency is the time from the beginning of one contraction to the beginning of the next contraction.
52. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?
The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." Recovery is total abstinence from all drugs.
53. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
The correct answer is A: Measure head circumference
In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.
54. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
The correct answer is B: With fear of rejection causing increased rage toward the victim. The fear of rejection and loss only serve to increase the batterer’s rage at his partner.
55. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?
The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.
56. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with
The correct answer is C: Life’s stressors
Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings.
57. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
The correct answer is A: High in carbohydrates and proteins
Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.
58. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
The correct answer is D: Should be limited to three to four cups of milk daily
More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.
59. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?
The correct answer is B: Set time aside to get the mother to express her feelings and concerns.
Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed.
60. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
The correct answer is B: Use oxygen during meals improves gas exchange
Clients with emphysema breathe easier when using oxygen while eating.
61. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
The correct answer is B: Place the client in a sitting position with legs dangling
Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.
62. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
The correct answer is C: Assessing the client''s learning style
As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.
63. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
The correct answer is B: Dehydration
Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.
64. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.
65. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?
The correct answer is A: Retractions in the soft tissues of the thorax
Slight intercostal retractions are normal. However in disease states, especially in severe airway obstruction, retractions become extreme.
66. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
The correct answer is B: Imitation of Sounds
Imitation of sounds such as "da-da" is expected at this time.
67. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"
At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.
68. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?
The correct answer is D: I can switch to a bottle if I need to take a break from breast feeding.
Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.
69. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
The correct answer is C: Mild emesis progressing to projectile vomiting
Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings.
70. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?
The correct answer is B: It assesses a child''s development.
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.
71. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
The correct answer is C: Compile a history of behavior patterns and developmental accomplishments
A complete behavioral, and developmental history plays an important role in determining the diagnosis.
72. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by
The correct answer is B: Minimizing the episode and underestimating the victim’s injuries
Many abusers lack an understanding of the effect of their behavior on the victim and use excessive minimization and denial.
73. The nurse, assisting in applying a cast to a client with a broken arm, knows that
The correct answer is C: The wet cast should be handled with the palms of hands
Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.
74. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
A toddler with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possible a secondary infection.
75. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
The correct answer is C: Tripled the birth weight
The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.
76. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
A) Age 40 years
The correct answer is D: Uses cocaine on weekends
Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.
77. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?
The correct answer is A: Leave the room and return five minutes later and give the medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.
78. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?
The correct answer is C: Riding a tricycle
Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.
79. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
The correct answer is A: All lesions crusted
The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.
80. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
The correct answer is D: Moist saline dressing
This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.
81. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
The correct answer is D: Reflects an average blood sugar for several months Glycosolated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 3-4 months and is used to monitor client adherence to the therapeutic regimen.
82. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
The correct answer is C: Assist the client with pursed lip breathing Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
83. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have
The correct answer is D: Heaviness in the affected testicle
The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.
84. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily
The correct answer is A: Psychological
With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that produces craving and compulsive use.
85. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
The correct answer is A: Separation anxiety
While a toddler will experience all of the stresses, separation from parents is the major stressor.
86. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
The correct answer is C: Perceived loss of control
For school age children, major fears are loss of control and separation from friends/peers.
87. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
The correct answer is A: Cardizem SR tablet (diltiazem)
Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.
88. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
The correct answer is B: Drug tolerance
Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
89. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
The correct answer is A: Acceptance of the pregnancy
During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.
90. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
The correct answer is B: Prescribed use of an MAO inhibitor
SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
91. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?
The correct answer is C: Apply bulky, loose dressing to nose and ears.
Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.
92. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
The correct answer is A: "Touching the abdomen could cause cancer cells to spread."
Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.
93. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
The correct answer is C: Respiratory rate of 32
Clients with deep vein thrombosis are at risk for the development of pulmonary embolism. The most common symptoms are tachypnea, dyspnea, and chest pain.
94. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is
The correct answer is A: Avoid alcohol use during this time
Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided
95. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?
The correct answer is B: Administer the medication with a syringe next to the tongue
Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.
96. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?
The correct answer is B: Talk with the client to find out about the preferred herbal preparation
Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health-care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death".
97. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating
The correct answer is A: "I will increase sodium and fluids and restrict potassium."
The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.
98. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
The correct answer is A: Promote verbal and nonverbal communication with both the client and the interpreter
The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues
99. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
The correct answer is D: Color
Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.
100. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
The correct answer is B: Frequent turning
Frequent turning will prevent skin breakdown.
The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)
2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by
The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.
3. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.
4. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?
The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.
5. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness. Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.
6. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be
The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.
7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggests altered thinking processes.
8. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?
The correct answer is B: Flexion of the hip and knees with passive flexion of the neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis.
9. Post-procedure nursing interventions for electroconvulsive therapy include
The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care.
10. The nurse is talking to parents about nutrition in school aged children. Which of the following is the
The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.
11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home
The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.
12. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.
13. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.
14. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should
The correct answer is C: Give the client simple information about what she will be doing. The distressed disoriented client should be gently oriented to reduce fear and increase the sense of safety and security. Environmental changes provoke stress and fear.
15. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?
The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.
16. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?
The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help you to reinforce the need for daily management of the disease whether or not the patient "feels better".
17. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is
The correct answer is B: "Your child has less red blood cells that carry oxygen." The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.
18. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
The correct answer is B: When the client threatens self-harm and harm to others. Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public.
19. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8 months.
20. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?
The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.
21. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.
22. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?
The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent''s pregnancies will result in a child with systic fibrosis.
23. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent?
The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.
24. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
The correct answer is C: Clothing has become tight around the waist
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.
25. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?
The correct answer is D: Occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.
26. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to
The correct answer is A: Ask the client about the refusal of certain pain medications. Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.
27. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.
28. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client??"
The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.
29. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?
The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss.
30. Which type of accidental poisoning would the nurse expect to occur in children under age 6?
The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.
31. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.
32. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
The correct answer is B: Twenty month-old who has just learned to climb stairs. Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.
33. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.
34. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?
The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia. Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.
35. A nurse is caring for a client with multiple myeloma. Which of the following should be included in the plan of care?
The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, client’s are at high risk for pathological fractures.
36. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
A) Reading
The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention.
37. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture and active and passive range of motion exercises important interventions for maintaining function of affected joints.
38. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?
The correct answer is C: Provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.
39. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?
The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
40. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
The correct answer is D: Note patterns of increased blood pressure
Hypertension is a key assessment in the course of the disease.
41. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alchohol intake.
42. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child?
The correct answer is B: Explain the surgery 1 week prior to the procedure
A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.
43. During the evaluation phase for a client, the nurse should focus on
The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation. Evaluation process of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care.
44. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
The correct answer is A: Review the medications the client is receiving
Antibiotics and medications containing sorbitol may induce diarrhea.
45. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?
The correct answer is D: Thiocyanate
Thiocyanate levels rise with the metabolism if nitroprusside and can cause cyanide toxicity.
46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates
The correct answer is C: Flight of ideas
Flight of ideas - defines nearly continuous flow of speech, jumping from 1 topic to another.
47. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?
The correct answer is B: Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood.
48. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to
The correct answer is B: Ask the client what foods are acceptable
Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.
49. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
The correct answer is B: Decreased colloidal osmotic pressure in the capillaries. The increased glomerular permeability to protein causes a decrease in serum albumin which results in decreased colloidal osmotic pressure.
50. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?
The correct answer is C: Bilirubin
In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.
51. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
The correct answer is C: 15 minutes
Frequency is the time from the beginning of one contraction to the beginning of the next contraction.
52. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?
The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." Recovery is total abstinence from all drugs.
53. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
The correct answer is A: Measure head circumference
In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.
54. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
The correct answer is B: With fear of rejection causing increased rage toward the victim. The fear of rejection and loss only serve to increase the batterer’s rage at his partner.
55. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?
The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.
56. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with
The correct answer is C: Life’s stressors
Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings.
57. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
The correct answer is A: High in carbohydrates and proteins
Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.
58. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
The correct answer is D: Should be limited to three to four cups of milk daily
More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.
59. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?
The correct answer is B: Set time aside to get the mother to express her feelings and concerns.
Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed.
60. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
The correct answer is B: Use oxygen during meals improves gas exchange
Clients with emphysema breathe easier when using oxygen while eating.
61. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
The correct answer is B: Place the client in a sitting position with legs dangling
Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.
62. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
The correct answer is C: Assessing the client''s learning style
As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.
63. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
The correct answer is B: Dehydration
Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.
64. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.
65. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?
The correct answer is A: Retractions in the soft tissues of the thorax
Slight intercostal retractions are normal. However in disease states, especially in severe airway obstruction, retractions become extreme.
66. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
The correct answer is B: Imitation of Sounds
Imitation of sounds such as "da-da" is expected at this time.
67. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"
At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.
68. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?
The correct answer is D: I can switch to a bottle if I need to take a break from breast feeding.
Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.
69. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
The correct answer is C: Mild emesis progressing to projectile vomiting
Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings.
70. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?
The correct answer is B: It assesses a child''s development.
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.
71. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
The correct answer is C: Compile a history of behavior patterns and developmental accomplishments
A complete behavioral, and developmental history plays an important role in determining the diagnosis.
72. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by
The correct answer is B: Minimizing the episode and underestimating the victim’s injuries
Many abusers lack an understanding of the effect of their behavior on the victim and use excessive minimization and denial.
73. The nurse, assisting in applying a cast to a client with a broken arm, knows that
The correct answer is C: The wet cast should be handled with the palms of hands
Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.
74. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
A toddler with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possible a secondary infection.
75. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
The correct answer is C: Tripled the birth weight
The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.
76. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
A) Age 40 years
The correct answer is D: Uses cocaine on weekends
Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.
77. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?
The correct answer is A: Leave the room and return five minutes later and give the medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.
78. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?
The correct answer is C: Riding a tricycle
Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.
79. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
The correct answer is A: All lesions crusted
The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.
80. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
The correct answer is D: Moist saline dressing
This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.
81. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
The correct answer is D: Reflects an average blood sugar for several months Glycosolated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 3-4 months and is used to monitor client adherence to the therapeutic regimen.
82. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
The correct answer is C: Assist the client with pursed lip breathing Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
83. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have
The correct answer is D: Heaviness in the affected testicle
The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.
84. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily
The correct answer is A: Psychological
With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that produces craving and compulsive use.
85. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
The correct answer is A: Separation anxiety
While a toddler will experience all of the stresses, separation from parents is the major stressor.
86. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
The correct answer is C: Perceived loss of control
For school age children, major fears are loss of control and separation from friends/peers.
87. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
The correct answer is A: Cardizem SR tablet (diltiazem)
Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.
88. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
The correct answer is B: Drug tolerance
Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
89. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
The correct answer is A: Acceptance of the pregnancy
During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.
90. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
The correct answer is B: Prescribed use of an MAO inhibitor
SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
91. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?
The correct answer is C: Apply bulky, loose dressing to nose and ears.
Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.
92. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
The correct answer is A: "Touching the abdomen could cause cancer cells to spread."
Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.
93. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
The correct answer is C: Respiratory rate of 32
Clients with deep vein thrombosis are at risk for the development of pulmonary embolism. The most common symptoms are tachypnea, dyspnea, and chest pain.
94. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is
The correct answer is A: Avoid alcohol use during this time
Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided
95. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?
The correct answer is B: Administer the medication with a syringe next to the tongue
Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.
96. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?
The correct answer is B: Talk with the client to find out about the preferred herbal preparation
Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health-care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death".
97. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating
The correct answer is A: "I will increase sodium and fluids and restrict potassium."
The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.
98. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
The correct answer is A: Promote verbal and nonverbal communication with both the client and the interpreter
The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues
99. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
The correct answer is D: Color
Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.
100. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
The correct answer is B: Frequent turning
Frequent turning will prevent skin breakdown.
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