NCLEX-RN NCLEX National Council Licensure Examination(NCLEX-RN). 100% pass rate, Graded A+

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NCLEX-RN NCLEX National Council Licensure Examination(NCLEX-RN) http://killexams.com/exam-detail/NCLEX-RNQuestion: 1 On the third postpartum day, the nurse would expect the lochia to be: A. Rubra... B. Serosa C. Alba D. Scant Answer: A Explanation: (A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge. Question: 2 A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that: A. The test is inconclusive and should be repeated B. Further testing is needed C. The test is normal and the fetus is reacting appropriately D. The fetus is distressed Answer: C Explanation: (A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress. Question: 3 Which stage of labor lasts from delivery of the baby to delivery of the placenta? A. Second B. Third C. Fourth D. Fifth Answer: B Explanation: (A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage of labor. Question: 4 A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as: A. Cefoperazone (Cefobid) B. Clindamycin (Cleocin) C. Dicloxacillin (Dycill) D. Erythromycin (Erythrocin)Answer: A Explanation: (A) Cefoperazone is indicated in the treatment of infection withPseudomonas aeruginosa.(B) Clindamycin is not indicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not indicated in the treatment of infection withP. aeruginosa.(D) Erythromycin is not indicated in the treatment of infection withP. aeruginosa. Question: 5 A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature: A. Orally in the morning and at bedtime B. Only one time during the day as long as it is always at the same time of day C. Rectally at bedtime D. As soon as she awakens, prior to any activity Answer: D Explanation: (A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulation relies on consistency in taking temperature. (C)Nightly rectal temperatures are more accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge. Question: 6 A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include: A. Administering diazepam (Valium) 1015 mg po q4h and q1h prn for hyperventilating episode B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur D. Using distraction to help control the client’s hyperventilation episodes Answer: C Explanation: (A) An adult diazepam dosage for treatment of anxiety is 210 mg PO 24 times daily. The order as written would place a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear. Question: 7 A client delivered a stillborn male at term. An appropriate action of the nurse would be to: A. State, "You have an angel in heaven." B. Discourage the parents from seeing the baby. C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time. D. Reassure the parents that they can have other children. Answer: C Explanation: (A) This is not a supportive statement. There are also no data to indicate the family’s religious beliefs. (B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say "good-bye." (C) Parents need time to get to know their baby. (D) This is not a comforting statement when a baby has died. Thereare also no guarantees that the couple will be able to have another child. Question: 8 A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is: A. Having a heart attack B. Wanting attention from the nurses C. Suffering from complete upper airway obstruction D. Hyperventilating Answer: D Explanation: (A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety. Question: 9 A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed: A. Gastritis B. Evisceration C. Peritonitis D. Pulmonary embolism Answer: C Explanation: (A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum. Question: 10 A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia: A. Is a type of regional anesthesia B. Uses equal amounts of inhalation agents and liquid agents C. Does not depress the central nervous system D. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complicationsAnswer: D Explanation: (A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a druginduced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications. Question: 11 Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should: A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations B. Obtain pulse and blood pressure readings noting rate and quality of pulse C. Reassure the client that his surgery is over and that he is in the recovery room D. Review physician’s orders, administering medications as ordered Answer: A Explanation: (A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse’s priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airway management. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes precedence over physician’s orders unless they specifically relate to airway management. Question: 12 A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent: A. Infection postoperatively B. Malignant hyperthermia C. Neuroleptic malignant syndrome D. Fever postoperatively Answer: B Explanation: (A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. (B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. (C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia. Question: 13 The family member of a child scheduled for heart surgery states, "I just don’t understand this open-heart or closedheart business. I’m so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is: A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed. B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed. C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heartsurgery. D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery. Answer: B Explanation: (A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels. Question: 14 A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given? A. 0.06 mL B. 0.38 mL C. 2.7 mL D. Information given insufficient to determine the amount of atropine to be administered Answer: B Explanation: (A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct. 0.4 mg = 1 mL:0.15 mg 5 = mL 0.4 x = 0.15 x = 0.15/0.4 x = 0.375 or 0.38 mL (D)Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given. Question: 15 A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to: A. Provide cathartic action within the colon B. Reduce the risk of wound infection from anaerobic bacteria C. Relieve the client’s concern regarding possible infection D. Reduce the risk of intraoperative fever Answer: B Explanation: (A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client’s risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation. Question: 16 A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is beinggiven digoxin. Prior to administering the medication, the nurse should: A. Not give the digoxin if the pulse is_60 B. Not give the digoxin if the pulse is_100 C. Take the apical pulse for a full minute D. Monitor for visual disturbances, a side effect of digoxin Answer: C Explanation: (A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children. Question: 17 A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 1015 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would: A. Provide food and fluids at the client’s request B. Maintain IV, increasing the rate hourly until the client voids C. Report to the surgeon if the client is unable to void within 8 hours of surgery D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention Answer: C Explanation: (A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void. Question: 18 A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is: A. Water will deplete electrolytes resulting in metabolic acidosis. B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation. C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period. D. Saline will increase peristalsis in the bowel. Answer: A Explanation: (A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. (B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. (C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. (D) A nasogastric tubeplaced in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well- functioning tube. Irrigating with saline will not increase peristalsis. Question: 19 The nurse writes the following nursing diagnosis for a client in acute renal failure–Impaired gas exchange related to: A. Decreased red blood cell production B. Increased levels of vitamin D C. Increased red blood cell production D. Decreased production of renin Answer: A Explanation: (A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention. Question: 20 A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include: A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position B. Administering analgesics as ordered C. Having the child turn, cough, and deep breathe every 12 hours D. Remaining with the child and keeping as calm and quiet as possible Answer: C Explanation: (A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis. (C) Having the client turn, cough, and deep breathe every 12 hours will aid in resolving the atelectasis. Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client’s anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness). Question: 21 A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as: A. Compensated metabolic alkalosis B. Respiratory acidosis C. Partially compensated metabolic alkalosis D. Combined respiratory and metabolic acidosis Answer: D Explanation:(A) Compensated metabolic alkalosis would be reflected by the following: pH within normal limit (7.357.45), PCO2 > 45 mm Hg, HCO3 >26 mEq/L. (B) Respiratory acidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 within normal limits (2226 mEq/L). (C) Partially compensated metabolic alkalosis would be reflected by the following: pH > 7.45, PCO2 > 45 mm Hg, HCO3 > 26 mEq/L. (D) Combined respiratory and metabolicacidosis would be reflected by the following: pH < 7.35, PCO2 > 45 mm Hg, HCO3 < 22 mEq/L. Question: 22 Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to: A. Remove the potassium from the body by renin exchange B. Protect the myocardium from the effects of hypokalemia C. Promote rapid protein catabolism D. Drive potassium from the serum back into the cells Answer: D Explanation: (A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. (B) Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. (C)Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. (D)The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum. Question: 23 The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly–High risk for injury: Increased susceptibility to bleeding related to: A. Increased absorption of vitamin K B. Thrombocytopenia due to hypersplenism C. Diminished function of the Kupffer cells D. Increased synthesis of the clotting factors Answer: B Explanation: (A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. (B) Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding. Question: 24 During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec’s cirrhosis of the liver. The nurse knows the pruritus is directly related to: A. A loss of phagocytic activity B. Faulty processing of bilirubin C. Enhanced detoxification of drugs D. The formation of collateral circulation Answer: B Explanation: (A) A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases thesusceptibility to infections. (B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin. (C) The detoxification of drugs is impaired with cirrhosis of the liver. (D)Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae. Question: 25 Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack? A. Fresh fruit B. A milkshake C. Saltine crackers and peanut butter D. A ham and cheese sandwich Answer: A Explanation: (A) High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. (B) Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C, D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a byproduct of protein metabolism. Question: 26 Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack? A. Fresh fruit B. A milkshake C. Saltine crackers and peanut butter D. A ham and cheese sandwich Answer: B Explanation: (A) Albumin, a blood volume expander, increases the circulating blood volume by exerting an osmotic pull on tissue fluids, pulling them into the vascular system. This fluid shift causes an increase in the heart rate and blood pressure. (B) Albumin, a blood volume expander, exerts an osmotic pull on fluids in the interstitial spaces, pulling the fluid back into the circulatory system. This fluid shift causes an increase in the urinary output. (C) Adventitious breath sounds and dyspnea can occur due to circulatory overload if the albumin is infused too rapidly. (D) Chills, fever, itching, and rashes are signs of a hypersensitivity reaction to albumin. Question: 27 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to: A. Prevent systemic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel Answer: C Explanation: (A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hepatic coma. (B)Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted. Question: 28 The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests? A. Number of platelets B. WBC count C. Hemoglobin level D. Number of lymphocytes Answer: A Explanation: (A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection. Question: 29 A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication? A. Increase your oral intake of fluids to at least 4000 mL every day. B. Avoid contact with people who have contagious illnesses. C. Brush your teeth at least 4 times a day with a firm toothbrush. D. Immediately stop taking the prednisone if you feel depressed. Answer: B Explanation: (A) Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. (B) Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. (C) An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). (D) Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly. Question: 30 When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash? A. Small round or oval reddish brown macules scattered over the entire body B. Scattered clusters of macules, papules, and vesicles over the body C. Bright red appearance of the palmar surface of the hands D. Reddened butterfly shaped rash over the cheeks and nose Answer: D Explanation: (A) The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. (B) The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. (C) Palmar redness is seen in clients with cirrhosis of the liver. (D) The characteristicbutterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus. Question: 31 Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate? A. Increased level of consciousness B. Increased rate and depth of respirations C. Increased peripheral vasodilation D. Increased perception of pain Answer: C Explanation: (A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief. Question: 32 A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room? A. Place him on NPO restriction for 4 hours. B. Monitor the catheterization site every 15 minutes. C. Place him in a high Fowler position. D. Ambulate him to the bathroom to void. Answer: B Explanation: (A) A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye. (B) Streptokinase activates plasminogen, dissolving fibrin deposits. To prevent bleeding, pressure is applied at the insertion site. The client is assessed for both internal and external bleeding. (C) The extremity used for the insertion site must be kept straight and be immobilized because of the potential for bleeding. (D) The client is kept on bed rest for 812 hours following the procedure because of the potential for bleeding. Question: 33 The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy? A. Serum electrolytes B. Arterial blood gases C. Complete blood count D. 12-Lead ECG Answer: A Explanation: (A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected inECG changes, but these changes do not occur until the abnormality is severe. Question: 34 Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication? A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision." B. "I could stop taking this medication when I begin to feel better." C. "I should only take the medication if my heart rate is greater than 100 bpm." D. "I should always take this medication with an antacid." Answer: A Explanation: (A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin. Question: 35 A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy? A. "If you forget to take your morning dose, double the night time dose." B. "You should take aspirin instead of acetaminophen (Tylenol) for headaches." C. "Carry a medications alert card with you at all times." D. "You should use a straight-edge razor when shaving your arms and legs." Answer: C Explanation: (A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding. Question: 36 A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis–Alteration in comfort, pain related to: A. Increased excretion of lactic acid due to myocardial hypoxia B. Increased blood flow through the coronary arteries C. Decreased stimulation of the sympathetic nervous system D. Decreased secretion of catecholamines secondary to anxiety Answer: A Explanation: (A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of thesympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart. Question: 37 A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication: A. Dissolves any clots already formed in the arteries B. Prevents the conversion of prothrombin to thrombin C. Interferes with the synthesis of vitamin K-dependent clotting factors D. Stimulates the manufacturing of platelets Answer: C Explanation: (A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. (B) Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. (D) Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs. Question: 38 A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure? A. Validate that he is not allergic to iodine or shellfish. B. Instruct him to start active range of motion of his left leg immediately following the procedure. C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure. D. Inform him that vital signs will be taken every hour for 4 hours after the procedure. Answer: A Explanation: (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 612 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding. Question: 39 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following: A. Both lower extremities warm to touch with 2_pedal pulses B. Both lower extremities cyanotic when placed in a dependent position C. Decreased or absent pedal pulse in the left leg D. The left leg warmer to touch than the right leg Answer: C Explanation: (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused byarterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation. Question: 40 One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: A. Blood pressure B. Level of consciousness C. Skin turgor D. Fluid intake Answer: B Explanation: (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client. Question: 41 A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a: A. Lactose-restricted diet B. Gluten-restricted diet C. Phenylalanine-restricted diet D. Fat-restricted diet Answer: B Explanation: (A) A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. (B) A gluten-restricted diet is the diet for children with celiac disease. (C) A phenylalaninerestricted diet is prescribed for children with phenylketonuria. (D) A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas. Question: 42 A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is: A. Disorientation B. Low-grade fever C. Diarrhea D. Hypertension Answer: A Explanation: (A) Disorientation is the first sign of sepsis in burn children. (B) Low-grade fever is not indicative of sepsis. (C) Diarrhea is not indicative of sepsis. (D)Hypertension is not indicative of sepsis. Question: 43 Nursing assessment of early evidence of septic shock in children at risk includes: A. Fever, tachycardia, and tachypnea B. Respiratory distress, cold skin, and pale extremities C. Elevated blood pressure, hyperventilation, and thready pulses D. Normal pulses, hypotension, and oliguriaAnswer: A Explanation: (A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock. Question: 44 A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child’s case manager knows that treatment has been effective when: A. The child is removed from the home and placed in foster care B. The child’s parents identify the ways in which he is different from the rest of the family C. The child’s father is arrested for child abuse D. The child’s parents can identify appropriate behaviors for children in his age group Answer: D Explanation: (A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as "different" from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children’s normal developmental needs often contributes to abuse or neglect. Question: 45 The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his: A. Behavior is not normal, and a child psychiatrist should be consulted. B. Mother is lying to protect herself. C. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality. D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong. Answer: C Explanation: (A) Because preschoolers often tell "stories" as they learn to differentiate fantasy from reality, the child’s behavior is normal. (B) The nurse has no reason to believe the child’s mother is lying, because children of his age often tell lies. (C) The child’s lying is actually "storytelling" as he learns to separate fantasy from reality, a normal developmental task for his age group. (D) The child’s behavior is consistent with his age and does not indicate a developmental delay. Question: 46 Often children are monitored with pulse oximeter. The pulse oximeter measures the: A. O2 content of the blood B. Oxygen saturation of arterial blood C. PO2 D. Affinity of hemoglobin for O2 Answer: B Explanation: (A) The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygensaturation. The pulse oximeter does not measure the PO2. (B) The pulse oximeter is a noninvasive method of measuring the arterial oxygen saturation. (C) The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure. (D) The affinity of hemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not measured by the pulse oximeter. Question: 47 A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must: A. Tell the physician her concerns B. Report her suspicions to the authorities C. Talk to the child’s father D. Confront the child’s mother Answer: B Explanation: (A) Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. (B) All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. (C) Talking to the child’s father may or may not help the child, and the nurse is not required by law to do so. (D) Confrontation may not be indicated; the nurse is not required by law to confront the child’s mother with these suspicions. Question: 48 The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include: A. Fewer alveoli, slower respiratory rate B. Diaphragmatic breathing, larger volume of air C. Larger number of alveoli, diaphragmatic breathing D. Rounded shape of chest, smaller volume of air Answer: D Explanation: (A) Although a child has fewer alveoli than an adult, the child’s respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child’s chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult. Question: 49 A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find: A. A productive cough B. Expiratory stridor C. Drooling D. Crackles in the lower lobes Answer: C Explanation: (A) A productive cough is not associated with epiglottitis. (B) Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. (C) Because of difficulty with swallowing, drooling often accompanies epiglottitis. (D) Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures. Question: 50Which of the following nursing care goals has the highest priority for a child with epiglottitis? A. Sleep or lie quietly 10 hr/day. B. Consume foods from all four food groups. C. Be afebrile throughout her hospital stay. D. Participate in play activities 4 hr/day. Answer: A Explanation: (A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition. Question: 51 Which of the following nursing orders has the highest priority for a child with epiglottitis? A. Vital signs every shift B. Tracheostomy set at bedside C. Intake and output D. Specific gravity every shift Answer: B Explanation: (A) Because of the possibility of fever or respiratory failure, vital signs should be done more often than every eight hours. (B) If the epiglottitis worsens, the edema and laryngospasm may close the airway and an emergency tracheostomy may be necessary. (C) Although intake and output are a part of the nursing care of a child with epiglottitis, it is not as important as the safety measure of keeping the tracheostomy set at the bedside. (D) Specific gravity will indicate hydration status, but it is not as important as keeping the tracheostomy set at the bedside. Question: 52 A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client’s: A. Level of insight B. Thought processes C. Mood and affect D. Abstracting abilities Answer: C Explanation: (A) Assessing the client’s level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client’s thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client’s mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client’s abstracting abilities is an important part of the MSE, but it does not reflect suicide potential. Question: 53 On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to theclient that she try: A. Doubling the daily dose of benztropine B. Decreasing the haloperidol dosage for a few days C. Taking the benztropine in the morning D. Taking her medication with food or milk Answer: C Explanation: (A) Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician’s order. (B) To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician’s order. (C) This response is an appropriate independent nursing action. Because motorrestlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. (D) Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect. Question: 54 The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is: A. Oculogyric crisis B. Hypertensive crisis C. Orthostatic hypotension D. Tardive dyskinesia Answer: B Explanation: (A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or druginduced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications. Question: 55 A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can’t stay still at night. I toss and turn and can’t fall asleep." The nurse suspects that she may be experiencing: A. Akathisia B. Akinesia C. Dystonia D. Opisthotonos Answer: A Explanation: (A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heelsare bent backward while the body is bowed forward, is an example of EPS. Question: 56 A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT? A. Thioridazine (Mellaril), lithium, and benztropine B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine) C. Sodium, potassium, and magnesium D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane) Answer: B Explanation: (A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C)These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior. Question: 57 A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of: A. Potassium-rich foods B. Tryptophan C. Tyramine D. Saturated fats Answer: C Explanation: (A) The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. (C) The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable. Question: 58 A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, "Nobody in here seems to really care about the clients. I thought nurses cared about people!" The client is exhibiting the ego defense mechanism: A. Reaction formation B. Rationalization C. Splitting D. Sublimation Answer: CExplanation: (A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client’s comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one’s feelings, behaviors, or motives. The client’s comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual’s inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client’s comment reveals that she is not engaging in sublimation. Question: 59 A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, "Nobody cares about the clients." The nurse’s most effective response would be: A. "How can you say that I don’t care? We just met." B. "What makes you think the nurses don’t care?" C. "You will feel differently about us in a few days." D. "You seem angry. Tell me more about how you feel." Answer: D Explanation: (A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the client’s "splitting" behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client’s emotions and the dynamics underlying "splitting" behavior. (D) By simultaneously acknowledging the client’s emotional intensity and gently challenging her "splitting" behavior, the nurse addresses the client’s current distortions and prepares for further interventions with angry or ambivalent feelings. Question: 60 A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be: A. Accepting her present body image B. Verbalizing realistic feelings about her body C. Having an improved perception of her body image D. Exhibiting increased self-esteem Answer: B Explanation: (A) This outcome criterion is inadequate because the term "accepts" is not directly measurable. (B) This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. (C) "Improved perception of body image" is not directly measurable and is therefore open to many interpretations. (D) Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe. Question: 61 A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include: A. Establishing routine tasks and activities around mealtimes B. Administering medications such as lithium C. Requiring the client to eat more during meals D. Checking the client’s room frequentlyAnswer: A Explanation: (A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. (B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client "eat more" at mealtimes increases the client’s feelings of powerlessness. (D) Like the previous strategy, checking the client’s room frequently contributes to the client’s feelings of powerlessness. Question: 62 One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It’s really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse’s best response would be: A. "That might be a problem. Tell me more about them." B. "Risk factors can often be controlled by self-responsibility." C. "It sounds like you’re intellectualizing your drinking problem." D. "Your grandfather and father were both alcoholics?" Answer: B Explanation: (A) Focusing is an effective therapeutic strategy. This response, however, allows the client to "defocus" off the topic of learning how to accept responsibility for his behavior and future growth. (B) The nurse can educate the client about both the "genetic risk" for the development of alcoholism and ways to make long-term healthy lifestyle changes. (C) This response is inappropriately confrontational and condescending to the client. (D)Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here. Question: 63 When preparing insulin for IV administration, the nurse identifies which kind of insulin to use? A. NPH B. Human or pork C. Regular D. Long acting Answer: C Explanation: (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV. Question: 64 A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client? A. Hematocrit, hemoglobin, and white blood cell (WBC) count B. Blood urea nitrogen, electrolytes, and creatinine C. Glucose, glucose tolerance test, and random blood sugar D. X-rays, electroencephalogram, and electrocardiogram(ECG) Answer: BExplanation: (A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning. Question: 65 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: A. Notify the physician immediately B. Hold the morning lithium dose and continue to observe the client C. Administer the morning lithium dose as scheduled D. Obtain an order for benztropine (Cogentin) Answer: C Explanation: (A) There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client’s lithium level is within therapeutic range (0.21.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium). Question: 66 A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on: A. Self-concept problems B. Interpersonal issues C. Ineffective coping skills D. Physiological stabilization Answer: D Explanation: (A) Self-concept and self-esteem problems may emerge during the client’s treatment, but these are not immediate concerns. (B) Interpersonal issues may become evident during the course of the client’s treatment, but these are also not immediate areas of concern. (C) Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. (D) Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client. Question: 67 A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia? A. 9 AM B. 1 PM C. 11 AM D. 3 PMAnswer: C Explanation: (A) This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. (B) This time is incorrect because it is after lunch when the NPH peaks. (C) Regular insulin peaks in 23 hours and has a duration of 46 hours. NPH insulin’s onset is 46 hours and peaks in 816 hours. Blood sugar would peak after meals and be lowest before meals and during the night. (D) This time is incorrect because it is before the NPH and after the regular insulin peak times. Question: 68 A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be: A. "You should ask your doctor about this." B. "Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin." C. "No, do not increase your insulin. Exercise will not affect your insulin needs." D. "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells." Answer: D Explanation: (A) A nurse can give this information to a client. (B) Exercise makes insulin more efficient in moving more glucose into the cells. No more insulin is needed. (C) Exercise makes insulin more efficient unless the diabetes is poorly controlled. (D) Exercise makes insulin more efficient in moving more glucose into the cells. Question: 69 The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is: A. Novolin Regular B. Humulin NPH C. Lente Beef D. Protamine zinc insulin Answer: A Explanation: (A) Novolin is a short-acting insulin. (B, C) NPH and Lente are intermediate-acting insulins. (D) Protamine zinc insulin is a long-acting insulin preparation. Question: 70 Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin: A. Transport of glucose into body cells and storage of glycogen in the liver B. Glycogenolysis and facilitation of glucose use for energy C. Glycogenolysis and catabolism D. Catabolism and hyperglycemia Answer: A Explanation:(A) Lack of insulin causes glycogenolysis, catabolism, and hyperglycemia. (B) Insulin promotes the conversion of glucose to glycogen for storage and regulates the rate at which carbohydrates are used by cells for energy. (C) Insulin is anabolic in nature. (D) Glucose stimulates protein synthesis within the tissue and inhibits the breakdown of protein into amino acids. Question: 71 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanation: (A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. Question: 72 A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 2448 hours postburn? A. Pain related to tissue damage from burns B. Potential for infection related to contamination of wounds C. Fluid volume deficit related to increased capillary permeability D. Potential for impaired gas exchange related to edema of respiratory tract Answer: D Explanation: (A, B, C) These answers are all correct; however, maintenance of airway is the top priority. (D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest. Question: 73 A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby’s condition. The nurse knows that the pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first? A. Call the orthopedist and request that he come to see the baby now. B. Question the mother and find out what the pediatrician has told her about the baby’s condition. C. Tell the mother that this is not a serious condition. D. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces. Answer: B Explanation: (A) The nurse should call the orthopedist after assessing the mother’s knowledge. (B) The nurse must first assess the knowledge of the parent before attempting any explanation. (C) The nurse should assess the mother’s knowledge of the baby’s condition as the first priority. (D) This answer is correct, but the priority is B. Question: 74A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care? A. Weigh the child twice daily on the same scale. B. Monitor intake and output. C. Check urine specific gravity of each voiding. D. Observe for edema. Answer: A Explanation: (A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid volume excess. Question: 75 The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents: A. Discussing their needs with the nursing staff B. Discussing their needs with other family members C. Seeking support from their minister D. Refusing to participate in the child’s care Answer: D Explanation: (A, B, C) These methods are healthy ways of dealing with anxiety. (D) Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them. Question: 76 A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours? A. Position on side or abdomen. B. Maintain elbow restraints in place unless she is being directly supervised. C. Clean suture line every shift. D. Offer pacifier when she cries. Answer: B Explanation: (A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring. Question: 77 A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority? A. Altered nutrition: less than body requirements related to inability to take in adequate calories B. Altered growth and development related to decreased intake of foodC. Activity intolerance related to imbalance between oxygen supply and demand D. Decreased cardiac output related to ineffective pumping action of the heart Answer: D Explanation: (A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development. Question: 78 Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for: A. Otitis media B. Asthma C. Conjunctivitis D. Tonsillitis Answer: A Explanation: (A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle. Question: 79 When assessing a female child for Turner’s syndrome, the nurse observes for which of the following symptoms? A. Tall stature B. Amenorrhea C. Secondary sex characteristics D. Gynecomastia Answer: B Explanation: (A) This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. (B) Amenorrhea is a symptom of Turner’s syndrome, which appears at puberty. (C) Sexual infantilism is characteristic of this syndrome. (D) Gynecomastia is a symptom in Klinefelter’s syndrome. Question: 80 The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms: A. Fever, runny nose, and hyperactivity B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness D. Fever, cough, paleness, and wheezing Answer: CExplanation: (A) The child with asthma may not have fever unless there is an underlying infection. (B) Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. (C) All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. (D) Coughing and wheezing are not early signs of difficulty. Question: 81 A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a "Trendelenburg gait." This gait is characteristic of: A. Scoliosis B. Dislocated hip C. Fractured femur D. Fractured pelvis Answer: B Explanation: (A, C, D) A Trendelenburg gait is not characteristic of any of these disorders. (B) The downward slant of one hip is a positive sign of dislocation in the weight-bearing hip. If one hip is dislocated, the child walks with a characteristic limp known as the Trendelenburg gait. Question: 82 Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually: A. Subsides in<3 weeks B. Is relieved by aspirin C. Is responsive to ibuprofen (Motrin) D. Subsides in 36 days Answer: A Explanation: (A) Joints usually remain inflamed and tender until the disease runs its course in<3 weeks. (B) This response does not answer the question of whether she will always be arthritic. (C) This response does not answer the question asked. (D) The disease takes<3 weeks to run its course. Question: 83 In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to: A. Give vinegar, lemon juice, or orange juice B. Phone the doctor C. Take the child to the emergency room D. Induce vomiting Answer: A Explanation: (A) The immediate action is to neutralize the action of the chemical before further damage takes place. (B) This action should be done after neutralizing the chemical. (C) This action should be done after neutralizing the chemical. (D) Never induce vomiting with a strong alkali or acid. Additional damage will be done when the child vomits the chemical. Question: 84 The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:A. Determine child’s activity pattern B. Reduce mother’s sense of guilt C. Instruct parents in use of ipecac D. Teach parents appropriate safety precautions Answer: D Explanation: (A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent’s knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents. Question: 85 A 4 year old has an imaginary playmate, which concerns the mother. The nurse’s best response would be: A. "I understand your concern and will assist you with a referral." B. "Try not to worry because you will just upset your child." C. "Just ignore the behavior and it should disappear by age 8." D. "This is appropriate behavior for a preschooler and should not be a concern." Answer: D Explanation: (A) This is normal for a preschooler, and a referral is not appropriate. (B) Telling a parent not to worry is unhelpful. This response does not address the mother’s concern. (C) This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. (D) This behavior is normal development for a preschooler. Question: 86 When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill? A. Open discussion and understanding B. Play-acting out feelings in different roles C. Storytelling D. Drawing pictures Answer: B Explanation: (A) When dealing with grief, siblings are usually most comfortable initially with open discussion. (B) Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. (C) This method may be helpful, but having the child take an active part through role playing is more effective. (D) This technique may be helpful, but being an active participant through role playing is more effective. Question: 87 During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by: A. Putting all joints through full range-of-motion twice daily B. Massaging the joints briskly with lotion or liniment after bath C. Immobilizing the joints in functional position using splints, rolls, and pillows D. Applying warm water bottle or heating pads over involved joints Answer: CExplanation: (A) Any movement of the joint causes severe pain. (B) Touching or moving the joint causes severe pain. (C) Immobilization in a functional position allows the joint to rest and heal. (D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin. Question: 88 The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to: A. Maintain contact with her parents B. Provide for physical and psychological rest C. Provide a nutritious diet D. Maintain her interest in school Answer: B Explanation: (A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase. Question: 89 During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate? A. Tinnitus and nausea B. Dermatitis and blurred vision C. Unconsciousness and acetone odor of the breath D. Chills and an elevation of temperature Answer: A Explanation: (A) These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate. Question: 90 In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to: A. Measure adequacy of nutritional management B. Check the accuracy of the fluid intake record C. Impress the child with the importance of eating well D. Determine changes in the amount of edema Answer: D Explanation: (A) Weighing a child with nephrosis is to assess for edema, not nutrition. (B, C) This is not the purpose for weighing the child. (D) Weight and measurement are the primary ways of evaluating edema and fluid shifts. Question: 91 The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that: A. Alopecia is an unavoidable side effect. B. There are several wig makers for children.C. Most children select a favorite hat to protect their heads. D. His hair will grow back in a few months. Answer: D Explanation: (A) Alopecia has occurred, and knowing it is a side effect does not address their concern. (B) Although true, it does not give them hope for the future. (C)Although true, it does not provide them with information of the temporary nature of the situation. (D) Knowing the hair will grow back provides comfort that the alopecia is temporary. Question: 92 Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to: A. Reinforce attempts to eat B. Help the child gain weight C. Increase his appetite D. Make mealtimes pleasant Answer: A Explanation: (A) Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake. (B) This goal is not specific enough or related to the loss of appetite. (C) This goal is not possible at this time based on his illness. (D) This goal is helpful, but alone will not address his loss of appetite. Question: 93 The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be: A. Using a water pik B. Rinsing with water C. Rinsing with hydrogen peroxide D. Rinsing with baking soda Answer: A Explanation: (A) This technique provides effective rinsing and gingival stimulation. (B) This technique does not provide gingival stimulation. (C) This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. (D) This technique provides effective rinsing but not gingival stimulation. Question: 94 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) D. Phenytoin (Dilantin) Answer: D Explanation: (A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplasticanemia is chloramphenicol (Chlormycetin). Question: 95 Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to: A. Report the findings to the physician B. Assist the client to do range of motion exercises C. Check the client’s potassium level D. Administer the as-needed dose of phenytoin (Dilantin) Answer: A Explanation: (A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. (B) Range of motion exercises are not appropriate topresenting symptoms. (C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. (D) Phenytoin is indicated for seizure activity mainly of neurological origin. Question: 96 The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client? A. "Do you take aspirin on a regular basis?" B. "Do you drink alcohol on a regular basis?" C. "Do you eat red meat?" D. "Have your stools been normal?" Answer: B Explanation: (A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character. Question: 97 An 18-month-old child has been playing in the garage. His mother brings him to a nurse’s home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has: A. Inhaled gasoline fumes B. Ingested a caustic alkali C. Eaten construction chalk D. Lead poisoning Answer: B Explanation: (A, C, D) These agents would not cause ulcerations on mouthand lips. (B) Strong alkali or acids will cause burns and ulcerationson the mucous membranes. Question: 98 The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice: A. Will bind calcium and therefore interfere with its metabolismB. Will cause more premenstrual cramping C. Interferes with iron absorption because the iron precipitates as an insoluble substance D. Causes competition at iron-receptor sites between iron and vitamin B1 Answer: C Explanation: (A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients. Question: 99 Which of the following lab data is representative of a client with aplastic anemia? A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000 C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000 Answer: D Explanation: (A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. (D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000. Question: 100 A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet? A. Cantaloupe B. Rice C. Chicken D. Green beans Answer: C Explanation: (A) Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A. (B) Rice contains about 4 g of protein per 200 g. (C) Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. (D) Green beans only contain 2 g of protein per cup. Question: 101 The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client’s chief complaint? A. "I’ve been having a dull pain at the upper left shoulder." B. "My legs have been numb for three months." C. "I’ve only been urinating three times a day lately." D. "I don’t remember anything in particular, I just haven’t felt well." Answer: DExplanation: (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position. Question: 102 A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse’s first action when admitting the client will be to: A. Obtain vital signs B. Connect the client to the cardiac monitor C. Ask the client if he is still having chest pain D. Complete the history profile Answer: B Explanation: (A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the client’s rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions. Question: 103 The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure? A. Pedal pulses 11 (weak) B. Twenty-four-hour intake 1000 mL/day for past 2 days C. Serum potassium 3.3 D. Pulse rate 150 bpm Answer: B Explanation: (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure. Question: 104 The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that: A. The client is more likely to remember to perform the TSE when in the nude B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate D. The examination will be less painful at this time Answer: C Explanation: (A) Nudity is not a trigger for reminding males to perform TSE. (B) Testicles become more firm when exposed to cool temperatures, but not large and bulky. (C) The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. (D) The examination should not be painful.Question: 105 The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse’s action would be: A. Call the physician and inform him that the client has expired. B. Remind the husband that the physician wrote an order not to resuscitate. C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts. D. Call a code and proceed with cardiopulmonary resuscitation. Answer: D Explanation: (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor. Question: 106 The nurse is in the hallway and one of the visitors faints. The nurse should: A. Sit the victim up and lightly slap his face B. Elevate the victim’s legs C. Apply a cool cloth to the victim’s neck and forehead until he recovers D. Sit the victim up and place the head between the knees Answer: B Explanation: (A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs. Question: 107 A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion: A. The risks of exposure of the visitor to infectious organisms is great. B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes. C. The client is at extreme risk of acquiring infections. D. Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel. Answer: C Explanation: (A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others. Question: 108 Which of the following physician’s orders would the nurse question on a client with chronic arterial insufficiency? A. Neurovascular checks every 2 hours B. Elevate legs on pillowsC. Arteriogram in the morning D. No smoking Answer: B Explanation: (A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder. Question: 109 Goal setting for a client with Meniere’s disease should include which of the following? A. Frequent ambulation B. Prevention of a fall injury C. Consumption of three meals per day D. Prevention of infection Answer: B Explanation: (A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Meniere’s disease. (C) Adequate nutrition is important, but the emphasis in Meniere’s disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem. Question: 110 Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to: A. Assess vital signs B. Elevate the extremity C. Perform a lower extremity neurovascular check D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use Answer: C Explanation: (A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. (B) The extremity will be elevated if ordered by the doctor. (C) Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring. (D) Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action. Question: 111 Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client? A. Nifedipine 10 mg SL for B/P 140/90 B. Furosemide 20 mg/PO for decreased urine output C. Magnesium salicylate to decrease inflammation D. Nitroglycerin gr 1/150 for chest pain Answer: A Explanation:(A) It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C, D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history. Question: 112 The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse’s action should be to: A. Encourage coughing and deep breathing each hour B. Obtain arterial blood gases C. Increase O2 from 23 L/min D. Remove the postoperative dressing to check for bleeding Answer: A Explanation: (A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information. Question: 113 A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent? A. The client requests pain medicine every 4 hours. B. He is asleep 30 minutes after receiving the IV morphine. C. He asks for pain medication although his blood pressure and pulse rate are normal. D. He is euphoric for about an hour after each injection. Answer: D Explanation: (A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain. Question: 114 Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis? A. Urine output 22 mL/hr for 2 hours B. Serum potassium level of 3.7 C. Small T wave of ECG D. Serum glucose level of 180 Answer: A Explanation: (A) Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. (B) Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. (C) A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. (D) Glucose levels of <200 are desirable. Question: 115Discharge teaching for the client who has a total gastrectomy should include which of the following? A. Need for the client to increase fluid intake to 3000 mL/day B. Follow-up visits every 3 weeks for the first 6 months C. B12 injections needed for the rest of the client’s life D. Need to eat three full meals with plenty of fiber per day Answer: C Explanation: (A) There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. (B) Followup visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. (C) With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person’s life. (D) Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome. Question: 116 The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: A. Inspiration is longer than expiration B. Breath sounds are high pitched C. Breath sounds are slightly muffled D. Inspiration and expiration are equal Answer: D Explanation: (A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area. (C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched. Question: 117 The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology? A. Hypernatremia B. Hypocalcemia C. Hypokalemia D. Hypomagnesemia Answer: C Explanation: (A) A deficit in sodium concentration results in muscular weakness and lethargy. (B) Muscle fatigue and hypotonia are caused by hypercalcemia. (C) Muscle weakness and fatigue are classic signs of hypokalemia. (D) Hypermagnesemia can cause muscle weakness, paralysis, and coma. Question: 118 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements? A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices." B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin." C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now." D. "As soon as I leave here, I’m throwing away my medicines. I never thought I needed them anyway."Answer: A Explanation: (A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C)This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance. Question: 119 The physician orders medication for a client’s unpleasant side effects from the haloperidol. The most appropriate drug at this time is: A. Lorazepam B. Triazolam (Halcion) C. Benztropine D. Thiothixene Answer: C Explanation: (A) Lorazepam is a benzodiazepine, or antianxiety agent, that potentiates the effects of _- aminobutyric acid in the CNS, which is not the CNS neurotransmitter EPS. (B) Triazolam is a benzodiazepine sedative-hypnotic whose action is mediated in the limbic, thalamic, and hypothalamic levels of the CNS by – aminobutyric acid. (C) Benztropine is an anticholinergic agent, and the drug of choice for blocking CNS synaptic response, which causes EPS. (D) Thiothixene is an antipsychotic and neuroleptic drug that blocks dopamine neurotransmission at the CNS synapses, thereby causing EPS. Question: 120 The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is: A. The client will settle down more quickly if he thinks the staff is medicating him B. The medication will sedate the client until the physician arrives C. Haloperidol is a minor tranquilizer and will not oversedate the client D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client Answer: D Explanation: (A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. (D) Haloperidol is a highpotency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation. Question: 121 Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with: A. Parkinsonism and dystonia B. Dystonia and akathisia C. Akathisia and parkinsonism D. Neuroleptic malignant syndrome Answer: BExplanation: (A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. (B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. (C) The client has symptoms of dystonia but not of parkinsonism. (D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse. Question: 122 A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is: A. Sensory-perceptual alteration: auditory command hallucinations B. Alteration in thought processes: paranoid delusions C. Potential for violence directed at others D. Impaired verbal communication: loose associations Answer: C Explanation: (A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life itself. (B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control. (C) Whether real or potential, violence directed at self or others is always high priority. (D) There is no evidence of loosening of associations. Question: 123 A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is: A. "I understand that the voices are real to you, but I want you to know I don’t hear them. They are a symptom of your illness." B. "Just don’t pay attention to the voices. They’ll go away after some medication." C. "You can’t leave here. This unit is locked and the doctor has not ordered your discharge." D. "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that." Answer: A Explanation: (A) This response validates the client’s experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client’s verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client’s potential for violence and loss of control. (D) This response is also threatening. The client’s behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone. Question: 124 A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing: A. Grandiose delusions B. Paranoid delusions C. Auditory hallucinations D. Visual hallucinationsAnswer: B Explanation: (A) There are no indications that the client’s thoughts reflect special powers or talents characteristic of grandiosity. (B) The client’s thought content is fixed, false, persecutory, and suspicious in nature, which is characteristic of paranoid delusions. (C, D) The client is not demonstrating a sensory experience. Question: 125 A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse: A. Dims the lights in her room B. Encourages her to breathe slowly and deeply C. Offers sips of warm liquids D. Places a large, soft pillow under her head Answer: A Explanation: (A) The discomfort of photophobia is alleviated by dimming the lights. (B) Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. (C) It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. (D) A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges. Question: 126 To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby’s mother to: A. Avoid touching the baby while in the room. B. Stay outside of the baby’s room. C. Wear a gown and gloves and wash her hands before and after leaving the room. D. Wear a mask while in the room. Answer: C Explanation: (A) The mother should be allowed and encouraged to touch her baby. (B) With care, transmission can be prevented. There is no need for the mother to stay outside the room. (C) Everyone entering the baby’s room should take appropriate measures to prevent transmission of pathogens. (D) Wearing a mask will not protect against transmission of pathogens. Question: 127 A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n): A. Allergy to seafood B. History of seizures C. Movable metal implant D. Pin or screw in any bone Answer: C Explanation: (A) Iodine is not used as a contrast medium for MRI. It is important to inquire about allergy to seafood if the client is to have an arteriogram or enhanced computer tomography. (B) MRI is safe if seizures are under control. It is more important to inquire about movable metal implants. (C) Clients with movable metal implants such as shrapnel or aneurysm clips or clients with permanent pacemakers or implanted pumps can be traumatized duringan MRI. (D) Nonmovable metal prostheses or hardware will not cause trauma during an MRI. Question: 128 The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is: A. Dandelion leaves B. Pencils C. Old paint D. Stuffing from toy animals Answer: C Explanation: (A) Dandelion leaves are not a source of lead. (B) Pencils are not a source of lead poisoning. (C) Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source. (D) Stuffed animals are not a source of lead. Question: 129 A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to: A. Limit activities which require focusing (close vision) B. Take more frequent naps C. Use artificial tears D. Wear a patch over one eye Answer: D Explanation: (A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex. Question: 130 In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis: A. Becomes progressively debilitating without remission B. Has unpredictable remissions and exacerbations C. Is rapidly fatal D. Responds quickly to antimicrobial therapy Answer: B Explanation: (A) Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. (B) Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. (C) Multiple sclerosis is usually slowly progressive. (D) Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course. Question: 131 A client with a head injury asks why he cannot have something for his headache. The nurse’s response is based on the understanding that analgesics could: A. Counteract the effects of antibiotics B. Elevate the blood pressure C. Mask symptoms of increasing intracranial pressureD. Stimulate the central nervous system Answer: C Explanation: (A) Analgesic medication does not counteract the effects of antibiotics. (B) Analgesic medication may lower blood pressure elevated due to anxiety. (C) Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. (D) Analgesics do not stimulate the CNS. Question: 132 The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis: A. Constipation B. Hypothermia C. Seizure D. Sunken fontanelles Answer: C Explanation: (A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles. Question: 133 The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should: A. Give her a small soft blanket to hold B. Give her good perineal care after each diaper change C. Leave the door open to her room D. Pick her up when she cries Answer: D Explanation: (A) A soft blanket may be comforting, but it is not directed toward developing a sense of trust. (B) Good perineal care is important, but it is not directed toward developing a sense of trust. (C) An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. (D)Consistently picking her up when she cries will help the child feel trust in her caregivers. Question: 134 A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should: A. Advise the mother not to give her aspirin B. Ask if the client is allergic to aspirin before giving further information C. Assess the function of the client’s cranial nerve VIII D. Check the aspirin bottle label to determine milligrams per tablet Answer: A Explanation: (A) Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye’s syndrome in children and adolescents. Children and adolescents should not be given aspirin. (B) Allergy to aspirin is notrelated to Reye’s syndrome. (C) Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye’s syndrome. (D) A 6- year-old child should not be given any baby aspirin. Question: 135 A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate? A. Assembling a puzzle with large pieces B. Being taken for a wheelchair ride C. Listening to a story about the Muppets D. Watching Sesame Street on television Answer: A Explanation: (A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself." (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy. Question: 136 A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report: A. Blood pressure increase from 100/80 to 115/85 after lunch B. Headache that is unresponsive to acetaminophen (Tylenol) C. Pulse rate ranges between 68 bpm and 76 bpm D. Temperature rise to 102_F rectally Answer: D Explanation: (A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control. Question: 137 An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client: A. Has a sudden and severe increase in intracranial pressure B. Has sustained an internal injury in addition to the head injury C. Is beginning to experience a dangerously high level of anxiety D. Is having intracranial bleeding Answer: B Explanation: (A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high bloodpressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP. Question: 138 The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should: A. Call the doctor immediately B. Help her to blow her nose carefully C. Test the discharge for sugar D. Turn her to her side Answer: C Explanation: (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data. Question: 139 A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report: A. Evidence of perineal irritation B. Pulse fell from 102 to 96 C. Pulse increased from 96 to 102 D. Temperature rose to 102_F rectally Answer: D Explanation: (A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury. Question: 140 The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig’s sign. The nurse expects her to react to discomfort if she: A. Dorsiflexes her ankle B. Flexes her spine C. Plantiflexes her wrist D. Turns her head to the side Answer: B Explanation: (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation. Question: 141 A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vitalsigns are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to: A. Encourage him to drink plenty of fluids B. Expect him to have nausea with vomiting C. Keep him awake for the next 12 hours D. Wake him up every 12 hours during the night Answer: D Explanation: (A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should know to notify the physician or hospital if they occur. (C) The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away. Question: 142 A 14-year-old boy fell off his bike while "popping a wheelie" on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would: A. Ask the physician to order a sedative B. Have the client describe his headache every 15 minutes C. Increase his fluid intake to 3000 mL/24 hr D. Offer diversionary activities Answer: D Explanation: (A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they could further depress the CNS. (B) The client should not be asked to think about his headache every 15 minutes. (C) Fluid intake should be normal or restricted for a client with a head injury. Normal fluid intake for a 14 year old is about 20002400 mL daily. (D) Diversion may help the child to focus on a pleasant activity instead of on his headache. Question: 143 A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to: A. Allow her privacy at mealtimes B. Praise her for eating everything C. Observe behavior for 12 hours after meals to prevent vomiting D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes Answer: C Explanation: (A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it. (B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be withheld until she eats everything. (C) The client should be observed eyeto- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime or engaging in selfinduced vomiting. (D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet. Question: 144 A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:A. Be comforted when he is held B. Cry C. Not notice that his mother has left D. Withdraw and become listless Answer: B Explanation: (A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior. Question: 145 The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is: A. 900 mL/24 hr B. 1300 mL/24 hr C. 1600 mL/24 hr D. 2000 mL/24 hr Answer: C Explanation: (A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours. Question: 146 A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from: A. Crying B. Falling asleep C. Rolling from his back to his tummy D. Sucking his thumb Answer: A Explanation: (A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb- sucking serves to reduce anxiety and should not be prevented at this time. Question: 147 Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is: A. Hypoglycemia from low-carbohydrate intake B. Possible cardiac dysrhythmias secondary to hypokalemia C. Dehydration from vomiting D. Anoxia secondary to anemia Answer: BExplanation: (A) There is no lab data to support hypoglycemia. (B) Hypokalemia, caused by vomiting and decreased dietary intake of potassium, can result in lifewww. vceplus.com – Download A+ VCE (latest) free Open VCE Exams – VCE to PDF Converter – VCE Exam Simulator – VCE Online – IT Certifications threatening dysrhythmias. (C) Evidence of dehydration is not life threatening at this time, although fluid volume deficit does need to be addressed. (D)The client’s hemoglobin does not reflect a life threatening value sufficient to render the client anoxic. Question: 148 A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, "I haven’t exercised in 6 days. I won’t be eating lunch today." This statement by her most likely reflects: A. Her lack of internal awareness about the outcome of the behavior B. Increased knowledge about personal exercise plans C. A manipulative technique to trick the nurse into allowing her to miss a meal D. A true desire to stay fit while in the hospital Answer: A Explanation: (A) Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client’s lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted. (B) Although the client is knowledgeable about exercise, knowledge about the balance between nutrition, exercise, and rest is absent. (C) The client’s level of denial and lack of awareness disallow this behavior as a manipulative trick. (D) The client’s illness-maintaining behaviors are inconsistent with fitness. Question: 149 A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is: A. "Okay, missing one meal won’t hurt." B. "You’ll have to eat lunch, or we’ll force-feed you." C. "It’s not appropriate for you to try to manipulate the staff into granting your wishes." D. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed." Answer: D Explanation: (A) This response reinforces the client’s maladaptive behavior, thereby contributing to the client’s risk. (B) Ultimatums are not therapeutic. (C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised. (D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle. Question: 150 A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to: A. Obtain an accurate weight B. Search the client’s purse for pills C. Assess vital signsD. Assign her to a room with someone her own age Answer: C Explanation: (A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority. Question: 151 Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with: A. Pregnancy B. Bulimia C. Gastritis D. Anorexia nervosa Answer: D Explanation: (A) Presenting behaviors collectively are inconsistent with depression. (B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia. (C) Symptoms and vital signs do not indicate the presence of infection. (D) All symptoms and vital signs are consistent with anorexia nervosa. Question: 152 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 12 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation. Question: 153 After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of: A. Lorazepam (Ativan) B. Benztropine (Cogentin) C. Thiothixene (Navane) D. Flurazepan (Dalmane)Answer: B Explanation: (A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B) Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D)Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia. Question: 154 Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when: A. The physician orders it B. A therapeutic alliance has been established, and violent behavior subsides C. The violent behavior subsides, and the client agrees to behave D. The nurse deems that removal of restraints is necessary Answer: B Explanation: (A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary. Question: 155 A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is: A. "You’ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment." B. "Visitors are not allowed. We will telephone you to inform you of her progress." C. "There’s really no need to stay with her. She’s going to sleep for several hours after the treatment." D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment." Answer: D Explanation: (A) It is within the nurse’s realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment. Question: 156 A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he’s going to cut out my heart." The nurse’s best response is: A. "I know you’re feeling frightened right now, but I want you to know that I don’t see anyone in the corner."B. "You’ll probably see strange things for a while until the PCP wears off." C. "Try to sleep. When you wake up, the devil will be gone." D. "You’re probably feeling guilty because you used illegal drugs tonight." Answer: A Explanation: (A) The nurse is the client’s link to reality. This response validates the authenticity of the client’s experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client’s feelings by offering a nontherapeutic interpretation of the motivation for the client’s actions. Question: 157 A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, "Isn’t that a lot?" The nurse’s best response is: A. "Yes, that does seem like a lot." B. "You’ll have to talk to the doctor about that. The physician knows what’s best for the client." C. "Six to 10 treatments are common. Are you concerned about permanent effects?" D. "Don’t worry. Some clients have lots more than that." Answer: C Explanation: (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband’s fears. (B) This response is "passing the buck" unnecessarily. The information needed to appropriately answer the husband’s question is well within the nurse’s knowledge base. (C) The most common range for affective disorders is 610 treatments. This response confirms and reinforces the physician’s plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husband’s underlying concerns about his wife. Question: 158 A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time? A. High carbohydrate, low cholesterol B. High protein, high carbohydrate C. 1 g sodium D. Tyramine-free Answer: D Explanation: (A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis. Question: 159 Two weeks after a client’s admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT? A. Brain tumor or other space-occupying lesionB. History of mitral valve prolapse C. Surgically repaired herniated lumbar disk D. History of frequent urinary tract infections Answer: A Explanation: (A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon. Question: 160 On admission to the postpartal unit, the nurse’s assessment identifies the client’s fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of: A. Normal involution B. A full bladder C. An infection pain D. A hemorrhage Answer: B Explanation: (A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul- smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention. Question: 161 A client’s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority? A. Assess quantity of fluid. B. Assess color and odor of fluid. C. Document on fetal monitor strip and chart. D. Assess fetal heart rate (FHR). Answer: D Explanation: (A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well- being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix. Question: 162 The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for thenurse to explain that with cigarette smoking there is increased risk that the baby will have: A. A low birth weight B. A birth defect C. Anemia D. Nicotine withdrawal Answer: A Explanation: (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn. Question: 163 Which of the following blood values would require further nursing action in a newborn who is 4 hours old? A. Hemoglobin 17.2 g/dL B. Platelets 250,000/mm3 C. Serum glucose 30 mg/dL D. White blood cells 18,000/mm3 Answer: C Explanation: (A) The normal range for hemoglobin in the newborn is 1719 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is 150,000400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,00040,000/mm3 is normal in the newborn. Question: 164 A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to: A. Assess level of consciousness B. Assess suicide potential C. Observe for sedation and hypotension D. Orient to her room and unit rules Answer: B Explanation: (A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit if comatose. (B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk. (C) The admission assessment should include observation for sedation and hypotension, but this is not in priority over suicide assessment. (D) Orientation to room and unit rules is of low priority at this time. Question: 165 A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical: A. Thready pulse B. Irregular pulse C. Tachycardia D. BradycardiaAnswer: D Explanation: (A) A thready pulse is indicative of hypotension and excessive blood loss and is often rapid. (B) Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman. (C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth. (D) Puerperal bradycardia with rates of 5070 bpm commonly occurs during the first 610 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume. Question: 166 A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor? A. Increased bloody show B. Progressive dilatation and effacement of the cervix C. Uterine contractions D. Decreased discomfort with ambulation Answer: B Explanation: (A) Bloody show is considered a sign of imminent labor, which usually begins in 2448 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort. Question: 167 In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity? A. A 31 patellar tendon reflex B. Respirations of 12 breaths/min C. Urine output of 40 mL/hr D. A 21 proteinuria value Answer: B Explanation: (A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing. (C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium. Urinary output of <100 mL in a 4- hour period may result in toxic levels of magnesium. (D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake. Question: 168 A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of: A. Lung immaturity B. Intrauterine growth retardation (IUGR) C. Intrauterine infectionD. Neural tube defect Answer: A Explanation: (A) At about 3032 weeks’ gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _- fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly. Question: 169 A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adultonset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is: A. Acute urinary retention B. Hesitancy in starting urination C. Increased frequency of urination D. Decreased force of the urinary stream Answer: A Explanation: (A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization. (B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening. Question: 170 A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: A. Bladder spasms B. Clot formation C. Scrotal edema D. Prostatic infection Answer: B Explanation: (A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A threeway system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication. Question: 171 Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client’s sexual functioning? A. "You may resume sexual intercourse in 2 weeks." B. "Many men experience impotence following TURP." C. "A transurethral resection does not usually cause impotence." D. "Check with your doctor about resuming sexual activity."Answer: C Explanation: (A) Sexual activity should be delayed until cleared by the client’s physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety. Question: 172 A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be: A. Determination of multiple gestations B. Determination of gross anomalies C. Determination of placental location D. Determination of fetal age Answer: C Explanation: (A) Sonography can be used to determine the presence of multiple gestation. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (B) Sonography can be used to determine the presence of gross anomalies. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (C) Prior to amniocentesis, the abdomen is scanned by ultrasound to locate the placenta, thus reducing the possibility of penetrating it with the spinal needle used to obtain amniotic fluid. (D) Sonography can be used to determine fetal age. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. Question: 173 A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: A. Chloride level of 99 mEq/L B. Sodium level of 136 mEq/L C. Potassium level of 3.1 mEq/L D. Potassium level of 6.3 mEq/L Answer: D Explanation: (A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.55.0 mEq/L. Question: 174 An IDDM client’s condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at: A. 8:30 AM10:30 AM B. 2:30 PM4:30 PM C. 7:30 PM9:30 PM D. 10:30 PM11:30 PMAnswer: B Explanation: (A) This time describes the time of onset of NPH insulin’s action, rather than its peak effect. (B) NPH insulin, an intermediateacting insulin, usually begins to lower serum glucose levels about 2 hours after administration. The action of NPH insulin peaks 814 hours after administration. It has a 2030 hour duration. (C) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM. (D) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM. Question: 175 After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for: A. One frankfurter B. One ounce of ham C. Two slices of bacon D. One-fourth cup dry cottage cheese Answer: D Explanation: (A) A frankfurter is a high-fat meat on the diabetic exchange list. (B) Ham is a medium-fat meat on the diabetic exchange list, unless it is a center-cut slice. (C) One strip of bacon equals onefatexchange rather than ameatexchange. Dietary substitutions should occur within exchange lists and not between exchange lists. (D) Diabetic meat-exchange lists are categorized into leanmeat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat), one- fourth cup, can substitute for one lean-meat exchange. Question: 176 When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that: A. When exercise is increased, insulin needs are increased B. When exercise is increased, insulin needs are decreased C. When exercise is increased, there is no change in insulin needs D. When exercise is decreased, insulin needs are decreased Answer: B Explanation: (A) If the client’s insulin is increased when activity level is increased, hypoglycemia may result. (B) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra activity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the client’s insulin dose does not need to be altered unless the blood sugar becomes unstable. Question: 177 Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients? A. Vitamin C and zinc B. Folic acid and niacin C. Vitamin A and biotin D. Thiamine and pyroxidine Answer: DExplanation: (A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine. (B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts. Question: 178 The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client’s best choice from the items below would be: A. Liver and onions, macaroni and cheese, tea with sugar B. Baked chicken, baked potato with bacon bits, milk C. Waffles with butter and honey, orange juice D. Cheese omelette with ham and mushrooms, milk Answer: C Explanation: (A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories. Question: 179 A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma? A. Hiccups B. Anorexia C. Mental confusion D. Fetor hepaticus Answer: C Explanation: (A) Hiccups are not a sign of impending hepatic coma. (B) Anorexia is not a sign of impending hepatic coma. (C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen. (D) This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may sometimes be noted when the liver fails. Question: 180 The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by: A. Decreasing nitrogen-forming bacteria in the intestines B. Acidifying colon contents by causing ammonia retention in the colon C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon D. Irritating the bowel and promoting evacuation of stool Answer: A Explanation: (A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin’s action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is aside effect of a drug, not the action of the drug. Question: 181 A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER? A. D50W by IV push B. NPH insulin SC C. Regular insulin by IV infusion D. Sweetened grape juice by mouth Answer: C Explanation: (A) This action would further increase the client’s blood sugar. (B) NPH insulin is an intermediate-acting insulin, with an average of 46 hours before onset of action. The client needs insulin that will act immediately. During a ketoacidotic state, the client is dehydrated, so any insulin administered SC will be poorly absorbed. (C) Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies. (D) This action would further increase the client’s blood sugar. Question: 182 The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of the following statements? A. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain." B. "Has anyone in your family ever had schizophrenia?" C. "If your son has a twin, he probably will eventually develop schizophrenia, too." D. "Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship." Answer: A Explanation: (A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms. (B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors. (C) This statement will cause the mother much alarm, and nothing was mentioned about any other child. (D) The motherchild relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety for the mother. Question: 183 A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse’s most therapeutic response will be: A. "I don’t see your mother in the room. Let’s talk about how you’re feeling." B. "OK, I’ll come back later when you’re feeling more like taking your medicine." C. "She may be here, but I can’t see her." D. "Why don’t you finish talking to her, and I’ll wait." Answer: AExplanation: (A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too. Question: 184 A female client with major depression stated that "life is hopeless and not worth living." The nurse should place highest priority on which of the following questions? A. "How has your appetite been recently?" B. "Have you thought about hurting yourself?" C. "How is your relationship with your husband?" D. "How has your depression affected your daily livingactivities?" Answer: B Explanation: (A) Although eating habits are important to assess, they are less important than suicidal intent. (B) Maintenance of the client’s life is the priority; assessment of suicidal intent is imperative. (C) Relationships and support systems are an important part of assessment, but they are less important than suicidal intent. (D) Daily living activities will give additional information about the level of depression, and are less significant than suicidal intent, although this information may give additional information about the actual plan for a suicidal attempt. Question: 185 A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to "fatigue," and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse’s assessment of her behavior would most likely be: A. Deep depression B. Psychotic depression C. Severe anxiety D. Severe depression Answer: D Explanation: (A) A client in deep depression would have been brought to the mental health center and would not be physically able to seek help for herself. (B) She is not manifesting psychotic symptoms in her behaviors. (C) The client’s symptoms are more indicative of depression than anxiety. (D) Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed. Question: 186 A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20- year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture? A. Lifting heavy objects B. Walking briskly C. Ingestion of barbiturates D. Ingestion of antacids Answer: AExplanation: (A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure. Question: 187 The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse: A. "I know it was my fault that it happened, because I shouldn’t have been out so late." B. "If I had not worn that sexy dress that night, he wouldn’t have raped me." C. "I know my date just had so much passion he couldn’t handle me saying `no.’ " D. "I know now that it was not my fault, but I want to continue counseling after my discharge." Answer: D Explanation: (A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapist’s behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge. Question: 188 A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information: A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group." B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don’t have to continue AA." C. "I really wasn’t addicted to alcohol when I came here, I just needed some help dealing with my divorce." D. "It really wasn’t my fault that I had to come here. If my wife hadn’t left, I wouldn’t have needed those drinks." Answer: A Explanation: (A) The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him–Alcoholics Anonymous. (B) The client is still using denial and is not dealing with his alcohol addiction. (C) The client is exhibiting denial about his alcohol addiction and projecting blame on his divorce. (D) The client is projecting blame onto his wife for being in the hospital while still denying his alcohol addiction. Question: 189 Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her deg [Show More]

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