Semester 3 final
16. A nurse is preparing to assess a new client's cognitive functions. Which areas will the nurse evaluate on the assessment? Select all that apply.
calculation language orientation recall
27 A cient who is receiving a benzodiazepine tels the nurse that their mouth feels really dry. Which suggestion woud the nurse inciude in the teaching plan for this client?
"Sucking on hard sugariess candy might help you."
22. A client, who wishes to preserve childbearing, asks the nurse to explain how taking oral contraceptives will work in the management of endometriosis. Which is the best response by the nurse?
"Symptoms of endometriosis are increased during normal menstrual cycle."
6. A nurse visits female victim of sexual assault for the fourth visit. The client expresses that she is unable to cope with the trauma Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?
"Tell me more about the aspects that make you feel as if it happened yesterday.
41. A student nurse asks the nursing instructor, "What will my role as a nurse encompass after I graduate?" What is the best response by the nursing instructor?
"You will care for individuals and families and play a role in health education, illness prevention, and promotion."
21. Most children who are diagnosed with acquired immunodeficiency syndrome (AlDS) are within which age range?
1 to 4 years of age
5. The nurse is assisting a 30-year-old client in scheduling an appointment for a cervical biopsy. The nurse would recommend that the client schedule the testing at which time?
1 week after completion of the client's menstrual cycle
9. A client receiving lithium is reporting nausea, vomiting, and dianhea. The nurse suspects lithium toxicity after noting which result on the blood lithium level?
1.6 mEg/L
6. The nurse is preparing a presentation for a health fair which will llustrate the development of a baby. The nurse should point out the fertilized egg is implanted in the endometrium by which day?
10
39. The 19-year-old client diagnosed with a severe herpes simplex 2 viral infection is admitted to the medical floor. The HCP prescribes acyclovir (Zovirax), an antiretroviral medication, 10 mg/kg VPB every 8 hours. The client weighs 220 pounds. How many milligrams will the nurse administer with each dose?
1000 mg
33. The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?
110 to 160 bpm
22. A nurse is explaining to a client about monthly hormonal changes. Starting with day 1 of the menstrual cycle, please place the following four hormones in the chronological order in which they elevate during the menstrual cycle.
2, 1, 3, 4
Rank in order performance 7. The client diagnosed with benign prostatic hypertrophy has had a transurethral resection of the prostate (TURP).
2, 4, 3, 5, 1
49. Which physical assessment data would the nurse find concerning and would warrant reporting to the physician?
A blood pressure of 128/80 in a preschool-aged child
45. The nursing supervisor has been notified of a large industrial fire with multiple injuries started with an electric short. When notifying the nursing peers, the nurse would classify this as which type of disaster
A human disaster, unintentionally caused
10. The nurse is discussing fertility issues Which statement indicates the couple is knowledgeable of fertility issues?
A multifetal pregnancy can result in preterm labor and birth."
9. A student nurse is studying clinical judgment theories and is working with Tanner's Model of Clinical Judgment. How can the student nurse best generalize this model?
A reflective process where the nurse notices, interprets, responds, and refiects in action.
50. In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse?
An individual with intellectual or developmental disabilities
notes pale skin and low normal hemoglobin on assessment. Which recommendation should 28. A pregnant client in her second trimester reports feeling tired all the time. The nurse the nurse prioritize for this client?
An iron supplement
49. A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient's condition, questions its appropriateness, and axamines altenative treatments. What is the nurse's best action?
Call the physician, explain rationale, and suggest a different medication.
17. The mother of an 8-year-old is concerned her child is developing too slawly when compared to a cousin. Which activities, based on Piaget's theories, would the nurse predict this child should be active in?
Can classify and organize information about their environment
2. The nurse is assessing a client who is prescribed an opiold analgesic. The nurse will monitor the client for which reaction if the client reveals the chronic use of aloohol?
Central nervous system depression
47. The nurse is caring for a group of clients at a public health clinic. Which sexually transmitted infection would the nurse focus the client education on curative goals?
Chlamydia
46. The nurse educator is developing a teaching plan to prepare nurses for a disaster situation. Which teaching method is best?
Conduct a simulation for the nurses to have a role as participants.
26. The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?
Cooperation by the parents with the hospital policies
12. People in Middle Eastern cultures do not drink milk after childhood. The nurse has provided yogurt for the client at mealtimes. This is an example of which approach?
Culturally congruent care
35. The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?
Darkened breast areolae
1. Veterans' hospitals are an example of which type of ownership?
Government-owned
34. What method for financing healthcare is based on the ability to keep clients healthy and out of the hospital through periodic screening, health education, and preventive services?
Health maintenance organization
3. A woman is noted to have multiple soft warts on her perineum and rectal areas. The nurse suspects that this client is infected with which of the following sexually transmitted infections?
Human papillomavirus (HPV).
19. The nurse is instructing a client on proper procedures to protect herself from sexually transmitted infections (STIS). Which statement, made by the client, needs clarification?
I consider myself protected because I am on birth control pills."
31. The 84-year-old female client is admitted with mutiple bum marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused?
The client is ashamed to admit being abused.
10. The nurse is collecting objective data on a 3-year-old child whose caregiver is present. Which action should the nurse prioritize at this point?
The nurse shows the caregiver the process for collecting a urine specimen and asks the caregiver to help the child.
22. The mother of 2-year-old triplets is anious and worried because one of the trio does would lead the nurse to question the need for further diagnostic testing for this child? not seem to be developing at the same rate as the other two. Which assessment finding
The tops of her ears are below the corners of her eyes.
24. The nursing instructor has completed a class discussion on the stages of AD. The instructor determines the class is succesaful when the students correctly choose which tactor as characteristic of preclinical AD
There are no cognitive changes noted
39. In an effort to cut costs, hospitals have instituted many changes. Which of these cost- cutting factors is most likely to jeopardize the qualilty of care?
Using unlicensed assistive personnel
30. A client with vaginitis complains of itching and burning of the perineum. Which suggestion would be most appropriate to relieve the client's symptoms?
VTake sitz baths frequently.
27. The nurse is interviewing a postmenopausal client during an annual gynecologic exam. Which assessment finding presents the greatest concern in the care of this client?
Vaginal bleeding
26. A client is brought into the emergency department by the rescue squad after involvement in a motorcycle accident with a severe spinal cord injury. What type of illness does the nurse view this event?
catastrophic
13. Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?
dopamine
18. A client with a fibroadenoma is being scheduled for diagnostic testing Which of the following would the nurse expect as most likely?
ultrasound
16 A nurse is caring for a client who has been prescribed a monoamine odase inhibitor MAOI Which food should the nurse instruct the client to avoid?
yogurt
12 A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she does not want to take the test and feels she should instead continue wMth the medication a little longer. Understanding that the client is anxious what is the most appropriate response by the nurse?
"Tell me more about how you are feeling."
16. . A newly delivered mother states, "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse?
"You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."
49. The 16-year-old female client tells the public health nurse that she thinks her boyfriend gave her a sexually transmitted disease (STD). Which statement by the nurse would be the best response?
"You need to have tests so you can be started on me dications now."
20. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
24 hour recall
should the nurse point out will be safe for this client with a low BMI? appearance and questions the nurse concerning dietary restrictions. How much weight gain 11. A client in her first trimester is concerned about how weight gain will affect her
28 to 40 pounds (13 to 18 kilograms)
7. A nurse is teaching an infertile couple about how the sperm travel through the man's body during ejaculation. Please put the following five major structures in order, beginning with the place where spermatogenesis occurs and continuing through the path that the sperm and semen travel until ejaculation.
3, 1, 5, 2, 4
44. A nurse must give vitamin K0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection?
5/8 inch, 25 gauge.
20. The client experiencing infertility is receiving menotropin (Pergonal), an ovarian stimulant, and human chorionic gonadotropin. Which diagnostic test would indicate the medications are effective?
A serum estrogen level.
5. A nurse worldng in a pediatric dlinic recognizes that which child is most at risk for cognitive Impairment?
A toddler living in an older home that is being remodeled
38. The 18-year-okt male cllent is dingnosed with gonorrhea of the pharynx The HCP has prescribed ceftriaxone (Rocephin), cephalosporin. Which intervention should the nurse implement?
Administer the medication intramuscularly in the gluteus muscle.
36. Which of the following would be most important for the nurse to include to ensure a thorough baseline history related to the reproductive system?
Age of menarche
29. The emergency department nurse writes the problem of "ineffective coping" for a client who has been raped. Which intervention should the nurse implement?
Allow the client to admit guilt for causing the rape
16. The nurse patted the head of the child after examining her but noticed her parents did not look pleased. In which of the following cultures ie touching the head Impolite?
Aslan American
13. The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?
Assess the Rh of the baby.
32. A female client is diagnosed with breast abscess. She would like to continue to breastfeed her newborn. Which of the following would be most appropriate in this situation?
Assist the client to pump the breasts to remove breast milk.
17. Which of the following instructions should a nurse provide a client with alcohol dependence who is prescribed disulfiram?
Avoid mixing disulfiram and alcohol.
45. Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply.
Choose rooms near stairwells. Ask questions about the routine of the unit. Wear over-sized clothing. Create a diversion on the unit.
30. A nurse is caring for a palient in a long-term care faclity who has not been sleeping well. She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the pationt has been having trouble adjusting. The nurse decides to meet wth the patient's care team. The team decides to assess the patient's willingness to participate in group recreational activilles, the patient agrees to participate. Alter 1 week, the nurse reevaluates the plan of care and notes that the pationt has been sleeping much better. Which of the folowing terms best describe processes used in the nurse's plan? (Select all that apply.)
Collaborative care planning The nursing process Clinical judgment
13. A client and partner are excited to discover they are expecting twins. The nurse is prepared to monitor the twins for which potential situation after noting they share an amniotic sac?
Cord entanglement
3. A nurse has administered an opioid to a client. Which activities should the nurse encourage the client to do?
Cough and breathe every 2 hours.
29. The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply.
Cystic fibrosis. Sickle cell disease. Galactosemia. Hypothyroidism
27. A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be golng on here. What is the best explanation for this statement?
Data on the chart can sometimes be documented In a blased manner.
30. A cient is receiving lithium and informs the nurse that they are also taking antacids for heartburn. The nurse would be alert for which reaction?
Decreased effectiveness of lithium
19. Which of the following is a purpose of affective touch in the context of nursing?
Demonstrating concern
1. Which of the following would the nurse expect to be done to assess the size of the prostate?
Digital rectal examination
49. Which of the following is least effective in encouraging a client to followa medication regimen?
Discuss perspective from the nurse's personal experience.
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7°F (36.5°C), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize?
Document normal findings.
28. The nurse notes a client with AD and receiving a cholinesterase inhibitor is losing weight on the ongoing assessment. Which action will the nurse prioritize when providing care to this client?
Encourage careful chewing.
39. The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents?
Encourage the parents to pick up the baby
42. Which of the following recommendations would a nurse advocate during infancy and childhood to help reduce potential adult complications such as orchitis?
Ensure immunizations against infectious diseases such as mumps.
11. The nurse is assessing a 5-year-old boy in the presence of his parents and notes they are concerned he is learning bad habits by 'playing with himself. They ask the nurse for the best punishment to address this issue. Which theorist should the nurse reference when answering their question to help the parents address this issue and ensure they are providing the child with the best attitude toward his body and sexuality?
Erik Erikson
43. A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as:
Five babies less than 28 days old per 1,000 live births died died.
5. A woman has contracted herpes simplex2 for the first time. Which of the following signs/symptoms is the client likely to complain of?
Flu-like symptoms
21. A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet?
Fortified cereals
43. A client with a normal prostate-specific antigen (PSA) level is reporting painful urination and the presence of blood in urine and semen. The nurse understands that the best option for management of this client includes which of the following?
Further evaluation
40. As part of the first prenatal visit, the nurse is assessing a pregnant woman's obstetrical history, which includes an 18-month-old daughter, born 2 days after her estimated date of birth; a 3-year-old son born at 35 weeks' gestation; and two lost pregnancies, one at 12 weeks and one at 21 weeks. How should the nurse document this history?
G5 T1 P2 A1 L2
31. The 18-year-old female client has been diagnosed with genital warts and has been treated with cryotherapy with liquid nitrogen, a freezing agent, on the external genitalia. Which discharge information should the nurse teach?
Gently cleanse the perineum with a squirt bottle and tepid water after urinating.
24. The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The clent has refused to leave her husband or to press charges against him Which action should the nurse
Give the woman the number of a women's shelter.
9. A nurse is dolng a newborn assesement on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply.
Grasp the baby's legs with the thumbs on the Inner thighs and forefingers on the outer thighs. Gently adduct and abduct the baby's thighs. Compare the lengths of the baby's legs. Palpate the trochanter during hip rotation.
48. The nursing instructor is leading a discussion on the theories of Sigmund Freud with a group of nursing students. The instructor determines the session is successful when the students correctly choose which example as indicating a child is in the anal stage of development?
Has a desire to mold and control the environment
1. A nuree has committed a serious medication error and has reported the error to the hoepitale adverse medication error hotline es well as to the unit manager. The manager is a firm belever in developing crilical thinking sklls. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error?
Have the nurse present an in-servilce related to the cause of the error.
23. The parent of a newborn angrily asks the nurse, Why would the doctor want to give my baby the vaccination for hepatitis B? It's a sexually transmitted disease, you know" Which of the following is the best response by the nurse?
Hepatitis B can be a life-threatening infection that is contracted by contact with contaminated blood as well as sexually."
45. A nurse finds that a client has infiltration around the Mline that needs to be removed. What explanation should the nurse give to reduce the client's andety?
I know that you are anxious, but removal will be painless and the IV location needs to be changed."
27. The lactation nurse is caring for a mother who is 2 weeks postpartum and has mastitis. Which statement, made by the client, requires instruction and is the probable cause of the mastitis?
I nurse the baby on one breast each feeding."
45. A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?
I will let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."
32. Which of the following client statements indicates successful teaching of a client who is scheduled to have a Pap test?
I will stop using any vaginal medications at least 48 hours before the test.".
23. A 2%-year-old boy is being seen by the primary health-care provider for a well-child checkup. Which of the following statements by the mother would indicate a need for teaching?
I worry that Johnny will get too close to the hot oven, so I put him in his playroom and have him play by himself with his toys while I'm making dinner."
21. A group of nursing students are examining information about antidepressants. The drugs as an example of a serotonin/norepinephrine and dopamine/norepinephrine reuptake instructor determines the session is successful when the students correctly choose which inhibitor? Select all that apply
Imbalanced Fluid Volume
50. Which nursing theorist stated that clients are open systems in constant interaction with their environment?
Imogene King
9. Which type of length of stay includes emergency department visits?
In-and-out care
18. A cient with aniety is prescribed anxiolytic therapy. Before administering the drug. which symptonms of anxiety would the nurse expect to find on the preadministration assessment?
Increased blood pressure
An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be ethibited by the patient?
Increased confusion
48. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement?
Leave a night light on in the room at all times.
25. The nurse is working with a group of caregivers of chiidren diagnosed with asthma. Which statement made by the caregivers is most accurate regarding the triggers that may cause an asthmatic attack?
My sister and her family love animals, and when we go to their house my daughter always has an asthma attack."
41. A cient is receiving an opioid analgesic. Assessment reveals that the respiratory rate has dropped. Which steps would the nurse expect to implement? Select all that apply.
Naloxone administration Coaching of the client to breathe
32. The hospital is having a problem with healthcare-associated infections. A committee has been established to study the problem and make recommendations. The nurse working on the committee knows that this work addresses what?
National Patient Safety Goals
33. The nursing instructor discussed the theory of energy forces exsting between organisms and objects in the universe and called this yin-yang. Yin-yang is an example of which societal view of illness?
Naturalistic perspective
2. A religious organization is an example of this type of ownership?
Nonprofit agency
44. A pregnant woman at 38 weeks' gestation is receiving care for preeclampsia and the nurse notes a firm, distended and painful abdomen and dark red vaginal bleeding? suddenly complains of sharp abdominal pain Which action should the nurse prioritize if
Obtain a full set of vital signs
6. A patient has been admitted for a skin graft following third degree bums to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan?
On admission, along with the initial assessment
10. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct?
Once the dehydration is corrected, the patient's confusion should improve."
30. A student nurse is preparing an illustration for a health fair depicting the various types of twins. Which format will the student use to depict identical twins?
One egg and one sperm
8. The nurse is caring for a breastfeeding client who has developed a breast abscess. When instructing on the cause of abscess formation, which organism is the most common cause?
Staphylococcus aureus
19. At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment the client is dilated to 4 cm with contractions every 1 minute and increased signs of fetal distress. What action should the nurse prioritize after noting the time is now 1200 hrs?
Stop the oxytocin infusion.
2. A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?
Tell me more about how it feels to eat with your family."
4. The LPN is caring for clients at the hospital's medical unit. What role does the LPNLVN have in the care of clients on this unit?
The LPN/LVN may provide care to clients who have a well-defined, common problem.
48. An LPN says to an RN, "I don't understand why I get pald less, yet we do the same thing here at work." What role does the RN have in the healthcare setting that the LPN does not?
The RN's role is more complex and involves management and coordination of all the care provided to a group of clients.
A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate?
The baby will urinate 6 to 10 times per day by 1 week of age.
7. Which situation should the nurse explore for possible emotional abuse of the child by the caregiver?
The caregiver of a 12-year-old reports, "Im sorry we missed Jamal's appointment last week, but he was supposed to remind me to come."
4. Which reaction would a nurse expect when giving a preschooler immunizations?
The child cries and tells the nurse that it hurts.
3. A client with chronic obstructive pulmonary disease visits a local long-term care facility once a week to lead a bingo game for the residents. How does the nurse determine that this client is achieving a high level of wellness?
The client is achieving a high quality of life within the limits of her illness.
14. The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order?
The neonatal gut is sterile.
18. The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choloes. The patllent states that they enjoy exerclsing and understand the need to diet; however, they can't see living without chocolate on a daly basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching?
The nurse examines the patient's daily glucose log and Incorporates the snack Into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.
1. The nursing instructor is illustrating the circulatory flow between the mother and fetus. The instructor determines the session is successful when the class correctly chooses which structure with which route?
The one umbilical vein carries oxygen-rich blood to the fetus from the placenta.
37. The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications?
The patient prescribed a beta-blocker for hypertenslon.
25. Which medications are capable of CNS depression, hypnosis, deep coma, respiratory depression, and prescribed infrequently?
barbiturates
23. The nurse is caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms The nurse knows that these clients would be classed as being victims of which of the following?
biologic disaster
4. The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
bladder distension
34. The nurse is assessing a 37-year-old woman, pregnant with twins in her second trimester, and notes the following over the past 3 visits: blood pressure 128/88, 134/90, and 130/86. Which nutritional supplement should the nurse suggest the client take?
calcium
15. Which type of learner processes information more adequately by listening or reading facts?
cognitive
47. A cient with AD is prescribed. Which finding on assessment should the nurse prioritize?
confusion
28. An older man has been sick for 3 weeks but will not seek medical help even though he is able to get to the doctor's office. The client does not know what his insurance will cover. The client has many medical bills from treatments not covered and does not want to be faced with more. Why is this client waiting to obtain medical treatment?
cost
31. The unlicensed assistive personnel was reluctant to allow the Muslim client room for a prayer rug in her room. The inability to recognize the values, beliefs, and practices of others because of strong ethnocentric preferences is which of the following?
cultural blindness
35. Which of the following is a process by which the nurse consistently works in the cultural context of the client, family, and community?
cultural competence
35. The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulfate. What chemical agent does the nurse know this client has been exposed to?
cyanide
36. Which of the following interventions should a nurse recommend for fostering effective coping skils and a sense of hardiness?
dally exercise
21 Which pharmacologic agents pose the greatest risk for urinary retention in a client with benign prostatic hyperplasia (BPH)?
decongestants
31. The nurse is calling to report to the emergency room from a long-teem care facility. The nurse states that the client abnuptly experienced a change in mentation including disorientation and confusion. Vital signs are tenperature, 1022 pulse rate, 88 beats/minute respiratory rate, 24 breathsminute and blood pressure 152/70 mem H Lungs are clear. Which potential dagnosis woud the anergency room physician place in the initial documentation?
delirium
21. Following a long binge of intense alcohol consumplion, the client is now experiencing symptoms of withdrawal. Which nursing assessment finding is most indicative of Korsakoffs psychosis?
dementia
39. Which of the following conditions triggers the general adaptation syndrome?
distress
correct to corelate the client's uncontrolled tremors as a physical characteristic of a lack of 15. The nurse is caring for a client diagnosed with Parkinson's disease. The nurse is most which neurotransmitter?
dopamine
8. A nursing instructor is teaching a class on the varlous antipsychotic drugs. The instructor delermines the class is successful when the students correctly choose which receptors as the target of antipsycholic medications? Select all that apply.
dopamine serotonin
26. The nurse is assessing a client who has been prescribed haloperidol. Which assessment findings should the nurse prioritize? Select all that apply.
dystonia fine tremor akathisia
35. A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which qualily should the nurse use in this situation?
empathy
46. The nurse enters the client's room and assesses that the client's affect appears sad. The client is sitting near the window, staring into the distance with a tear in the eye. The nurse approaches and places a hand on the client's shoulder asking for the client's thoughts. What type of emotion is the nurse projecting?
empathy
27. Which of the following is a reason why silence is considered therapeutic?
encourages a client's verbal communication.
22. Native Americans who are wearing their tribal dress are demonstrating their native dance to a community group. This is an example of which of the following?
ethnicity
38. An elderly Japanese client refuses the care provided by a Korean-born nurse. The outcome of this nurse-client assignment could be attributed to which cultural concept?
ethnicity
5. Which of the following is the belief that one's values and beliefs are superior to others?
ethnocentrism
7. Which stage of tobacco dependence occurs when a person uses tobacco sporadically?
experimentation
15. The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago. Although the client insists she is not pregnant due to a negative home pregnancy test, which assessment should the nurse prioritize to assess for a possible pregnancy?
fetal heartbeat
29. Which setting has been the traditional site for the nursing work force?
inpatient units
34 A nurse is caring for a clent wth depression The nunse finds that the clent is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?
is that a new shirt you're wearing?"
40. A nursing instructor is teaching a group of students about sedatives and hypnotics The instructor determines the class is successful when the students correctly choose which situation as necessitating cautious administration?
lactation
49. The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which of the following?
lymphedema
6. Which nursing assessment finding is most significant in determining the plan of care in a client with erectile dysfunction?
medication use
37. A client is struggling with symptoms of irritability and "feeling crazy at times. Which assessment data would provide the most important information needed in the development of a treatment plan for this client?
menstrual diary
41. Which level of anxiety is constructive and prepares a person to take action in appropriate situations?
mild
33. The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. They are discussing various disorders related to the integumentary system. One of the nurses describes a disorder by telling the group that it is common in children during the summer when it is hot or when the child is overdressed. Which disorder is the nurse most likely referring to?
miliaria rubra
12. Anurse is assossing a client who has a known history of subetance abuse. Which signs and symptoms should the nurse prioritiae? Select all that apply.
mydrlasis tachycardia
17. Which of the following types of condoms is appropriate only if the client is in a long- standing monogamous relationship?
natural membrane condom
29. The nurse is taking a class on chemical disasters with the local emergency response team, What toxins would the nurse be learning about? Select all that apply.
nerve agents blistering agents cyanide
18. Which of the following is a component of nonverbal communication?
paralanguage
9. A group of nursing students are preparing a presentation which will illustrate various components of the birthing process. When presenting the pelvis, the students should point out that it is often referred to as which term?
passageway
12. A nurse is educating a parent regarding the immunizations that a child is to receive during the first year of life. Which of the following immunizations did the nurse discuss?
polio
questioned by the nurse, the woman denies any problems have is the most probable reason the woman denies being abused? 32. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching it the student responded that family assessment is used to gain an understanding of which aspect of the family?
political views
11. A client complaining of bloody urine has scheduled an appointment with a family practitioner. What type of care is the client receiving?
primary
24. A client presents with symptoms of menstrual difficulties and infertility. Which hormone is essential in the maintenance of the endometrium?
progesterone
46. A cient is diagnosed with post-traumatic stress disorder (PTSD). The client is exhibiting withdrawal and ignoring problem and issues. This in recognized an which of the following?
psychic numbing
37. The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus?
supine
31. Which of the following infections is often contracted by having contact with an infected dog or cat?
tinea corporis
50. Which of the following refers to the reduction in a drug's effect that follows persistent use?
tolerance
32. The nurse is doing discharge teaching for a child who has had a tonsillectomy. The nurse tells the client and family that the child should have plenty of fluids. In addition, the nurse would explain to the child's caregiver that the child may:
vomit dark, old blood, but the caregiver should call the clinic if the child has bleeding between the fifth and seventh days postoperatively.
31. A woman has been diagnosed with pelvic inflammatory disease (PID). Which of the following organisms are the most likely causative agents? Select all that apply.
🔘Neisseria gonorrhoeae. 🔘Chlamydia trachomatis.
16. Which statements related to sexual dysfunction are correct? (Select all that apply.)
🔘The best predictor of sexual health is emotional well-being. 🔘The patient with sexual dysfunction is at risk for anxiety and depression.
49. The nurse is performing an assessment on a new client and suspects major depression based on which finding? Select all that apply.
🔸Feelings of hopelessness 🔸Excessive guilt 🔸Loss of energy
Which would the nurse identify as a common early reaction to this group of drugs? Select 48. Alter adminestering an aroiolytic, the nurse assesses the clent for adverse reactions al that apply
🔸dizziness 🔸lightheadedness 🔸sedation 🔸headache
42. After toaching a group of nursing students about benzodiampines, the instructor determines that the teaching was successful when the students correctly choose which drugs as an example? Select all that apply.
🔸lorazepam 🔸alprazolam 🔸chlordiazopoxide
46. The nurse is providing counseling to a group of sexually active single women. Most of the women have expressed a desire to have children in the future but not within the next few years. Which of the following actions should the nurse suggest the women take to protect their fertility for the future? Select all that apply.
🔺Refrain from smoking cigarettes. 🔺Maintain an appropriate weight for height 🔺Exercise in moderation. 🔺Use condoms during intercourse.
20. A nurse suspects that a client who is receiving lorazepam may be experiencing benzodiazepine withdrawal based on which assessment finding? Select all that apply.
🔺metallic taste 🔺tremors 🔺anxiety
14. A client who reports they are unable to sleep is presoribed a hypnotic. The nurse explains that the insomnia may be related to which factors? Select all that apply.
🔺stress 🔺chronic pain 🔺hospitalization
37. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, Chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the healthcare practitioner?
Ortolani sign.
32. An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion?
Pain medication recieved earlier in the night
11. Following morning hygiene of an elderly client, the nurse is unable to replace the retracted foreskin of the penis. Which is the most likely outcome?
Painful swelling
11. The nursing instructor is discussing with the students about botulism The instructor tells the students that when caring for a client wth botulism, what condition is most likely to cause dealh?
Paralysis of respiratory muscles
42. A client with severe chronic pain is to receive an opioid analgesic agent. The nurse will monitor the client for signs of tolerance which can develop at different rates related to which factors? Select all that apply.
Route of administration Dosage
29. An infertile woman has been diagnosed with endometriosis. She asks the nurse why that diagnosis has made her infertile. Which of the following explanations is appropriate for the nurse to make?
Scarring surrounds the ends of your tubes, preventing your eggs from being fertilized by your partner's sperm."
47. The nurse is assessing a client at her first prenatal visit and reports her LMP started December 1. Which date will the nurse predict for the EDD?
September 8
14. The nurse is caring for a client who states having an irregular menstrual period. Which diagnostic test provides information of the body's ability to ovulate?
Serum follicie-stimulating hormone
that this client is at highest risk for the development of which of the following? Select all that sexual engagement. chlamydia infection, and treatment for gonorrhea. The nurse knows 45. While collecting data on reproductive history, the client discloses early menarche, early apply.
Sexually transmitted infections Cervical cancer
42. R is predicted that by 2080, Caucasians will be a minority in the United States. Which statement best illustrates the correct assumption of the nurse regarding minority groups in the United States today?
Society views minority groups as having less influence and power.
14 The emergency department nurse is working triage during a disaster, Why should the nurse tag a victim after assessment in a disaster situation?
Someone else does not duplicate the assessment.
30. Which statement by the client indicates that she understands the teaching provided about the intrauterine device (IUD)
"The IUD can remain in place for a year or more."
10. A client admitted for insomnia related to stress is prescribed a sedative. Which actions would the nurse include in the plan of care to promote the effectiveness of the drug?
Provide back rubs.
42. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA?
Provide discharge teaching to the mother of a 4-day-old baby.
30. While providing personal care for a client, the nurse observes that the client is not comfortable with the close physical proximity. How will the nurse alleviate the discomfort of the client during personal care?
Provide simple explanations of the need for physical proximity.
22. Which of the following is a nurse's role in providing nutritional support to clients in their final stages of Alzheimer's disease?
Providing gastrostomy tube feedings
14. Which of the following is one of the four categories of client needs identified by the National Council of State Boards of Nursing?
Psychosocial integrity
25. Which of the following describes the role of the nurse as defined by Florence Nightingale?
Putting the client in the best condition for nature to act upon him or her
36. Since losing his right leg years ago, the client and his wife have formed a community walking group to raise money for the homeless in his area. Which of these has contributed to him being viewed as "healthy"?
R The cllent is experlencing high quality of life within the limits of the physical condition
38. The nurse in a pediatric clinic is caring for a 9-year-old girl who has been diagnosed with gonorrhea. Which of the following actions is appropriate for the nurse to take?
Report the girl's medical findings to child protective services.
34. The caregiver of a client with AD who is receiving cholinesterase inhibitor therapy reports several falls with more apparent clumsiness up at night multiple times; a fair appetite and compliance with medication regimen. When developing the care plan, which nursing diagnosis should the nurse prioritize?
Risk for Injury
25. The nurse is instructing a health class on the proper use of a condom. Place the steps of applying a condom in the proper order. Use all options.
B, A C. E, D
diagnosed with prostatitis. The nurse understands that which 26. A client who comes to the clinic complaining of perineal pain, dysuria, and fever is of the following organisms would be the most likely cause?
Escherichia coli
13. A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit. She asks the nurse why she has never been able to get pregnant. Which response is best?
Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in Infertility.
23. The nurse is assessing a breastfed infant at a well-child visit and determines the child is lethargic and losing weight. Which assessment question should the nurse prioritize?
"Are you currently taking any medications?"
46. A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse's best response is:
"At 6 months his weight should be approximately twice his birth weight."
29. The nurse is providing teaching to a client who is scheduled for a mammogram. Which of the following would the nurse include as a way to avoid artifacts on the x-ray film?
"Avoid using a deodorant with aluminum hydroxide."
8. A client with anxiety has informed the nurse they no longer want to take the benzodiazepine. What is the best response from the nurse?
"Be sure to gradually decrease the dosage over time."
19. The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is?
"It estimates a child's level of pain utilizing behavioral and physical responses."
15. A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be?
"It is recommended that powder not be put on babies."
9. The nurse is completing community education when asked by a client without health insurance why a mammogram is needed if the women are completing breast self- examinations at home. The nurse is most correct to respond stating which of the following?
"Mammograms can detect cysts or tumors too small to palpate."
19. The nurse is instructing a community education class on stress. The nurse asks the participants, "is al stress bad for you? Which answer, by the participants, is most accurate?
"No, the right amount of stress can be motivating to accomplish goals."
38. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response?
"There is no treatment that reverses dementia."
28. The nurse planning to assess the structure of a family should ask which question?
"Who lives with you in this home ?"
2. A woman, whose menstrual cycle is 35 days long, states that she often has a slight pain on one side of her lower abdomen on day 21 of her cycle. She wonders whether she has ovarian cancer. Which of the following is the nurse's best response?
"Women often feel a slight twinge when ovulation occurs."
3. A nurse is examining a 3-year-old child with conjunctivitis. During the examination, the child starts crying and refuses to sit still. Which statement is appropriate for the nurse tell the child?
"Would you like to see my flashlight?"
5. After teaching a client who is prescribed lithlum about the drug, the nurse determines that the teaching was successful when the client states which comment?
1 should take the drug with food."
34., The client diagnosed with benign prostatic hypertrophy has had a transurethral resection of the prostate. The client returns to the unit with a continuous bladder irrigation (Murphy drip) in place. The unlicensed assistive personnel records emptying the catheter bag of red drainage three times during the shift of 1500 ml, 2100 mL, and 1950 ml. The nurse records infusing 4100 ml. of normal saline irrigation fluid. Which is the client's corrected urinary output for the shift?
1450 mL
50. The LPN is preparing to assist the RN with the initial admissions assessment of the newborn. The nurse should explain to the new mother that this will be completed in what time frame after birth?
2 hours
17. A woman is to receive 2.4 million units of penicillin G benzathine IM to treat syphilis. The medication is available as 1,200,000 units/mL. How many ml should the nurse administer?
2 mL
4. A client who is prescribed a hypnotic asks the nurse, "About how long wt I be taking this medication? Which time frame would the nurse most likely indlude in the response?
2 weeks
6. The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on?
Acceptina the preanancv
24. A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?
Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications.
36. The dermatologist treating a 16-year-old girl with a history of severe acne has ordered a pregnancy test so she can be started on a course of isotretinoin. The teen's caregiver has said that her daughter is a virgin and she refuses to allow her to have the required pregnancy testing. What would be the best action for the nurse to take?
Acknowledge the caregiver's discomfort about the pregnancy testing but encourage her to allow the daughter to have the testing so that she can use the medication.
33. Clinical manifestations of methamphetamine use include which of the following?
Acne
28. A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
Baby is showing signs of hunger and frustration.
43. Building trust is especially critical to developing a therapeutic relationship with an anious client. Which of the following interventions contributes to this trust?
Be available and attentive to the client's requirements.
41. The nurse has completed an assessment on a 1-day old newborn. Which finding should the nurse prioritize?
Blood sugar 42 mg/dL
43. A woman is menstruating. If hormonal studies were to be done at this time, which of the following hormonal levels would the nurse expect to see?
Both estrogen and progesterone are low.
38. The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the cient is resting?
Call the cllent's name to awaken him or her, but don't touch the client.
22. Which type of therapy assists the clients to allter their irrational thinking?
Cognitive Therapy
43. Which of the following is a client responsibility in the nurse-client relationship?
Comply with the therapeutic regimen.
21. Freestanding apartments are an example of which type of alternative healthcare setting?
Congregate housing
40. A nurse has designed an individualzed nursing care plan for a pallent, but the patilent is not meeting goals. Further assessment reveals that the patient is not following through on many itema. Which action by the nurse would be best for determining the cause of the problem?
Determine whether the patient agrees with the care plan.
27. A mother tells the nurse that it is difficult to get her 4-year-old child to bed at night. Which of the following should the nurse suggest that the mother do?
Develop a bedtime routine that is followed every night.
36. A new nurse appears to be second-quessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient's behalf. This seems to be annoying some of the nurse's coworkers. What is the nurse manager's best response?
Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills.
46. The client is asking if there is a pill that can be ordered to control the symptoms of menopause. Which assessment finding is most important in determining nursing care in association with hormone replacement therapy?
Family history of breast cancer
35. Culture of client's vaginal discharge reveals Gardnerella vaginalis. Which of the following would the nurse expect to assess?
Fishy smelling watery discharge
8. A 9-year-old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that says "No boys allowed" printed on it. The child's parents are concerned that she is excluding their neighbor's son, and they are upset. What should the school nurse tell the child's parents?
Her behavior is common among school-age children.
44. Which type of sexually transmitted infection is the nurse most accurate to highlight in the client's history as it remains dormant in the body and can reoccur at any time?
Herpes infection
47. Which type of care is used for clients with terminal illness who have a life expectancy of less than 6 months?
Hospice care
15. A group of students are reviewing class material on sexually transmitted infections in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as the cause of condylomata?
Human papilloma virus
12. A client with a history of HSV-2 infection asks the nurse about future sexual activity. Which of the following responses would be most appropriate?
Inform all potential sexual partners about the infection, even if it is inactive."
10. A woman at 9 weeks' gestation is admitted to the obstetrical unit for hyperemesis gravidarum. Which action should the nurse prioritize immediately?
Instruct on NPO status
40. A school nurse is providing an education session for parents of high school students. Which of the following information should be included in the teaching session?
It is important for teens to catch up on their sleep on weekends.
41. When describing sexually transmitted infections and testing, the nurse explains that a client is typically tested for chlamydia, gonorrhea, and syphilis at the same time for which reason?
It is not unusual for clients to have concurrent infections with more than one sexually transmitted Infection (STI).
41. A client who is uncertain when her LMP occurred is given an EDD of April 23 after the first ultrasound. Based on this information, the nurse determines the client's LMP was probably which day?
July 16
47. The nurse identifies the family with a child graduating from college as being in which family lfe cycle?
Launching children and moving on
24. The nurse is leading a cardiac rehabilitation support group. How can the nurse best demonstrate meeting the clients need holistically?
Lead an exercise, show a video about healthy lifestyle changes, and invite a spiritual leader to talk with the group.
37. Which of the following is a person's intellectual ability to remember and apply new information?
Learning capacity
8. The nurse is preparing the female client for a pelvic examination. In which position will the nurse assist the client?
Lithotomy position
18. A group of camp nurses is discussing various types of tick bites. One of the nurses states that deer ticks are carried by white-footed mice and white-tailed deer, and can carry the organism that causes which disease?
Lyme disease
16. When a nurse is teaching a woman about her menstrual cycle, which of the following is the most important change that happens during the follicular phase of the menstrual cycle?
Maturation of the graafian follicle.
7. A client informs the nurse that she is a single parent with four children and cannot afford to pay for medical insurance for her and her family. What coverage does the nurse understand this client and her family may be eligible for?
Medicaid
3. During a class for caregivers of children with asthma, a caregiver asks the nurse the following question when medications are being discussed. "They told about a plastic device my child can hold in his a hand which will give him a premeasured and exact amount of his corticosteroid." The nurse recognizes that the caregiver is most likely referring to which device?
Metered-dose inhaler
33. The nurse is presenting a poster at a workshop and includes information from a new emerging area of medicine called psychobiologic disorders. The nurse is most correct to state that this area links which of the followng?
Mind and body
50. A nurse is preparing an in-service presentation about hypnotics. Which factor would the nurse plan to include?
Most likely administered at bedtime
1. Clients with obsessive-compulsive disorder (OCD) may be concermed about which of the following signs and symptoms?
Performing ritualistic behaviors
19. Which of the following assessment findings is observed in a clent with opiate use?
Pinpoint-sized pupils
44. The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit?
Plan for a structured daily routine of events and caregivers.
44. Which of the following concepts characterizes transcultural nursing?
Planning care compatible with the client's health belief system
1. A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta
13. Managed care organizations are insurers that carefully plan and closely supervise the distribution of healthcare services. What i s one of the goals of managed care?
Preventing illness through screening and promotion of health activities
48. A woman's temperature has just risen 0.4"F and will remain elevated during the remainder of her cycle. She expects to menstruate in about 2 weeks. Which of the folowing hormones is responsible for the change?
Progesterone
33. A nurse is employed by a fertility clinic. Diagnostic testing is being completed to determine the source of the male not producing viable sperm to enable ovum fertilization. Which male structures does the nurse consider if the problem is narrowed to sperm survivability?
Prostate gland
13. Which assessment finding is most important in determining nursing care of a client withdrawing from cocaine?
Suicide precautions
2. An instructor is teaching a group of students about the incidence of sexually transmitted infections (STIS) and those that must be reported by law. The instructor determines that the students have understood the information when they state that which STI must be reported?
Syphills
17. Which of the following is a positive interpretation of body language?
TIlt of head
23. A client with syphilis did not receive treatment and has now progressed into the tertiary stage of the disorder. Which of the following would the nurse expect the client to exhibit?
Tabes dorsalis, blindness, and Charcot's joints
48. Which instruction should the nurse discuss with the client who is prescribed oral contraceptives for birth control?
Take a missed pill as soon as you realize you have missed it.
39. A cient who has been receiving treatment for psychosis presents to the clinic for follow up. On assessment the nurse discovers the client is currently displaying rhythmic, involuntary facial movements to include chewing-like movements and tongue protrusion. The nurse interprets these findings as an indication of which disorder?
Tardive dyskinesia
28. A client with primary syphilis is allergic to penicillin. The nurse would expect the physician to order which agent?
Tetracycline
11. The nurse writes a nursing điagnosis of "risk for injury as a result of physical abuse by spouse" for a client. Which is an appropriate goal for this client?
The client will admit the abuse is happening and get help.
40. Which of the following describes the goal of alternative care facilities?
The facility provides the least restrictive living arrangement.
39. The nurse is monitoring the client's vital signs and notes: 100.2°F (37.9°C), heart rate 82, respiratory rate 17, and blood pressure 124/78. What is the best response when the client's partner asks if she is getting sick?
The fever may be due to the epidural."
37. Which of the folowing is a true statement regarding a panic disorder?
The first instinct is to escape to a safer place.
8. Which of the following means of comprehending new information best describes a cognitive learner?
The learner processes information by listening to facts.
36. The client arrives at a public health clinic worried that she has breast cancer since finding a lump in her breast. When assessing the breast, which assessment finding is characteristic of fibrocystic disease?
The lump is round and movable.
26. A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."
24. In interacting for several days with a dying child, the nurse realizes that the child has not mentioned death. There are some dead flowers in a vase on the child's window sill. The child looks at the flowers and says, "Did they die?" Which statement would be most appropriate for the nurse to make to give the child an opportunity to open up and talk about dying?
These flowers are dead now. What do you think it would be like to die?"
4. The client is prescribed a 28-day oral contraceptive pack. Which statement best describes the scientific rationale for this birth control product?
This ensures that the client will take a pill every day.
38. A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding?
Tickling the baby's lips with the nipple.
26. A client complains of having tender and painful breasts, often feeling multiple lumps within her breast tissue. The nurse would need to gather additional information about which of the following?
Timing of symptoms in relation to the menstrual cycle
50. Which of the following sexually transmitted infections is characterized by a foul smelling, yellow-green discharge that is often accompanied by vaginal pain and dyspareunia?
Trichomoniasis
44 A nurse is caning for arn older adult clent. What strategy should the nurse include in order to facilitate effective communication?
Use active listening during communication
3. Following a vasectomy, which is the most important instruction to provide to the client?
Use another form of birth control until further notice.
40. Which of the following would be most important to include in a teaching plan for a client who has had a vasectomy?
Using reliable method of contraception for several weeks
18. A client is ordered a vaginal cream for the treatment of a yeast infection. As the nurse provides instruction, which step for inserting vaginal medications should be highlighted?
Wash applicator after each use.
47. The nurse is preparing to assess the pulse on a newborm who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?
Wear clean gloves.
25. During a follow-up visit, a female client who underwent a mastectomy presents with an infection that requires an antibiotic She admits she has been doing some gardening. What further instruction and reinforcement of teaching is needed?
Wear gloves and protective clothing to avoid any injuries.
35. Which should the nurse recommend to the parents of a 9-year-old hospitalized following a bicycle injury? To prevent future injury, their child should:
Wear safety equipment while riding bicycles.
14. A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client?
With a pillow under her right hip
23. Advocacy and support are activities associated with which learning style?
affective
25. A client presents for a follow up visit and reports they have stopped taking chlorpromazine because "they don't like the way it makes them feel and after 5 weeks they should feel better." Which assessment finding should the nurse anticipate noting? Select all that apply.
anhedonia delusions dystonia hallucinations flattened affect
12. A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia instead of an epidural. Which medication will the nurse prepare to give the client first?
antacid
2. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to
anticipatory guidance.
20. The nurse is caring for a client with a hearing difficulty. The nurse is in the room during client and physician discussion and will relate the information to the client's power of attorney. Which term best describes the role the nurse is assuming?
caregiver
20. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, Including
functional status
34. The nurse is caring for a child diagnosed with Hepatitis B. Which system is most likely to have complications from this diagnosis?
gastrointestinal
45. A 17-year-old client is having protected sex one to two times a week in a monogamous relationship. What is the client participating in?
health maintenance
10. The nurse le providing a program at the local YMCA about stro00-reduction techniques combined with a 1-mile walk around the indoor track once a week. What does this type of program address for the community?
health promotion
42. The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize?
hemorrhage
4. The nurse caring for victims of a volcano eruption knows that this disaster is categorized as a natural disaster. What is the other category of disaster?
human
15. The nurse is caring for dlients in the emergency department who have been admitted from the area surrounding a nuclear power plant. There had been a small eoplosion at the plant, and a small amount of radiation had escaped. The nurse knows that this is what type of a disaster?
radiologic
17. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to
role model appropriate support.
43. Anurse is preparing to teach a client about the prescribed clozapine. Which potential adverse effects would the nurse prioritize for the client to report? Select all that apply.
sore throat wekness chills fever
6. Which of the following refers to a group that shares characteristics identifying the group as a distinct entity?
subculture
