NCSBSN Study Questions PART 5
What is the best way for the nurse to obtain the health history of a 14 year-old client? A) Have the mother present to verify information B) Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent D) Focus the discussion of risk factors in the peer group
B
The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A) review the medications the client is receiving B) increase the formula infusion rate C) increase the amount of water used to flush the tube D) attach a rectal bag to protect the skin
A
A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement? A) Have respiratory support equipment available B) Immediately place her in the seclusion room C) Assess the client for anxiety and agitation D) Administer prn dose of IM antipsychotic medication
A
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis? A) Low hemoglobin B) Hypernatremia C) High serum creatinine D) Hyperkalemia
A
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate? A) Retractions in the intercostal tissues of the thorax B) Chest pain aggravated by respiratory movement C) Cyanosis and mottling of the skin D) Rapid, shallow respirations
A
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? A) High Fowler's B) Supine C) Left lateral D) Low Fowler's
A
A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority? A) Counsel the woman to consent to HIV screening B) Perform tests for sexually transmitted diseases C) Discuss her high risk for cervical cancer D) Refer the client to a family planning clinic
A
A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that the most likely reason for the HSV-1 infection in this client is A) immunosuppression B) emotional stress C) unprotected sexual activities D) contact with saliva
A
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate? A) bronchial breath sounds in outer lung fields B) decreased tactile fremitus C) hacking, nonproductive cough D) hyper-resonance of areas of consolidation
A
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts? A) They occur about 2 years earlier than for males. B) They begin about the same time for males. C) They begin just prior to the onset of puberty. D) They are characterized by an increase in height of 4 inches each year.
A
A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent? A) Age of the child B) Sibling position in family C) Stressful family events D) Parental discipline strategies
A
A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse? A) elbow B) mummy C) jacket D) clove hitch
A
Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects? A) Red reflex test B) Visual acuity C) Pupil response to light D) Cover test
A
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A) Arrange to change client care assignments B) Explain that this behavior is expected C) Discuss the appropriate use of "time-out" D) Explain that the child needs extra attention
B
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball
B
A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to A) have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) ask the client what foods are acceptable or are unacceptable C) encourage her to eat for healing and strength D) schedule the dietitian to meet with the client as soon as possible
B
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client? A) Hyperextension of the neck with passive shoulder flexion B) Flexion of the hip and knees with passive flexion of the neck C) Flexion of the legs with rebound tenderness D) Hyperflexion of the neck with rebound flexion of the legs
B
A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? A) 9 month-old who stays with a sitter 5 days a week B) 20 month-old who has just learned to climb stairs C) 10 year-old who occasionally stays at home unattended D) 15 year-old who likes to repair bicycles
B
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet? A) Vegetables B) Cereal C) Fruit D) Meats
B
The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver? A) "It measures a child's intelligence." B) "It assesses a child's development." C) "It evaluates psychological responses." D) " It helps to determine problems."
B
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) Interpretation of events originate from their own perspective D) Conclusions are based on previous experiences
B
A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-emotional growth and development due to A) loss of control B) insecurity C) dependence D) lack of trust
C
At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform? A) Say 2 words B) Pull up to stand C) Sit without support D) Drink from a cup
C
Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? A) Neuro malignant syndrome B) Acute extrapyramidal syndrome C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors
C
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns
D
The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care? A) Avoid climbing stairs for 3 months B) Ambulate using crutches only C) Sleep only on your back D) Do not cross your legs
D
The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses? A) Nutrition B) Elimination C) Activity D) Safety
D
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate."
A
At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should A) Inform the client that she must wait until the program ends at 5:00 pm to leave B) Give the client simple information about what she will be doing C) Tell the client you will call someone to come for her and suggest joining the exercise group while she waits D) Firmly direct the client to her assigned group activity
C
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions? A) 14 minutes B) 10 minutes C) 15 minutes D) Nine minutes
C
During seizure activity which observation is the priority to enhance further direction of treatment? A) Observe the sequence or types of movement B) Note the time from beginning to end C) Identify the pattern of breathing D) Determine if loss of bowel or bladder control occurs
A
In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize A) learning relaxation techniques B) limiting alcohol use C) eating smaller meals D) avoiding passive smoke
A
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care? A) Encourage the client to cough and deep breathe every 2 hours B) Place the client in contact isolation C) Provide a diet high in protein D) Institute seizure precautions
A
At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response? A) "This is normal at this time of day." B) "How long has this been occurring?" C) "Do you offer fluids at night?" D) "Have you tried waking her to urinate?"
B
Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A) craving B) crashing C) outward bound D) nodding out
B
The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first? A) Clear the area of any hazards B) Place the child on its side C) Restrain the child D) Give the prescribed anticonvulsant
B
A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A) The alveoli will degenerate B) Chronic bronchoconstriction of the large airways will occur C) Lung remodeling and permanent changes in lung function will result D) The client will experience frequent bouts of pneumonia
C
A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it A) contains less lactose B) is higher in calories/ounce C) provides antibodies D) has less fatty acid
C
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A) transparent film dressing B) wet dressing with debridement granules C) wet to dry with hydrogen peroxide D) moist saline dressing
D
In a child with suspected coarctation of the aorta, the nurse would expect to find A) strong pedal pulses B) diminishing carotid pulses C) normal femoral pulses D) bounding pulses in the arms
D
The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect? A) Pelvic tip downward B) Right leg lengthening C) Ortolani sign D) Characteristic limp
D
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication? A) Involuntary rhythmic stereotypic movements and tongue protrusion B) Cheek puffing, involuntary movements of extremities and trunk C) Agitation, constant state of motion D) Hyperpyrexia, severe muscle rigidity, malignant hypertension
D
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include? A) Allow the child to continue normal activities B) Schedule frequent rest periods C) Limit exposure to other children D) Restrict activities to inside the house
A
A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next? A) Give the medication as ordered B) Call the provider to clarify the dose C) Recognize that antibiotics are over-prescribed D) Hold the medication as the dosage is too low
A
A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? A) All lesions crusted B) Elevated temperature C) Rhinorrhea and coryza D) Presence of vesicles
A
A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to A) ask the client about the refusal of certain pain medications B) talk with the client's family about the situation C) report the situation to the primary care provider D) document the situation in the notes
A
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation
A
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate the leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest
A
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to A) Notify the primary care provider immediately B) Suggest in-patient psychiatric care C) Respect the client's confidential disclosure D) Phone the family to warn them of the risk
A
A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? A) The state nurse practice act in which the assignment is made B) With a nurse colleague who has worked in that state 2 years ago C) The policies and procedures of the assigned agency in that state D) The Nursing Social Policy Statement within the United States
A
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse? A) 50% increase in birth weight B) Head circumference greater than chest C) Crying when the parents leave D) Able to stand up briefly in play pen
A
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client's behaviors are warning signs to indicate that the client may be A) headed for relapse B) feeling hopeless C) approaching recovery D) in need of increased socialization
A
A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? A) An 18 month-old who ate an undetermined amount of crystal drain cleaner B) A 14 month-old who chewed 2 leaves of a philodendron plant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
A
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child? A) Maintain good nutrition B) Stay in school C) Keep in contact with the child's father D) Get adequate sleep
A
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the nurse's best response to the parent? A) "When a child asks a question, give a simple answer." B) "Children ask many questions, but are not looking for answers." C) "This question indicates interest in sex beyond this age." D) "Full and detailed answers should be given to all questions."
A
Clients taking which of the following drugs are at risk for depression? A) Steroids B) Diuretics C) Folic acid D) Aspirin
A
Clients with mitral stenosis would likely manifest findings associated with congestion in the A) pulmonary circulation B) descending aorta C) superior vena cava D) bundle of His
A
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to A) avoid overheating during physical activities B) maintain normal activity with some restrictions C) be cautious of others with viruses or temperatures D) maintain routine immunizations
A
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?" C) "These feelings are a symptom of your illness." D) "You're safe here. I won't let anyone poison you."
A
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle
A
The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce
A
The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is A) urinary output of 30 ml per hour B) no complaints of thirst C) increased hematocrit D) good skin turgor around burn
A
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents? A) Report a persistent cough to the health care provider B) The child can return to school in 4 days C) Administer chewable aspirin for pain D) The child may gargle with saline as necessary for discomfort
A
The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to A) check for subcutaneous emphysema in the upper torso B) reposition the client to improve the level of comfort C) call the provider as soon as possible D) check for any increase in the amount of thoracic drainage
A
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should A) Offer small meals of high calorie soft food B) Assist the client to sit in a chair for meals C) Provide additional servings of fruits and raw vegetables D) Encourage the client to eat fish, liver and chicken
A
The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions
A
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) high in carbohydrates and proteins B) low in carbohydrates and proteins C) high in carbohydrates, low in proteins D) low in carbohydrates, high in proteins
A
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown A) Ileostomy B) Transverse colostomy C) Ileal conduit D) Sigmoid colostomy
A
The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? A) The ethical sense and feelings of justice are developing B) Attempts to control the family use new coping styles C) Insecurity and attention getting are common motives D) Complex thought processes help to resolve conflicts
A
What is the most important aspect to include when developing a home care plan for a client with severe arthritis? A) Maintaining and preserving function B) Anticipating side effects of therapy C) Supporting coping with limitations D) Ensuring compliance with medications
A
When an autistic client begins to eat with her hands, the nurse can best handle the problem by A) placing the spoon in the client's hand and stating, "Use the spoon to eat your food." B) commenting, "I believe you know better than to eat with your hand." C) jokingly stating, "Well I guess fingers sometimes work better than spoons." D) removing the food and stating, "You can't have anymore food until you use the spoon."
A
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to A) avoid smoking near the client B) turn off oxygen during meals C) adjust the liter flow to 10 as needed D) remind the client to keep mouth closed
A
Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A) measure head circumference B) place in airborne isolation C) provide passive range of motion D) provide an over-the-crib protective top
A
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? A) Direct sunlight B) Foods containing tyramine C) Foods fermented with yeast D) Canned citrus fruit drinks
A
Which of these variations in the newborn results from the presence of maternal hormones? A) Engorgement of the breasts B) Mongolian spots C) Edema of the scrotum D) Lanugo
A
Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? A) Sports and games with rules B) Finger paints and water play C) "Dress-up" clothes and props D) Chess and television programs
A
Which type of accidental poisoning would the nurse expect to occur in children under age 6? A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes
A
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? A) Altered nutrition: less than body requirements B) Potential complication hemorrhage C) Ineffective individual coping D) Fluid volume excess
B
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) administer pain medication B) suction excessive tracheobronchial secretions C) assist client to turn, deep breathe and cough D) monitor oxygen saturation
B
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should A) eat foods high in sodium to increase sputum liquefaction B) use oxygen during meals to improve gas exchange C) perform exercise after respiratory therapy to enhance appetite D) cleanse the mouth of dried secretions to reduce risk of infection
B
A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I've made some decisions about my life." What should be the nurse's initial response? A) "You've made some decisions." B) "Are you thinking about killing yourself?" C) "I'm so glad to hear that you've made some decisions." D) "You need to discuss your decisions with your therapist."
B
A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority? A) Hold the infant at frequent intervals. B) Assess for neonatal withdrawal syndrome C) Offer fluids to prevent dehydration D) Administer paregoric to stop diarrhea
B
A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider? A) "My partner's breathing rate is usually below 12." B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." C) "It seems our sex life is nonexistent over the past 6 months." D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."
B
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) use of improper hot foods, herbs and plants D) a failure to keep life in balance with nature and others
B
A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? A) Discuss with the mother sharing parenting responsibilities B) Set time aside to get the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision
B
A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A) With acceptance and views the victim's comment as an indication that their marriage is in trouble B) With fear of rejection causing increased rage toward the victim C) With a new commitment to seek counseling to assist with their marital problems D) With relief, and welcomes the separation as a means to have some personal time
B
An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of A) septicemia B) dehydration C) hypokalemia D) hypercalcemia
B
At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment
B
During the evaluation phase for a client, the nurse should focus on A) All finding of physical and psychosocial stressors of the client and in the family B) The client's status, progress toward goal achievement, and ongoing re-evaluation C) Setting short and long-term goals to insure continuity of care from hospital to home D) Select interventions that are measurable and achievable within selected timeframes
B
Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by A) seeking medical help for the victim's injuries B) minimizing the episode and underestimating the victim's injuries C) contacting a close friend and asking for help D) being very remorseful and assisting the victim with medical care
B
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and A) increased retention of albumin in the vascular system B) decreased colloidal osmotic pressure in the capillaries C) fluid shift from interstitial spaces into the vascular space D) reduced tubular reabsorption of sodium and water
B
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client? A) Compliance with treatment regimens B) Looking different from their peers C) Lacking independence in activities D) Reliance on family for their social support
B
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client
B
The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter
B
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? A) Standing and sitting B) In both arms C) After exercising D) Supine position
B
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment? A) Stressors in the home B) Medication compliance C) Exposure to hot temperatures D) Alcohol use
B
The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse should understand that adolescents with hemophilia _______. A) must have structured activities B) often take part in active sports C) explain limitations to peer groups D) avoid risks after bleeding episodes
B
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation
B
The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN antianxiety agent
B
The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization? A) Younger siblings adapt very well B) Visitation is helpful for both C) The siblings may enjoy privacy D) Those cared for at home cope better
B
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse? A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease D) 1 in 2 chance that each child will have the disease
B
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention? A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus B) Opening the bottom of the pouch, allowing the flatus to be expelled C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape D) Assisting the client to ambulate to reduce the flatus in the pouch
B
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? A) Increase fluid intake to prevent dehydration B) Place client on a pressure reducing support surface C) Use skin care products designed for use with incontinence D) Increase caloric intake to aid healing
B
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client A) should remain on bed rest in a semi-Fowler's position B) should alternate ambulation with bed rest with legs elevated C) may ambulate and sit in chair as tolerated D) may ambulate as tolerated and remain in semi-Fowlers position in bed
B
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C) Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a day
B
The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would best prepare the child? A) Introduce the child to all staff the day before surgery B) Explain the surgery 1 week prior to the procedure C) Arrange a tour of the operating and recovery rooms D) Encourage the child to bring a favorite toy to the hospital
B
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? A) Low tar cigarettes are less harmful during pregnancy B) There is a relationship between smoking and low birth weight C) The placenta serves as a barrier to nicotine D) Moderate smoking is effective in weight control
B
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures B) Withdrawal C) Craving D) Marked tolerance
B
The nurse understands that during the "tension building" phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of A) anger B) helplessness C) calm D) explosiveness
B
The nurse understands that one reason domestic violence remains extensively undetected is A) few battered victims seek medical care B) there is typically a series of minor, vague complaints C) expenses due to police and court costs are prohibitive D) very little knowledge is currently known about batterers and battering relationships
B
The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is A) "Although the results are here, your doctor will explain them later." B) "Your child has fewer red blood cells that carry oxygen." C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation."
B
Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene
B
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero? A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated
B
When a client is having a general tonic clonic seizure, the nurse should A) hold the client's arms at their side B) place the client on their side C) insert a padded tongue blade in client's mouth D) elevate the head of the bed
B
When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection? A) Gonorrhea B) Chlamydia C) Herpes D) HIV
B
Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training? A) The child learns voluntary sphincter control through repetition B) Myelination of the spinal cord is completed by this age C) Neuronal impulses are interrupted at the base of the ganglia D) The toddler can understand cause and effect
B
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A) Compulsive behavior B) Sense of impending doom C) Fear of flying D) Predictable episodes
B
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? A) Strange bed and surroundings B) Separation from parents C) Presence of other toddlers D) Unfamiliar toys and games
B
While planning care for a preschool aged child, the nurse takes developmental needs into consideration. Which of the following would be of the most concern to the nurse? A) Playing imaginatively B) Expressing shame C) Identifying with family D) Exploring the playroom
B
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend."
C
A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy
C
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first? A) Provide the ordered humidified oxygen via mask B) Suction the mouth and the nose C) Check the mouth and radial pulse D) Start the ordered intravenous fluids
C
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as A) autistic B) echopraxis C) echolalic D) catatonic
C
A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? A) Blood urea nitrogen B) Acid phosphatase C) Bilirubin D) Sedimentation rate
C
A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asked to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse demonstrating emotional support for the client? A) "No, it would be best if you brought the client some reading material that she could read at night." B) "No, your presence may cause the client to become more anxious." C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." D) "Yes, would you like to spend the night when the client's behavior indicates that she is frightened?"
C
A client is unconscious following a tonic-clonic seizure. What should the nurse do first? A) check the pulse B) administer Valium C) place the client in a side-lying position D) place a tongue blade in the mouth
C
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for A) Anxiety, unconscious anger, and hostility B) Guilt, indecisiveness, poor self-concept C) Psychomotor retardation or agitation D) Meticulous attention to grooming and hygiene
C
A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with A) recreational and social needs B) feelings of anger C) life's stressors D) issues of guilt and disappointment
C
A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch
C
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently
C
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is A) Participative or democratic B) Ultraliberal or communicative C) Autocratic or authoritarian D) Laissez faire or permissive
C
A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) congenital cardiac defects B) an acute febrile illness C) prolonged hypoxemia D) severe multiple trauma
C
A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a glass of wine with dinner is healthy." B) "Beer is not really hard alcohol, so I guess I can drink some." C) "If I drink, my baby may be harmed before I know I am pregnant." D) "Drinking with meals reduces the effects of alcohol."
C
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother? A) Teaching the child self care skills B) Preparing for independent toileting C) Promoting the child's optimal development D) Helping the family decide on long term care
C
Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass? A) Touring the coronary intensive unit B) Mailing a video tape to the home C) Assessing the client's learning style D) Administering a written pre-test
C
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother? A) "My child has lost 3 pounds in the last month." B) "Urinary output seemed to be less over the past 2 days." C) "All the pants have become tight around the waist." D) "The child prefers some salty foods more than others."
C
First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? A) The pediatrician must examine the baby B) Emergency equipment should be available C) This breathing pattern is normal D) A future referral may be indicated
C
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing? A) White patches B) Green drainage C) Reddened tissue D) Eschar development
C
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference
C
Post-procedure nursing interventions for electroconvulsive therapy include A) applying hard restraints if seizure occurs B) permitting client to sleep for 4 to 6 hours C) remaining with client until oriented D) expecting long-term memory loss
C
The nurse has been assigned to four clients in the emergency room, each experiencing one of these conditions. Which client condition would the nurse check first? A) Viral pneumonia with atelectasis B) Spontaneous pneumothorax with a respiratory rate of 38 C) Tension pneumothorax with slight tracheal deviation to the right D) Acute asthma with episodes of bronchospasm
C
The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year B) Weight and height in the 10th percentile since birth C) Takes frequent rest periods while playing D) Changing food preferences and dislikes
C
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation? A) Glucose level of 120 B) History of myocardial infarction C) Long term steroid usage D) Diet high in carbohydrates
C
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds: A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children."
C
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy
C
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A) perform defibrillation B) administer epinephrine as ordered C) assess for presence of pulse D) institute CPR
C
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia
C
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered
C
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding? A) Large volume of urinary output with each voiding B) Involuntary voiding with coughing and sneezing C) Frequent urination D) Urine is dark and concentrated
C
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? A) observe for edema proximal to the site B) irrigate with 5 ml of 0.9% Normal Saline C) palpate for a thrill over the fistula D) check color and warmth in the extremity
C
The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to A) dehydration B) diminished blood volume C) decreased cardiac output D) renal failure
C
The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities
C
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when A) an individual displays restlessness B) there are obvious signs of depression C) conducting any health assessment D) the resident reports memory lapses
C
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first? A) Elicit reflexes B) Measure height and weight C) Auscultate heart and lungs D) Examine the ears
C
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A) reports of difficulty falling and staying asleep B) expression of persistent suicidal thoughts C) lack of enjoyment in usual pleasures D) reduced senses of taste and smell
C
The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? A) Bulimia B) Anorexia 147 C) Obesity D) Malnutrition
C
The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's remarks most likely indicate A) neologisms B) flight of ideas C) loose associations D) word salad
C
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first A) assess the client's airway B) call for help C) establish that the client is unresponsive D) see if anyone saw the client fall
C
The nurse, assisting in applying a cast to a client with a broken arm, knows that the A) cast material should be dipped several times into the warm water B) cast should be covered until it dries C) wet cast should be handled with the palms of hands D) casted extremity should be placed on a cloth-covered surface
C
The nursing care plan for a client with decreased adrenal function should include A) encouraging activity B) placing client in reverse isolation C) limiting visitors D) measures to prevent constipation
C
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is A) pain B) impaired gas exchange C) cardiac output altered: decreased D) fluid volume excess
C
The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should A) observe the child's behavior on at least 2 occasions B) consult with the teacher about how to control impulsivity C) compile a history of behavior patterns and developmental accomplishments D) compare the child's behavior with classic signs and symptoms
C
When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? A) follow-up on lab values before the visit B) observe client findings for the effectiveness of antibiotics C) ask for a log of urinary output D) ask for the log of the oral intake
C
Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) "I noticed a little lump a little above the belly button." B) "The baby seems hungry all the time." C) "Mild vomiting turned into vomiting that shot across the room." D) "We notice irritation and spitting up immediately after feedings."
C
Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client? A) An accurate measurement of intake is not reliable B) The food pyramid is not used in this age group C) A serving size at this age is about 2 tablespoons D) Total intake varies greatly each day
C
While teaching a client about their medications, the client asks how long it will take before the therapeutic effects of lithium occur. What is the best response of the nurse? A) Immediately B) Several days C) 2 weeks D) 1 month
C
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to A) Promote healing and strengthen the immune system B) Provide a well balanced nutritional intake C) Stimulate increased peristalsis absorption D) Spare protein catabolism to meet metabolic needs
D
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following? A) Call the health care provider B) Check vital signs C) Position in high Fowler's D) Administer oxygen
D
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize? A) Maintain a low sodium diet B) Take a diuretic with lithium and avoid excessive fluids C) Don't be overly concerned if feelings of depression occur D) Come in for evaluation of serum lithium levels regularly
D
A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A) transparent dressing B) dry sterile dressing with antibiotic ointment C) wet to dry dressing D) occlusive moist dressing
D
A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication? A) Potassium level B) Arterial blood gasses C) Blood urea nitrogen D) Thiocyanate
D
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by A) requiring the client to mop the floor B) restricting the client's fluids throughout the day C) withholding privileges each time the voiding occurs D) toileting the client more frequently with supervision
D
A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly "bothers" other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? A) Reading B) Checkers C) Cards D) Ping-pong
D
A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family gatherings." B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C) "A recovering person needs to get in touch with their feelings. Do you want a drink?" D) "A recovering person cannot return to drinking without starting the addiction process over."
D
A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome for this client's care will be A) expresses feelings appropriately through verbal interactions B) accurately interprets events and behaviors of others C) demonstrates improved social relationships D) engages in meaningful and understandable verbal communication
D
A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse? A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
D
After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment, but I don't want my husband to leave me." Which response by the nurse would assist the client? A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well." B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come." C) "In early recovery it's quite common to have mixed feelings, perhaps it would be best to seek treatment on an outpatient basis." D) "In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."
D
In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A) Age 40 years B) Lactose intolerance C) Family history of breast cancer D) Use of cocaine on weekends
D
Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse? A) Tell the parents to bring the child to the clinic for further evaluation B) Refer the school officials to printed materials about this viral illness C) Inform the teacher that the child is receiving antibiotics for the rash D) Explain that this rash is not contagious and does not require isolation
D
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention? A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue B) To cover the bony prominence and areas where there is skin breakdown C) The client knows what type of clothing to wear when weighed D) To reduce the tendency of the client to hide objects under his or her clothing
D
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? A) Denial B) Projection C) Intellectualization D) Rationalization
D
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sippy cup
D
The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be A) "Do you want to discuss this with your pastor?" B) "We will help you deal with those thoughts." C) "Is your life so terrible that you want to end it?" D) "Have you thought about how you would do it?"
D
The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? A) Arterial septal defect B) Patent ductus arteriosus C) Aortic stenosis D) Ventricular septal defect
D
The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that A) circumcision can be performed at any time B) initial repair is delayed until 6-8 years of age C) post-operative appearance will be normal D) surgery will be performed in stages
D
The nurse is caring for a post-op colostomy client. The client begins to cry, saying "I'll never be attractive again with this ugly red thing." What should be the first action taken by the nurse? A) Arrange a consultation with a sex therapist experienced in working with colostomy clients B) Suggest sexual positions that hide the colostomy C) Invite the partner to participate in colostomy care after viewing an instructional video D) Encourage the client to discuss her feelings about the colostom
D
The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A) Dress the child warmly to avoid chilling B) Keep the child away from other children for the duration of the rash C) Clean the affected areas with tepid water and detergent D) Wrap the child's hand in mittens or socks to prevent scratching
D
The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily
D
The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the provider? A) Lifts head from the prone position B) Rolls from abdomen to back C) Responds to parents' voices D) Falls forward when sitting
D
The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse? A) "Do you want to take this pretty red medicine?" B) "You will feel better if you take your medicine." C) "This is your medicine, and you must take it all right now." D) "Would you like to take your medicine from a spoon or a cup?"
D
The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? A) "I should position my baby completely facing me with my baby's mouth in front of my nipple." B) "The baby should latch onto the nipple and areola areas." C) "There may be times that I will need to manually express milk." D) " I can switch to a bottle if I need to take a break from breast feeding."
D
The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these describes the normal pathway? A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers
D
The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take? A) Notify the provider B) Palpate the anterior fontanel C) Feel the posterior fontanel D) Record these normal findings
D
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include A) pointing out inconsistencies in speech patterns to correct thought disorders B) accepting client and the client's behavior unconditionally C) encouraging dependency in order to develop ego controls D) consistent limit-setting enforced 24 hours per day
D
When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first? A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations
D
When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother? A) It is likely that all sons are affected B) There is a 50% probability that sons will have the disease C) Every daughter is likely to be a carrier D) There is a 25% chance a daughter will be a carrier
D
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach? A) Speak directly to the interpreter while presenting information and use pauses for questions B) Talk to the interpreter in advance and leave the client and interpreter alone C) Include a family member and direct communications to that person D) Face the client while presenting the information as the interpreter talks in the native language
D
Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure
D
Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration
D
Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings? A) Direct confrontation B) Reality orientation C) Projective identification D) Active listening
D