NCLEX Study Cards

How often should the position of a child in a wheelchair be changed to prevent pressure ulcers? 1. 5 minutes 2. 10 minutes 3. 15 minutes 4. 20 minutes

Correct answer - 15 minutes Option 1: In order to avoid pressure ulcers, there should be change in the child's position every 15 minutes. Option 2: The minimum time for a change in position of a child confined to a wheelchair is 15 minutes. Option 3: Sitting in a wheelchair for a long duration can cause pressure ulcers. To move the weight of the child off the bony prominences, the child's position should be shifted every 15 minutes. Option 4: The ideal time for changing the position of a child bound to a wheelchair is 15 minutes.

Which cognitive-behavioral technique is the least effective in reducing chronic pain? 1. Guided imagery 2. Expressive writing 3. Relaxation techniques 4. Distraction techniques

Correct answer - Distraction techniques Option 1: Guided imagery is used to calm and relax the client with the help of auditory and imaginary processes. This technique is helpful in managing acute and chronic pain. Option 2: Writing about stressful events or experiences provides a positive outlet for the client's emotions. This aids in reducing chronic pain. Option 3: Relaxation techniques such as sequential muscle relaxation (SMR) are especially used to manage chronic pain in clients. Option 4: Distraction techniques lower the client's awareness to pain by diverting the mind toward other things. It is more effective in managing mild to moderate short-term pain.

The nurse instructs a client to wear dark eyeglasses while stepping out of the house or under bright light in home. Which drug has the client most likely been prescribed? 1. Quinine 2. Rifampin 3. Quinidine 4. Diazepam

Correct answer - Quinidine Option 1: Quinine is used in the treatment of malaria. It may cause visual changes so driving should be avoided. It does not increase sensitivity to light. Option 2: Rifampin changes the color of tears, but does not increase sensitivity to light. Option 3: Quinidine can increase the photosensitivity of the eye to light, so the client should wear dark glasses for protection. Option 4: Diazepam can cause sedation but does not increase photosensitivity.

A working mother wants to frequently feed her baby breast milk by collecting her breast milk. Which is the most suitable breast pump that a nurse can recommend for this woman? 1. Manual breast pump 2. Retail electric breast pump 3. Hospital-grade electric pump 4. Battery powered breast pump

Correct answer - Retail electric breast pump Option 1: If the mother wants to collect extra milk once in a while it is helpful for her. Option 2: Working mother needs consistent pumping to collect breast milk so a personal, single user, retail electric breast pump is more suitable. Option 3: Hospital-grade electric pump is recommended when the child is not able to breast feed because of prematurity, surgery to the mother, or illness in mother. It is a multi-purpose pump. Option 4: If the mother wants to collect extra milk once in a while, a battery powered breast pump or manual breast pump is helpful for her.

A nurse is applying moist heat to provide comfort to a client. What method should the nurse follow if the client's skin is intact? 1. The nurse should soak gauze in a heated solution and apply the compress to the affected area. 2. The nurse should soak a washcloth in warm water, squeeze out extra water and apply it to the affected area. 3. The nurse should soak the affected area in a sterilized bath. 4. The nurse should soak the client's affected area in a sitz bath for 15 minutes.

Correct answer - The nurse should soak a washcloth in warm water, squeeze out extra water and apply it to the affected area. Option 1: A gauze compress is applied to open areas and wounds, and the nurse is required to use sterile technique to perform the procedure. Option 2: If the client's skin is intact, the nurse should soak a washcloth or towel in warm water, squeeze out excess water, and then apply it to the client's affected area. Option 3: If the client has open wounds that need to be cleansed, the nurse should soak the affected area in a sterilized bath. Option 4: A sitz bath is used to cleanse a client's perineal area.

A nurse is performing a postural drainage task to clear the airways of a client. The client is placed on a flat bed in a prone position with a pillow under the stomach. Which lung field is drained using this method? 1. The posterior section of the upper lobes 2. The posterior lower lobes 3. The middle or lower lobes 4. The apical areas of the upper lobes

Correct answer - The posterior lower lobes Option 1: To drain the posterior section of the upper lobes of the lungs, the nurse places the client in a supine position with a pillow under the hips and knees flexed. The client is then turned slightly away from the side to be drained. Option 2: The nurse places the client prone on a flat bed with a pillow under the stomach to drain the posterior lower lobes of the lungs. Option 3: When draining the middle or lower lobes, the nurse places the client in Sims' position by keeping the bed in the Trendelenburg position. The client is then turned on the left or right side to clear the right or the left lung, respectively. Option 4: To drain the apical areas of the upper lobes of the lungs, the nurse helps the client to sit at the edge of the bed or in the high-Fowler's position with a pillow at the base of the spine for support.

What is the average healthy lifestyle score?

The lifestyle score is given by assessing 17 parameters, which include physical activity, strength exercise, smoking status, alcohol consumption, sleep, eating practices, mental health, social support, community, safety, safer sex, and preventive exams. The average lifestyle score when completing the assessment tool is 9.4.

What is an appropriate nonpharmacological therapy to prevent post-surgery swelling in a client who underwent an invasive surgery? 1. Acupuncture 2. Heat therapy 3. Cold therapy 4. Effleurage

Correct Answer - Cold therapy Option 1: Acupuncture therapy can be performed by trained specialists to treat nausea post-surgery. Option 2: Heat therapy facilitates the healing process and provides pain relief. Option 3: Cold therapy reduces muscle tension and helps prevent swelling after a surgical procedure. Option 4: Effleurage massage is used to relieve pain in clients post-surgery.

The nurse finds that a 2-year-old child has genu varum, and may benefit from use of assistive braces. What should the nurse inform the parents about use of braces in the child? 1. "Braces will be applied at 6 years of age." 2. "Braces are applied to reverse the bow legs." 3. "Braces are applied after surgical correction." 4. "Braces can slow down the progression of deformity."

Correct answer - "Braces can slow down the progression of deformity." Option 1: Braces should be applied before the age of 4 years because the growth plate may get damaged as the child grows with the deformity. Option 2: Braces can slow down the progression of the disease, but cannot reverse it. Option 3: Surgery is indicated in adolescents and adults. For children the treatment options are typically observation, bracing, and basic care. Option 4: In genu varum (bow legs), the lateral side of the tibial bone grows larger than medial side of the bone. Braces help in slowing down this process, although they cannot reverse it.

A 67-year-old client has partial dentures with metal clasps. The nurse has to teach the client about the care of the dentures. Which is the most appropriate teaching provided to the client? 1. "Wear them in day time and remove them during the night." 2. "Brush the dentures without removing from the mouth." 3. "Do not soak the dentures in cleaning solution overnight." 4. "Use hot water to remove the food particles lodged in the denture."

Correct answer - "Do not soak the dentures in cleaning solution overnight." Option 1: Removing the denture can cause shrinking of the gums and further loss of gums. Option 2: Dentures should be brushed after removing from the mouth to clean all of the deposited food particles. Option 3: Soaking of dentures with metal parts is contraindicated as the metal parts get damaged due to soaking. Option 4: Dentures are fragile and hot water can change the shape of the dentures.

What instructions should be included when teaching clients about care of hearing aids? 1. "The batteries should be stored in a cool place, such as a refrigerator, when not in use." 2. "Soapy water can be used to clean a detachable ear-mold." 3. "Alcohol should be used to clean the ear-mold of the hearing aid to stop the growth of bacteria." 4. "If the battery becomes wet, it should be removed and reinserted after drying it overnight."

Correct answer - "Soapy water can be used to clean a detachable ear-mold." Option 1: Storing batteries in a refrigerator may cause condensation and corrosion within the battery. Option 2: A hearing aid should never be immersed in water. A detachable ear-mold can be soaked in soapy water, and then it should be rinsed and dried thoroughly and attached to the hearing aid. Option 3: Cleaning the ear-mold with alcohol can damage it. Option 4: Wet batteries should not be used as moisture can corrode the battery. They should always replace with a new battery.

Which explanation of reflexology therapy given by the nurse is correct? 1. "The practitioner will realign the vertebrae manually to relieve stress." 2. "The practitioner will relax the muscles and manipulate the soft tissues to reduce stress." 3. "The practitioner will apply pressure to specific points on the hands, feet, or ears to relieve stress." 4. "The practitioner will channel healing energy through the hands to reduce stress."

Correct answer - "The practitioner will apply pressure to specific points on the hands, feet, or ears to relieve stress." Option 1: When using chiropractic technique, the practitioner realigns the vertebrae manually to relieve stress. Option 2: When using massage therapy, the practitioner manipulates the soft tissues and relaxes the muscles to reduce stress. Option 3: When using the reflexology technique, the practitioner applies pressure to specific points on the hands, feet, or ears to relieve stress. Option 4: When using Reiki and therapeutic touch techniques, the practitioner attempts to channel healing energy through hands to relieve stress.

A student nurse is being taught to give a bath to an elderly adult to balance the hydration level of the skin. Which action stated by the student nurse indicates effective learning? 1. "Washcloths must be used to dry the skin of the client." 2. "Hot water must be used for bathing the client." 3. "Warm water must be used for bathing the client." 4. "Soap must be used daily while bathing the client."

Correct answer - "Warm water must be used for bathing the client." Option 1: Because washcloths are rough, the nurse should gently pat the fragile skin to dry after rinsing thoroughly. Option 2: Hot water can lead to drying of the skin and may even cause burns. Option 3: The nurse should use warm water when bathing an elderly adult because this prevents skin breakdown. Option 4: Soap can remove oils and reduce the moisture content of the skin. The nurse should use a soap only when it is required and not on a daily basis.

A 54-year-old diabetic client asks the nurse to teach him about foot care. What should the nurse advise him on foot care? 1. "You may apply water-soluble lotions on your feet but not between your toes." 2. "You have to wear cotton socks as wool socks cannot absorb the sweat." 3. "Canvas shoes do not permit air circulation, so you should not wear them." 4. "You should prefer to wear open-toed shoes, as they allow air circulation."

Correct answer - "You may apply water-soluble lotions on your feet but not between your toes." Option 1: "You may apply water-soluble lotions on your feet but not between your toes. "If water-soluble lotion is applied between the toes, it would cause maceration. Option 2: Wool and cotton can absorb sweat. Option 3: Canvas is a natural material. It has the property of allowing air circulation through it like leather. Option 4: Open-ended shoes cannot prevent injuries to toes so they should be avoided.

A child has undergone osteotomy surgery for Legg-Calve-Perthes disease (LCPD). What should the nurse inform the parents of the child? 1. "Your child will be in hip-spica cast and should have total bed rest." 2. "Your child can resume normal life in 1 week after discharge." 3. "Your child has to walk with the help of a walker for the rest of his or her life." 4. "Your child will have increased bone density if he or she walks with the help of crutches."

Correct answer - "Your child will be in hip-spica cast and should have total bed rest." Option 1: After surgical procedure for the hip, a hip-spica cast is applied to restrict the movement at the hip. Option 2: The child can resume normal activities in about 3 to 4 months after discharge from hospital. Option 3: LCPD is a self-limiting disease. In some cases, It can be corrected conservatively or by surgery. Option 4: Weight bearing is not allowed as it can dislocate the joint or break the hip bone.

Which food and beverages are restricted in the Islamic religion? Select all that apply. 1. Pork 2. Alcohol 3. Meat 4. Shell fish 5. Coffee and tea

Correct answer - 1, 2 Option 1: Intake of pork is restricted in Islam. Option 2: Consumption of alcohol is restricted in Islam. Option 3: Meat is restricted in Catholicism during holy days. Option 4: Shell fish is restricted in Seventh-Day Adventist. Option 5: Coffee and tea are restricted in Seventh-Day Adventist.

A six-year-old child is diagnosed with Duchenne's muscular dystrophy (DMD). The primary health-care provider prescribes braces on the leg. What should the nurse inform the child's parents? Select all that apply. 1. "Laxatives can cause diarrhea in your child, so avoid them." 2. "Allow the child to swim in water. It is a good activity for him." 3. "Feed him with a diet high on calories and having moderate proteins." 4. "The maximum life span of 90% children with DMD is 40 years." 5. "The braces are applied to prevent muscle contractures in your child."

Correct answer - 1, 2, 5 Option 1: For the prevention of constipation, stool softeners and laxatives are added in the treatment regimen of DMD. Option 2: Swimming is recommended in DMD as it is a very low weight bearing activity. Option 3: To prevent obesity in DMD children, a diet with low calories and high proteins is advised. Option 4: Rarely, children diagnosed with DMD live beyond 20 years of age. Common cause of death is respiratory complications. Option 5: In DMD, muscle fibers degenerate. Wasting and contractures of muscles lead to replacement with fat. Braces are applied to prevent contractures of muscles such as the calf muscles.

A 34-year-old postpartum non--breast-feeding woman complains of pain in her breast. On examination, the nurse notices engorgement of the breast. What should the nurse tell the woman? Select all that apply. 1. "I will give you a painkiller; it will help to alleviate the discomfort." 2. "Avoid wearing any supportive bra, it aggravates the pain." 3. "Apply ice packs; it will give you some pain relief." 4. "Massage the breast every now and then, you may feel better." 5. "You need antibiotics, so I will refer you to a physician."

Correct answer - 1, 3 Option 1: Analgesics are effective in relieving the pain from breast engorgement. Option 2: A supportive bra gives pain relief by protecting the breast against gravity. Option 3: Ice packs can decrease the inflammation and thereby provide pain relief. Option 4: Stimulation of breast causes increase in blood flow and engorgement. Option 5: Breast engorgement is not due to infection, so antibiotics are not required.

An elderly client who has a history of falling is provided a safe environment by the nurse. What are the steps taken by the nurse to help promote safety? Select all that apply. 1. Organize hourly nursing rounds 2. Provide a room distant to the nursing station 3. Encourage the client to wear red cotton socks 4. Place a warning sticker on the door of the client's room 5. Elevate the bed to a high position to keep the client on the bed

Correct answer - 1, 3, 4 Option 1: Hourly rounds give the opportunity to monitor the client and correct factors, which can cause falls. Option 2: The nurse can attend a client at risk if he or she is in a room near to the nursing station. It would be easy for the nurse to go for hourly rounds if the client's room is near to the nursing station. Option 3: Red or bright colored socks can be easily identified when compared to dark colored socks. These can alert the caregivers. Option 4: This reminds the nurses and caregivers about the risk status of the client. Option 5: If the client is at a risk of falling, the bed should be lowered for easy maneuvers. The risk is high if the client tries to get down from an elevated bed.

Which statements by a student nurse show effective learning about monitoring clients during the application of heat and cold therapies? Select all that apply. 1. "A nurse should closely monitor elderly clients when applying heat or cold therapy." 2. "A nurse should keep a close watch on all areas other than the fingers, hands, face, and perineum when applying heat and cold." 3. "A nurse should carefully monitor clients with sensory impairment." 4. "A nurse should be highly alert when applying heat and cold therapy to small areas." 5. "A nurse should keep a special watch when applying heat and cold to injured skin and wounds."

Correct answer - 1, 3, 5 Option 1: Elderly clients have lower tolerance toward heat and cold therapies. Therefore, they should be closely monitored to prevent injuries. Option 2: Highly vascular areas such as the fingers, hands, face, and perineum should be closely monitored when applying heat and cold therapy. These areas are at high risk for injuries as they are very sensitive to changes in temperature. Option 3: A client with sensory impairment might be unable to feel changes in temperature, thus increasing the risk for injuries. The nurse should keep a close watch on them to prevent such injuries. Option 4: A nurse should be highly alert when applying heat and cold therapy to large areas. Option 5: Injured skin and wounds have lower tolerance toward heat and cold therapies than intact skin. Therefore, the nurse should monitor carefully.

Which nonpharmacological devices are used to manage urinary incontinence (UI) in a client? Select all that apply. 1. External occlusive device 2. Bulking agents 3. Drip collector 4. Kock pouch 5. Internal urethral meatus plug

Correct answer - 1, 3, 5 Option 1: An external occlusive device is a nonpharmacological device used to manage UI. A urethral meatus covering is used for women and a reusable, soft spongy rubber device is used for men. Option 2: A bulking agent such as collagen is injected beside the urethra that helps in managing urine flow. However, this is a pharmacological procedure. Option 3: Drip collectors, worn by men in order to manage urinary incontinence, are nonpharmacological devices. Option 4: Kock pouch is a surgically implanted pouch that collects urine and prevents its uncontrolled flow. Option 5: An internal urethral meatus plug is a Nonpharmacological device used to manage UI. It is a disposable, single-use device, which is usually used during activities that cause stress incontinence.

Which essential oils may be used for aromatherapy to reduce a client's muscle tension? Select all that apply. 1. Eucalyptus 2. Geranium 3. Lavender 4. Rosemary 5. Ylang Ylang

Correct answer - 1, 4, 5 Option 1: Eucalyptus reduces muscle tension and gives the immune system a boost. Option 2: Geranium helps women in balancing hormones and is not used to ease muscle tension. Option 3: Lavender is helpful in treating wounds, burns, and skin infections. It is not used to reduce muscle tension. Option 4: Rosemary relieves muscle tension and is also used to promote mental stimulation. Option 5: Ylang Ylang aids in reducing muscle tension and is used as an antidepressant.

A pregnant woman in 2nd stage of labor is unable to voluntarily push the fetus. The nurse has to prepare the mother for vacuum-assisted birth. Which conditions contraindicate a vacuum-assisted birth? Select all that apply. 1. Preterm fetus 2. Vertex presentation 3. Rupture of membranes 4. Cephalo pelvic distortion 5. Fetal scalp blood sampling

Correct answer - 1, 4, 5 Option 1: Vacuum device can cause damage to the head of a preterm fetus as it is very soft and fragile. Option 2: In vertex presentation, a vacuum cup can be applied over the posterior fontanel of the fetal head. Option 3: Rupture of membranes indicates that the delivery should progress spontaneously. If it does not, the fetus should be delivered by forceps, vacuum device, or caesarean surgery. Option 4: In cephalo pelvic distortion (CPD), head of fetus cannot pass through the narrow birth canal. Hence, caesarean birth is recommended. Option 5: Following fetal scalp blood sampling, application of vacuum over scalp results in bleeding from head.

A 19-year-old client takes isotretinoin for acne and wears contact lenses for myopia. What should the nurse inform the client? Select all that apply. 1. "You should avoid driving during nighttime or in darkness." 2. "The color of your contact lenses may become yellow." 3. "Wash your face with soap frequently to clear the debris from skin." 4. "You need to expose the skin to sunlight as it is the best source of Vitamin D." 5. "You should consult the primary health-care provider to get a prescription for eye lubricants."

Correct answer - 1, 5 Option 1: Isotretinoin can cause a sudden decrease in night vision. Therefore, the client should avoid driving at nighttime. Option 2: Isotretinoin does not change the color of tears. Option 3: The skin may become dry when taking isotretinoin. Frequent washing of face aggravates dryness. Option 4: The photosensitivity reaction is an adverse effect of isotretinoin. So, sun exposure should be avoided during treatment. When going out, the client should wear sun protective clothing. Option 5: Isotretinoin can cause dryness in the eyes so the client should use eye lubricants.

The primary health-care provider prescribed cradle boots to a chronic bedridden diabetic client. What are the advantages and disadvantages of using cradle boots? Select all that apply. 1. Cradle boots can cause foot drop. 2. Cradle boots prevent strain in hip. 3. Cradle boots prevent skin damage. 4. Cradle boots increase bone density. 5. Cradle boots can cause hallux valgus.

Correct answer - 2, 3 Option 1: Cradle boots prevent foot drop. Option 2: Cradle boots keep the leg in neutral position, thereby preventing strain on hip ligaments. Option 3: Cradle boots are soft and prevent damage due to friction with bed linen. Option 4: The client lies on the bed in resting position with cradle boots so it may not increase the bone density directly. Weight bearing exercises can improve bone density. Option 5: It is a progressive first metatarsal joint disorder, leading to a change in the angle of the great toe.

Which health screenings techniques help diagnose risk of genetic disorders during pregnancy? Select all that apply. 1. Ultrasound 2. Amniocentesis 3. Sigmoidography 4. Alpha-fetoprotein level 5. Chorionic villus sampling

Correct answer - 2, 4, 5 Option 1: Ultrasound is used to scan the pregnant woman's abdomen to get a picture of the baby and placenta. It does not play any role in the diagnosis of genetic disorders. Option 2: Amniocentesis is an amniotic fluid test that helps diagnose fetal chromosomal abnormalities (genetic disorders). Option 3: Sigmoidography is used in the diagnosis of colorectal cancers in adults. Option 4: The alpha-fetoprotein level test is used in pregnant women to diagnose various fetal problems such as neural tube defects, defects in the wall of the abdomen, and genetic defects. Option 5: Chorionic villus sampling is a screening test used for the diagnosis of fetal chromosomal abnormalities (genetic disorders).

The primary health-care provider prescribes rectal tube insertion to a post surgical client. What should the nurse keep in mind about the procedure? Select all that apply. 1. The tube should be left in the rectum for at least 30 minutes. 2. Knee-chest position helps in the passage of gasses as they are lighter. 3. Shallow breathing is required for easy insertion of the tube. 4. Tube insertion can inhibit the vagus nerve and cause bradycardia. 5. Tip of the rectal tube should be properly lubricated before insertion.

Correct answer - 2, 5 Option 1: The tube should be left for no more than 20 minutes as it can cause pressure necrosis in the mucosa of the rectum. Option 2: As air is lighter than liquids, if the anus is held up in the knee-chest position, the flatus will be released. Option 3: Deep breathing relaxes the anal sphincter and makes the tube insertion easier. Option 4: Tube insertion stimulates the vagus nerve. The stimulated vagus nerve inhibits the heart, leading to bradycardia. Option 5: To prevent damage to the inner lining of the rectum, application of lubricant to the tip of rectal tube is recommended.

Which is true regarding holistic care? Select all that apply. 1. People who benefit from holistic care will have a low need for affiliation. 2. People who benefit from holistic care will have more side effects. 3. People who benefit from holistic care will wish to prevent disease. 4. People who benefit from holistic care will be concerned about typical biomedical care. 5. People who benefit from holistic care will be hopeful.

Correct answer - 3, 4, 5 Option 1: People likely to benefit from holistic care will have a high need for affiliation and relational style of health care. Option 2: People likely to benefit from holistic care will have fewer side effects. Option 3: People likely to benefit from holistic care will wish to prevent disease or enhance wellness. Option 4: People likely to benefit from holistic care will be concerned with the invasiveness of typical biomedical care. Option 5: People likely to benefit from holistic care will not be hopeless.

The nurse is supervising an elderly client who is using crutches to walk on an even floor. From the tripod position, the client advanced both the crutches first. Which gait is the client likely using? Select all that apply. 1. 4-point gait 2. 2-point gait 3. Swing-to gait 4. Waddling gait 5. Swing through gait

Correct answer - 3, 5 Option 1: For a 4-point gait, the client has to advance one crutch from the tripod position. Option 2: For a 2-point gait, the client has to advance one foot and the opposite crutch from the tripod position. Option 3: For the swing-to gait, the client has to advance both crutches from the tripod position. Option 4: The waddling gait is an abnormal gait due to the weakness of pelvic musculature. Option 5: For the swing through gait, the client has to advance both crutches from the tripod position.

An elderly client has been advised to avoid using a weight-bearing gait. What type of gait would the nurse advise if the client wants to walk with crutches? 1. 4-point gait 2. 2-point gait 3. Swing-through gait 4. 3-point gait

Correct answer - 3-point gait Option 1: The 4-point gait is used for partial weight-bearing. Option 2: The 2-point gait is used for partial weight-bearing. Option 3: The swing-through gait is used when weight-bearing is permitted. Option 4: The 3-point gait is used when weight-bearing must be avoided.

The nurse measures the flexion of the elbow while a client holds his or her walking stick in an erect standing posture. What is the most appropriate flexion of elbow in this situation? 1. 10 degrees 2. 30 degrees 3. 40 degrees 4. 50 degrees

Correct answer - 30 degrees Option 1: The lower the flexion angle, the shorter should be the walking stick. A 10-degree angle would mean that the cane is too short. Option 2: A flexion angle of 30 degrees is the correct length for the walking stick or the cane. Option 3: A flexion of 40 degrees indicates that the cane is long. Option 4: A flexion of 50 degrees indicates that the cane is too long.

Which equipment listed by the nurse as required to perform nonpharmacological postural drainage indicates the need for reevaluation of the list? 1. A flat and immovable bed 2. Emesis basin 3. Suction equipment 4. Pillows

Correct answer - A flat and immovable bed Option 1: In order to perform postural drainage, the nurse needs a bed that can be placed in Trendelenburg position. Option 2: The emesis basin is used to collect the fluid drained. Option 3: Suction equipment must be kept ready for use when performing postural drainage. Option 4: Pillows are used to place clients in certain positions and provide support. Hence, it is essential to have these ready before performing postural drainage.

A student nurse is being educated on the nonpharmacological therapies that can be used to treat nausea after surgery. Which therapy does the nurse correctly identify? 1. Relaxation techniques 2. Contralateral stimulation 3. Acupuncture 4. Effleurage

Correct answer - Acupuncture Option 1: This therapy is used to minimize chronic pain. The process involves tensing and releasing a group of muscles for 15 seconds and then the process is repeated with another set of muscles. Option 2: This method is used to provide relief to clients with phantom pain after an amputation. The pain is relieved by stimulating the skin in an area opposite to the painful site. Option 3: Acupuncture is widely used to treat nausea after surgery; it helps in stimulating the endogenous analgesia system. This is done by applying extremely fine needles to specific sites of the body to relieve pain. Option 4: Effleurage is used to treat obstetrical clients during labor and postsurgical clients. This is done by using slow, long, guiding strokes of massage.

Which action taken by the nurse when caring for a client who has signs indicating the onset of mild seizures needs correction? 1. Administering oxygen immediately 2. Helping the client into bed, lowering the head, and raising siderails 3. Moving hard or sharp objects away from the client 4. Loosening the client's clothing

Correct answer - Administering oxygen immediately Option 1: The nurse should administer oxygen only if the seizure is prolonged or hypoxemia is present. Moreover, this is not an immediate relief plan because oxygen can be administered only if prescribed, in order to avoid hypoxia. Option 2: The nurse should immediately put a client experiencing seizures into bed. This is done to prevent the client from falling and incurring head injuries. Option 3: The nurse should move hard or sharp objects away from a client experiencing seizures because these could injure the client. Option 4: The client's clothing should be loosened to ease breathing.

The nurse is teaching a client about caring for an artificial eye. What is an appropriate step in the cleaning and reinsertion of an artificial eye? 1. Before inserting into the eye socket, the artificial eyeball should be dried thoroughly 2. After removing the eyeball, it should be stored in a container filled with saline. 3. The artificial eye has to be cleaned daily with mild disinfectants. 4. The eye socket should be cleaned from inner canthus to outer canthus.

Correct answer - After removing the eyeball, it should be stored in a container filled with saline. Option 1: Inserting the wet artificial eye would be easier, and would help prevent damage due to friction. Option 2: The artificial eyeball should be stored in a labeled container with saline to prevent drying. Option 3: Chemicals such as disinfectants and alcohol can damage the artificial eye and cause irritation in the socket after insertion. Option 4: The eye socket should be cleaned from outer canthus to inner canthus with a moistened cotton ball.

The nurse has to do a physical assessment of a woman who is on hypoglycemia medication for diabetes and who is using a hearing aid. What is the appropriate action? 1. Remove the hearing aid and keep it in a labeled container 2. Allow the client to wear the hearing aid during assessment 3. Delegate an assistant nurse to check and clean the hearing aid 4. Take out the hearing aid and give to her husband or a caregiver

Correct answer - Allow the client to wear the hearing aid during assessment Option 1: Removing the hearing aid can lead to misunderstanding. Option 2: During the physical assessment, the nurse has to encourage the client to use a hearing aid. It facilitates the understanding of the assessment procedures and instructions. Option 3: After the assessment is completed, check the hearing aid for any damages and clean it, if it is required. Option 4: Removing the hearing aid can lead to misunderstanding.

In a screening program, the primary health-care provider examines the x-ray report of a 12-year-old girl and notices scoliosis with a 28-degree curve. Her vital signs, ECG, and respiratory examinations are normal. What is an appropriate intervention? 1. Perform the surgery as the girl is fit for it. 2. Advise the girl to avoid physical exercises. 3. Apply back bracing for 23 hours per day. 4. Administer transcutaneous electrical stimulation.

Correct answer - Apply back bracing for 23 hours per day. Option 1: Surgery is recommended if the scoliosis is over 40 degrees with respiratory complication in the girl. Option 2: Exercises are recommended as they increase the strength in the back muscles, under the guidance of a physical therapist. Option 3: Scoliosis between 10 and 40 degrees is considered mild. Back bracing for 23 hours/day stops the progression of scoliosis. The girl can remove it before taking a shower. Option 4: Transcutaneous electrical stimulation is ineffective in improving the strength in the back muscles of the scoliosis clients.

Which action performed by the nurse while applying heat and cold therapy can actually cause injury to the client? 1. Applying ice pack on the affected area after covering it with a washcloth 2. Applying heat or cold intermittently for more than 15 minutes at a time 3. Checking the skin for extreme redness, cyanosis, or blanching 4. Discontinuing the treatment when the client expresses discomfort with the therapy

Correct answer - Applying heat or cold intermittently for more than 15 minutes at a time Option 1: Direct contact with the heating or cooling object must be avoided. A cold pack must be applied only after covering it with a washcloth or fitted sleeve. Option 2: Hot and cold therapy must be applied intermittently for no more than 15 minutes. This prevents tissue injury. Hence, this action performed by the nurse can injure the client. Option 3: Applying a cold pack to the injured site numbs the area and reduces pain. But in some clients with very sensitive skin, there can be cyanosis or blanching and the nurse must repeatedly check for any such occurrences. Option 4: Hot compresses promote blood circulation, which speeds the healing process but if the client is uncomfortable with the therapy, the nurse must discontinue it.

Which type of hearing disability would benefit most from the use of hearing aids? 1. Presbycusis 2. Central deafness 3. Conductive deafness 4. Cranial nerve VIII damage

Correct answer - Conductive deafness Option 1: Presbycusis is a progressive sensorineural deafness that occurs with aging. Hearing aids are not helpful in sensorineural deafness. Option 2: In central deafness, the brain is unable to perceive sounds, so the hearing aids may not be helpful. Option 3: In conductive deafness, amplification of sound enables the client to listen and communicate. Option 4: Deafness due to damage to cranial nerve VIII, cannot be fixed by hearing aid.

A client with fibromyalgia repeatedly laments, "Where did I go wrong? Why did this happen to me?" What course of action should the nurse take to provide spiritual support to the client? 1. Discuss own spiritual beliefs. 2. Contact the health-care facility's chaplain. 3. Notify the primary health-care provider. 4. Pray for the client.

Correct answer - Contact the health-care facility's chaplain. Option 1: The nurse should let a spiritually distressed client express feelings and lead the discussion. Option 2: The nurse should contact with the agency's chaplain to address a client's specific spiritual needs. Option 3: While the primary health-care provider may be contacted to inform him or her of the client's spiritual distress, the nurse should contact the organization's chaplain to help provide spiritual support to the client. Option 4: The nurse must provide spiritual support after clarifying the exact wishes of the client, keeping in mind the distinction between praying with and praying for the client.

A registered nurse instructs a student nurse to list nonpharmacological methods of wound debridement. Which answer provided by the student nurse indicates a need for further teaching? 1. Enzymatic debridement 2. Autolysis 3. Hydrotherapy 4. Sharp debridement

Correct answer - Enzymatic debridement Option 1: Using proteolytic agents to break down necrotic tissue is enzymatic debridement. This is a pharmacological method of wound debridement. Option 2: The use of nonocclusive moisture-retaining dressings along with the body's enzymes to remove necrotic tissue is called autolysis. This is a nonpharmacological method. Option 3: Hydrotherapy is the process of debriding wounds by placing them in a whirlpool containing lukewarm water for a prescribed time period. This is a nonpharmacological technique. Option 4: The use of sharp objects such as scalpels or scissors to remove necrotic tissue is called sharp debridement. This nonpharmacological procedure requires special training.

Which active listening intervention falls beyond the scope of standardized Nursing Interventions Classification (NIC)? 1. Presence 2. Reminiscence therapy 3. Touch 4. Exploring meaning

Correct answer - Exploring meaning Option 1: This intervention requires the nurse to be physically present by the bedside and allow the client to lead discussions. This is a standardized NIC intervention. Option 2: Reminiscence therapy aids in exploring and clarifying past experiences. This is a standardized NIC intervention. Option 3: The nurse uses the 'touch' intervention to aid the communication process by holding the client's hands and using soothing touch. This is a standardized NIC procedure. Option 4: The nurse uses this intervention to aid the client in search for meaning and purpose of life. This is not a standardized NIC intervention.

An elderly diabetic client is unable to clip his or her toenails. What is the best nursing action? 1. Trim the client's nails with a nail clipper 2. File the client's nails with an emery board 3. Trim the client's nails short in a convex shaped manner 4. Soak the client's feet in warm water for 10 minutes

Correct answer - File the client's nails with an emery board Option 1: Nail clippers can cause injury to soft tissue. Injuries to diabetic foot may lead to ulcers. Option 2: Sharp and long nails can cause injuries to the client so they should be filed straight across. Nail files do not cause injury to soft tissue. Option 3: Nails should be cut straight across, not in convex shape. Short nails can lead to ingrown nails. Option 4: Diabetic foot may involve sensory deficit, making the client vulnerable to injuries and infections. Therefore, soaking should be avoided.

A 24-year-old woman was involved in an automobile accident. X-ray shows fracture of a bone. The primary health-care provider prescribes a sling versus figure-of-eight bandage to this client. Which of these is an indication for using figure-of-eight bandage? 1. Fracture in distal radius bone 2. Supracondylar fractures of humerus 3. Lateral condylar fractures of humerus 4. Fracture in middle third of the collar bone

Correct answer - Fracture in middle third of the collar bone Option 1: Short arm cast for three to six weeks is applied for distal radius bone fracture. Option 2: Long arm cast with elbow at 90 o is recommended with neutral forearm. Option 3: Long arm cast and posterior splint are recommended. Option 4: The other name for clavicle is collarbone. Figure-of-eight bandage and a simple sling can effectively heal the mid-clavicle fracture.

What should the nurse do to help a client with stress management using nonpharmacological means? 1. Perform chiropractic adjustments on the client. 2. Give a back massage to the client. 3. Use acupuncture to help the client. 4. Promote relaxation using reflexology.

Correct answer - Give a back massage to the client. Option 1: Making chiropractic adjustments to the vertebrae helps in releasing tension and promoting relaxation. However, this should be done only by a specialized practitioner. Option 2: The nurse may give a back massage to the client to release tension and promote relaxation. Option 3: Acupuncture is the insertion of extremely fine needles at specific points in the body to promote relaxation. This method should be performed by trained practitioners only. Option 4: Applying pressure to specific points on the hands, feet, or ears to promote relaxation is called reflexology. This technique is performed by trained practitioners only.

The nurse is testing the near vision of a client using Jaeger cards. Which procedure does the nurse implement during the test? 1. Administering mydriatic eye drops before the test 2. Having the client hold the card at a distance of 14 inches 3. Instructing the client to identify the color on the card 4. Asking the client to identify the figure in the card

Correct answer - Having the client hold the card at a distance of 14 inches Option 1: The nurse administers mydriatic drops before an ophthalmic examination. Option 2: The nurse ensures that the client holds the Jaeger card at a distance of 14 inches during the test. Option 3: The nurse asks the client to identify the color on the Ishihara's hard to assess the client's color vision. Option 4: The Ishihara's card displays colored dots containing an embedded colored number or figure. This card is used to assess the color vision of the client.

Which wellness intervention ensures quality care to the clients by comparing the requirement of polices and standards of the health care system with current practices? 1. Patient contracting 2. Program development 3. Health system guidance 4. Health policy monitoring

Correct answer - Health policy monitoring Option 1: Patient contracting is a nursing intervention in which the nurse encourages the clients to identify their own goal, but not what the primary health care provider expects. Option 2: The nurse assists the community in identifying significant health needs during program development. Option 3: In health system guidance, the nurse informs the client of state accreditation and requirements of the state health department and helps the client judge the quality of the health care facility. Option 4: The nurse monitors the health policy and ensures quality care of the client by comparing the requirement of polices and standards of the health care system with its current practices.

The nurse is trying to teach a client to balance activity and rest. Which health promotion outcome does this represent? 1. Health promoting behavior 2. Knowledge: health behavior 3. Knowledge: health resources 4. Knowledge: health promotion

Correct answer - Health promoting behavior Option 1: Balancing activity and rest is an example of health promoting behavior. The personal actions to sustain or increase wellness indicate the health promotion outcome, health promoting behavior. Option 2: Knowledge: health behavior is defined as the extent of understanding conveyed about the protection and promotion of health. Option 3: The health promotion outcome, knowledge: health resources is defined as the extent of understanding conveyed regarding the relevant health care resources. Option 4: The health promotion outcome, knowledge: health promotion is defined as the extent of understanding conveyed about the information needed to obtain and maintain optimal health.

A nurse is giving a back massage to a client to promote blood circulation. The nurse uses the thumbs to apply horizontal strokes from near the spine across the bottom of the scapula, pushes thoroughly across the scapula from the spine, and repeats the step until the entire scapula and the top of the shoulder are massaged. What purpose does this step serve? 1. Helps relax tightened areas in the paraspinal muscles 2. Helps loosen the trapezius muscles 3. Helps relax the latissimus dorsi muscles 4. Helps promote relaxation of the back muscles

Correct answer - Helps loosen the trapezius muscles Option 1: The movement of applying pressure in circles down both sides of the spine by starting from the upper shoulder and working down to the lower back using the heels of the hand helps relax tightened areas in the paraspinal muscles. Option 2: The movement of applying horizontal strokes from near the spine across the bottom of the scapula, then pushing out thoroughly across the scapula from the spine, and repeating the step until the entire scapula and the top of the shoulder are covered using a thumb helps loosen the trapezius muscles. Option 3: The movement of applying horizontal strokes using the heels of the hands across the latissimus dorsi muscle near the spine below the scapula, then pushing out from the spine across to the ribs, and working down across the lower back relaxes the latissimus dorsi muscles. Option 4: Gently rubbing the hands up on either side of the spine from the base of the back to the base of the neck and then down the sides of the back and repeating the movement several times promotes relaxation of the back muscles.

Which best indicates risk of metabolic syndrome? 1. Less skin fold thickness 2. High waist-to-hip ratio (WHR) 3. Low abdominal circumference 4. High mid-upper arm circumference

Correct answer - High waist-to-hip ratio (WHR) Option 1: Skin fold thickness helps measure the subcutaneous fat in different areas of the body. High skin fold thickness is seen in obese clients. Option 2: High waist-to-hip ratio (WHR) indicates that the client has high abdominal fat. Therefore, the client will have a high risk for changes in body metabolism and metabolic syndrome. Option 3: Low abdominal circumference indicates less fat accumulation in the abdominal region. However, this does not alter body metabolism. Therefore, the client does not have any risk for metabolic syndrome. Option 4: High mid-upper arm circumference indicates high fat accumulation in the extremities, which is not hazardous and does not increase the risk for metabolic syndrome.

The primary health-care provider prescribed an indwelling catheter for a postsurgical client. Which type of catheter is more appropriate if it is supposed to be left undisturbed for up to three months? 1. Hydrogel-coated catheter 2. Polyvinyl chloride catheter 3. Silver alloy-coated catheter 4. Teflon-bonded latex catheter

Correct answer - Hydrogel-coated catheter Option 1: Hydrogel-coated catheter prevents formation of crusts around the urinary meatus. It makes the insertion and removal easy. So, it can be left as such for up to three months. Option 2: A polyvinyl chloride catheter can be used up to six weeks. Option 3: A silver alloy-coated catheter can be left in place for less than seven days. After seven days, it is less effective. Option 4: A Teflon-bonded latex catheter should be removed before 28 days.

A nurse is performing a postural drainage task to provide comfort to a client with pneumonia. What would be the appropriate position of the client while draining the middle or lower lobes of the lungs? 1. In prone position with a pillow under the stomach by keeping the bed flat 2. In supine position with a pillow under the hips and knees flexed 3. In Sims' position by keeping the bed in the Trendelenburg position 4. In sitting position at the edge of the bed with a pillow at the base of the spine

Correct answer - In Sims' position by keeping the bed in the Trendelenburg position Option 1: The client should be placed in a prone position with a pillow under the stomach to drain the posterior lower lobes of the lungs. This is done by keeping the bed flat. Option 2: The client should be placed in a supine position with a pillow under the hips and knees flexed to drain the posterior section of the upper lobes. The nurse should assist the client to rotate slightly away from the side that requires drainage. Option 3: The client should be placed in Sims' position by keeping the bed in the Trendelenburg position to drain the middle or lower lobes of the lungs. The client should be positioned on the right side to drain the left lung and on the left side to drain the right lung. Option 4: The client should be placed in a sitting position at the edge of the bed with a pillow at the base of the spine for support to drain the apical areas of the upper lobes. If the client is unable to sit, the high-Fowler's position can be used.

A full term pregnant woman has labor pains. Her first child was delivered by caesarean section. On examination, the nurse finds that the cervix is not effaced. The membranes are intact. What should be the next most appropriate step by the nurse? 1. Inflate a balloon catheter after inserting it into the cervix. 2. Insert 25 mcg of misoprostol in the posterior vaginal fornix. 3. Apply low forceps to hold the head and gently pull out the baby. 4. Administer 10 units of oxytocin in 100 mL of NS for slow IV infusion.

Correct answer - Inflate a balloon catheter after inserting it into the cervix. Option 1: Inflation of balloon catheter causes pressure on the vaginal wall and induces the release of endogenous prostaglandin, which can cause cervical ripening, dilatation, and facilitate labor. Option 2: Misoprostol is contraindicated, if there is a history of surgery on uterus as it may cause rupture of the uterus. Option 3: Low forceps are not applied if the cervix is not fully dilated and membranes are intact. Option 4: Oxytocin is contraindicated, if there is a history of surgery on uterus as it may cause rupture of the uterus.

What is an appropriate nursing action while cleaning the hearing aid? 1. Remove the hearing aid and clean it with soapy water. 2. Insert the hearing aid into the ear canal after turning the power button off. 3. Remove the hearing air battery aid and dry it under the sun. 4. Insert the hearing aid into the ear canal with the volume control at the bottom.

Correct answer - Insert the hearing aid into the ear canal after turning the power button off. Option 1: Detachable ear-mold can be cleaned with soapy water but immersion of hearing aid in the water may lead to damaging the hearing aid. Option 2: If the power is on when inserting the hearing aid, it may cause discomfort to the client. It has to be inserted with power off. Option 3: Heat decreases the life of battery, so drying under the sun should be avoided. Option 4: Insert the hearing aid with the volume control at the top. Improper insertion can damage the aid.

A pregnant woman, in the labor unit of a hospital, has internal electrodes for fetal heart rate (FHR) monitoring. She wants to bathe in a whirlpool tub. What is the appropriate step in this situation? 1. Water temperature should be maintained between 99.8o F to 102.8o F. 2. Internal electrodes for FHR monitoring can be removed before the bath. 3. A long, continuous bath is more effective than repeated submerging. 4. The woman should not be allowed to take a bath as long as she wants.

Correct answer - Internal electrodes for FHR monitoring can be removed before the bath. Option 1: Over heating can be dangerous so water temperature should be maintained between 96.8 °F to 100.4 °F. Option 2: FHR monitoring can be done intermittently or continuously with Doppler technique, fetoscope. Hence, internal electrodes can be removed. Option 3: Long immersions may cause hyperthermia so intermittent bathing is more effective. Option 4: A pregnant woman can stay in the whirlpool tub as long as she desires, provided the water temperature should be maintained between 96.8 °F to 100.4 °F. If she feels intense pain or slowing of labor, she should come out.

What purpose does a heated washcloth serve when used to give a client a sponge bath? 1. It is used to cleanse wounds and remove encrusted material. 2. It is used to provide relaxation if the client's skin is intact. 3. It is used to prevent swelling after surgery. 4. It is used to cleanse the client's perineal area.

Correct answer - It is used to provide relaxation if the client's skin is intact. Option 1: A soak or a bath is used to cleanse wounds and remove encrusted material. Option 2: If the client's skin is intact, a heated washcloth or towel is used to provide relaxation. Option 3: Cold therapy is used to prevent swelling after surgery. Option 4: A sitz bath is used to soak and cleanse a client's perineal area.

A pregnant woman is in prolonged 2nd stage of labor with full cervical dilatation and ruptured membranes. The nurse finds that the head is at +2 station but the woman is too exhausted to push down. Which forceps is more appropriate to assist the delivery of the baby? 1. Mid forceps 2. Low forceps 3.Piper forceps 4.Outlet forceps

Correct answer - Low forceps Option 1: When the head is at less than +2 station, the head should be engaged. Option 2: When the station of head is at +2 or more, low forceps are used. Option 3: Piper forceps are used to deliver the head of the fetus in breech presentation. Option 4: Outlet forceps are applied when the scalp of the fetus is visible between labia without manual separation of labia.

Which is an example of relaxation therapy? 1. Massage, music, holding, and positioning 2. Puzzles and coloring 3. Pain medication 4. Hypnosis

Correct answer - Massage, music, holding, and positioning Option 1: Massage, music, holding, and positioning are all practices that are part of relaxation therapy. Option 2: Puzzles and coloring are a kind of play therapy. Option 3: Pain medication is part of pain relief therapy. Option 4: Hypnosis is a psychotherapy, and may or may not put the client at ease.

What should the nurse do to clean the teeth, tongue, and gums of a client whose upper limbs are paralyzed? 1. Use more toothpaste, if there is more plaque. 2. Hold the brush at an angle of 90° to the gum line. 3. Move the floss up and down to clean the teeth. 4. Move the floss back and forth to clean the gums.

Correct answer - Move the floss up and down to clean the teeth. Option 1: Using extra toothpaste can cause dryness of the mouth. It does not help in cleaning the mouth. Option 2: The toothbrush should be held at an angle of 450 to the gum line. Option 3: Moving the floss up and down helps clean the teeth, and reduces potential to damage the gums. Option 4: Moving the floss back and forth can damage the gums.

A 12-year-old child who has been hospitalized wears leg braces. What is the most appropriate nursing intervention for prevention of pressure sores due to braces in this child? Select all that apply. 1. Inspect for redness every other day. 2. Notify the health-care provider if skin redness is present. 3. Apply oil and reapply the brace if there is skin irritation. 4. Apply betamethasone ointment on any reddened areas of the skin daily.

Correct answer - Notify the health-care provider if skin redness is present. Option 1: Inspection of the skin every day gives the opportunity to find out any minor change in the color or damage to the skin. Option 2: If reddened area of skin is found, the nurse should not re-apply the braces and must inform the primary health-care provider. Option 3: Reapplying the brace can cause further damage, so the nurse should wait for the instructions of primary health-care provider. Option 4: Daily application of topical steroids can cause thinning of the skin and may lead to skin damage.

Which wellness intervention is associated with encouraging the client to identify his or her own goals, but not those he or she believes that the primary health care provider expects? 1. Health screening 2. Patient contracting 3. Program development 4. Health system guidance

Correct answer - Patient contracting Option 1: Health screening is associated with monitoring the vital signs and other conditions of the client. Option 2: Patient contracting is a nursing intervention in which the nurse encourages the client to identify his or her own goals, but not those that he or she believes the primary health care provider expects. Option 3: During program development, the nurse assists a group of individuals in identifying significant health needs or problems. Option 4: Health system guidance is an intervention, which is associated with activities such as informing the client about accreditation and state health department requirements for determining the quality of a facility.

What is health-promoting behavior? 1. Personal actions to sustain or increase wellness 2. Personal actions to promote optimal wellness and recovery 3. Personal commitment to health behavior as lifestyle priority 4. Personal actions of an adult to control behaviors that can cause physical injury

Correct answer - Personal actions to sustain or increase wellness Option 1: Any personal action that is used to sustain or increase wellness is known as a health-promoting behavior. Option 2: Personal action to promote optimal wellness and recovery is called health-seeking behavior. Option 3: Personal commitment to health behavior as a lifestyle priority is called health orientation. Option 4: The personal actions of an adult to control behaviors that can cause physical injury is personal safety behavior.

After performing a 3-minute step test in a 40-year-old female client, the nurse finds that the client's heart rate is 138 beats/min. What is the client's physical condition based on this finding? 1. Poor 2. Good 3. Very poor 4. Average

Correct answer - Poor Option 1: If females aged 36 to 45 have a heart rate of 129-140 beats/min, then it indicates that the clients are in poor physical condition. As the client's heart rate in the given condition is 138/min, the nurse concludes this is poor physical condition. Option 2: The physical condition of the client is said to be good if the heart rate is 90-102 beats/min. Option 3: The physical condition of the client is said to be very poor if the heart rate is >140 beats/min. Option 4: The physical condition of the client is said to be average if the heart rate is 111-118 beats/min.

The primary health-care provider prescribed Welch Allyn ear wash to a two-year eight-month-old child. What should the nurse do to straighten the ear canal of this child before inserting the nozzle of the device? 1. Pull forward and upward 2. Pull upward and backward 3. Pull forward and downward 4. Pull backward and downward

Correct answer - Pull upward and backward Option 1: If the ear is pulled forward and upward, the ear canal would not be straightened. Option 2: If the ear is pulled upward and backward, the ear canal would not be straightened. Option 3: If the ear is pulled forward and downward, the ear canal would not be straightened. Option 4: In children under three years, pulling the ear backward and downward straightens the ear canal.

A cast is applied to the left leg of a client with fracture of the left tibia. On examination, there is a swelling in the ankle. What should the nurse do first, if the client is at the risk of developing compartment syndrome? 1. Put a pillow under the ankles 2. Elevate the head end of the bed 3. Administer morphine on PRN basis 4. Administer antibiotics to prevent infection

Correct answer - Put a pillow under the ankles Option 1: Elevation of ankles relieves swelling by facilitating the flow of fluids into the lymphatic circulation. Prevention of compartment syndrome is a priority intervention. Option 2: Elevation of the head end of the bed causes accumulation of inflammatory fluids in the dependent areas such as ankle. Option 3: Morphine can give pain relief by acting centrally on the brain but it cannot reduce the swelling. Option 4: For inflammation, antibiotics are not recommended.

Which therapy is involves applying pressure on specific points of the feet, hands, or ears to treat stress-related illnesses? 1. Therapeutic touch (TT) 2. Reflexology 3. Acupuncture 4. Effleurage

Correct answer - Reflexology Option 1: In TT therapy, the hands do not have to touch the client's body. Healing energy may be directed through the practitioner's hands. Option 2: Reflexology involves applying pressure on specific points of the feet, hands, or ears to cure anxiety and stress. Option 3: Acupuncture involves insertion of extremely fine needles on specific points of the body to treat stress and depression. Option 4: Effleurage is a type of massage where slow, long, guiding strokes are used to treat clients during labor and as back rubs post surgery.

A nurse is preparing a care plan for an anxious and stressed client. Which action may aggravate the client's condition? 1. Encouraging the client to participate in fun and non-stressful activities 2. Assisting the client in nonpharmacological therapies 3. Refraining from pointing out the situations or conditions that cause anxiety 4. Staying with the client to pacify fears, anxiety, and confusion

Correct answer - Refraining from pointing out the situations or conditions that cause anxiety Option 1: Participating in fun activities would help the client focus on something other than what is causing stress. Option 2: Nonpharmacological therapies such as biofeedback, meditation, and therapeutic touch help in reducing anxiety. Option 3: The nurse should point out the situations that cause anxiety to the client. This will help the client identify and cope with such situations in the future. Option 4: Staying with the client will promote trust and bonding, and will gradually help in minimizing the anxiety level.

Which medication, if prescribed to the client who wears soft contact lenses, may cause a change in the color of the lenses due to its effect of changing the color of tears? 1. Atenolol 2. Glipizide 3. Rifampin 4. Zidovudine

Correct answer - Rifampin Option 1: Atenolol is an anti-hypertensive drug; it does not change the color of the tears. Option 2: Glipizide is hypo-glycemic drug; it does not change the color of the tears. Option 3: Rifampin is an anti-tuberculosis drug. Clients taking this medication may secrete red-orange to red-brown tears. The colored tears may cause permanent color change of soft contact lenses. Option 4: Zidovudine is a retroviral drug. It does not change the color of the tears.

The nurse is helping a client walk with crutches. What should be the sequence of movements, if the client is using a 2-point gait? 1. Right crutch; left foot; left crutch, right foot 2. Right crutch and left foot; left crutch and right foot 3. Right crutch and Left crutch; left foot and right foot 4. Right foot and left foot ; right crutch and left crutch

Correct answer - Right crutch and left foot; left crutch and right foot Option 1: In 4-point gait, the client is advised to move the right crutch first followed by left foot, then left crutch followed by right foot. Option 2: In 2-point gait, the client has to bear weight on the left foot and on the right crutch. In the next level, the weight has to be transferred to the right foot and on left crutch by moving forward in that sequence. Option 3: The sequence right crutch and left crutch; left foot and right foot is appropriate for swing to or swing through gait. Option 4: The sequence right foot and left foot; right crutch and left crutch is appropriate for either swing to or swing through gait, depending on which side is affected. This sequence of movements would not be appropriate for 2-point gait.

The nurse teaches the parent of a newborn baby about the proper use of a bulb syringe. Which action of the parent may cause complication in the baby? 1. Cleaning the bulb syringe in warm, soapy water after use 2. Sucking the oral secretions by not inserting the bulb syringe into the throat 3. Suctioning the nasal cavities prior to suctioning the mouth with bulb syringe 4. Compressing the bulb syringe before it can be inserted into the nose

Correct answer - Suctioning the nasal cavities prior to suctioning the mouth with bulb syringe Option 1: To remove the remaining oral secretion in the bulb syringe, prevent the growth of bacteria, and spread of infections, the bulb syringe should be cleaned in warm, soapy water after each use, every day. Option 2: Touching the back of the throat and palate can trigger gag reflex. Therefore, it should be avoided. Option 3: If there is respiratory obstruction, placing the bulb syringe in the nostril will activate an inspiratory gasp, which further draws the secretions into the respiratory tract. Nasal cleaning should be done after suctioning the oral cavity. Option 4: Compression of bulb syringe before insertion creates negative pressure in it, and this negative pressure sucks the secretions. If it is sucked when it is in the mouth or nose, the gush of air from the bulb can push secretions further into the respiratory tract.

Which stage in the transtheoretical model of change has no risk of relapse? 1. Action stage 2. Maintenance stage 3. Termination stage 4. Precontemplation stage

Correct answer - Termination stage Option 1: The action stage of the transtheoretical model of change involves implementation of plan. Therefore, the client will have a risk since this is the revolving door process. Option 2: The client who enters the maintenance stage is in danger of relapse if he or she exits the stage before the end of it. Option 3: The client who enters the termination phase is not in danger of relapse because of the completion of the maintenance stage and changed behavior. Option 4: The precontemplation stage precedes change and helps identify clients who are not ready for the contemplation change. The client has risk of relapse as the treatment is not complete.

Upon assessing the records of a 17-year-old client, the nurse concludes that the client has good cardiorespiratory fitness. Which test's outcome was the basis for the nurse's conclusion? 1. The client completed a 1-mile run in 7½ minutes. 2. The client completed a 1-mile run in 10 minutes. 3. The child completed a 1-mile run in 12 minutes. 4. The child completed a 1-mile run in 15 minutes. 4. The child completed a 1-mile run in 15 minutes.

Correct answer - The client completed a 1-mile run in 10 minutes. Option 1: A 17-year-old client should be able to complete a 1-mile run in approximately 7½ minutes. This indicates that the client has good cardiorespiratory fitness. Option 2: A client with good cardiovascular fitness can run a mile in 7½ minutes; therefore this client's records do not indicate good cardiovascular fitness. Option 3: A client with good cardiovascular fitness can run a mile in 7½ minutes; therefore this client's records do not indicate good cardiovascular fitness. Option 4: A client with good cardiovascular fitness can run a mile in 7½ minutes; therefore this client's records do not indicate good cardiovascular fitness.

Which nonpharmacological device for managing chronic neurological pain needs to be surgically implanted? 1.The anti-incontinence device 2. The transcutaneous electrical nerve stimulator (TENS) device 3. The percutaneous electrical stimulation (PENS) device 4. The spinal cord stimulator (SCS)

Correct answer - The spinal cord stimulator (SCS) Option 1: The antiincontinence device is used to help reduce urinary incontinence (UI). This nonpharmacological device provides a pathway for urine flow. This is not used to manage chronic neurological pain. Option 2: The TENS unit is worn intermittently, or for long periods of time, depending on the client's pain. It provides relief from pain. This nonpharmacological device stimulates A-delta sensory fibers to minimize pain. However, this is not effective in managing chronic neurological pain. Option 3: The PENS device is used to provide relief from acute and chronic pain, and for improving sleep. This nonpharmacological device stimulates the peripheral sensory nerves to provide comfort. However, this device cannot be used to manage chronic neurological pain. Option 4: The SCS is a nonpharmacological device, which is surgically implanted to provide relief to a client with chronic neurological pain. It produces impulses that control the pain.

A registered nurse is explaining a relaxation technique that involves the use of hands to generate healing energy in the client's body. How is this technique classified? 1. Sequential muscle relaxation 2. Acupressure 3. Effleurage 4. Therapeutic touch

Correct answer - Therapeutic touch Option 1: The process involves tensing and releasing a group of muscles for 15 seconds to relieve pain. Option 2: Acupressure is the use of fingertips to provide firm, gentle pressure over various parts of the body. Option 3: This is a massage technique that uses slow, long, guiding stroke to provide pain relief. Option 4: This process involves the use of hands to generate healing energy in the client's body without any physical contact.

The primary health-care provider prescribes lower limb braces to an eight-year-old girl diagnosed with Duchenne's muscular dystrophy (DMD). What other disorder could be associated with DMD in this client? 1. Down syndrome 2. Wilson syndrome 3. Turner's Syndrome 4. Sheehan's syndrome

Correct answer - Turner's Syndrome Option 1: Trisomy of chromosome 21 is called Down syndrome. It is an autosomal disorder, whereas DMD is a sex-linked recessive disorder. Option 2: Wilson syndrome is due to the congenital defect in Ceruloplasmin. It is not a chromosomal disorder. Option 3: DMD is an X-linked recessive disorder. Only males are affected. Females are usually carriers, unless they have only one sex chromosome. In Turner's syndrome, the girl receives one X-gene from mother but does not receive another X-gene from father. If the X-gene from mother carries DMD, the girl will develop signs and symptoms of DMD. Option 4: Post-partum pituitary necrosis is called Sheehan's syndrome.

A 76-year-old client has pain in the right knee and complains of shortness of breath when walking. Which type of walking aid should the nurse recommend for this client? 1. Axillary crutches 2. Walker with a seat 3. Forearm support crutches 4. Cane with three prongs

Correct answer - Walker with a seat Option 1: When the client has shortness of breath, the client may need to take rest intermittently by sitting or sleeping. Standing or walking with a crutch may aggravate shortness of breath. Option 2: Using a walker with a seat may help the client to stop and sit in the seat and take some rest. This prevents aggravation and shortness of breath. Option 3: Forearm crutches are recommended for clients with permanent limitations. These cannot give proper rest to the client when there is shortness of breath due to walking or standing. Option 4: The client can stand with the support of a cane but it cannot prove to be helpful when the client has shortness of breath.

A student nurse is listing the nonpharmacological therapies used for pain management. Which therapy listed needs to be corrected? 1. Acupuncture 2. Maggot Debridement therapy 3. Contralateral stimulation 4. Guided imagery

Correct answer -Maggot Debridement therapy Option 1: Acupuncture involves the application of extremely fine needles on specific sites of the body to relieve pain. Option 2: Biotherapy or Maggot Debridement therapy involves the use of maggots to stimulate wound healing. This is a nonpharmacological measure performed for wound debridement and cannot be used for pain management. Option 3: Stimulating the area opposite from the painful site by scratching, rubbing, or applying heat or cold to reduce pain is known as contralateral stimulation. Option 4: Guided imagery therapy involves the use of auditory and imaginary processes to cure physical and psychological pain. It is effectively used in pain management.