NCLEX Practice Questions

The nurse educates a client on smoking cessation. The client demonstrates understanding by which statements? Select all that apply. A) "I may experience somnolence when trying to quit smoking." B) "Tobacco withdrawal can lead to seizure activity." C) "Weight loss should be expected with tobacco withdrawal." D) "I may experience depression when trying to quit smoking." E) "Hypnosis may help me successfully quit smoking."

D) "I may experience depression when trying to quit smoking" and E) "Hypnosis may help me successfully quit smoking

A client is angry that the nurse is unable to administer more opioid analgesic and grabs the nurse's wrist. How does the nurse respond? A) "Let go of my wrist, and I will ask the doctor to order you more medication." B) "Aggressive behavior is not tolerated, and I will not get you more medication." C) "Let go of my wrist, and we can discuss your pain control needs calmly." D) "I will call the staff to restrain you if you do not stop being aggressive."

C) "Let go of my wrist, and we can discuss your pain control needs calmly."

A client taking lamotrigine reports the absence of seizures. Which statement made by the nurse indicates an understanding of this medication's intended effects? A) "Notify the health care provider." B) "It can cause tremors." C) "This means the medication is working." D) "You should stop taking this drug."

C) "This means the medication is working"

The nurse prepares to administer cyanocobalamin to a client with pernicious anemia. When the client asks why the medication has to be given in an injection, which response does the nurse give? A) "I will contact your health care provider about changing your prescription to the oral form of vitamin B12." B) "Giving your vitamin B12 in an injection will work faster than a pill, so you will feel better sooner." C) "Your body does not have enough intrinsic factor to absorb vitamin B12 when taken by mouth." D) "Most people prefer the injection because vitamin B12 tablets can stain your teeth."

C) "Your body does not have enough intrinsic factor to absorb vitamin B12 when taken by mouth."

The nurse receives report on the client with sickle cell anemia. Which population does the nurse recognize is at increased risk for having sickle cell anemia? A) Caucasian B) Native American C) African American D) Hispanic

C) African American Rationale: The client with African American heritage is at increased risk for having sickle cell anemia as well as stroke, hypertension, lactose intolerance, and keloids.

The nurse plans care for a client with polymyositis. Which complication does the nurse look for? A) Bowel incontinence B) Weight gain C) Aspiration D) Altered mental status

C) Aspiration Rationale: Polymyositis is an autoimmune disorder causing symmetrical muscle atrophy. It leads to muscle weakness and causes dysphagia and can increase the risk of aspiration.

Parents bring a toddler-age client into the emergency department stating, "We are concerned the babysitter is physically abusing our toddler." What action should the nurse take first to care for the client? A) Notify the social worker B) Call health care provider (HCP) C) Call Child Protective Services D) Assess the client

D) Assess the client Rationale: The nurse's first priority is to gain information from the parents about suspected abuse. The nurse might ask what causes the parents to suspect abuse. The nurse would look at the physical findings.

A nurse providing care to a client with multiple environmental allergies recognizes which WBCs as being responsible for histamine release? A) Neutrophils B) Lymphocytes C) Eosinophils D) Basophils

D) Basophils Rationale: Histamine is released by basophils and mast cells when triggered by IgE

The nurse cares for an adolescent client. The client reports anxiety in social situations due to constant scrutiny by peers about actions and appearance. The nurse recognizes the client is in which stage of cognitive development? A) The client is in the sensorimotor stage. B) The client is in the preoperational stage. C) The client is in the concrete operational stage. D) The client is in the formal operations stage.

D) The client is in the formal operations stage

A nurse cares for a client undergoing therapy for anxiety associated with mysophobia. Which behavior would be characteristic of this client? A) The client climbs 10 flights of stairs to avoid the elevator. B) The client asks to turn on all ceiling lights and lamps in the room. C) The client reviews location of all fire exits upon entering a room. D) The client wipes the seat with a disinfecting wipe before sitting.

D) The client wipes the seat with a disinfecting wipe before sitting

A client is admitted for care after a traumatic brain injury. The client has a history of atrial fibrillation and obesity. Which prescribed medication does the nurse question? A) Pantoprazole B) Mannitol C) Ondansetron D) Warfarin

D) Warfarin

A nurse performs a developmental assessment on an 11-month-old client. Which finding causes the nurse concern? A) Able to stand alone momentarily B) Head circumference greater than chest circumference C) Weight of double the birthweight D) Unable to walk unassisted

C) Weight of double the birthweight Rationale: Infants should double their birthweight by six months of age and triple birthweight by age one. This infant is underweight and will cause the nurse to assess further. Head circumference is greater than chest circumference at birth, but by age one or two, the measurements should be nearly equal.

The phone triage nurse answers a call from a client who reports having a positive enzyme-linked immunosorbent assay (ELISA) test for HIV. The client anxiously asks the nurse to explain what this means. How does the nurse respond? A) "You will need a follow up blood test to help interpret your ELISA test results." B) "A Western blot test should be performed next." C) "The ELISA test provides information about the viral load." D) "This test indicates it is probable that you have acquired immunodeficiency syndrome, or AIDS."

A) "You will need a follow up blood test to help interpret your ELISA test results." Rationale: The ELISA test is used to detect antibodies, so the test result should be confirmed. False positives may occur in pregnant women and people with altered immune function.

The nurse counsels a client who has tested negative for human immunodeficiency virus (HIV) after a recent exposure to contaminated blood. Which instruction does the nurse provide? A) "You will need to repeat the test in six months." B) "This indicates that you have immunity to HIV." C) "This indicates that you are not contagious." D) "The test shows that you are not infected with HIV."

A) "You will need to repeat the test in six months" Rationale: False negatives may occur during the first three weeks to six months after exposure. This occurs because antibodies to HIV have not reached measurable amounts. A repeat test should be done in six months. A negative test does not indicate immunity to HIV.

A toddler's parents ask a nurse how long the child is required to use a front facing car seat. The nurse responds with which statement? A) "Your child should use a car seat with a harness as long as possible until the car seat is outgrown." B) "The child must be at least six years old to use a regular seat belt." C) "Your child must be at least four years old and able to see out the window." D) "When the child is mature enough to stay seated in a booster seat, you can stop using the front facing car seat."

A) "Your child should use a car seat with a harness as long as possible until the car seat is outgrown."

A nurse inspects a four-year-old client's mouth at a routine office visit. When the parent asks how many teeth the child should have, which answer does the nurse give the parent? A) 20 B) 16 C) 24 D) 12

A) 20 Rationale: By age three, all primary teeth should be erupted. Children do not begin to lose primary teeth until age five or six.

A client is upset because the health care provider changed the intravenous opioid analgesic to an oral preparation and throws a meal tray at the nurse when offered the oral medication. What is the nurse's response? A) Acknowledge the client's anger and ask to speak about the pain control plan. B) Ignore the behavior and document the oral medication as refused. C) Call the health care provider and request a prescription for an intravenous opioid. D) Tell the client acts of aggression can result in the client being refused treatment.

A) Acknowledge the client's anger and ask to speak about the pain control plan

A nurse plans care for a client admitted with a sickle cell crisis. After beginning hydration and oxygen supplementation, which is the priority intervention? A) Instruct the client in the use of a patient-controlled analgesia pump. B) Request an evaluation by the physical therapist to limit loss of function. C) Use standardized scales to assess the client for signs of depression. D) Monitor weight and provide high-protein snacks between meals as needed.

A) Instruct the client in the use of a patient-controlled analgesia pump

A nurse reviews laboratory results for a client admitted to the hospital with suspected systemic lupus erythematosus (SLE). Which results best support the diagnosis? A) Positive antinuclear antibody B) Elevated erythrocyte sedimentation rate C) Hemoglobin of 10.1 g/dL D) Presence of urinary protein

A) Positive antinuclear antibody

The nurse prepares to infuse packed RBCs into a client with anemia. To limit the likelihood of a type II hypersensitivity reaction, which action does the nurse take? A) Request that the blood bank divide the unit into smaller-volume bags B) Carefully check identification of donor blood and client C) Administer diphenhydramine 30 minutes before transfusion D) Have epinephrine ready for injection as needed

B) Carefully check identification of donor blood and client

A client with acquired immunodeficiency syndrome (AIDS) has a body mass index (BMI) of 17.1. Which instructions does the nurse provide to the client? Select all that apply. A) "Choose nutrient-rich foods." B) "Eat small, frequent meals." C) "Follow this meal plan carefully." D) "Take the prescribed megestrol acetate." E) "Strive to gain two pounds per week."

A) "Choose nutrient-rich foods," B) "Eat small, frequent meals," and D) "Take the prescribed megestrol acetate." Rationale: A BMI of 17.1 indicates the client is underweight. To prevent further weight loss, the client should consume nutrient-rich foods. Snacks should be calorie- and nutrient-rich, not low-calorie. To prevent and treat anorexia and cachexia, the client should eat small, frequent meals. These may be better tolerated than larger, more infrequent meals. Megestrol acetate is a progestin used for the treatment of anorexia, weight loss, and cachexia associated with AIDS.

The nurse assesses the client who is 24 months of age. The nurse asks the parents to provide more information related to which statement concerning gross motor assessment finding? A) "Crawls up stairs without help" B) "Must balance to kick a ball" C) "Squats to picks up an object" D) "Runs with a widened stance"

A) "Crawls up stairs without help"

The pediatric nurse assesses a six-month-old whose birthweight was eight pounds, two ounces. The infant now weighs thirteen pounds, nine ounces. Which information does the nurse obtain from the parents? Select all that apply A) "Does your baby roll over unassisted?" B) "Were your other children overweight?" C) "How many ounces of formula does your baby take each day?" D) "Do you give your baby water in addition to formula?" E) "Does your baby spit up large amounts frequently?"

A) "Does your baby roll over unassisted?", C) How many ounces of formula does your baby take each day?", D) "Do you give you baby water in addition to formula?", E) "Does your baby spit up large amounts frequently?"

A home health nurse assessed an elderly client whose grandchild is the live-in caregiver. Which statements by the grandchild indicate that the client is at risk for elder abuse? Select all that apply. A) "I get annoyed with all of the demands that are part of the job, but no one else is going to take care of her." B) "Providing care is the only purpose I have anymore. The things I used to enjoy don't interest me." C) "I have a hard time remembering to take care of myself sometimes, but my support group helps." D) "I felt hopeless when I lost my parent. Providing care gives me a sense of purpose I didn't have then." E) "I love my grandma, but I feel like I am the only one who cares about her, and I'm really overwhelmed."

A) "I get annoyed with all of the demands that are part of the job, but no one else is going to take care of her," B) "Providing care is the only purpose I have anymore. The things I used to enjoy don't interest me," E) "I love my grandma, but I feel like I am the only one who cares about her, and I'm really overwhelmed." Rationale: The caregiver indicates a feeling of burden, which indicates a potential risk for abuse. The caregiver indicates anhedonia, a loss of joy from usually joyful activities. This is a sign of depression, which is common in caregivers and a sign of having difficulty coping. This could increase the risk for abuse. The last answer indicates a sense of being overwhelmed and a lack of support, which are common factors increasing the risk for abusive behavior against the client.

A 10 year old client grieves the loss of their sibling. Which response from the nurse is appropriate? A) "It' s okay to feel angry and sad." B) "I'm sorry, but I can't share details with you." C) "You should stay home from school for a while." D) "I promise you'll start to feel better in no time."

A) "It's okay to feel angry and sad"

A client diagnosed with systemic lupus erythematosus (SLE) asks the nurse whether the client's children will get the disease. The nurse provides which information to the client? Select all that apply. A) "SLE is more common in females than in males." B) "SLE is more common in Caucasians." C) "SLE runs in families." D) "SLE is usually diagnosed after age 50." E) "SLE is more common in underweight people."

A) "SLE is more common in females than in males," C) "SLE runs in families." Rationale: Women are ten times more likely to develop SLE than men are. SLE has a genetic link and tends to be hereditary. SLE is most common in black women. SLE is most commonly diagnosed after puberty, typically in the 20s and 30s. Being overweight increases the risk of developing an autoimmune disorder.

A nurse reviews the treatment plan for a client with iron-deficiency anemia. Which action does the nurse take prior to administering iron dextran? A) Administer a test dose of iron dextran and observe the client closely B) Prepare the prescribed dose in a syringe for direct injection into the IV line C) Prepare for a rapid increase in BP after the administration of iron D) Inform the client that fatigue and facial flushing are common side effects

A) Administer a test dose of iron dextran and observe the client closely Rationale: Anaphylaxis has been reported in 0.3% of clients receiving iron dextran. For this reason, a small test dose of 25 mg is given to ensure the client does not have a reaction. If no reaction is observed, the remaining infusion may be started after one hour has passed.

A public health nurse reviews recent screening results for a population. The public health nurse reports what conditions to the Centers for Disease Control and Prevention (CDC)? Select all that apply. A) Botulism B) Herpes C) Pertussis D) Methicillin-resistent Staphylococcus aureus (MRSA) infection E) rabies

A) Botulism, B) Pertussis, and E) Rabies Rationale: Botulism is a potentially fatal illness caused by Clostridum botulinum, which is normally spread by ingesting affected food. Reporting cases enables the tracking of affected foods. Pertussis, or whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. Due to the high risk for spreading and potentially fatal outcomes, this is a notifiable disease in both Canada and the US. Rabies is a viral disease that attacks the CNS of mammals and is most often spread when one mammal bites another. It needs to be reported so that infected animals can be identified and isolated or removed to prevent further infections.

A client taking tamoxifen reports flushing. Which action does the nurse take? A) Explain that flushing is a common side effect. B) Notify the health care provider of the client's symptoms. C) Take an orthostatic blood pressure immediately. D) Prepare supplies to collect a blood sample.

A) Explain that flushing is a common side effect

A client taking an estrogen-progestin oral contraceptive reports vaginal bleeding. Which action does the nurse take? A) Explain that vaginal bleeding is a common side effect. B) Notify the health care provider of the client's symptoms. C) Monitor the client's vital signs every 30 minutes. D) Arrange for the client to be transported to the hospital.

A) Explain that vaginal bleeding is a common side effect

A primigravida client comes to the clinic for her 36-week checkup. The nurse prepares for which test that is done at every prenatal visit? A) Fetal heart rate using Doppler B) Fetal ultrasound testing C) Laboratory draw to assess for anemia D) Measure of capillary blood glucose

A) Fetal heart rate using Doppler

Before administration of the influenza vaccine, the nurse informs the client about which common side effects? Select all that apply. A) Fever with myalgia B) Injection site pain C) Constipation D) Blurred vision E) Tinnitus

A) Fever with myalgia and B) Injection site pain Rationale: Immunizing vaccines, including the influenza vaccine, may cause fever, myalgia, adenopathy, and pain at the injection site.

A nurse cares for a newborn born at 28 weeks' gestation. The nurse notifies the health care provider for possible development of necrotizing enterocolitis (NEC) after gathering which assessment data? A) Gastric residual of 5mL one hour after an 8mL feeding B) Abdominal girth of 25 cm, from 26 cm 12 hours earlier. C) Heart rate of 156 beats/min. and 162 beats/min. on the last assessments D) Four loose stools within the last 24 hours.

A) Gastric residual of 5mL one hour after an 8mL feeding Rationale: Gastric residual volume should be less than 50% one hour after feeding. A larger residual can be an indication of decreased GI function and the potential development of NEC. Bloody stools is an indication of NEC. Loose stools are normal in the newborn.

A client is prescribed carbamazepine. The nurse educates the client on which adverse effects? Select all that apply. A) Hepatotoxicity B) Hyponatremia C) Bone marrow suppression D) Stevens-Johnson syndrome E) Renal toxicity

A) Hepatotoxicity, B) Hyponatremia, C) Bone marrow suppression, D) Stevens-Johnson syndrome, E) Renal toxicity Rationale: Carbamazepine can cause liver impairments ranging from mild elevations in liver enzymes to liver failure. Hyponatremia is caused by syndrome of inappropriate ADH secretion, which is thought to be related to the dose of carbamazepine. Older adult clients and clients taking diuretics are at greatest risk for hyponatremia. Carbamazepine has a US box warning for the risk of agranulocytosis, which can lead to bone marrow depression. Carbamazepine has a US box warning for the risk of Stevens Johnson syndrome, a potentially fatal skin reaction. Renal or kidney toxicity has been seen in clients taking this. It should be avoided in clients with moderate to severe renal impairment.

A nurse cares for a client in the preoperative period. The nurse notified the health care provider when the client reports taking which medication on the day of surgery? Select all that apply. A) Ibuprofen B) Aspirin C) Acetaminophen D) Carbamazeapine E) Metoprolol

A) Ibuprofen and B) Aspirin Rationale: The health care provider will instruct the client to stop taking the NSAID drugs, such as ibuprofen/aspirin, several days to weeks before the day of surgery. Other blood thinners and herbal supplements that can alter clotting mechanisms will be stopped as well. The surgery might continue as scheduled, but the HCP must be made aware of the additional risk of client hemorrhage.

The parents of an eight-year-old express surprise that their child is finally becoming more cooperative and understanding that actions have consequences. The nurse explains that the child has achieved which stage of development? A) Industry vs. inferiority B) Basic trust vs. mistrust C) Initiative vs. guilt D) Identity vs. role confusion

A) Industry vs. inferiority

An older adult client is found to have a hemoglobin of 10.1 g/dL on routine labwork. Which actions does the nurse take? Select all that apply. A) Instruct the client how to obtain stool samples for occult blood B) Ask whether the client is experiencing night sweats C) Request the client complete a 24-hour dietary recall D) Assess for tachycardia at rest E) Obtain a blood sample for type and crossmatch

A) Instruct the client how to obtain stool samples for occult blood, C) Request the client complete a 24-hour dietary recall, D) Assess for tachycardia at rest

An adult client arrives at the ED and reports being stung by wasps. The nurse assess the client for which signs indicating anaphylaxis? Select all that apply. A) Pulse of 120 beats/min B) BP of 168/92 mmHg C) Nausea and vomiting D) A feeling of impending doom E) Audible stridor

A) Pulse of 120 beats/min, C) Nausea and vomiting, D) A feeling of impending doom, and E) Audible stridor Rationale: Anaphylaxis is a type I reaction due to IGE-mediated histamine release. Pulse is rapid and weak in anaphylaxis. Anaphylaxis causes hypotension due to vascular collapse. Histamine release may cause cramping, nausea, vomiting, and diarrhea. Clients often experience headache, dizziness, and a feeling of impending doom. Bronchospasm causes coughing, wheezing, tachypnea, and stridor.

A client with severe dust mite allergies asks a nurse how to prevent outbreaks of rhinitis. The nurse instructs the client to take which actions? Select all that apply. A) Sleep in an air-conditioned room B) Keep floors bare and avoid carpeting C) Use impermeable covers on pillows and mattresses D) Wear a surgical face mask when sleeping E) Clean all surfaces weekly with a bleach solution

A) Sleep in an air-conditioned room, B) Keep floors bare and avoid carpeting, and C) Use impermeable covers on pillows and mattresses Rationale: Dust mites prefer an environment warmer than 70 F with high humidity. Air conditioning reduces temperature and humidity. Dust mites live on skin shed from humans and pets, and skin flakes are difficult to clean from carpeting. Shed skin flakes collect in pillows and mattresses and allow dust mites to thrive. Using hypoallergenic covers prevents dust mites from collecting in these areas.

A nurse prepares a prenatal class for a group of adolescents in the first trimester of pregnancy. The nurse includes diet and nutrition information for which potential adolescent pregnancy complication? A) Small for gestational age (SGA) infant B) Large for gestational age (LGA) infant C) Gestational diabetes D) Preeclampsia

A) Small for gestational age (SGA) infant

A nurse cares for a client admitted with anorexia nervosa. Which signs and symptoms is the nurse likely to observe? Select all that apply. A) The client has a potassium level of 3.2 mEq/L. B) The client reports numbness in the feet. C) The client has lanugo on the face and back. D) The client reports menorrhagia. E) The client has a blood pressure of 152/93.

A) The client has a potassium level of 3.2 mEq/L, B) The client reports numbness in the feet, and C) The client has lanugo on the face and back Rationale: Clients with anorexia nervosa are likely to experience hypokalemia from purging behaviors or malnutrition. Clients with anorexia nervosa lose the insulating lipid layer covering their neurons due to malnutrition. As a result, the neurons have difficulty transmitting information, resulting in neuropathy of the extremities. Clients with anorexia nervosa experience a drop in their metabolic rate due to starvation. The slowed metabolic rate causes the clients to feel cold. The body compensates by growing lanugo, a fine, downy hair, in an attempt to insulate the body. Clients will have lowered sex hormone levels. Females are likely to experience irregular menstruation or amenorrhea. Menorrhagia is a heavy period. Clients will also experience hypotension, not hypertension. The hypotension results from starvation and the lack of fuel available to pump the heart.

The nurse admits a client with Wernicke encephalopathy. The nurse places an intravenous catheter in anticipation of which intravenous therapy? A) Thiamine B) Magnesium C) Caffeine D) Ascorbic acid

A) Thiamine Rationale: Wernicke encephalopathy is commonly treated with large doses of intravenous thiamine for 1-2 weeks. Wernicke encephalopathy is an acute, reversible condition that develops in clients with a history of heavy alcohol use.

Which situations indicate to the nurse that the client meets the criteria for involuntary commitment? A) Threatens to kill one's children B) Neglecting one's children C) Exhibiting depressed mood D) Diagnosis of schizophrenia E) Actively plans to harm self

A) Threatens to kill one's children and E) Actively plans to harm self Rationale: Threatening to kill others qualifies for involuntary hospitalization, along with danger to self, failure to meet basic needs, or requirement for further psychological treatment. The client who plans self-harm is eligible for involuntary hospitalization to maintain client safety until suicidal or self-harm ideation passes. The client who neglects children may or may not require hospitalization, depending on what behaviors cause the neglect of children. The personal responsible for neglect does not require involuntary hospitalization, unless the client poses a threat to self or others, cannot meet basic needs, or requires further psychological treatment.

A nurse provides human immunodeficiency virus (HIV) education at a community clinic. The nurse includes in the education that which factor affects the transmission of HIV? Select all that apply. A) Type of sexual contact B) Gender C) Type of bodily fluid D) Viral load E) Age

A) Type of sexual contact, B) Gender, C) Type of bodily fluid, and D) Viral load

The nurse performs a developmental assessment on a 15-month-old client. Which finding causes the nurse concern? A) Unable to stand for two seconds B) Unable to run or hop C) Speaks in one-word sentences D) Unable to put on clothes

A) Unable to stand for two seconds

A nurse cares for a school aged-child recently diagnosed with neuroblastoma. What is the best way for the nurse to assess if the client is experiencing pain? A) Use the Wong Faces Scale with vital signs. B) Monitor heart rate and blood pressure. C) Observe for changes in behavior. D) Assess the abdominal skin for lumps.

A) Use the Wong Faces Scale with vital signs

The nurse cares for a client with four young children. The nurse recognizes which client statement reflects the developmental theory for families? A) "Every family member has a different role to make our family complete." B) "How we respond to the kids now will influence the future of our family." C) "If something affects one person in the family, it affects our whole family." D) "Stress helps our family to grow and is a positive part of our family's life."

B) "How we respond to the kids now will influence the future of our family." Rationale: The developmental theory state that families change over time, but how the family does at one stage influences the following stage. Also, this theory says that families entering a new life cycle stage are in disequilibrium.

A nurse interviews a newly admitted adolescent client to collect a health history. The nurse follows up on which client statement? A) "I have a lot of trouble waking up in the morning." B) "I only eat vegetables, and I have lost 10 pounds in the past 3 weeks." C) "My mood is always changing." D) "When I am stressed out, I like to go on a date."

B) "I only eat vegetables, and I have lost 10 pounds in the past 3 weeks." Rationale: Eating only vegetables can lead to nutrient deficiencies. the nurse needs to assess the client's nutrition further.

A client's friend calls asking if the client is still being treated on the unit. What is the best response from the nurse regarding the client? A) "I am not permitted to give you any information." B) "Let me look further into this matter for you." C) "The client went home from here this morning." D) "I will check the client's release of information."

B) "Let me look further into this matter for you." Rationale: Stating that "I am not permitted to give information" confirms that the client was hospitalized, which could be a breach of HIPAA. Instead, "I do not have any information to give about that person." By stating, "Let me look further into this matter for you," the nurse does not reveal any information about the client being in the hospital, and it allows the nurse to check the release of information. If the client did not wish this friend to know anything about the hospitalization, the nurse has effectively respected the client's right to privacy.

A health care provider prescribes a once-daily nitroglycerin transdermal patch. Which instruction from the nurse indicates a lack of understanding of medication administration? A) "Place the patch on the chest for 12 to 14 hours." B) "Replace the patch on the same site each day." C) "Dispose the patch by folding the adhesive ends together." D) "Apply the patch to a dry, hairless area on the body."

B) "Replace the patch on the same site each day." Rationale: Application sites for nitroglycerin patches must be rotated every application to prevent skin irritation and sensitization. Nitroglycerin patches can be applied for 12-14 hours, followed by a 10 to 12 hour nitrate-free period. The chest is a common and appropriate site to place the patch. Nitroglycerin patches should be applied to a dry, hairless area on the body.

A client with schizophrenia approaches the psychiatric nurse and asks to read the medical record. The nurse gives which best initial response to the client? A) "Viewing your medical record is against policy." B) "Tell me more about wanting to see your records." C) "Talk to your lawyer to request access to records." D) "Let me discuss this matter with my supervisor."

B) "Tell me more about wanting to see your records." Rationale: The nurse first tries to gain more insight into why the client wants to review medical records. After further assessing what the client wants, the nurse checks with a supervisor regarding records release. A client with a mental illness such as schizophrenia may not be granted access to medical records if it could cause harm to the client's well being, either physical or mental.

A nurse cares for a teenaged client diagnosed with bulimia nervosa. The client expresses distress regarding a weight gain of two pounds. Which response by the nurse is best? A) "Your mom will be happy to see you're not so thin." B) "Tell me why gaining two pounds is upsetting." C) "I felt that way when I had bulimia." D) "Your health care provider wants you to gain weight."

B) "Tell me why gaining two pounds is upsetting."

A client admitted to the ICU asks, "Why must I sign a document stating my wishes regarding life support?" How does the nurse respond best to the client? A) "If you die, you may still be able to donate organs or tissue." B) "We want to respect your wishes regarding your health care." C) "Every client must sign that form when admitted to the ICU." D) "We want you to be prepared in case something goes wrong."

B) "We want to respect your wishes regarding your health care." Rationale: Advance directives communicate with the health care team the care the client wishes to receive if the client becomes unable to communicate about the care desired. Ideally, the client fills out advance directives before becoming ill or incapacitated.

What educational background is required for a nurse to serve as a group psychotherapist? A) A doctorate degree in nursing practice B) An advanced degree in psychiatric nursing C) A master's degree in nursing leadership D) Board certification as a mental health nurse

B) An advanced degree in psychiatric nursing Rationale: A nurse with a master's or doctorate degree in psychiatric nursing may provide psychotherapy.

The parent of a two-year-old expresses frustration due to the child's refusal to follow directions. The nurse explains that this behavior is normal as the child is trying to meet which developmental need? A) Identity B) Autonomy C) Initiative D) Trust

B) Autonomy

A client on a psychiatric unit with a panic disorder approaches a nurse in the hallway reporting anxiety, dizziness, palpitations, and shortness of breath. Which actions does the nurse take to help this client? Select all that apply. A) Administer 1 mg lorazepam by mouth as prescribed B) Encourage the client to exercise after anxiety subsides C) Take the client to a quiet area on psychiatric unit D) Tell the client to share symptoms with other clients E) Guide the client through a relaxation technique

B) Encourage the client to exercise after anxiety subsides, C) Take the client to a quiet area on psychiatric unit, and E) Guide the client through a relaxation technique Rationale: Exercising 30 minutes daily is shown to increase brain-derived neurotropic factor (BDNF), a chemical in the brain associated with decreasing anxiety. Physical exercise may help decrease the frequency and duration of panic attacks for certain clients. Decreasing stimulation by bringing the client to a quiet area may help the client cope with the panic attack. Some clients become more anxious in social situations and do not like others staring at them during a panic attack. Relaxation techniques or guided imagery may help the client cope until a panic attack subsides. The nurse promotes healthy coping during a panic attack. The nurse may give as-needed benzodiazepines after attempting relaxation techniques for the client.

Which treatment does the nurse anticipate for a client with acute kidney injury (AKI)? A) Transfusion with packed RBCs B) IV insulin and dextrose C) Oral hydration with hypotonic saline D) IV potassium chloride

B) IV insulin and dextrose Rationale: The client with AKI commonly experiences hyperkalemia and has the potential for life-threatening dysrhythmias. Administering insulin intravenously helps to drive potassium back into the cells and out of the plasma. Insulin will cause hypoglycemia, which is why it is imperative that dextrose be given along with the insulin.

The nurse cares for a client who is four years old at a well child check. What behavior observed by the nurse would be unexpected for the client who is 4 years old? A) Hides from health care provider. B) Needs parent to put on shirt. C) Speaks to a purple dragon. D) Throws toy at older sibling.

B) Needs parent to put on shirt

A nurse cares for a client diagnosed with von Willebrand disease (VWD). Which clinical findings does the nurse document as supporting this diagnosis? A) Increased PLT count B) Prolonged activated partial thromboplastin time C) Prolonged prothrombin time D) Increased international normalized ratio

B) Prolonged activated partial thromboplastin time Rationale: Due to a reduction in factor VIII, the activated partial thromboplastin time is prolonged to varying degrees in VWD.

A seven-year-old client has begun bedwetting again after the birth of a new sibling. The child's parents ask the nurse whether this is normal. The nurse teaches the parents about which ego defense mechanism? A) Dissociation B) Regression C) Projection D) Repression

B) Regression

The nurse cares for a client hospitalized for acute mania. Which interventions would the nurse implement for this client? Select all that apply. A) Arrange mealtimes in group settings with shared serving dishes. B) Remove the client's wedding ring from their possession. C) Offer fluids and high-fiber snacks throughout the day. D) Assist the client in selecting outfits on a daily basis. E) Encourage the client to participate in a group crafting project.

B) Remove the client's wedding ring from their possession, C) Offer fluids and high-fiber snacks throughout the day, and D) Assist the client in selecting outfits on a daily basis Rationale: During a period of mania, clients struggle with rational judgment. Removing valuables helps to protect the client from giving away valuable possessions. In addition to maintaining caloric intake, fluids and high fiber snacks are important in maintaining peristalsis and avoiding constipation or fecal impaction. Client pays little attention to clothing choices during acute mania. Assisting the client with selecting outfits helps the client choose appropriate clothing for both the temperature and social situation. Decreasing ridicule helps to maintain client dignity and reduces the possibility of defensive behavior. Clients will have little attention span during periods of mania and would be easily distracted in a group meal setting. Maintain caloric intake by offering high-calorie protein drinks and foods that can be eaten while moving, such as sandwiches, fruit, and milkshakes. Maintaining a low level of stimuli and providing structured, solitary activities with nursing supervision are preferred over group activities during acute mania.

A nurse completes intake documentation on a group of teenage clients and their two-week-old newborns. Which client data indicates a need for referral? A) The client who goes to school during the day and leaves the newborn with her mother B) The client who reports the newborn cries so much she has to shake the newborn to make it stop C) The client reporting the newborn cries so much she leaves the newborn alone to cry in the crib D) The client who states she feeds the newborn every time the newborn cries

B) The client who reports the newborn cries so much she has to shake the newborn to make it stop

The mental health nurse receives reports on four clients. Which of the clients does the nurse assess first? A) The client in seclusion with aggression and mania who was last assessed fifteen minutes ago. B) The client with a history of self-injury who was admitted overnight for suicidal ideation. C) The client with alcohol dependency who reports tremors, sweating, and palpitations. D) The client with type 1 diabetes and schizophrenia refusing a capillary blood glucose check.

B) The client with a history of self-injury who was admitted overnight for suicidal ideation

A client is angry that the nurse is unable to administer more opioid analgesic and grabs the nurse's wrist. How does the nurse respond? A) "Let go of my wrist, and I will ask the doctor to order you more medication." B) "Aggressive behavior is not tolerated, and I will not get you more medication." C) "Let go of my wrist, and we can discuss your pain control needs calmly." D) "I will call the staff to restrain you if you do not stop being aggressive."

C) "Let go of my wrist, and we can discuss your pain control needs calmly."

A client is prescribed depot medroxyprogesterone acetate. Which statement made by the client concerns the nurse? A) "I am taking this medication as a form of contraceptive." B) "I have been experiencing spotting and irregular bleeding." C) "I go to the clinic to receive this shot twice a year." D) "I have gained ten pounds since I started this medication."

C) "I go to the clinic to receive this shot twice a year." Rationale: Medroxyprogesterone acetate is given every three months or 13 weeks. Late or infrequent doses can result in unplanned pregnancy. It is a progestin-only contraceptive that is administered through injection (intramuscular or subcutaneous). It can be used to regulate hormones or decrease excessive menstruation. Unscheduled bleeding is a common side effect. Weight gain is a common side effect.

Which does the nurse include in the discharge plan for a client recovering from a cocaine addiction? Select all that apply. A) Smoke cigarettes as alternative to cocaine. B) Exercise vigorously 30 minutes daily. C) Follow the prescribed medication regimens. D) Participate in a support group on a regular basis. E) Confront other friends with drug addiction.

C) Follow the prescribed medication regimens and D) Participate in a support group on a regular basis Rationale: Encourage the client to follow medication regimes as prescribed. If the client abuses substances as self-treatment for depression, taking antidepressant medications as prescribed may help prevent a relapse. Relapse support groups help clients maintain sobriety by role playing stressful situations, providing examples of how to maintain sobriety, and problem solving. The client recovering form addiction may require a completely new support system, if current friends are drug addicted. Clients who have abused drugs may have residual brain damage from the drug abuse. The nurse tries to keep the discharge plan as simple as possible for this client population, encouraging the client to avoid situations where likely to relapse, attend a support group, and take medication as prescribed. Interactions with drug-addicted friends may lead to relapse. Encourage the client to develop groups of friends who do not use drugs to help prevent relapse.

A nurse interviews a teenage client during a sports physical. The client states, "I hate that I have to wear make-up so no one can see my acne." The nurse records that the client is in which stage of development? A) Industry vs. inferiority B) Basic trust vs. mistrust C) Identity vs. role confusion D) Initiative vs. guilt

C) Identity vs. role confusion

A nurse reviews the CBC with differential for a client with cytomegalovirus. The nurse expects an elevation of what value? A) Basophils B) Neutrophils C) Lymphocytes D) Eosinophils

C) Lymphocytes Rationale: Lymphocytes help defend against viruses, especially the natural killer cells. Lymphocyte count is elevated in a viral infection. Cytomegalovirus is a virus. Basophils may be elevated during allergic responses or with neoplasms. Neutrophils are elevated during a bacterial infection. Eosinophils are elevated during a parasitic infection.

A client is receiving hospice services at home. How do the hospice providers best address the needs of the younger sibling? A) Provide opportunities for play therapy. B) Allow the sibling to participate in family meetings. C) Provide support from the social worker. D) Allow sibling to participate in care.

C) Provide support from the social worker Rationale: This would be the best way to support a younger sibling. The social worker would be able to assess and address the needs of the child in an age-appropriate way as they deal with the health issues of their sibling.

The nurse cares for a client with pernicious anemia. The nurse immediately reports what finding to the health care provider? A) Report of fatigue despite having adequate amounts of sleep B) Presence of jaundice of sclera and generalized pallor elsewhere C) Reports of dizziness and a 15 mmHg drop in systolic blood pressure D) Reports of ongoing mild tingling bilaterally to hands and feet

C) Reports of dizziness and a 15 mmHg drop in systolic blood pressure

The nurse performs a developmental assessment on a four-and-a-half-year-old client. Which finding causes the nurse concern? A) Unable to brush teeth without help B) Unable to tie shoe strings C) Speech is not completely understandable D) Unable to ride a bike

C) Speech is not completely understandable

A client has made several inappropriate comments about the nurse's physical appearance and has been flirtatious. The nurse takes what action? A) Request that the charge nurse assign the client's care to another nurse. B) Ignore the client's inappropriate comments since it is harmless behavior. C) Tell the client this is inappropriate and makes the nurse feel uncomfortable. D) Only interact with the client when necessary and avoid acting friendly.

C) Tell the client this is inappropriate and makes the nurse feel uncomfortable Rationale: Because the behavior has been repeated, it must be dealt with. The nurse should begin by labeling the behavior as inappropriate and telling the client how it makes the nurse feel. From there, the nurse will attempt to reset the tone of the relationship as a healthy nurse-client one.

The nurse cares for a client with a history of alcohol abuse. Which signs and symptoms would indicate the client is experiencing alcohol withdrawal? A) The client reports extreme hunger. B) The client experiences hypotension. C) The client displays episodes of agitation. D) The client experiences bradycardia.

C) The client displays episodes of agitation

The nurse admits a client to the hospital unit. The client's medical history indicates excoriation disorder. What signs or symptoms is the nurse likely to observe upon physical assessment? A) The client reports having a 20-year newspaper collection at home. B) The client has areas of baldness on the scalp and underarm. C) The client displays small wounds over the face, arms, and hands. D) The client reports a fear of rejection due to the shape of their nose.

C) The client displays small wounds over the dace, arms, and hands

The nurse cares for a client with alcohol use disorder. The client has had multiple relapses and recently started a medication that induces nausea, vomiting, and headache when alcohol is ingested. This is an example of which type of therapy? A) The client is undergoing psychoanalytic therapy. B) The client is undergoing interpersonal therapy. C) The client is undergoing aversion therapy. D) The client is undergoing systematic desensitization therapy.

C) The client is undergoing aversion therapy. Rationale: Aversion therapy is a behavioral therapy. It pairs a negative stimulus with a specific behavior in an attempt to suppress the behavior. Aversion therapy is used when other less drastic measures have failed to produce desired effects.

A nurse in the newborn nursery trains a graduate nurse. Which action taken by the graduate indicates a need for the nurse to provide additional education? A) The graduate nurse turns the infant's head to one side and observes extremity movement. B) The graduate nurse places a gloved finger in the infant's mouth to elicit a response. C) The graduate nurse slides her finger downward and across the bottom of the newborn's foot to elicit a response. D) The graduate nurse touches the corner of an infant's mouth to elicit a response.

C) The graduate nurse slides her finger downward and across the bottom of the newborn's foot to elicit a response.

Parents of an eight-month-old client at a community outreach clinic ask the pediatric nurse how many teeth their baby should have. Which information does the nurse provide? A) "Your baby is not expected to have any teeth until age one." B) "All babies are different, and there is no way to estimate this." C) "At this age, babies should have eight to twelve teeth." D) "At this age, babies may have up to four teeth."

D) "At this age, babies may have up to four teeth."

The nurse cares for a client with pernicious anemia. Which statement will the nurse include in the client teaching regarding this condition? A) "A diet rich in protein and leafy vegetables treats your disease." B) "Medications that decrease gastric and acid and increase intrinsic factor." C) "Epoetin alfa is given intramuscularly to produce RBCs." D) "Cyanocobalamin is given IM at regular intervals."

D) "Cyanocobalamin is given IM at regular intervals." Rationale: Cyanocobalamin (Vitamin B12) is given intramuscularly at regular intervals for the treatment of pernicious anemia. Pernicious anemia is caused by an absence of intrinsic factor, secreted by the gastric mucosa. Intrinsic factor is required for cobalamin (extrinsic factor) absorption. This means that, without intrinsic factor, cobalamin will not be absorbed. Epoetin alfa is administered intravenously or subcutaneously and is given to increase the production of erythropoietin, which will lead to increased red blood cells. It will not fix the client's underlying problem of intrinsic factor deficiency and is not the primary treatment for this client.

A nurse cares for a client who is prescribed daily enteric-coated aspirin. Which statement made by the client requires intervention? A) "I should take this medication at the same time each day." B) "I will notify the health care provider of bowel movement changes." C) "I should take this medication with a full glass of water." D) "I can crush the tablet and mix it in food."

D) "I can crush the tablet and mix it in food."

A nurse educates a client with Korsakoff syndrome. Which statement indicates further education is needed? A) "I will need thiamine treatment for 3-12 months." B) "I will have difficulty retrieving previous memories." C) "The nerve cells in my brain are damaged." D) "I will fully recover if I stop drinking alcohol."

D) "I will fully recover if I stop drinking alcohol." Rationale: Treatment for Korsakoff syndrome involves replacement of thiamine for 3-12 months, providing proper nutrition, and hydration. Main features of Korsakoff syndrome are problems in acquiring new information, establishing new memories, and in retrieving previous memories. Nerve cells and supporting cells in the brain and spinal cord are damaged, as well as the part of the brain involved with memory. Stopping alcohol use may prevent further nerve and brain damage, but most clients never fully recover.

A nurse cares for an infant client receiving digoxin. The client's heart rate before medication administration is 85 beats/min. Which statement by the parent concerns the nurse? A) "The heart rate was up to 120 last night." B) "The baby has been sleeping a lot today." C) "The baby's oxygen level was 94%." D) "My child has been vomiting today."

D) "My child has been vomiting today."

A nurse cares for a client admitted to the mental health unit for heroin abuse. Which statement or question is most important to include in the initial history and assessment? A) "Is this the first time you have experimented with heroin?" B) "Tell me how many times you have used heroin this week." C) "Have you used other drugs along with the heroin?" D) "Tell me about when you first started using heroin."

D) "Tell me about when you first started using heroin." Rationale: Asking a client about what situation was occurring when first using heroin allows the client to discuss any social problems that may have contributed to the initial drug use. Discovering these issues may help the client to recognize deeper reasons for drug abuse which may help when trying to overcome the addiction.

A visiting family member tells the psychiatric nurse, "That client in the red shirt is being sexually inappropriate with the other clients!" Which response by the nurse is most appropriate to help the clients? A) "Can you please tell the other nurse?" B) "Tell the other clients to walk away" C) "Can you just try to ignore that client?" D) "Tell me more about the situation"

D) "Tell me more about the situation" Rationale: The nurse assesses the situation by questioning the family member about what has happened. This allows the nurse to determine the most appropriate response.

The nurse provides discharge teaching to a female client prescribed ferrous sulfate for iron-deficiency anemia. Which client statement requires intervention by the nurse? A) "I will take a stool softener if the iron tablets cause me to become constipated." B) "I'm hoping to become pregnant in the next year and a half." C) "I am training for a five-kilometer run at the end of the month." D) "The iron tablets should lessen the fatigue I feel when my colitis flares up."

D) "The iron tablets should lessen the fatigue I feel when my colitis flares up." Rationale: Iron supplements such as ferrous sulfate are contraindicated in clients with ulcerative colitis, as they may exacerbate the disease and cause symptoms to flare up.

A client at a routine prenatal visit in the first trimester expresses concern to the nurse because she is experiencing urinary frequency and a white vaginal discharge. Which is the most appropriate response by the nurse? A) "Urinary frequency is to be expected and will continue throughout the remainder of the pregnancy." B) "You can expect to have frequent vaginal infections throughout the pregnancy." C) "We should test your partner to determine whether he has transmitted an infection to you." D) "You can expect urinary frequency to diminish as you move into the second trimester."

D) "You can expect urinary frequency to diminish as you move into the second trimester."

A nurse cares for a young adult with depression who has voluntarily sought admission to an inpatient psychiatric facility. The client asks the nurse, "How long do I need to stay there?" What is the nurse's response? A) "You may leave the facility before assessment if you sign the appropriate paperwork." B) "Once admitted, you will need to ask your case manager about when you can return home." C) "Once admitted, a court date will be set to determine your capacity to return home." D) "You may leave the facility after the health care provider determines you are safe to leave."

D) "You may leave the facility after the health care provider determines you are safe to leave." Rationale: The client is free to leave the facility after the health care provider has assessed the client and determined that the client is safe to return home. A client who voluntarily admits himself or herself to a psychiatric facility has full legal rights. The client may choose to leave at any point after admission to the facility once the health care provider has assessed the client and determined that the client is safe to return home. The client does not need to ask for permission from anyone or have a court date in order to be discharged from the psychiatric facility.

A client who is pregnant for the first time is prescribed additional iron supplementation due to anemia. Which information does the nurse provide to help the client understand why anemia is more common in pregnancy? A) "Your body stops making red blood cells during pregnancy." B) "You are not eating enough to keep your iron levels high." C) "Your body is giving more of your red blood cells to your baby." D) "Your blood volume has increased, but your red blood cell count has not."

D) "Your blood volume has increased, but your red blood cell count has not." Rationale: Blood volume increases in pregnancy, but it is an increase in plasma, creating a lower ratio of red blood cells to plasma, that results in physiologic anemia. Red blood cells transport oxygen to the fetus, but transfer of blood cells does not occur.

A nurse cares for a client who received an emergent central catheter to the femoral vein 48 hours ago and has since been stabilized. The nurse prioritizes what intervention? A) Teaching the client how to keep the area clean B) Maintaining bed rest to prevent displacement C) Assessing the client for signs of infection D) Advocating changing the site of IV access

D) Advocating changing the site of IV access Rationale: The CDC recommend using an upper-extremity site for catheters due to the decreased risk for catheter-related infections. If the femoral site is used, the CDC recommends that is is replaced to an upper extremity site as soon as possible.

An infant client has received an incorrect dose of diazepam. Which is the first action by the nurse caring for this client? A) Administer oxygen. B) Report the medication error. C) Inform the parents. D) Assess respiratory status.

D) Assess respiratory status

An intensive care unit nurse monitors a client with sepsis. Lab values include decreased hemoglobin, hematocrit, fibrinogen, and platelet levels. Which complication does the nurse suspect? A) Bone marrow depression B) Systemic inflammatory response syndrome C) Hypovolemic shock D) Disseminated intravascular coagulation

D) Disseminated intravascular coagulation Rationale: Bone marrow depression causes decreases in WBC, RBC, and platelets. Hemoglobin and hematocrit may be decreased, but fibrinogen is not impacted. In systemic inflammatory response syndrome, the platelet count is low. Other symptoms include elevated lactic acid levels and hyperglycemia. Hemoglobin and hematocrit may be decreased in hypovolemic shock due to hemorrhage or increased in shock due to dehydration. Fibrinogen and platelet counts are not affected in hypovolemic shock. In disseminated intravascular coagulation, fibrinogen and platelet levels are decreased. As bleeding continues, hemoglobin and hematocrit levels will also drop. Sepsis is the presence of infectious organisms in the bloodstream. As numbers of bacteria increase, widespread inflammation occurs due to infection escaping local control. As perfusion drops, tissues become hypoxic and organ failure begins. Widespread microthrombi formation causes clots to form throughout the body, using up platelets and clotting factors known as disseminated intravascular coagulation.

A health care provider (HCP) prescribes low molecular weight (LMW) heparin therapy. The nurse questions the prescription in a client with which disorder? A) Myocardial infarction B) Pulmonary embolism C) Deep vein thrombosis D) Heparin-induced thrombocytopenia

D) Heparin-induced thrombocytopenia

A nurse reviews the CBC of a healthy client. Which WBCs does the nurse expect to be most numerous? A) Basophils B) Eosinophils C) Lymphocytes D) Neutrophils

D) Neutrophils Rationale: Neutrophils (granulocytes) normally account for 55-70% of WBCs. Due to their appearance, mature neutrophils are often called segs, and immature neutrophils may be called bands. Basophils normally account for 0.5-1% of WBCs. Eosinophils normally account for 1-4% of WBCs. Lymphocytes normally account for 20-40% of WBCs.

A nurse cares for a client who is prescribed ticlopidine. Which laboratory value indicates to the nurse that the client is experiencing an adverse reaction? A) Hemoglobin 12.1 g/dL B) Glucose 235 mg/dL C) Potassium 3.1 mEq/L D) Neutrophils 500 cells/mm³

D) Neutrophils 500 cells/mm3

A nurse is preparing insurance applications for a client who is transitioning from inpatient to an outpatient treatment setting that requires pre approval of private insurance coverage. The nurse performs what action first? A) Send the information to the outpatient clinic and ask them to apply for the client B) Tell the client to contact the insurance company once discharged to set up for outpatient services C) Submit all medical records and documentation to the insurance authorization underwriter D) Obtain informed consent and signed release of information from the client

D) Obtain informed consent and signed release of information from the client Rationale: The client will have to consent to the release of this information before the nurse sends the necessary documentation for insurance coverage. The nurse cannot submit client information without the client's consent. Confidentiality of care and treatment remains an important right for all clients, particularly psychiatric clients.

The nurse plans care for a preschool-aged client hospitalized multiple times for leukemia. After observing the client using several coping mechanisms, which intervention does the nurse include? A) Avoid painful procedures. B) Provide materials for journaling. C) Administer anti-anxiety medications promptly. D) Plan time for therapeutic play.

D) Plan time for therapeutic play

The family of a hospitalized client with acquired immunodeficiency syndrome (AIDS) brings raw fish with rice for the client's dinner. Which action does the nurse take? A) Encourage the client to enjoy this high-protein meal B) Assist the client in hand washing before the client eats C) Inform the family that food from home is not allowed D) Remind the client of prescribed dietary restrictions

D) Remind the client of prescribed dietary restrictions Rationale: Sushi often contains raw fish or meat, and the nurse must intervene to protect the client's health.

A client who is breastfeeding her newborn requests assistance from the lactation nurse. Which reflex does the nurse explain in order to assist with latching on? A) Swallowing reflex B) Tonic neck reflex C) Extrusion reflex D) Rooting reflex

D) Rooting reflex

An unlicensed assistive personnel (UAP) informs a nurse that the toddler-age client admitted the previous afternoon is crying while the UAP attempts to feed the child. The nurse informs the UAP that which situation is the most likely reason for the child's behavior? A) The presence of other children B) A lack of familiar toys C) Dislike of the UAP D) Separation from the parents

D) Separation from the parents

A nurse provides care for a client with thrombocytopenia who has developed epistaxis. The nurse assists the client into which position? A) Standing erect with arms raised above the head B) Sitting upright with neck hyperextended C) Lying supine with neck extended D) Sitting upright and leaning forward

D) Sitting upright and leaning forward Rationale: Raising the arms will not help prevent aspiration of blood or stop the bleeding. Hyperextension of neck increases the risk of aspiration of blood. Lying supine will promote drainage of blood into stomach and increase risk of aspiration. An upright and forward position will prevent blood from entering the stomach and lungs. It helps avoid aspiration of blood. The client should be kept quiet and still to reduce anxiety and blood pressure.

The nurse cares for an older adult client who has chosen to discharge home with hospice care. The client shares life stories and reports feeling at peace with death. The nurse understands the client has resolved which developmental crisis? A) The client has resolved generativity versus stagnation. B) The client has resolved intimacy versus isolation. C) The client has resolved autonomy versus shame and doubt. D) The client has resolved integrity versus despair.

D) The client has resolved integrity versus despair Rationale: Integrity versus despair occurs during old age or end-of-life. In this stage, the older adult is faced with challenges of physical and social loss, loss of status and function, and the search of meaning of life. The older adult reviews their life experiences with either a sense of integrity or despair. Generativity versus self-absorption occurs during middle age. In this stage, the individual focuses on supporting future generations. Achieving generativity means contributing to future generations through parenthood, teaching, mentoring, and community involvement. An inability to achieve generativity results in stagnation.