adaptive quizzing set 1
In specific situations gloves are used to handle newborns whether or not they are positive for human immunodeficiency virus (HIV). When is it unnecessary for the nurse to wear gloves while caring for a newborn? Correct1 Offering a feeding 2 Changing the diaper 3 Giving an admission bath 4 Suctioning the nasopharynx
1
Which fine motor skill should be seen in a 10-month-old infant? Correct1 Picking up finger foods 2 Releasing a cube in a cup 3 Building towers of two blocks 4 Turning many pages in a book
1
Which hormone is crucial for ovulation and complete maturation of a client's ovarian follicles? Correct1 Luteinizing hormone Incorrect2 Follicle stimulating hormone 3 Gonadotropin releasing hormone 4 Human chorionic gonadotropin hormone
1
Which nursing intervention should the nurse consider to be a priority for clients with fluid overload? 1 Ensuring client safety 2 Providing drug therapy 3 Providing nutritional therapy 4 Preventing future fluid overload
1
A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? 1 Progressive deterioration until death 2 Deficiencies of essential neurotransmitters 3 Increased risk for respiratory complications 4 Involuntary twitching of small muscle groups
3
While assessing a client who experienced an accident, the nurse found that the client is unable to move eyeballs laterally. Which nerve damage led to this condition in the client? 1 Optic nerve 2 Facial nerve Correct3 Abducens nerve 4 Oculomotor nerve
3
A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. What is the nurse's best reply? 1 "I suggest that you buy a commode exclusively for your child's use." 2 "Your child may use the bathroom, but you need to use disposable toilet covers." 3 "You will need to clean the bathroom from top to bottom every time a family member uses it." Correct4 "All family members, including your child, need to wash their hands after using the bathroom."
4
A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with? 1 Safety 2 Quality improvement 3 Patient-centered care 4 Evidence-based practice
4
An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? 1 Instructing the client to be quiet 2 Allowing the client to act out until fatigue sets in 3 Guiding the client from the room by gently holding the client's arm Correct4 Giving the client one simple direction at a time in a firm, low-pitched voice
4
Who is responsible for client outcomes in the functional model of care? 1 Charge nurse 2 Nurse manager 3 Registered nurse 4 Medication nurse
2
Which conditions are given a green tag according to triage disaster tag system? Select all that apply. Correct1 Strains Correct2 Abrasions 3 Open fractures 4 Airway obstruction 5 High cervical spinal cord injury
1,2
What are the steps of performing a primary survey according to priority to assess a client with severe injuries from a bomb blast? 1. Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure
1,2,3,4,5
A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? 1 Add extra salt to food 2 Consume high-potassium foods 3 Omit protein foods at each meal 4 Restrict the daily intake of fluids to 1 L
1
A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? 1 Allows excess tissue fluid to be excreted 2 Helps to control the volume of food intake and thus weight 3 Aids the weakened heart muscle to contract and improves cardiac output 4 Assists in reducing potassium accumulation that occurs when sodium intake is high
1
A nurse is preparing to change a client's dressing. Which information should the nurse recall for using surgical asepsis? Correct1 Keep the area free of microorganisms. 2 Protect self from microorganisms in the wound. 3 Confine the microorganisms to the surgical incision site. 4 Limit the number of opportunistic microorganisms to a minimum.
1
Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? 1 Use lemon juice to season meat. 2 Put condiments on food to add flavor. 3 Include canned vegetables in meal preparation. 4 Drink carbonated beverages instead of decaffeinated coffee.
1
Which stage of Lawrence Kohlberg's theory of moral development is associated with a person following a law even if it is discriminatory to a racial group? Correct1 Social contract orientation Incorrect2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation
1
Which diseases are caused by viruses? Select all that apply. Correct1 Mumps 2 Tetanus Correct3 Measles Correct4 Hepatitis B 5 Diphtheria
1,3,4
A client with a family history of goiter is experiencing changes in voice and breathing. Which diagnostic study does the nurse consider to be beneficial in confirming a diagnosis? 1 Thyroglobulin Correct2 Thyroid antibodies 3 Thyroxine (free T4), total 4 Thyroid-stimulating hormone (TSH)
2
A client with bone cancer is receiving hospice care at home. The hospice program also provides respite care. What is the purpose of respite care? 1 Assisting the client with meals and personal care 2 Providing short-term relief to the family caregiver 3 Providing skilled nursing interventions for the client 4 Providing counseling and treatment for behavioral problems
2
An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client? 1 Clinical nurse specialist (CNS) 2 Certified nurse midwife (CNM) 3 Certified nurse practitioner (CNP) 4 Certified registered nurse anesthetist (CRNA)
2
The emergency department nurse is conducting an interview and assisting with the physical examination of a female sexual assault victim. What is most important for the nurse to document on this client's record? 1 Observations about the client's reaction to male staff members 2 Statements by the client about the sexual assault and the rapist 3 Information about the client's previous knowledge of the rapist 4 Summary statement about the client's description of the assault and the rapist
2
The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition? 1 Hypothyroidism 2 Down syndrome 3 Turner syndrome 4 Fetal alcohol syndrome
2
What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? 1 Surgery 2 Comfort 3 Education 4 Motivation
2
Which nursing model includes a registered nurse (RN) paired with technical assistance? 1 Team nursing model 2 Co-primary nursing model 3 Patient-focused care model 4 Functional model of nursing
2
Which period of Piaget's theory explains animism in a child? 1 Period I Correct2 Period II 3 Period III 4 Period IV
2
Which quality of the nursing assistant should be known by the delegator when assigning a task? 1 Ability 2 Willingness 3 Interaction 4 Relationship
1
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1 Urinary output 2 Sensation to touch 3 Neurologic status 4 Respiratory exchange
4
A client with dehydration is prescribed an intravenous (IV) fluid infusion. Which healthcare professional would the nurse expect to be delegated this task? 1 Registered nurse (RN) 2 Licensed practical nurse (LPN) 3 Licensed vocational nurse (LVN) 4 Unlicensed assistive personnel (UAP)
1
Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? 1 Apples 2 Chocolate 3 Rye bread 4 Cheddar cheese
1
Which would the nurse consider to be an example of a potential internal disaster? 1 Hospital fire 2 Fertilizer plant explosion 3 Nuclear reactor explosion 4 Terrorist device explosion
1
A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using? 1 Regression Correct2 Transference 3 Reaction formation 4 Cognitive distortion
2
A nurse teaches a client with type 1 diabetes about the treatment of hypoglycemia. If the teaching is effective, which foods does the client identify to manage hypoglycemia? 1 Hard candy and fruit juice Correct2 Cheese sandwich and sugar 3 Chocolate candy and an orange Incorrect4 Peanut butter crackers and a glass of milk
2
During a nutritional counseling session, an adolescent says to a nurse, "I am not following my diet properly, but I know I should do it." Which stage of change model does the adolescent belong? 1 Maintenance Correct2 Contemplation 3 Precontemplation 4 Preparation/Determination
2
Which statement is true about the sleep pattern of preschoolers? 1 Daytime naps are very common among preschoolers. 2 On average, a preschooler sleeps about 12 hours a night. 3 Partial awakening leading to sleeplessness is common among preschoolers. 4 About 30% of sleep time in preschoolers is spent in the rapid eye movement sleep (REM) cycle.
2
Which task can be safely delegated by a registered nurse (RN) to unlicensed nursing personnel (UNP) for a client with thrombocytopenia? 1 Shaving the client Correct2 Positioning the client 3 Maintaining oral hygiene 4 Giving intravenous platelet infusions
2
Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family? 1 Orem's theory 2 Peplau's theory 3 Leininger's theory 4 Henderson's theory
2
Which theory states that the leadership traits in an individual are born and not made? 1 Style theory 2 Great Man theory 3 Two-factor theory 4 Situational-contingency theory
2
Which type of language development is seen in 4-year-olds? 1 Names four or more colors Correct2 Knows simple songs 3 Has vocabulary of about 2100 words 4 Uses sentences of six to eight words, with all parts of speech
2
Blood studies are being performed on a client with the potential diagnosis of hyperparathyroidism. What serum blood level should the nurse expect to be decreased when reviewing this client's hematologic studies? 1 Calcium 2 Chloride Correct3 Phosphorus 4 Parathormone
3
During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented? 1 Stork bites 2 Forceps marks Correct3 Mongolian spots 4 Ecchymotic areas
3
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? 1 Stimulate continuous formation of urine. 2 Facilitate the measurement of urinary output. 3 Prevent the development of clots in the bladder. 4 Provide continuous pressure on the prostatic fossa.
3
The nurse is caring for a client with a burn injury and suspects atelectasis and hypoxia. Which age-related changes should the nurse associate these findings? 1 Reduced mobility 2 Reduced healing time 3 Reduced thoracic compliance 4 Reduced inflammatory and immune responses
3
The nurse is providing care to a client who has had a transurethral resection of the prostate (TURP). Which goal is the priority? 1 Maintain patency of the cystostomy tube. Incorrect2 Prevent wound hemorrhage and infection. Correct3 Maintain patency of the indwelling catheter. 4 Prevent the abdominal dressing from draining.
3
Which is an inborn error of metabolism that affects growth and development? Incorrect1 Cystic fibrosis 2 Achondroplasia 3 Turner syndrome Correct4 Hunter syndrome
4
A financially struggling, large family is instructed by the home health nurse about ways to increase the dietary intake of calcium. Which suggestion should the nurse make? Correct1 Collards or kale in one meal a day 2 Fruit-flavored yogurt every other day 3 Bread made with cornmeal each morning 4 Eight ounces (240 mL) of milk with every meal
1
A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action? 1 Placing the child's head on a pillow for support Correct2 Immobilizing the child's spine to limit additional injury 3 Log-rolling the child to check for lacerations on the back 4 Moving the child onto a firm stretcher for transport to the radiography department
2
A nurse is assessing the urine of a client with a urinary tract infection. Which assessment finding is consistent with a urinary tract infection? 1 Smoky 2 Cloudy 3 Orange-amber 4 Yellow-brown
2
A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? 1 Frothy stools 2 Weak, rapid pulse 3 Pale, copious urine 4 Bulging anterior fontanel
2
A nurse is developing a plan of care for an infant with nonorganic failure to thrive. What is the most important aspect of care to be incorporated into the plan? 1 Maintaining silence while feeding the infant 2 Following a structured routine throughout the day 3 Periodically changing the seating arrangement during meals 4 Distracting the infant with playful activities during feedings
2
After an assessment, the nurse finds that the client has a partial loss of peripheral vision. The client's eye examination report shows an intraocular pressure of 24 mmHg. What does the nurse suspect is causing this condition? 1 Reduced elasticity of the lens 2 Unevenness in the cornea Correct3 Excess production of aqueous humor 4 Presence of nontransparent substance in the vitreous humor
3
An infant is admitted to the neonatal intensive care unit with exstrophy of the bladder. What covering should the nurse use to protect the exposed area? 1 Loose diaper 2 Dry gauze dressing Correct3 Moist sterile dressing 4 Petroleum jelly gauze pad
3
At which stage of development should the nurse anticipate that pediatric clients will begin to show differences in play activities that are related to gender? 1 Preschool 2 Adolescence Correct3 Late school-age Incorrect4 Early school-age
3
A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the healthcare provider? 1 Fat-free 2 Protein-enriched 3 Phenylalanine-free Correct4 Low-phenylalanine
4
A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority? 1 Notifying the receiving unit of the transfer 2 Having the client's records ready for the transfer 3 Verifying that the family has been notified of the transfer 4 Checking that a bag-valve mask is available during the transfer
4
Which finding indicates that a newborn has vernix caseosa? 1 Brown hair on the skin 2 Rosy to yellowish skin 3 Light-pink to reddish-brown skin 4 Cheese-like substance on the skin
4
Which information is correct about the cognitive changes of a teenager? 1 A teenager deals with actual problems. 2 A teenager thinks in terms of the present. 3 A teenager cannot consider the possibilities of a situation occurring. Correct4 A teenager considers an infinite variety of causes and solutions
4
Which term refers to the nurse's ability to plan, direct, control, and evaluate others in different situations? 1 Delegation 2 Leadership 3 Followership 4 Management
4
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? 1 Check for a pulse 2 Start cardiac compressions 3 Prepare to defibrillate the client 4 Administer oxygen via an ambu bag
1
A client is scheduled to have a contraction stress test (CST) to determine fetal well-being. Which type of fetal heart rate (FHR) decelerations constitutes a nonreassuring outcome? Correct1 Late 2 Early 3 Baseline 4 Variable
1
A 14-month-old toddler is able to recognize the shapes of objects and fit smaller boxes into larger boxes. Which type of cognitive development does this action indicate? 1 Domestic mimicry 2 Causal relationship Correct3 Spatial relationship 4 Object permanence
3
Who functions as a liaison between team leaders and other healthcare providers? 1 Charge nurse 2 Registered nurse 3 Nursing manager 4 Chief nursing officer
1
Which statement is true about prescriptive theories? 1 Prescriptive theories are action-oriented. 2 Prescriptive theories help to explain client assessment. 3 Prescriptive theories focus on a specific field of nursing. 4 Prescriptive theories are the first level of theory development.
1
A client newly diagnosed with tuberculosis has a productive cough. Which is the most appropriate nursing intervention to teach the client? 1 Exercise daily Correct2 Use disposable tissues 3 Avoid foods high in sodium 4 Monitor blood pressure weekly
2
While assessing the reproductive health of a female client, the nurse observes age-related changes in the client. Which findings support the nurse's conclusion? Select all that apply. 1 Smaller clitoris 2 Shrunken vulva 3 Dimpling of breasts 4 Narrow vaginal opening 5 Green discharge from the vulva
1,2,4
A serious train accident occurs in the community. At the scene of the accident, a triage nurse is identifying and labeling victims according to triage acuity principles. With what color tag should the nurse label a client who is experiencing respiratory distress? 1 Red 2 Black 3 Green 4 Yellow
1
What steps would the nurse explain are to be followed for preventing post-traumatic stress disorder (PTSD) in hospital staff during a mass casualty event? Select all that apply. 1 Drinking plenty of water 2 Encouraging co-workers 3 Monitoring each other`s stress levels 4 Being quiet and isolated from others 5 Working for more than 12 hours each day
1,2,3
A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse? 1 "Wear warm clothes to keep moisture in the skin." 2 "Use a moisturizer on the skin daily to help reduce itching." 3 "Take hot tub baths only twice a week to reduce drying of the skin." 4 "Expose the skin to the air to help reduce the sensation of itching."
2
A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized with regard to the infant's motor development? 1 Sits up Correct2 Rolls over 3 Crawls short distances 4 Stands while holding on to furniture
2
According to Kohlberg's theory of moral development, which stage is a part of conventional reasoning? 1 Social contract orientation Correct2 Society-maintaining orientation 3 Instrument relativist orientation 4 Universal ethical principle orientation
2
According to the disaster triage tag system, which color tag would the nurse feel is most suitable for a client who died in an earthquake? 1 Red 2 Black 3 Green 4 Yellow
2
An older female client tells the nurse in the clinic that she has a cystocele that was diagnosed a year ago. She has urinary frequency and burning on urination. The client asks, "The primary healthcare provider wanted me to have surgery for the cystocele last year; but, I can manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse respond? 1 "Not really, but it should be done." Correct2 "Yes, you're risking kidney damage." 3 "Yes, you're risking bowel obstruction." 4 "Not really, but you'll be more comfortable if you have it."
2
While performing a newborn assessment after a vaginal birth, a student nurse observes a swelling on one side of the top of the head that does not cross the suture line. The student nurse has identified what clinical manifestation? 1 A bulging fontanel Correct2 A cephalhematoma 3 Caput succedaneum 4 Normal molding pattern
2
A nurse leader has prepared an objective for strategic planning. Which point indicates that the nurse possesses the ability to write objectives clearly and concisely? 1 Inclusion of the timeline and deadline 2 Leaving expectations open to interpretation 3 Starting with an article followed by a noun 4 Specifying multiple dates for the attainment of a goal
1
A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply. 1 The infant cries without noise. Correct2 Aspiration produces a small quantity of light-yellow or light-green liquid. 3 The tube is inserted to a depth from the ear to the tip of the nose to the sternum. Incorrect4 A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. Correct5 Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.
2,5
The student nurse is performing a rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse. Which parameters should the student nurse consider for proper assessment? Select all that apply. 1 Level of anxiety 2 Reaction to pain 3 Response to voice 4 Body temperature 5 Evidence of assault
2,3
A 2-month-old infant is admitted to the pediatric unit with a diagnosis of respiratory syncytial virus infection. The nurse plans to position the infant to improve the respiratory effort. What positions are best? Select all that apply. 1 Prone Correct2 Semi-Fowler 3 Trendelenburg Incorrect4 Hyper-extended head Correct5 Head in sniffing position
2,4,5
Which interventions are in the scope of a licensed practical nurse (LPN)? Select all that apply. 1 Client teaching 2 Ambulating the client 3 Interpreting lab data 4 Assisting the client with bathing 5 Administering intramuscular medications
2,4,5
A client with a reddish-blue generalized skin alteration is hospitalized. Laboratory findings show an increase in the overall amount of hemoglobin. Which condition might the nurse suspect? 1 Albinism 2 Addison's disease Correct3 Polycythemia vera 4 Methemoglobinemia
3
A client with a skin infection on the hand reports itching near the site of infection. Upon assessment, the nurse notices serpiginous patches with elevated borders. What could be the possible diagnosis? 1 Tinea pedis 2 Tinea capitis 3 Tinea manus 4 Tinea corporis
3
A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the primary healthcare provider's prescriptions. What should the nurse identify as the priorities in this client's plan of care? 1 Intake and output Incorrect2 Diet and nutrition Correct3 Hygiene and comfort 4 Body mechanics and posture
3
What is the most effective strategy for preventing the transmission of infection? 1 Wearing gloves and a gown 2 Applying face mask and a gown 3 Applying a face mask and gloves Correct4 Wearing gloves and hand hygiene
4
Upon assessment of a client, the nurse discovers the following (see image). Which condition is shown? (nasty toe nails) 1 Tinea pedis 2 Tinea cruris 3 Tinea corporis 4 Tinea unguium
4
A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? Select all that apply. 1 Increasing high-fiber foods 2 Eating just three meals a day Correct3 Increasing food intake gradually Correct4 Limiting mealtime to half an hour Correct5 Providing privileges for goal achievement
3,4,5
Which growth characteristics does the nurse anticipate for a 16-year-old female client? Select all that apply. 1 Physically mature 2 Reaching peak velocity Correct3 Decreasing rate of growth Correct4 Reaching ninety-five percent of adult height Correct5 Having well advanced secondary sexual characteristics
3,4,5
The mother of a 5-year-old child recovering from varicella (chickenpox) calls the nurse in the pediatric clinic, asking how the child's itching can be relieved. What is the best response by the nurse? 1 Have the child wear mittens. 2 Rub an antibiotic ointment on the lesions. 3 Use wet-to-dry saline dressings over the oozing vesicles. 4 Pat the lesions while applying the prescribed calamine lotion.
4
A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate? 1 "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." 2 "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." 3 "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." 4 "You may not be producing enough milk; it'll be important for you to supplement feedings with formula."
1
According to Kohlberg's theory of moral development, which statement about conventional reasoning is true? Correct1 A person wants to fulfill family expectations. 2 A child's thinking is mostly based on likes and pleasures. 3 A child recognizes that there is more than one correct view. 4 An individual moves away from moral decisions based on authority.
1
Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? Correct1 Affective instability 2 Repetitive motor mechanisms 3 Depersonalization and derealization 4 Disheveled and unkempt physical appearance
1
During testing of the neurologic reflexes of an infant, which reflex should the nurse expect to appear at 3 months and persist until 24 to 36 months of age? Correct1 Neck righting 2 Body righting 3 Otolith righting 4 Labyrinth righting
1
From which client does the nurse expect dramatic physical growth and marked development? Correct1 9-month-old infant 2 24-month-old toddler 3 4-year-old preschool-age child 4 10-year-old school-age child
1
Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process? Correct1 Promoting vasodilation 2 Cleansing perineal tissue 3 Softening the incision site 4 Tightening the rectal sphincter
1
After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings through a nasogastric tube. A family member asks why this is necessary. What is the nurse's best response? Incorrect1 "Tube feedings prevent aspiration of food into the lungs." Correct2 "Tube feedings promote healing by reducing the risk for infection." 3 "Let me show you how to do a gavage. It will make you less anxious." 4 "You seem concerned about the gavage. You probably will not have to do this at home."
2
The parents of a 5-month-old infant tell the nurse that they have started to feed the baby fortified cereal mixed with formula. They ask in which order they should introduce new foods. What foods should be selected first? Incorrect1 Meats and fish 2 Eggs and cheeses 3 Citrus fruits and bread Correct4 Vegetables and noncitrus fruits
4
What is the average increase in height of preschoolers per year? 1 2 inches (5 cm) 2 2 to 8 inches (5 to 20 cm) 3 4 to 8 inches (10 to 30 cm) Correct4 2.5 to 3 inches (6.2 to 7.5 cm)
4
What legal complications might a nurse face for using a restraint without a legal warrant on a client? 1 The nurse may be charged with libel. 2 The nurse may be charged with negligence. 3 The nurse may be charged with malpractice. 4 The nurse may be charged with false imprisonment
4
Which description of accountability is correct? 1 Accomplishment of the task and fulfilling the requirements 2 Provision of guidance and oversight of a delegated nursing task 3 Obligation to accomplish work with reliability and dependability 4 Determination of appropriate actions and provide detailed explanations of the actions
4
Which school-age client should the nurse assess for symptoms related to burnout? 1 7-year-old 2 8-year-old 3 9-year-old Correct4 10-year-old
4
Which statement is true about Piaget's theory of cognitive development? 1 Piaget's theory includes five periods that are related to age. Incorrect2 In the late preoperational stage, the children experience animism. 3 In the preoperational stage, children are able to perform mental operations. Correct4 During the sensorimotor stage, infants develop an action pattern for dealing with their environment.
4
A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion? Correct1 Difficulty breathing 2 Decline in physical mobility 3 Disturbed sensory perception 4 Decreased tolerance to activity
1
A nurse is caring for a client who had a subtotal gastrectomy. Which assessment finding indicates the client is ready for postoperative oral feedings? Correct1 Presence of flatulence 2 Extent of incisional pain 3 Stabilization of hematocrit levels 4 Occurrence of dumping syndrome
1
The nurse is using Piaget's theory to assess the cognitive development in a child. What is most likely to be the age of the child who has reached a developmental milestone by grasping the concept of conservation of numbers for the first time? Correct1 5 years 2 7 years 3 9 years 4 12 years
1
The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? Correct1 Two 2 Three 3 Four 4 Five
1
The ophthalmologist assesses a client's reports as depicted in the figure. Which type of surgery performed by the ophthalmologist will be appropriate in managing the client's condition? 1 Keratoplasty 2 Catarct removal 3 Trabeculectomy 4 Laser in situ keratomileusis (LASIK)
1
What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux? Correct1 Avoid walking swiftly by the client. Incorrect2 Keep the client in the prone position. 3 Discontinue oral hygiene temporarily. 4 Massage both sides of the face frequently.
1
What does the nurse understand to be the role of emergency medical technicians (EMTs) in emergency nursing after a disaster? Correct1 To monitor vital signs 2 To provide intubation 3 To establish intravenous (IV) access 4 To perform advanced airway management
1
The nurse determines that dietary teaching for a client with mild preeclampsia has been effective when the client makes which statement? 1 "I should follow a diet that includes high sodium and calories and low protein." Incorrect2 "I should follow a diet that includes low sodium and calories and high protein." Correct3 "I should follow a diet that includes unrestricted sodium and lots of calories and protein." 4 "I should follow a diet that includes moderate sodium and low calories with ample protein."
3
A nurse counsels the mother of an 8-month-old infant to be sure that the floors are free of small objects when her child is crawling. What is the rationale for this instruction? 1 Sharp objects can injure the fragile skin of an infant. 2 Eight-month-old infants hide small objects, making them difficult to locate. 3 Floors may cause infections in infants when they pick up and mouth objects. Correct4 Eight-month-old infants pick up small objects and place them in their mouths.
4
A registered nurse is educating a nursing student about the stages of changes in a client's health behavior. Which statement describes the stage of contemplation? 1 "The client considers a change within the next 6 months." 2 "The client does not intend to make changes within the next 6 months." 3 "The client is actively engaged in strategies to change behavior; this lasts up to 6 months." 4 "The client displays sustained change over time; this begins 6 months after action has started and continues indefinitely."
1
After a large-scale disaster event, a client reports a feeling of numbness for 1 month. On assessment, the nurse notes a high score of all subscales of the impact of event scale—revised (IES-R) tool. Which healthcare professional should the nurse refer the client to for further evaluation? 1 Psychiatrist 2 Triage officer 3 Social worker 4 Mental health counselor
1
Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? 1 Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. 2 Arrange for a supply of heparin for the client to take to the rehab center. 3 Explain to the client that anticoagulant therapy will no longer be needed. 4 Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.
1
The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? 1 Notify the practitioner, because circumoral pallor may indicate cardiac problems 2 Notify the practitioner, because both signs are indicative of increased intracranial pressure 3 Take no specific action, because both signs are expected in a newborn until 2 weeks of age 4 Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying
1
An 8-year-old child with a history of asthma is brought to the emergency department because of respiratory distress. The nurse immediately places the child in a bed with the head of the bed elevated and administers oxygen by means of a face mask. The healthcare provider performs a physical assessment, writes prescriptions, and admits the child to the pediatric unit. Which instruction should the nurse carry out first? 1 Teach incentive spirometer use. 2 Administer the nebulizer treatment. 3 Obtain a blood specimen for a complete blood count. 4 Notify the respiratory therapist to perform chest physiotherapy.
2
Which statement about Orem's theory needs to be corrected? 1 It determines self-care needs. 2 It explains the types of nursing care. 3 It aids in the design of nursing interventions. 4 It describes factors supporting the health of the family.
4
Which is an example of an internal disaster in a hospital? 1 A hurricane 2 Oil spill from a marine oil tanker 3 Loss of communications capabilities 4 Malfunction of a nuclear reactor with radiation exposure
3
Which method of delivering client care works well in disaster situations? 1 Team nursing 2 Primary nursing Correct3 Functional nursing Incorrect4 Total patient care nursing
3
Which nursing care delivery system works well in emergency situations that necessitate prioritization of care? 1 Team nursing 2 Primary nursing 3 Functional nursing 4 Patient-Centered nursing
3
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait? 1 Elbows should be kept in rigid extension. 2 Most of the weight should be supported by axillae. 3 The client must be able to bear weight on both legs. 4 The affected extremity should be kept off the ground.
3
Which school-age client does the nurse anticipate will experience sibling rivalry as a source of stress? 1 A 9-year-old male 2 A 7-year-old male Correct3 A 6-year-old female Incorrect4 An 8-year-old female
3
Who is mainly responsible for analyzing the knowledge and work of newly hired unlicensed assistive personnel (UAP) before delegating a task? 1 Charge nurse 2 Associate nurse 3 Registered nurse 4 Nursing manager
3
A 6-year-old child begins sucking her thumb after surgery. The child did not engage in this behavior before the surgery. What is the best action for the nurse to take? Correct1 Accepting the thumb-sucking Incorrect2 Distracting the child by playing checkers 3 Reporting this behavior to the healthcare provider 4 Telling the child that thumb-sucking causes buck teeth
1
The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of most concern to the nurse? 1 Continued bloody show 2 Cervical dilation of 4 cm 3 Contractions every 4 minutes Correct4 Spontaneous rupture of membranes 3 hours ago
4
A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief? 1 "Eat dry crackers before you get out of bed." 2 "Increase your fat intake before bedtime." 3 "Drink high-carbohydrate fluids with meals." 4 "Eat two small meals a day and a snack at noon."
1
A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? 1 A young adult client with pneumonia 2 An adolescent client with a fractured leg 3 An older adult client who had a brain attack 4 A middle-aged client who has cholecystitis
1
A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? 1 Low fat 2 Low carbohydrate 3 Soft-textured and bland 4 High protein and kilocalories
1
A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission? 1 Monitor vital signs 2 Increase fluid intake 3 Obtain a foam mattress 4 Improve nutritional status
1
Which statement does the nurse recognize as true according to chaos theory? 1 Health-care organizations must be self-organizing. 2 Health-care organizations must accept that change is avoidable. 3 Successful managers are those who are intolerant to ambiguity. 4 Successful nurse leaders are those who committed to short-term learning.
1
Which would the nurse state is an example of a natural disaster? Correct1 Floods 2 Terrorism 3 Fire explosion 4 Building collapse
1
Why does the nurse recommend that parents give their child food rich in vitamin A? Correct1 To help the child improve visual acuity 2 To help the child improve language skills 3 To help the child develop gross motor skills 4 To help the child improve concentration levels
1
At which stage of Kohlberg's theory is the child afraid of punishment? Correct1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4
1
What is the priority nursing intervention before a client undergoes amniocentesis? 1 Starting an intravenous infusion of normal saline 2 Performing a vaginal and rectal examination 3 Ensuring that informed consent has been obtained from the client 4 Informing the client that the procedure may precipitate an infection
3
Which color should the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station? 1 Red 2 Black Correct3 Green 4 Yellow
3
Which feelings are enhanced in the school-age child through the use of positive reinforcement of success by adults? Select all that apply. Correct1 Happiness Correct2 Likeability Correct3 Feeling worthwhile to others 4 Feeling disrespected by others Correct5 Capability of valuable contributions
1,2,3,5
Which of the following interventions will assist in creating and maintaining a therapeutic environment on an acute care mental health unit? Select all that apply. 1 Reorienting clients to the rules of the unit whenever necessary 2 Providing a posted schedule of unit activities 3 Monitoring each client for the potential of aggressive behavior 4 Assuring the clients that they will have unlimited access to the telephone 5 Encouraging the clients to take an active role in planning the unit's activities
1,2,3,5
Which behaviors should the nurse anticipate when conducting a developmental assessment for a newborn? Select all that apply. Correct1 Sucking on a pacifier Correct2 Grasping a parents finger 3 Discovering hands and feet Correct4 Swallowing while breastfeeding Correct5 Rooting when the cheek is stroked
1,2,4,5
A registered nurse is teaching a nursing student about the role of estrogen in adolescents. Which statements made by the nursing student indicates the need for further teaching? Select all that apply. 1 High levels of estrogen tend to promote skeletal growth 2 Nipples grow and darken under the influence of estrogen 3 Estrogen has an inhibitory effect on the growth of axillary hair 4 Estrogen is responsible for breast enlargement during adolescence 5 Estrogen production results in formation of endometrial lining of uterus
1,3
Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? Select all that apply. Correct1 Paramedics 2 Unlicensed assistive personnel Correct3 Nurses appointed to a field team 4 A physician who survives the incident 5 Community response team members
1,3
Which teratogenic effects can be suspected in the newborn if a pregnant client was prescribed cyclophosphamide? Select all that apply. 1 Shortened limbs 2 Secondary cancer 3 Internal organ defects 4 Limb malformations 5 Central nervous system malformation
1,3,4,5
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply. Correct1 "Wash your hands before touching the newborn." 2 "Send the newborn to nursery to be monitored during the night." Correct3 "All client identification bands should remain in place until discharge." 4 "Do not let anyone remove the infant from your sight while you are in the hospital." Correct5 "Check the identification of staff, and if there is a question of validity, call the nursing station."
1,3,5
What services do nurse-managed clinics provide in preventive and primary care services? Select all that apply. 1 Crisis intervention 2 Wellness counseling 3 Health risk appraisal 4 Employment readiness 5 Communicable disease control
2,3,4
A nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. 1 When consent has been obtained from the spouse 2 When consent has been given specifically by a court 3 When self-consent has been granted by a court order 4 When consent has been given by a grandparent 5 When consent has been obtained from at least one parent of the minor
2,3,5
The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply. Incorrect1 "I will eat a bland diet." Correct2 "I will not drink fluids when I eat meals." Correct3 "I will avoid sweetened and spicy foods." 4 "I will eat a low-protein, high-carbohydrate diet." Correct5 "I will eat small, frequent meals instead of three large meals a day."
2,3,5
Which qualities of a leader indicate a transformational approach to leadership? Select all that apply. 1 Being punitive in nature 2 Possessing charismatic behavior 3 Possessing contingent reward behavior 4 Possessing intellectually stimulating behavior 5 Having inspirational and motivational behavior
2,4,5
A client with foot ulcers is admitted to the hospital. The nurse manager should delegate the task of maintaining hygiene to which staff members to maximize efficient use of human resources? Select all that apply. 1 Registered nurse (RN) 2 Patient care associate (PCA) 3 Licensed practical nurse (LPN) 4 Licensed vocational nurse (LVN) 5 Unlicensed nursing practitioner (UNP)
2,5
A primary healthcare provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply. 1 Diarrhea with black feces Correct2 Intolerance to foods high in fat 3 Vomiting of coffee-ground emesis 4 Gnawing pain when stomach is empty Correct5 Pain that radiates to the right shoulder
2,5
To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply. 1 Eggs Correct2 Liver 3 Cheese 4 Salmon Correct5 Shellfish
2,5
A 15-month-old child is hospitalized after ingesting toilet bowl cleaner. The mother confides that she feels guilty about leaving the cleaner where her child could get it. What is the best response by the nurse? 1 "Anyone could make a mistake. Don't dwell on it." 2 "Let's not worry about the past. Your child is going to get better." Correct3 "It was an accident, but you should consider special locks on your closets." 4 "That was careless of you. Please make sure that you poison-proof your house."
3
A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child? 1 Flexion of the hip 2 Extension of the hip 3 Adduction of the hip 4 Abduction of the hip
4
A newborn weighing 9 lb 14 oz (4479 g) is delivered by cesarean due to cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which nursing action should be taken after the initial physical assessment? 1 Administer oxygen by hood Correct2 Determine the blood glucose level 3 Pass a gavage tube for a formula feeding Incorrect4 Transfer the newborn to the neonatal intensive care unit
2
A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include? 1 Withholding oral feedings for several days 2 Encouraging continuation of breastfeeding 3 Placing the infant in the Trendelenburg position 4 Positioning the infant supine with the head of the crib elevated
2
A client asks the nurse what advantage breast-feeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? 1 Amino acids Correct2 Gamma globulins 3 Essential electrolytes 4 Complex carbohydrates
2
A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history? 1 Evaluating the client's adjustment to the unit Correct2 Providing the client with a sense of security and safety 3 Exploring the client's memory loss and fear of going out 4 Assessing the client's perception of reasons for the hospitalization
2
A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? 1 Prepare to intubate the client. 2 Increase the oxygen flow rate per facility protocol. 3 Decrease the tension of oxygen in the plasma. 4 Have the arterial blood gases redone to verify accuracy.
2
A mother with the diagnosis of acquired immunodeficiency syndrome (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine? 1 If she has kissed the baby Correct2 If the baby is breast-feeding 3 When the baby last received antibiotics 4 How long she has been caring for the baby
2
A nurse needs to perform a postural drainage of both lung apices in a 4-year old child. In what position should the nurse place the child? 1 Sitting on side of bed 2 Supine with head elevated 3 Supine in Trendelenburg position 4 Sitting on nurse's lap, leaning forward
4
During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1 Diapers should be changed at least every 4 hours. 2 Frequent diaper changes with cleansing are needed. 3 Medicated ointment should be applied six times a day. 4 Powder may be used in the perineal area when it becomes wet.
2
During which week of pregnancy does placental development occur? Incorrect1 First Correct2 Third 3 Fifth 4 Seventh
2
How can a nurse best soothe a hospitalized infant who appears to be in pain? 1 Feeding the infant 2 Holding the infant 3 Playing soft music in the room 4 Providing a quiet environment
2
Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client? 1 Oxygen is flammable. Correct2 Oxygen supports combustion. 3 Oxygen has unstable properties. 4 Oxygen converts to an alternate form of matter.
2
The nurse is providing care to a client who has a suspected pelvic fracture as the result of a motor vehicle accident. Which is the priority nursing action? 1 Logrolling for transfers 2 Inspecting the genitalia 3 Preparing for a pelvic examination 4 Administering prescribed pain medication
2
What is the expected average weight for a 6-month-old child? 1 680 g (1.5 lb) Correct2 7.26 kg (16 lb) 3 11.34 kg (25 lb) 4 9.75 kg (21.5 lb)
2
A nurse in the postpartum unit must complete several interventions before a client's discharge from the hospital. The nurse plans to delegate some of the tasks to an unlicensed health care worker. Which activity must be performed by the nurse? 1 Taking the neonate's picture 2 Placing the infant car seat in the car Correct3 Comparing the identification bands of mother and infant Incorrect4 Preparing the discharge packet and distributing them to parents
3
A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? 1 Neurologic 2 Wound 3 Pain 4 Skin
3
A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1 Maligning a person's character while threatening to do bodily harm 2 A legal wrong committed by one person against property of another 3 The application of force to another person without lawful justification 4 Behaving in a way that a reasonable person with the same education would not
3
A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? 1 Analysis 2 Evaluation 3 Explanation 4 Interpretation
3
What is one strategy that will improve client outcomes, communication, and collaboration between all health care providers? 1 Primary nursing 2 Client-focused care 3 Interprofessional education 4 Community-based transitional program
3
A 28-year-old woman who has phenylketonuria (PKU) visits the fertility clinic for genetic counseling. After deciding that she wants to become pregnant, she tells the nurse that she ate a low-phenylalanine diet until she was 18 years old. What is the nurse's best response? 1 "Eat a regular pregnancy diet after becoming pregnant." 2 "Start the low-phenylalanine diet during the third trimester." 3 "Maintain a low-protein diet starting in the second trimester." Correct4 "Return to the low-phenylalanine diet before becoming pregnant."
4
A child is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. What does the nurse conclude about isolation? 1 It is unnecessary during the incubation period. Incorrect2 It is required for 7 to 10 days until the fever subsides. 3 It will be unnecessary after the diagnosis is confirmed. Correct4 It will be necessary for 24 to 72 hours after the initiation of antibiotic therapy.
4
A client expresses concern that because of supply and demand there is no vaccine available for the annual flu vaccine. What is the nurse's best reply? 1 "It's unfortunate, but there was such a limited supply available." 2 "There are many others who also were unable to get a flu vaccine." 3 "It doesn't matter because the vaccine is for just one particular strain." Correct4 "There are other things you can do to prevent the flu, such as hand washing."
4
A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1 Private room 2 Semiprivate room 3 Room with windows that can be opened Correct4 Negative-airflow room
4
A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest? 1 Wearing loose but warm clothing 2 Planning a short rest break periodically 3 Avoiding excessive physical stress and fatigue 4 Taking a hot tub bath or shower in the morning
4
A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care? 1 Administering analgesics 2 Administering intravenous antibiotics 3 Administering nerve block anesthesia 4 Administering mouth wash for oral hygiene
4
A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1 Strip the chest tube periodically. 2 Administer the prescribed cough suppressant at the scheduled times. 3 Empty and measure the drainage in the collection chamber each shift. 4 Keep the drainage system lower than the level of the client's chest.
4
An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs? 1 Low in fat and vitamin D 2 High in calories and fiber 3 Low in residue and bland 4 High in protein and vitamin C
4
At what age does a child start to crawl? 1 3 months 2 5 months Incorrect3 7 months Correct4 9 months
4
During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? 1 Suggest that an antiemetic be prescribed 2 Change the feeding schedule to omit nights 3 Request that the type of solution be changed 4 Gather more data from the night nurse about the technique used
4
How soon should a client with multiple traumas receive treatment according to the five-level emergency severity index (ESI)? 1 Within 2 days 2 Within 1 hour 3 Within 5 minutes 4 Within 10 minutes
4
The nurse is assessing the development of a male child and finds that the child is tall, with deficient secondary sex characteristics and hypogenitalism. Which chromosomal notation is associated with the child's condition? Incorrect1 45,XO 2 47,XXX 3 47,XYY Correct4 48,XXXY
4
The nurse is explaining to the mother of two teenage children why her daughter's height is comparatively less than her son's height. What is the reason for lower overall height in girls compared with boys? 1 Increase in muscle mass 2 Hypertrophy of the laryngeal mucosa 3 Maturation of structural appendages of the skin Correct4 Closure of epiphyses because of estrogen secretion
4
The nurse is teaching hygiene practices to a 16-year-old client who has recently had her first menstrual flow. Under which phase of development does the nurse classify the client? 1 Prepubescence 2 Postpubescence 3 Late adolescence Correct4 Middle adolescence
4
A 13-year-old is found to have idiopathic scoliosis. She is upset about the treatment regimen and is worried about being different from her friends. What should the nurse do to help the child maintain a positive self-image during treatment? 1 Remind her how crooked her back will be if she refuses treatment. 2 Help her investigate appropriate clothing to enhance her appearance. 3 Disregard her negative characteristics and focus on her positive attributes. 4 Refer her for psychological counseling until the treatment program is completed.
2
A child wants to be on time for a family dinner. According to Kohlberg's theory, what stage of development is the child going through? 1 Good boy-nice girl orientation 2 Society-maintaining orientation Correct3 Instrumental relativist orientation 4 Universal ethical principle orientation
3
A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, what should the nurse encourage the client to do? Correct1 Assume a standing position for voiding. 2 Void every four hours and attempt to hold urine between set times. 3 Attempt to void more frequently in the afternoon than in the morning. Incorrect4 Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake.
1
A multiple motor vehicle crash occurs on a major interstate. Who is responsible for triaging the victims of this crash? Correct1 Emergency first responders 2 Nurses in the acute care areas 3 Nurses in the emergency room 4 Physicians in the emergency room
1
What gross motor skill is observed in children between 8 and 10 months old? Correct1 The child can creep on his or her hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. 4 The child can bear his or her weight on forearms when prone.
1
What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)? Correct1 Removing the catheter 2 Keeping the drainage bag off of the floor 3 Washing hands before and after assessing the catheter Incorrect4 Cleansing the urinary meatus with soap and water daily
1
Which activity indicates improper follow-through on the part of the delegatee? 1 Failure to report results 2 Failure of effective communication 3 Performing a task in the absence of a delegator 4 Failure in following guidelines provided by a delegator
1
A nurse is assessing the condition of a school-aged child with acute glomerulonephritis. What clinical finding does the nurse anticipate? 1 Ketonuria Correct2 Periorbital edema 3 Increased appetite 4 Decreased blood pressure
2
A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited? 1 Striking the surface of the crib suddenly Correct2 Stroking the outer sole of the foot from the heel to the little toe 3 Maintaining the supine position and applying pressure to the soles of the feet 4 Holding the infant's body upright and allowing the feet to touch the surface of the crib
2
A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs? 1 Level 1 Correct2 Level 2 3 Level 3 4 Level 4
2
A school nurse is teaching a group of parents about pediculosis capitis (head lice). What common secondary infection does the nurse teach the parents to identify? 1 Eczema Correct2 Impetigo 3 Cellulitis 4 Folliculitis
2
An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube? 1 Once a day 2 Before each feeding 3 At every shift change 4 During the night shift
2
The postpartum nurse is delegating tasks to an unlicensed health care worker. Which task should the nurse delegate? 1 Evaluation of a postpartum client's lochia 2 Vital signs on a client 4 hours after delivery 3 Assessment of a postpartum client's episiotomy 4 Assisting the postpartum client to breastfeed for the first time
2
Which color tag is used for a client who is expected to die after a disaster with mass casualties? 1 Red tag 2 Black tag 3 Green tag 4 Yellow tag
2
Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? 1 Red 2 Black 3 Green 4 Yellow
2
Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation? 1 Domain 1 Correct2 Domain 2 3 Domain 3 4 Domain 4
2
A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux? 1 Increase your intake of fat with each meal. 2 Lie down after eating to help your digestion. 3 Reduce your caloric intake to foster weight reduction. 4 Drink several glasses of fluid during each of your meals.
3
A client has a pulse deficit. Which documentation by the nurse supports this finding? 1 Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. 2 Capillary refill greater than 3 seconds indicating pulse deficit. 3 Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. 4 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.
3
A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for indicators that strangulation of the intestine may have occurred. What is an early indicator of strangulation? 1 Increased flatus 2 Projectile vomiting Correct3 Sharp abdominal pain 4 Decreased bowel sounds
3
A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker? 1 Angina 2 Chest pain Correct3 Heart block 4 Tachycardia
3
A client is ready to walk with crutches after knee surgery. Which crutch-walking technique will the nurse most likely need to reinforce after the client returns from physical therapy? 1 Two-point 2 Four-point Correct3 Three-point 4 Swing-through
3
A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? 1 Restore the client's health. 2 Promote the client's recovery. 3 Relieve the client's discomfort. 4 Support the client's significant others.
3
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1 Pouring warm water over the perineum 2 Ensuring the patency of the catheter 3 Removing the catheter within 24 hours 4 Cleaning the catheter insertion site
3
Which statement by the nurse is true about health promotion in infants and toddlers? Incorrect1 Allow a toddler to sleep on his side. 2 Place pillows in the crib of an infant. Correct3 Remove grocery plastic bags from the home. 4 Keep pacifiers on a ribbon around a toddler's neck.
3
A student in high school asks the school nurse why a classmate has been absent for so long. What is the best response by the nurse? 1 "Have you asked his girlfriend?" 2 "I wonder why you're so curious." 3 "Students sometimes miss school for long periods." 4 "I know you're concerned, but you'll need to ask your classmate for yourself."
4
According to Erikson's stages of life, what is the stage when a child begins walking, feeding, and using the toilet? 1 Trust versus mistrust Incorrect2 Initiative versus guilt 3 Identity versus role confusion Correct4 Autonomy versus sense of shame and doubt
4