ATI Comprehensive Exit Examination 1 | 100 of the frequently occuring Questions and Answers plus Rationale

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ATI Comprehensive Exit Examination 1 | 100 of the frequently occuring Questions and Answers plus Rationale 1. The nurse enters the room as a 3 year-old is having a generalized seizure. Which interven... tion should the nurse do first? A) Clear the area of any hazards B) Place tke ckild on tke side C) Restrain the child D) Give the prescribed anticonvulsant 2. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and cought D) Monitor oxygen saturation 3. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assiged to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma Prolonged hypoxemia Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia. Children usually have both cardiac and respiratory arrest. 4. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration Observe a return demonstration Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique. 5. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year B) Weight and height in 10th percentile since birth C) Takes frequent rest periods while playing D) Changing food preferences and dislikes Takes frequent rest periods while playing Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children. 6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? A) An 18 month-old who ate an undetermined amount of crystal drain cleaner B) A 14 month-old who chewed 2 leaves of a philodendron plant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid : An 18 month-old who ate an undetermined amount of crystal drain cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize this substance. 7. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy Anticipation of the birth Directing activities toward preparation for the newborn''s needs and personal adjustment are indicators of appropriate emotional response in the third trimester. 8. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene Excessive fluoride intake The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel''s porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride. 9. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? A) Direct sunlight B) Foods containing tyramine C) Foods fermented with yeast D) Canned citrus fruit drinks : Avoid direct sunlight Phenothiazine increases sensitivity to the sun, making clients especially susceptible to sunburn. 10. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate." : "Eat a balanced diet for your age." A diet for a teenager with acne should be a well balanced diet for their age. There are no recommended additions and subtractions from the diet. 11. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns Observe swallowing patterns The nurse should observe for increased swallowing frequency to check for hemorrhage. 12. The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care? A) Cough and deep breathe every 2 hours B) Place the client in contact isolation C) Provide a diet high in protein D) Institute seizure precautions : Cough and deep breathe every 2 hours Respiratory infections are common because of fluid in the retro peritoneum pushing up against the diaphragm causing shallow respirations. Encouraging the client to cough and deep breathe every 2 hours will diminish the occurrence of this complication. 13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the client with nutrition needs, the nurse should A) Offer small meals of high calorie soft food B) Assist the client to sit in a chair for meals C) Provide additional servings of fruits and raw vegetables D) Encourage the client to eat fish, liver and chicken : Offer small meals of high calorie soft food If the client is losing weight because of poor appetite due to the pain, assist in selecting foods that are high in calories and nutrients, to provide more nourishment with less chewing. Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw movements when eating, suggest that foods be pureed. 14. A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to A) Notify the health care provider immediately B) Suggest in-patient psychiatric care C) Respect the client's confidential disclosure D) Phone the family to warn them of the risk : Notify the health care provider immediately The health care provider must be contacted immediately as the client is a danger to self and others. Hospitalization is indicated. 15. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?" C) "These feelings are a symptom of your illness." D) "You’re safe here. I won’t let anyone poison you." : "You think that someone wants to poison you?" This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt. 16. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? A) Altered nutrition: less than body requirements B) Potential complication hemorrhage C) Ineffective individual coping D) Fluid volume excess Potential complication hemorrhage Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise. 17. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sippy cup A 30 month-old only drinking from a sippy cup A 30 month-old should be able to drink from a cup without a cover. 18. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? A) Neuromalignant syndrome B) Acute extrapyramidal syndrome C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors Glaucoma, prostatic hypertrophy Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) as the drug is an anticholinergic agent. 19. A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) Insecurity C) Dependence D) Lack of trust Dependence The client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal. 20. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that A) The client should remain on bed rest in a semi-Fowler's position B) The client should alternate ambulation with bed rest with legs elevated C) The client may ambulate and sit in chair as tolerated D) The client may ambulate as tolerated and remain in semi-Fowlers position in bed The client should alternate ambulation with bed rest with legs elevated. Encourage alternating periods ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client with gradually increasing periods of ambulation. 21. In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client? A) Compliance with treatment regimens B) Looking different from their peers C) Lacking independence in activities D) Reliance on family for their social support Looking different from their peers Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery. 22. The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first? A) Elicit reflexes B) Measure height and weight C) Auscultate heart and lungs D) Examine the ears Auscultate heart and lungs The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order. 23. Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client? A) An accurate measurement of intake is not reliable B) The food pyramid is not used in this age group C) A serving size at this age is about 2 tablespoons D) Total intake varies greatly each day A serving size at this age is about 2 tablespoons In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake. 24. The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation? A) Glucose level of 120 B) History of myocardial infarction C) Long term steroid usage D) Diet high in carbohydrates Long term steroid usage Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased. 25. Which of the following nursing assessments indicate immediate discontinuance of an antipsychotic medication? A) Involuntary rhythmic stereotypic movements and tongue protrusion B) Cheek puffing, involuntary movements of extremities and trunk C) Agitation, constant state of motion D) Hyperpyrexia, severe muscle rigidity, malignant hypertension Hyperpyrexia, severe muscle rigidity, malignant hypertension, hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of NMS (neuroleptic malignant syndrome). 26. A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that the most likely cause of the HSV-1 infection in this client is A) Immunosuppression B) Emotional stress C) Unprotected sexual activities D) Contact with saliva : Immunosuppression The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HSV-1. However they are not the most likely cause in clients with HIV. 27. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take? A) Notify the health care provider B) Palpate the anterior fontanel C) Feel the posterior fontanel D) Record these normal findings Record these normal findings The question is D. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age. 28. At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response? A) "This is normal at this time of day." B) "How long has this been occurring?" C) "Do you offer fluids at night?" D) "Have you tried waking her to urinate?" "How long has this been occurring?" Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons. 29. A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by A) Requiring the client to mop the floor B) Restricting the client’s fluids throughout the day C) Withholding privileges each time the voiding occurs D) Toileting the client more frequently with supervision Toileting the client more frequently with supervision With altered thought processes the most appropriate nursing approach to alter the behavior is by attending to the physical need. 30. The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention? A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus B) Opening the bottom of the pouch, allowing the flatus to be expelled C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape D) Assisting the client to ambulate to reduce the flatus in the pouch Opening the bottom of the pouch, allowing the flatus to be expelled. The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and dose the bottom of the pouch. 31. The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet? A) Vegetables B) Cereal C) Fruit D) Meats Cereal Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron. 32. When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother? A) It is likely that all sons are affected B) There is a 50% probability that sons will have the disease C) Every daughter is likely to be a carrier D) There is a 25% chance a daughter will be a carrier There is a 25% chance a daughter will be a carrier Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male. 33. When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to A) Avoid smoking near the client B) Turn off oxygen during meals C) Adjust the liter flow to 10 as needed D) Remind the client to keep mouth closed : Avoid smoking near the client Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment. 34. The nurse is caring for a post-op colostomy client. The client begins to cry saying, "I'll never be attractive again with this ugly red thing." What should be the first action by the nurse? A) Arrange a consultation with a sex therapist B) Suggest sexual positions that hide the colostomy C) Invite the partner to participate in colostomy care D) Determine the client's understanding of her colostomy Determine the client''s understanding of her colostomy. One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However, the specific concern of the client needs to be assessed before specific suggestions for dealing with the sexual concerns are given. 35. A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome for this client’s care will be A) Expresses feelings appropriately through verbal interactions B) Accurately interprets events and behaviors of others C) Demonstrates improved social relationships D) Engages in meaningful and understandable verbal communication Engages in meaningful and understandable verbal communication. Data support impaired verbal communication deficit. The outcome must be related to the diagnosis and supporting data. No data is presented related to feelings or to thinking processes. 36. A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to A) Promote healing and strengthen the immune system B) Provide a well balanced nutritional intake C) Stimulate increased peristalsis absorption D) Spare protein catabolism to meet metabolic needs Spare protein catabolism to meet metabolic needs Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue. 37. The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? A) The ethical sense and feelings of justice are developing B) Attempts to control the family use new coping styles C) Insecurity and attention getting are common motives D) Complex thought processes help to resolve conflicts : The ethical sense and feelings of justice are developing. The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. 38. A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child? A) Maintain good nutrition B) Stay in school C) Keep in contact with the child's father D) Get adequate sleep : Maintaining good nutrition Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies. 39. A client continually repeats phrases that others have just said. The nurse recognizes this behavior as A) Autistic B) Ecopraxic C) Echolalic D) Catatonic Echolalic Echolalic - repeating words heard. 40. A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis? A) Low hemoglobin B) Hypernatremia C) High serum creatinine D) Hyperkalemia : Low hemoglobin Although hemodialysis improves or corrects electrolyte imbalances it has not effect on improving anemia. 41. The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents? A) Report a persistent cough to the health care provider B) The child can return to school in 4 days C) Administer chewable aspirin for pain D) The child may gargle with saline as necessary for discomfort : Report a persistent cough to the health care provider. Persistent coughing should be reported to the health care provider as this may indicate bleeding. 42. The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse? A) 1in 4 chance for each child to carry that trait B) 1in 4 risk for each child to have the disease C) 1in 2 chance of avoiding the trait and disease D) 1in 2 chance that each child will have the disease 1 in 4 risk for each child to have the disease Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease. 43. The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate? A) Bronchial breath sounds in outer lung fields B) Decreased tactile fremitus C) Hacking, nonproductive cough D) Hyperresonance of areas of consolidation : Bronchial breath sounds in outer lung fields Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields. 44. During seizure activity which observation is the priority to enhance further direction of treatment? A) Observe the sequence or types of movement B) Note the time from beginning to end C) Identify the pattern of breathing D) Determine if loss of bowel or bladder control occurs : Protect the client from injury It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description. 45. Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training? A) The child learns voluntary sphincter control through repetition B) Myelination of the spinal cord is completed by this age C) Neuronal impulses are interrupted at the base of the ganglia D) The toddler can understand cause and effect Myelination of the spinal cord is completed by this age. Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, sometime between the ages of 18 to 24 months of age. 46. A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following? A) Call the health care provider B) Check vital signs C) Position in high Fowler's D) Administer oxygen Administer oxygen When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation. Starting oxygen is a priority. 47. The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate finding? A) Large volume of urinary output with each voiding B) Involuntary voiding with coughing and sneezing C) Frequent urination D) Urine is dark and concentrated Frequent urination Clients with Benign Prostatic Hypertrophy have overflow incontinence with frequent urination in small amounts day and night. 48. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the nurse's best response to the parent? A) "When a child asks a question, give a simple answer." B) "Children ask many questions, but are not looking for answers." C) "This question indicates interest in sex beyond this age." D) "Full and detailed answers should be given to all questions." : "When a child asks a question, give a simple answer." During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer. When they are ready, they will ask about the other pieces. 49. A 3 year-old child is treated in the emergency department after ingestion of 1ounce of a liquid narcotic. What action should the nurse do first? A) Provide the ordered humidified oxygen via mask B) Suction the mouth and the nose C) Check the mouth and radial pulse D) Start the ordered intravenous fluids Check the mouth and radial pulse The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation; then stabilize the client. The other nursing actions will follow. 50. The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention? A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue B) To cover the bony prominence and areas where there is skin breakdown C) So the client knows what type of clothing to wear when weighed D) To reduce the tendency of the client to hide objects under his or her clothing To reduce the tendency of the client to hide objects under his or her clothing. The client may conceal weights on their body to increase weight gain. 51. In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to A) Avoid overheating during physical activities B) Maintain normal activity with some restrictions C) Be cautious of others with viruses or temperatures D) Maintain routine immunizations : Avoid overheating Fluid loss caused by overheating and dehydration can trigger a crisis. 52. The nurse understands that during the "tension building" phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of A) Anger B) Helplessness C) Calm D) Explosive Helplessness The battered individual internalizes appropriate anger at the batterer’s unfairness and instead feels depressed with a sense of helplessness, when the partner explodes in spite of best efforts to please the batterer. 53. A parent has numerous questions regarding normal growth and development of a 10 month- old infant. Which of the following parameters is of most concern to the nurse? A) 50% increase in birth weight B) Head circumference greater than chest C) Crying when the parents leave D) Able to stand up briefly in play pen : 50% increase in birth weight Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18 months. 54. The nurse has been assigned to these clients in the emergency room. Which client would the nurse go check first? A) Viral pneumonia with atelectasis B) Spontaneous pneumothorax with a respiratory rate of 38 C) Tension pneumothorax with slight tracheal deviation to the right D) Acute asthma with episodes of bronchospasm Tension pneumothorax with slight tracheal deviation to the right. Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest. 55. The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect? A) Pelvic tip downward B) Right leg lengthening C) Ortolani sign D) Characteristic limp Characteristic limp Developmental dysplasia produces a characteristic limp in children who are walking. 56. A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include? A) Allow the child to continue normal activities B) Schedule frequent rest periods C) Limit exposure to other children D) Restrict activities to inside the house : Allow the child to continue their normal activities Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help develop normal breathing patterns. 57. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown A) Ileostomy B) Transverse colostomy C) Ileal conduit D) Sigmoid colostomy : Ileostomy Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in several hours. Because of the caustic nature of this stoma output adequate peristomal skin protection must be delivered to prevent skin breakdown. 58. A client is unconscious following a tonic-clonic seizure. What should the nurse do first? A) Check the pulse B) Administer Valium C) Place the client in a side-lying position D) Place a tongue blade in the mouth Place the client in a side-lying position Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. 59. The nurse is teaching a client who has a hip prostheses following total hip replacement. Which of the following should be included in the instructions for home care? A) Avoid climbing stairs for 3 months B) Ambulate using crutches only C) Sleep only on your back D) Do not cross legs Do not cross legs Hip flexion should not exceed 60 degrees. 60. A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? A) The state nurse practice act in which the assignment is made B) With a nurse colleague who has worked in that state 2 years ago D) The Nursing Social Policy Statement within the United States C) The policies and procedures of the assigned agency in that state : The state nurse practice act in which the assignment is made. The state nurse practice act is the governing document of what can be done in the assigned state. 61. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse? A) Tell the parents to bring the child to the clinic for further evaluation B) Refer the school officials to printed materials about this viral illness C) Inform the teacher that the child is receiving antibiotics for the rash D) Explain that this rash is not contagious and does not require isolation Explain that this rash is not contagious and does not require isolation. Fifth Disease is a viral illness with an uncertain period of communicability (perhaps 1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider. 62. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero? A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated The infant is very susceptible to infections HIV infected children are susceptible to opportunistic infections due to a compromised immune system. 63. While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse? A) Immediately B) Several days C) 2 weeks D) 1 month 2 weeks Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s symptoms. 64. The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization? A) Younger siblings adapt very well B) Visitation is helpful for both C) The siblings may enjoy privacy D) Those cared for at home cope better Visitation is helpful for both Contact with the ill child helps siblings understand the reasons for hospitalization and maintains the relationship. 65. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A) Craving B) Crashing C) Outward bound D) Nodding out Crashing Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling referred to as crashing. 66. One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care B) There is typically a series of minor, vague complaints C) Expenses due to police and court costs are prohibitive D) Very little knowledge is currently known about batterers and battering relationships There is typically a series of minor, vague complaints. Signs of abuse may not be clearly manifested and a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness may be covert indications of abuse undetected. Complaints may be vague. 67. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? A) Follow-up on lab values before the visit B) Observe client findings for the effectiveness of antibiotics C) Ask for a log of urinary output D) As for the log of the oral intake Ask for a log of urinary output The nurse must monitor the urine output as a priority because it is the best indictor of renal function. The other options would be done after an evaluation of the urine output. 68. When a client is having a general tonic clonic seizure, the nurse should A) Hold the client's arms at their side B) Place the client on their side C) Insert a padded tongue blade in client's mouth D) Elevate the head of the bed Place the client on their side This position keeps the airway patent and prevents aspiration. 69. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway? A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers SA node, AV node, Bundle of His, Purkinje fibers The pathway of a normal electrical impulse through the heart is: SA node, AV node, Bundle of His, Purkinje fibers. 70. Clients with mitral stenosis would likely manifest findings associated with congestion in the A) Pulmonary circulation B) Descending aorta C) Superior vena cava D) Bundle of His : Pulmonary circulation Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left ventricle and the lack of a competent valve to prevent back flow into the pulmonary vein. 71. In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing? A) White patches B) Green drainage C) Reddened tissue D) Eschar development Reddened tissue As the wound granulates, redness indicates healing. 72. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include A) Pointing out inconsistencies in speech patterns to correct thought disorders B) Accepting client and the client's behavior unconditionally C) Encouraging dependency in order to develop ego controls D) Consistent limit-setting enforced 24 hours per day Consistent limit-setting enforced 24 hours per day Treatment approaches that include restructuring the personality, assisting the person with developmental level and setting limits for maladaptive behavior such as acting out. 73. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement? A) Have respiratory support equipment available B) Immediately place her in the seclusion room C) Assess the client for anxiety and agitation D) Administer prn dose of IM antipsychotic medication : Have respiratory support equipment available Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure. 74. The nurse asks a client with a history of alcoholism about the client’s drinking behavior. The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? A) Denial B) Projection C) Intellectualization D) Rationalization Rationalization Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfies the teller as well as the listener. 75. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? A) Low tar cigarettes are less harmful during pregnancy B) There is a relationship between smoking and low birth weight C) The placenta serves as a barrier to nicotine D) Moderate smoking is effective in weight control There is a relationship between smoking and low birth weight. Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta previa, decreasing the growth potential of the fetus. 76. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? A) Observe for edema proximal to the site B) Irrigate with 5 mls of 0.9% Normal Saline C) Palpate for a thrill over the fistula D) Check color and warmth in the extremity Palpate for a thrill over the fistula To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. Other options are not related to evaluation for patency. 77. Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings? A) Direct confrontation B) Reality orientation C) Projective identification D) Active listening Active listening Use of therapeutic communication skills such as silence and active listening encourages verbalization of feelings. 78. The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first A) Assess the client's airway B) Call for help C) Establish that the client is unresponsive D) See if anyone saw the client fall Establish that the client is unresponsive The first step in CPR is to establish unresponsiveness. Second is to call for help. Third is opening the airway. 79. What is the best way for the nurse to accomplish a health history on a 14 year-old client? A) Have the mother present to verify information B) Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent D) Focus the discussion of risk factors in the peer group Allow an opportunity for the teen to express feelings Adolescents need to express their feelings. Generally, they talk freely when given an opportunity and some privacy to do so. 80. A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is A) Participative or democratic B) Ultraliberal or communicative C) Autocratic or authoritarian D) Laissez faire or permissive Autocratic or authoritarian Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience and who need strong direction, while participative or democratic style is usually more successful on nursing units. 81. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next? A) Give the medication as ordered B) Call the health care provider to clarify the dose C) Recognize that antibiotics are over-prescribed D) Hold the medication as the dosage is too low : Give the medication as ordered Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered. 82. The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider? A) Lifts head from the prone position B) Rolls from abdomen to back C) Responds to parents' voices D) Falls forward when sitting Falls forward when sitting Sitting without support is expected at this age. 83. The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when A) An individual displays restlessness B) There are obvious signs of depression C) Conducting any health assessment D) The resident reports memory lapses Conducting any health assessment A mental status assessment is a critical part of baseline information, and should be a part of every examination. 84. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia? A) Must have structured activities B) Often take part in active sports C) Explain limitations to peer groups D) Avoid risks after bleeding episodes Often take part in active sports Establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of this age group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments. 85. When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first? A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations 4. Continue to monitor respirations 12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause for concern. At that point pulse oximetry is taken, as that rate could be tolerated. Vigorous stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask the RN to check findings. 86. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize A) Learning relaxation techniques B) Limiting alcohol use C) Eating smaller meals D) Avoiding passive smoke : Learning relaxation techniques The only factor that can enhance the client''s response to pain medication for angina is reducing anxiety through relaxation methods. Anxiety can be great enough to make the pain medication totally ineffective. 87. The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is A) Pain B) Impaired gas exchange C) Cardiac output altered: decreased D) Fluid volume excess Cardiac output altered: decreased All nursing interventions should be focused on improving cardiac output. Increasing cardiac output is the primary goal of therapy. Comfort will improve as the client improves and the respiratory status will improve as cardiac output increases. 88. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment but I don’t want my husband to leave me." Which response by the nurse would assist the client? A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can’t get well." B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come." C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an outclient bases." D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you." "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you." This response gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. Dependence issues are great for the client fostering ambivalence. 89. Clients taking which of the following drugs are at risk for depression? A) Steroids B) Diuretics C) Folic acid D) Aspirin : Steroids Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples include: phenothiazines, steroids, and reserpine. 90. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be A) "Do you want to discuss this with your pastor?" B) "We will help you deal with those thoughts." C) "Is your life so terrible that you want to end it?" D) "Have you thought about how you would do it?" "Have you thought about how you would do it?" This response provides an opening to discuss intent and means of committing suicide. 91. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to A) Check for subcutaneous emphysema in the upper torso B) Reposition the client to a position of comfort C) Call the health care provider as soon as possible D) Check for any increase in the amount of thoracic drainage : Check for subcutaneous emphysema in the upper torso. Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an air leak in the sytem. Thus the conclusion is that the problem is one of an air leak in the lung. This client may need to be returned to surgery to deal with the sustained air leak. Action by the health care provider is required to prevent further complications. 92. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that A) Circumcision can be performed at any time B) Initial repair is delayed until ages 6-8 C) Post-operative appearance will be normal D) Surgery will be performed in stages Surgery will be performed in stages Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery. 93. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? A) Maintain a low sodium diet B) Take a diuretic with lithium C) Come in for evaluation of serum lithium levels every 1-3 months D) Have blood lithium levels drawn during the summer months Have blood lithium levels drawn during the summer months. Clients taking lithium therapy need to be aware that hot weather may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration. 94. When an autistic client begins to eat with her hands, the nurse can best handle the problem by A) Placing the spoon in the client’s hand and stating, "Use the spoon to eat your food." B) Commenting "I believe you know better than to eat with your hand." C) Jokingly stating, "Well I guess fingers sometimes work better than spoons." D) Removing the food and stating "You can’t have anymore food until you use the spoon." : Placing the spoon in the client’s hand and stating "Use the spoon to eat your food." This response identifies adaptive behavior with instruction and verbal expectation. 95. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation : Auscultation of an S3 heart sound Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles. 96. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority? A) Hold the infant at frequent intervals. B) Assess for neonatal withdrawl syndrome C) Offer fluids to prevent dehydration D) Administer paregoric to stop diarrhea Assess for neonatal withdrawl syndrome Neonatal withdrawl syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyper irritability and gastro-intestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the period of withdrawal. 97. While planning care for a preschool aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse? A) Playing imaginatively B) Expressing shame C) Identifying with family D) Exploring the playroom Expressing shame Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage. 98. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response? A) "You’ve made some decisions." B) "Are you thinking about killing yourself?" C) "I’m so glad to hear that you’ve made some decisions." D) "You need to discuss your decisions with your therapist." "Are you thinking about killing yourself?" Sudden mood elevation and energy may signal increased risk of suicide. The nurse must validate suicide ideation as a beginning step in evaluating seriousness of risk. 99. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? A) Artrial septal defect B) Patent ductus arteriosus C) Aortic stenosis D) Ventricular septal defect Ventricular septal defect While assessments for conduction disturbance should be included following repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances. 100. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to A) Dehydration B) Diminished blood volume C) Decreased cardiac output D) Renal failure Decreased cardiac output Cardiac output and urinary output are directly correlated. The nurse should suspect a drop in cardiac output if the urinary output drops. Comprehensive Examination 2 October 24, 2007 1. In a child with suspected coarctation of the aorta, the nurse would expect to find A) Strong pedal pulses B) Diminishing cartoid pulses C) Normal femoral pulses D) Bounding pulses in tke asms 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 nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy 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 A) Anxiety, unconscious anger, and hostility B) Guilt, indecisiveness, poor self-concept C) Psychomotor retardation or agitation D) Meticulous attention to grooming and hygiene 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? A) "The violence is temporarily caused by unusual circumstances; don’t stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do." "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 A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others 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 A) headed for relapse B) feeling hopeless C) approaching recovery D) in need of increased socialization : 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 A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment 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? A) Hyperextension of the neck with passive shoulder flexion B) Flexion of the hip and knees with passive flexion of the neck C) Flexion of the legs with rebound tenderness D) Hyperflexion of the neck with rebound flexion of the legs 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 A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory loss 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 most common nutritional disorder in this age group? A) Bulimia B) Anorexia C) Obesity D) Malnutrition 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 B) Medication compliance C) Exposure to hot temperatures D) Alcohol use 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? A) Standing and sitting B) In both arms C) After exercising D) Supine position 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? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia 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 A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity 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? A) Gonorrhea B) Chlamydia C) Herpes D) HIV 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? A) Degeneration of the alveoli B) Chronic bronchoconstriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia 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 A) "Although the results are here, your doctor will explain them later." B) "Your child has less red blood cells that carry oxygen." C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation." "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? A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client 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? A) Say 2 words B) Pull up to stand C) Sit without support D) Drink from a cup 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? A) The pediatrician must examine the baby B) Emergency equipment should be available C) This breathing pattern is normal D) A future referral may be indicated 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? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball 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? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend." "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? A) Age of the child B) Sibling position in family C) Stressful family events D) Parental discipline strategies : 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? A) My child has lost 3 pounds in the last month. B) Urinary output seemed to be less over the past 2 days. C) All the pants have become tight around the waist. D) The child prefers some salty foods more than others. 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? A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing 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 A) Ask the client about the refusal of certain pain medications B) Talk with the client's family about the situation C) Report the situation to the health care provider D) Document the situation in the notes : 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? A) Increase fluid intake to prevent dehydration B) Place client on a pressure reducing support surface C) Use skin care products designed for use with incontinence D) Increase caloric intake to aid healing 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? A) "No, it would be best if you brought the client some reading material that she could read at night." B) "No, your presence may cause the client to become more anxious." C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." D) "Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?" "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? A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities 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? A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes : 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? A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently 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? A) 9 month-old who stays with a sitter 5 days a week B) 20 month-old who has just learned to climb stairs C) 10 year-old who occasionally stays at home unattended D) 15 year-old who likes to repair bicycles 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? A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle : 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? A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions : 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? A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered 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 B) Checkers C) Cards D) Ping-pong 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? A) Maintaining and preserving function B) Anticipating side effects of therapy C) Supporting coping with limitations D) Ensuring compliance with medications : 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? A) Contains less lactose B) Is higher in calories/ounce C) Provides antibodies D) Has less fatty acid 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? A) Red reflex test B) Visual acuity C) Pupil response to light D) Cover test : 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? A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure 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? A) Seizures B) Withdrawal C) Craving D) Marked tolerance 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? A) Introduce the child to all staff the day before surgery B) Explain the surgery 1 week prior to the procedure C) Arrange a tour of the operating and recovery rooms D) Encourage the child to bring a favorite toy to the hospital 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 A) All finding of physical and psychosocial stressors of the client and in the family B) The client's status, progress toward goal achievement, and ongoing re-evaluation C) Setting short and long-term goals to insure continuity of care from hospital to home D) Select interventions that are measurable and achievable within selected timeframes 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 A) Review the medications the client is receiving B) Increase the formula infusion rate C) Increase the amount of water used to flush the tube D) Attach a rectal bag to protect the skin : 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? A) Potassium B) Arterial blood gasses C) Blood urea nitrogen D) Thiocyanate 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 A) Neologisms B) Dissociation C) Flight of ideas D) Word salad 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? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation 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 A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) Ask the client what foods are acceptable or bad C) Encourage her to eat for healing and strength D) Schedule the dietitian to meet with the client as soon as possible 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 A) Increased retention of albumin in the vascular system B) Decreased colloidal osmotic pressure in the capillaries C) Fluid shift from interstitial spaces into the vascular space D) Reduced tubular reabsorption of sodium and water 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? A) Blood urea nitrogen B) Acid phosphatase C) Bilirubin D) Sedimentation rate 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? A) 14 minutes B) 10 minutes C) 15 minutes D) Nine minutes 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? A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings." B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C) "A recovering person needs to get in touch with their feelings. Do you want a drink?" D) "A recovering person cannot return to drinking without starting the addiction process over." "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? A) Measure head circumference B) Place in airborne isolation C) Provide passive range of motion D) Provide an over-the-crib protective top : 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? A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble B) With fear of rejection causing increased rage toward the victim C) With a new commitment to seek counseling to assist with their marital problems D) With relief, and welcomes the separation as a means to have some personal time 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? A) "My partner's breathing rate is usually below 12." B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." C) "It seems our sex life is nonexistant over the past 6 months." D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print." "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 A) Recreational and social needs B) Feelings of anger C) Life’s stressors D) Issues of guilt and disappointment 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 A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins : 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? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily 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? A) Discuss with the mother sharing parenting responsibilities B) Set time aside to get the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision 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 A) Eat foods high in sodium increases sputum liquefaction B) Use oxygen during meals improves gas exchange C) Perform exercise after respiratory therapy enhances appetite D) Cleanse the mouth of dried secretions reduces risk of infection 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? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN antianxiety agent 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? A) Touring the coronary intensive unit B) Mailing a video tape to the home C) Assessing the client's learning style D) Administering a written pre-test 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 A) Septicemia B) Dehydration C) Hypokalemia D) Hypercalcemia 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? A) "I understand that a glass of wine with dinner is healthy." B) "Beer is not really hard alcohol, so I guess I can drink some." C) "If I drink, my baby may be harmed before I know I am pregnant." D) "Drinking with meals reduces the effects of alcohol." "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? A) Retractions in the intercostal tissues of the thorax B) Chest pain aggravated by respiratory movement C) Cyanosis and mottling of the skin D) Rapid, shallow respirations : 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? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter 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? A) "Do you want to take this pretty red medicine?" B) "You will feel better if you take your medicine." C) "This is your medicine, and you must take it all right now." D) "Would you like to take your medicine from a spoon or a cup?" "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? A) "I should position my baby completely facing me with my baby's mouth in front of my nipple." B) "The baby should latch onto the nipple and areola areas." C) "There may be times that I will need to manually express milk." D) "I can switch to a bottle if I need to take a break from breast feeding." 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? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. 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? A) It measures a child’s intelligence. B) It assesses a child's development. C) It evaluates psychological responses. D) It helps to determine problems. 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 A) Observe the child's behavior on at least 2 occasions B) Consult with the teacher about how to control impulsivity C) Compile a history of behavior patterns and developmental accomplishments D) Compare the child's behavior with classic signs and symptoms 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 A) Seeking medical help for the victim's injuries B) Minimizing the episode and underestimating the victim’s injuries C) Contacting a close friend and asking for help D) Being very remorseful and assisting the victim with medical care 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 A) The cast material should be dipped several times into the warm water B) The cast should be covered until it dries C) The wet cast should be handled with the palms of hands D) The casted extremity should be placed on a cloth-covered surface 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 A) Dress the child warmly to avoid chilling B) Keep the child away from other children for the duration of the rash C) Clean the affected areas with tepid water and detergent D) Wrap the child's hand in mittens or socks to prevent scratching 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? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference 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 B) Lactose intolerance C) Family history of breast cancer D) Uses cocaine on weekends 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? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce : 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? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch 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? A) All lesions crusted B) Elevated temperature C) Rhinorrhea and coryza D) Presence of vesicles : 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 A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing 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: A) Provides a more precise blood glucose value than self-monitoring B) Is performed to detect complications of diabetes C) Measures circulating levels of insulin D) Reflects an average blood sugar for several months 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 A) Instruct the client to breathe into a paper bag B) Place the client in a high Fowler's position C) Assist the client with pursed lip breathing D) Administer oxygen at 6L/minute via nasal cannula 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 A) Scrotal discoloration B) Sustained painful erection C) Inability to achieve erection D) Heaviness in the affected testicle 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 A) Psychological B) Physical C) Biological D) Social-cultural : 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? A) Separation anxiety B) Fear of pain C) Loss of control D) Bodily injury : 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? A) Change in body image B) An unfamiliar environment C) Perceived loss of control D) Guilt over being hospitalized 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? A) Cardizem SR tablet (diltiazem) B) Lanoxin liquid C) Os-cal tablet (calcium carbonate) D) Tylenol liquid (acetaminophen) : 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? A) Skin irritation B) Drug tolerance C) Severe headaches D) Postural hypotension 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? A) Acceptance of the pregnancy B) Acceptance of the termination of the pregnancy C) Acceptance of the fetus as a separate and unique being D) Satisfactory resolution of fears related to giving birth : 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? A) History of obesity B) Prescribed use of an MAO inhibitor C) Diagnosis of vascular disease D) Takes antacids frequently 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? A) Pack the nose and ears with sterile gauze B) Apply pressure to the injury site C) Apply bulky, loose dressing to nose and ears D) Apply an ice pack to the back of the neck 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? A) "Touching the abdomen could cause cancer cells to spread." B) "Examining the area would cause difficulty to the child." C) "Pushing on the stomach might lead to the spread of infection." D) "Placing any pressure on the abdomen may cause an abnormal experience." : "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? A) Temperature of 102 degrees Fahrenheit B) Pulse rate of 98 beats per minute C) Respiratory rate of 32 D) Blood pressure of 90/50 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 A) Avoid alcohol use during this time B) Observe the client for hypotension C) Abrupt discontinuation of the drug D) Assess for mild physical symptoms : 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? A) Allow the infant to drink the liquid from a medicine cup B) Administer the medication with a syringe next to the tongue C) Mix the medication with the infant's formula in the bottle D) Hold the child upright and administer the medicine by spoon 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? A) Report the behavior to the charge nurse B) Talk with the client to find out about the preferred herbal preparation C) Contact the client's health care provider D) Explain the importance of the medication to the client 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 A) "I will increase sodium and fluids and restrict potassium." B) "I will increase potassium and sodium and restrict fluids." C) "I will increase sodium, potassium and fluids." D) "I will increase fluids and restrict sodium and potassium." : "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 A) Promote verbal and nonverbal communication with both the client and the interpreter B) Speak only a few sentences at a time and then pause for a few moments C) Plan that the encounter will take more time than if the client spoke English D) Ask the client to speak slowly and to look at the person spoken to : 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? A) Heart rate B) Muscle tone C) Cry D) Color 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? A) Massage legs frequently B) Frequent turning C) Moisten skin with lotions D) Apply moist heat to reddened areas Frequent turning Frequent turning will prevent skin breakdown. [Show More]

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