Question 1

To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?

Skin turgor

Hydration

Organs

Question 2

A client is brought to the emergency department and the physician determines he has gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first priority?

assessment of vital signs

complete abdominal examination

insertion of a nasogastric tube and Hematest of emesis

thorough investigation of precipitating events

Incorrect.The answer isassessment of vital signs

Explanation:

The Correct answer is:assessment of vital signs

Vital sign assessment would be the priority nursing intervention. This would provide an indication of the amount of blood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The other answers (b, c, and d) are important but not priority actions.

Question 3

When providing instructions to the adolescent regarding physical development of her body, the RN should do all of the following EXCEPT

Discuss the importance of avoiding social events in order to stay out of trouble.

Explain that body hair distribution increases and is normal.

Discuss that it is normal to gain weight during puberty.

Instruct on active sebaceous and sweat glands.

Correct.The answer isDiscuss the importance of avoiding social events in order to stay out of trouble.

Explanation:

The Correct answer is:Discuss the importance of avoiding social events in order to stay out of trouble.

Socialization is very important to teenagers and is a normal part of their development. The other answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding development.

Question 4

The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client will be discharged home with home health nursing care. The nurse provides the home health agency with details regarding the needs of the patient. The nurse made which of the following to the home health agency?

A care plan.

A referral.

A transfer to another unit.

A request for at home physical therapy.

Incorrect.The answer isA referral.

Explanation:

Correct answer:A referral

A referral is recommending home care services or giving information to an home care service regarding the client and the client's needs. Typically the sources of referral to a home care agency are family members, nurses, physicians, social workers, discharge planners or therapists.

Question 5

Which of the following is the normalserum electrolyte level for magnesium?

98 to 106 mEq/L.

1.3 to 2.1 mEq/L.

4.5 to 5.3 mEq/L.

135 to 148 mEq/L.

Incorrect.The answer is1.3 to 2.1 mEq/L.

Explanation:

Correct answer:1.3 to 2.1 mEq/L

Choice A is the normal value for chloride. Choice C is the normal value for calcium and choice D, sodium.

Question 5

Which of the following is the normalserum electrolyte level for magnesium?

98 to 106 mEq/L.

1.3 to 2.1 mEq/L.

4.5 to 5.3 mEq/L.

135 to 148 mEq/L.

Incorrect.The answer is1.3 to 2.1 mEq/L.

Explanation:

Correct answer:1.3 to 2.1 mEq/L

Choice A is the normal value for chloride. Choice C is the normal value for calcium and choice D, sodium.

Question 6

The school nurse is approached by a mother who explains that her kindergarten childis constantly scratching the perianal area and that the area is irritated. The RN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when?

After bathing.

When the child is put to bed.

In the morning, when the child awakens.

After toileting.

Incorrect.The answer isIn the morning, when the child awakens.

Explanation:

The Correct answer is:in the morning, when the child awakens

Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens, before toileting or bathing.

Question 7

A 20-year-old patient is admitted to the hospital with respiratory failure. Hes intubated, given oxygen, and is coughing with copious secretions in his lungs. What should be done first?

Suction the lungs

Call his family

Call for assistance in restraining the patient

Check his heart rate and blood pressure

Correct.The answer isSuction the lungs

Explanation:

The correct answer is A.

The first priority is to make sure the clients airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe.

Question 7

A 20-year-old patient is admitted to the hospital with respiratory failure. Hes intubated, given oxygen, and is coughing with copious secretions in his lungs. What should be done first?

Suction the lungs

Call his family

Call for assistance in restraining the patient

Check his heart rate and blood pressure

Correct.The answer isSuction the lungs

Explanation:

The correct answer is A.

The first priority is to make sure the clients airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe.

Question 8

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and intervention, what would be the MOST desirable outcome?

The student discusses conflicts over drug use

The student accepts a referral to a substance abuse counselor

The student agrees to inform his parents of the problem

The student reports increased comfort with making choices

Incorrect.The answer isThe student accepts a referral to a substance abuse counselor

Explanation:

The correct answer is the student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

Question 9

The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication?

Normal saline (0.9%)solution.

Dextrose 5% and half-normal saline (0.45%) solution.

Dextrose 5% solution.

Lactated ringer's solution.

Correct.The answer isNormal saline (0.9%)solution.

Explanation:

The Correct answer is:normal saline (0.9%)solution

Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication precipitation.

Question 10

Which of the following terms corresponds with the phrase: a woman that is pregnant?

Octomomesis

Placenta previa

Gravida

Spermatogonia

Incorrect.The answer isGravida

Explanation:

The correct answer is C. Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells.

Question 11

A healthy first time pregnant client asks the nurse, "How long will I stay in the hospital after my baby is born." The client is scheduled for a Caesarean section. The nurse understands the average timeframe for the hospital stay for a Caesarean section is what?

12-24 hours.

30-36 hours.

37-48 hours.

72-96 hours.

Incorrect.The answer is72-96 hours.

Explanation:

Correct answer:72 - 96 hours

The hospital stay for a healthy mother who has delivered an infant varies depending on the type of delivery. The length of stay in the hospital for a vaginal birth is typically 48 hours. The length of stay in the hospital for a Caesarean section that does not have any complications is 72-96 hours.

Question 12

The community nurse is planning a smoking cessation program.What would be the best health promotion program?

Utilizing a variety of media for information dissemination

Conducting health risk surveys

Providing counseling for lifestyle and behavior change

Facilitating environmental control programs

Incorrect.The answer isConducting health risk surveys

Explanation:

The correct answer is:Conducting health risk surveys

Firstconductinitial assessments to determine if there is ahealth risk. Then follow the course of action in place in this event.

Question 13

A woman is two months pregnant when her five-year-old child develops rubella. What is most likely to be given to her?

Immune serum globulin

RhoGam

Rubella antitoxin

MMR

Incorrect.The answer isImmune serum globulin

Explanation:

The correct answer is immune serum globulin. Immune serum globulin gives her a passive immunity and helps keep her from developing rubella, which can have devastating effect on her unborn child. MMR is a live virus and is not given to pregnant women. RhoGam prevents anti Rh antibody development. There is no such thing as rubella antitoxin.

Question 14

What is the normal value of urine potassium?

12-17 mEq/24 hr

135-145mEq/24 hr

25-100 mEq/24 hr

0.3-1.7mEq/24 hr

Incorrect.The answer is25-100 mEq/24 hr

Explanation:

Correct answer:25-100 mEq/24 hrThe normal value for urine potassium is 25-100 mEq/24 hr

Question 15

Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The findings that are often associated with genitourinary abnormalities are what?

one artery, one vein.

two arteries, one vein.

two veins, one artery.

two veins, two arteries.

Correct.The answer isone artery, one vein.

Explanation:

The correct answer isone artery, one vein.

Two arteries and one vein are present in a normal umbilical cord. The presence of one artery in the umbilical cord is associated with genitourinary abnormalities.

Question 16

You are assigned to educated the nursing assistants regarding caring for the older adult. It is important that the assistants understand that which of the following situations portrays ageism?

Accepting differences among older adults.

Advising older adults to forgo aggressive treatment.

Allowing older adults to make decisions.

Informing the older adult of their rights.

Incorrect.The answer isAdvising older adults to forgo aggressive treatment.

Explanation:

The Correct answer is:Advising older adults to forgo aggressive treatment.

Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older persons are different from "me" and will remain different from "me." The other answers (a, c, and d) identify supporting roles of the nurse for the older person.

Question 17

When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?

bread

carrots

oranges

strawberries

Correct.The answer isstrawberries

Explanation:

The correct answer isstrawberries.

Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and oranges rarely cause allergic reactions.

Question 17

When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?

bread

carrots

oranges

strawberries

Correct.The answer isstrawberries

Explanation:

The correct answer isstrawberries.

Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and oranges rarely cause allergic reactions.

Question 18

A nurse who violates the civil rights of an individual may be committing what?

A tort.

Negligence.

Malpractice.

An unintentional tort.

Incorrect.The answer isA tort.

Explanation:

Correct answer:A tort

A tort is the process of violating civil law when dealing with an individual or an individual's property. The types of torts are commission and omission. Further, negligence and malpractice are not the best choices as these deal with unintentional torts.

Question 19

A patient with Addison's disease has been given an inadequate steroid dosage. Which of the following are NOT symptoms the patient could experience?

Weight gain.

Fatigue.

Weakness.

Dizziness.

Correct.The answer isWeight gain.

Explanation:

Correct answer:Weight gain

Weight loss is more likely. Choices B, C, and D are often indicated.

Question 19

A patient with Addison's disease has been given an inadequate steroid dosage. Which of the following are NOT symptoms the patient could experience?

Weight gain.

Fatigue.

Weakness.

Dizziness.

Correct.The answer isWeight gain.

Explanation:

Correct answer:Weight gain

Weight loss is more likely. Choices B, C, and D are often indicated.

Question 19

A patient with Addison's disease has been given an inadequate steroid dosage. Which of the following are NOT symptoms the patient could experience?

Weight gain.

Fatigue.

Weakness.

Dizziness.

Correct.The answer isWeight gain.

Explanation:

Correct answer:Weight gain

Weight loss is more likely. Choices B, C, and D are often indicated.

Question 20

Which of the following behavior does NOT show improvement in a client with Obsessive Compulsive Disorder?

Client uses will power to stop rituals.

Refrains from rituals during stress.

Client uses thought stopping when obsessive thoughts occur.

Client verbalizes a relationship between stress and rituals.

Incorrect.The answer isClient uses will power to stop rituals.

Explanation:

Correct answer:Client uses will power to stop rituals

The client can employ appropriate intervention techniques and more about the disease process such as B, C and D. Will power alone will not be effective in dealing with Obsessive Compulsive Disorder.

Question 21

Of the following, which is the normal respirations range for an adult?

16-20

24-32

20-24

12-20

Incorrect.The answer is12-20

Explanation:

The correct answer is D.

Choice A is the normal range for an adolescent. Choice B is normal for a toddler and Choice C, for an adolescent.

Question 22

Which of the following is the generic name for Nizoral?

Ketoconazole.

Isotretinoin.

Nystatin.

Flucinonide.

Correct.The answer isKetoconazole.

Explanation:

Correct answer:Ketoconazole

Choice B is the generic name for Accutane. Choice C is the generic name for Mycostatin and choice D, a generic name for Lidex.

Question 23

Which of the following is not a goal for a client with social phobia?

Manage fear in groups.

Verbalize feelings in stressful situations.

Develop a plan for stressful situations.

Use suppression.

Correct.The answer isUse suppression.

Explanation:

Correct answer:Use suppression

A client needs concrete goals, such as A, B and C, to pursue. Suppression would be very counterproductive to a person with social phobia.

Question 24

A client has had pain in the right leg for 3 weeks. The nurse understands that the MOST LIKELY effect of this pain is?

The disruption of sleep.

Irregular heart beat.

Dizziness.

Drowsiness.

Correct.The answer isThe disruption of sleep.

Explanation:

Correct answer:The disruption of sleep

Pain can have many effects on the human body. Clients with acute pain may have a decrease in appetite, decrease in fluid intake, nausea, vomiting and disruption in sleep.

Question 25

Which of the following is the sixth provision of the Code of Ethics for Nurses?

The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

Correct.The answer isThe nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

Explanation:

Correct answer:The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action

Choice A is provision number five of the code of ethics for nurses. Choice C is provision number seven and choice D, provision number nine.

Question 25

Which of the following is the sixth provision of the Code of Ethics for Nurses?

The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

Correct.The answer isThe nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

Explanation:

Correct answer:The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action

Choice A is provision number five of the code of ethics for nurses. Choice C is provision number seven and choice D, provision number nine.

Question 26

Which of the following is a brand name for Raberprazole?

Zantac.

Aciphex.

Carafate.

Azulfidine.

Incorrect.The answer isAciphex.

Explanation:

Correct answer:Aciphex

Choice A is a brand name for Ranitidine. Choice C is a brand name for Sucralfate and choice D, for Sulfasalazine.

Question 26

Which of the following is a brand name for Raberprazole?

Zantac.

Aciphex.

Carafate.

Azulfidine.

Incorrect.The answer isAciphex.

Explanation:

Correct answer:Aciphex

Choice A is a brand name for Ranitidine. Choice C is a brand name for Sucralfate and choice D, for Sulfasalazine.

Question 27

Which of the following is MOST likely a characteristic found with individuals who are diagnosed with borderline personality disorder?

timidness

social discomfort

fear of negative feedback

identity disturbance

Incorrect.The answer isidentity disturbance

Explanation:

The correct answer is identify disturbance. Individuals with borderline personality have an identity disturbance where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality disorder.

Question 27

Which of the following is MOST likely a characteristic found with individuals who are diagnosed with borderline personality disorder?

timidness

social discomfort

fear of negative feedback

identity disturbance

Incorrect.The answer isidentity disturbance

Explanation:

The correct answer is identify disturbance. Individuals with borderline personality have an identity disturbance where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality disorder.

Question 28

The nurse at the family planning clinic has performed teaching on oral contraceptives. The nurse knows that the teaching has been effective when one of the clients responds:

"I can't take 'the pill' if I'm over 30."

"I can take 'the pill,' even though I smoke heavily."

"My periods will become slightly heavier when I take 'the pill'."

"I can't take 'the pill' if I have gallbladder disease."

Incorrect.The answer is"I can't take 'the pill' if I have gallbladder disease."

Explanation:

The correct answer is"I can't take 'the pill' if I have gallbladder disease."

Oral contraceptive is contraindicated in women with gallbladder disease and those who are heavy smokers. There is not an age specification. Menstrual flow is decreased with the use of oral contraceptives.

Question 29

Which of the following clinical signs would the nurse expect to see in a child with respiratory depression?

Sleep apnea.

Increased pulse rate.

Shallow breathing.

Unstable angina.

Correct.The answer isShallow breathing.

Explanation:

Correct answer:Shallow breathing

Respiratory depression is the breaths per minute that are less than 12 breaths per minute in a child who is two years of age and younger. Respiratory depression is one of the complications associated with opioids (for example morphine, codeine, Demerol, Oxycodone), which are a common analgesic given to client's after surgery or to treat a severe injury. Children who experience respiration depression exhibit clinical signs such as shallow breathing, sleepiness and small pupils.

Question 30

Which of the following possible blood transfusion reactions is a rare, severe reaction in which the donated blood type is not compatible with that of the patient?

Allergic

None of these

Hemolytic

Febrile

Incorrect.The answer isHemolytic

Explanation:

The correct answer is C. Choice A is usually due to a patients sensitivity to the plasma proteins of the donors blood. Choice D is a reaction caused by the incompatibility of leukocytes.

Question 31

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stool to look like which of the following?

Coffee ground-like.

Clay-colored.

Black and tarry.

Bright .

Correct.The answer isBlack and tarry.

Explanation:

Correct answer:Black and tarry

Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes in the blood. Vomitus associated with upper GI tract bleeding is commonly described as coffee ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

Question 32

A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases are transmitted through blood transfusions?" The nurse should respond that there is a low risk of contracting diseases through blood transfusions. However, a possible illness is which of the following?

Cytomegalovirus.

Hypertension.

Seizure disorder.

Cushing's disease.

Correct.The answer isCytomegalovirus.

Explanation:

Correct answer:Cytomegalovirus

Blood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV, Cytomegalovirus and Malaria,to name a few. Also, the nurse should assure the client that the transmission of these diseases is low since blood banks have rigorous screening procedures to test blood.

Question 32

A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases are transmitted through blood transfusions?" The nurse should respond that there is a low risk of contracting diseases through blood transfusions. However, a possible illness is which of the following?

Cytomegalovirus.

Hypertension.

Seizure disorder.

Cushing's disease.

Correct.The answer isCytomegalovirus.

Explanation:

Correct answer:Cytomegalovirus

Blood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV, Cytomegalovirus and Malaria,to name a few. Also, the nurse should assure the client that the transmission of these diseases is low since blood banks have rigorous screening procedures to test blood.

Question 33

In which of the following stages of reaction toward stress does a body increase in hormone levels in order to mobilize for a fight?

Alarm.

Exhaustion.

None of these.

Resistance.

Incorrect.The answer isAlarm.

Explanation:

Correct answer:Alarm

During the exhaustion stage, the body becomes "exhausted" because it did not positively respond to the stress. The body undergoes many physiological changes such as taking more air into the lungsin order to prepare for fight or flight during the resistance stage.

Question 34

In a client with acute hepatitis, the nurse assesses the client's aspartate aminotransferase (AST) range on the laboratory test at 520 units. What should the nurse understand about this test value?

The AST is normal.

The AST is decreased.

The AST is elevated.

The AST is stable.

Correct.The answer isThe AST is elevated.

Explanation:

Correct answer:The AST is elevated

In clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (AST) is elevated. The normal range for this enzyme in the blood is 10 to 26 units per liter. In clients with acute hepatitis, the enzyme may be elevated four times above the normal range.

Question 35

The nurse who teaches nutrition at a community center is asked "how much water does a person need to drink daily". The nurse's best response would be:

two quarts

two pints

one gallon

four cups

Incorrect.The answer istwo quarts

Explanation:

The correct answer is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The remaining answer choices are not correct.

Question 35

The nurse who teaches nutrition at a community center is asked "how much water does a person need to drink daily". The nurse's best response would be:

two quarts

two pints

one gallon

four cups

Incorrect.The answer istwo quarts

Explanation:

The correct answer is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The remaining answer choices are not correct.

Question 36

Which of the following tasks can a registered nurse delegate to a nursing assistant in an acute mental health setting?

Assessing mental status on admission.

Checking for sharp objects.

Administering medication.

Discussing the treatment plan.

Incorrect.The answer isChecking for sharp objects.

Explanation:

Correct answer:Checking for sharp objects

A nursing assistant may be assigned to search a client's luggage or room for potentially harmful objects, such as glass or sharp metal. A mental status assessment should be conducted by the nurse on admission. Administering medication cannot be delegated to an unlicensed person. A nurse or physician must discuss the treatment plan with the client.

Question 37

The nurse observes a child's nasal discharge. The discharge is clear in both nasal cavities. The discharge most likely indicates what type of condition?

nosebleed

upper respiratory infection

allergy

foreign body

Correct.The answer isallergy

Explanation:

The correct answer is allergy. A child who has clear, watery discharge is associated with allergies. The remaining answer choices are not the best options as bloody discharge is indicative of a nosebleed or a trauma. Itchy mucus containing discharge indicates an upper respiratory infection. If there is mucoid or purulent nasal discharge in one side of the nostrils, the child may have a foreign body lodged in the nostril.

Question 38

A female client who complains of chest pain is admitted. The nurse can expect which of the following laboratory tests ordered by the physician to confirm a myocardial infarction diagnosis?

creatine kinase

electrocardiogram

radionuclide imaging

hemodynamic monitoring

Incorrect.The answer iscreatine kinase

Explanation:

The correct answer is creatine kinase. The physician orders laboratory tests and diagnostic tests to confirm a diagnosis of myocardial infarction. Creatine kinase is an enzyme located in the cardiac muscle, brain and skeletal muscle. As this enzyme rises, there is injury to the muscle cells. Further, the higher the serum CK, the more the muscle tissue that is damaged. Electrocardiogram, radionuclide imaging and hemodynamic monitoring are used to diagnosis a myocardial infarction. However, these are diagnostic tests and not laboratory tests.

Question 39

The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms

yearly after age 40

after the birth of the first child and every 2 years thereafter

after the first menstrual period and annually thereafter

every 3 years between ages 20 and 40 and annually thereafter

Correct.The answer isyearly after age 40

Explanation:

The correct answer is yearly after age 40.

The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are not correct. It is recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years.

Question 40

The client had a nephrectomy for the removal of kidney due to major lacerations two hours ago. What is a nursing priority?

Asses the client's bladder for distention.

Decrease the client's fluid intake to under 2500 mL.

Encourage client to do breathing exercises.

Maintain the drainage tube patency.

Incorrect.The answer isMaintain the drainage tube patency.

Explanation:

Correct answer:Maintain the drainage tube patency

The nurse should monitor the drainage tube patency every 4 hours for 24 to 48 hours after the client's nephrectomy procedure. By doing so, the nurse can ensure the client's tubes drain freely and help prevent hydronephrosis, which is urine collected in the renal pelvis because of obstruction with the outflow of the urine.

Question 40

The client had a nephrectomy for the removal of kidney due to major lacerations two hours ago. What is a nursing priority?

Asses the client's bladder for distention.

Decrease the client's fluid intake to under 2500 mL.

Encourage client to do breathing exercises.

Maintain the drainage tube patency.

Incorrect.The answer isMaintain the drainage tube patency.

Explanation:

Correct answer:Maintain the drainage tube patency

The nurse should monitor the drainage tube patency every 4 hours for 24 to 48 hours after the client's nephrectomy procedure. By doing so, the nurse can ensure the client's tubes drain freely and help prevent hydronephrosis, which is urine collected in the renal pelvis because of obstruction with the outflow of the urine.

Question 41

The nurse is talking with a woman who has been told she will never be able to bear children. The woman states, "I have decided to adopt a baby, because there are so many children in the world who need the kind of home I could provide a child." The nurse recognizes this woman is using what defense mechanism?

denial

displacement

rationalization

compensation

Incorrect.The answer iscompensation

Explanation:

The correct answer is compensation. Compensation is covering a weakness with a more desirable trait or behavior, such as replacing the desire to have children with adopting a child. Denial is avoiding unwanted realities by refusing to acknowledge they exist, such as the woman who refuses to accept that she is unable to bear children. Rationalization is justifying behavior with faulty logic, such as the woman who uses drugs or alcohol and says that it is due to being unable to have children. Displacement is discharging emotion from one person or object to another person or object, such as the woman who learns she cannot have children and goes home and argues with her husband.

Question 41

The nurse is talking with a woman who has been told she will never be able to bear children. The woman states, "I have decided to adopt a baby, because there are so many children in the world who need the kind of home I could provide a child." The nurse recognizes this woman is using what defense mechanism?

denial

displacement

rationalization

compensation

Incorrect.The answer iscompensation

Explanation:

The correct answer is compensation. Compensation is covering a weakness with a more desirable trait or behavior, such as replacing the desire to have children with adopting a child. Denial is avoiding unwanted realities by refusing to acknowledge they exist, such as the woman who refuses to accept that she is unable to bear children. Rationalization is justifying behavior with faulty logic, such as the woman who uses drugs or alcohol and says that it is due to being unable to have children. Displacement is discharging emotion from one person or object to another person or object, such as the woman who learns she cannot have children and goes home and argues with her husband.

Question 42

A client is admitted with tuberculosis. The client should be placed in which type of precaution based isolation?

Droplet.

Contact.

Protective.

Airborne.

Correct.The answer isAirborne.

Explanation:

Correct answer:Airborne

The nurse should use airborne precautions when caring for a client with known or suspected tuberculosis to reduce the spread of the tuberculosis. Precautions that are employed are private room that has its own hand washing station and bathroom, special ventalation system that is separate from the hospital wide ventilation system and providing masks for anyone entering the room to see the client.

Question 43

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with insomnia?

Enuresis.

Irritability.

Sleep talking.

Sleepwalking.

Correct.The answer isIrritability.

Explanation:

Correct answer:Irritability

Insomnia is the inability to fall asleep or stay sleep. Individuals who experience insomnia complain of unrefreshed sleep, daytime sleepiness, trouble concentrating, irritability, and waking up several times at night.

Question 43

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with insomnia?

Enuresis.

Irritability.

Sleep talking.

Sleepwalking.

Correct.The answer isIrritability.

Explanation:

Correct answer:Irritability

Insomnia is the inability to fall asleep or stay sleep. Individuals who experience insomnia complain of unrefreshed sleep, daytime sleepiness, trouble concentrating, irritability, and waking up several times at night.

Question 44

The physician prescribes home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member will be responsible for evaluating the client's knowledge of home oxygen use?

home health nurse

physician

hospital staff nurse

social worker

Incorrect.The answer ishome health nurse

Explanation:

Correct answerhome health nurseThe home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in the home, so they cannot adequately evaluate the client's knowledge of home oxygen use.

Question 44

The physician prescribes home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member will be responsible for evaluating the client's knowledge of home oxygen use?

home health nurse

physician

hospital staff nurse

social worker

Incorrect.The answer ishome health nurse

Explanation:

Correct answerhome health nurseThe home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in the home, so they cannot adequately evaluate the client's knowledge of home oxygen use.

Question 45

The normal blood glucose range is which of the following?

60-100 mg/dl

80-140 mg/dl

100-150 mg/dl

70-120 mg/dl

Correct.The answer is70-120 mg/dl

Explanation:

The correct answer is D.

Any reading higher than 126 ml should prompt the nurse to check with the doctor for follow-up. However, a recent ingestion of sugar or carbohydrates could cause a high reading.

Question 46

Which is a FALSE statement regarding the factors contributing to its development?

In most theories of schizophrenia, stress plays an essential role in triggering schizophrenic episodes.

Some investigators suggest that communication disorders in parents and family members may be a predisposing factor for schizophrenia.

The dopamine hypothesis fits only some cases of schizophrenia.

In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan.

Incorrect.The answer isIn order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan.

Explanation:

Correct answer:In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan

It is becoming more clear ever day, the damage schizophrenia is doing to the brain, but researchers are nowhere near finding all of the answers. Different researchers are still arguing over the conclusiveness of the data that does exist. Other scientists are trying to discover the cause of schizophrenia.

Question 46

Which is a FALSE statement regarding the factors contributing to its development?

In most theories of schizophrenia, stress plays an essential role in triggering schizophrenic episodes.

Some investigators suggest that communication disorders in parents and family members may be a predisposing factor for schizophrenia.

The dopamine hypothesis fits only some cases of schizophrenia.

In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan.

Incorrect.The answer isIn order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan.

Explanation:

Correct answer:In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan

It is becoming more clear ever day, the damage schizophrenia is doing to the brain, but researchers are nowhere near finding all of the answers. Different researchers are still arguing over the conclusiveness of the data that does exist. Other scientists are trying to discover the cause of schizophrenia.

Question 47

Pain has which of the following effects on respiratory rate?

None.

Decreases.

Increases.

First decreases, then increases.

Correct.The answer isIncreases.

Explanation:

Correct answer:Increases

Pain will increase respiratory and heart functions. This can be counteracted with morphine if indicated.

Question 47

Pain has which of the following effects on respiratory rate?

None.

Decreases.

Increases.

First decreases, then increases.

Correct.The answer isIncreases.

Explanation:

Correct answer:Increases

Pain will increase respiratory and heart functions. This can be counteracted with morphine if indicated.

Question 48

What hormone does the anterior pituitary produce?

Follicle-stimulating hormone.

Antidiuretic hormone.

Oxytoxin.

Thyroid releasing hormone.

Incorrect.The answer isFollicle-stimulating hormone.

Explanation:

Correct answer:Follicle-stimulating hormone.

The anterior pituitary regulates several physiological processes including stress, growth, and reproduction.Its regulatory functions are achieved through the secretion of various peptide hormones that act on target organs including the adrenal gland, liver, bone, thyroid gland, and gonads.

Question 49

The nurse is performing an assessment on a client who is complaining of pain in the abdomen. The nurse understands to do what?

Use palpation throughout the assessment.

Use palpation at the end of the assessment only.

use palpation at the beginning of the assessment only.

Do not palpate the abdomen during the assessment.

Correct.The answer isUse palpation at the end of the assessment only.

Explanation:

Correct answer:Use palpation at the end of the assessment only

When performing an assessment on the abdomen, the palpation of the abdomen should be performed last. The reason is the pressure placed on the abdominal wall along with the contents will affect the bowel sounds that are heard through auscultatio

Question 49

The nurse is performing an assessment on a client who is complaining of pain in the abdomen. The nurse understands to do what?

Use palpation throughout the assessment.

Use palpation at the end of the assessment only.

use palpation at the beginning of the assessment only.

Do not palpate the abdomen during the assessment.

Correct.The answer isUse palpation at the end of the assessment only.

Explanation:

Correct answer:Use palpation at the end of the assessment only

When performing an assessment on the abdomen, the palpation of the abdomen should be performed last. The reason is the pressure placed on the abdominal wall along with the contents will affect the bowel sounds that are heard through auscultatio

Question 50

Which is the most numerous type of white blood cell (WBC)?

Neutrophil.

Eosinophil.

Basophil.

Lymphocyte.

Correct.The answer isNeutrophil.

Explanation:

Correct answer:Neutrophil

Neutrophil are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, while basophils are the least abundant.

Question 51

A female client is discharged from the hospital post delivery. The nurse escorts a mother and her newborn to the car. Which of the following approaches should the nurse instruct the new mother to place the newborn?

in the mother's lap with the seat beat across both the mother and the baby

on the front passenger side with the car seat facing forward

in the back seat of the car with the car seat facing backwards

in the middle section of the backseat with the baby positioned in the car seat facing forward

Correct.The answer isin the back seat of the car with the car seat facing backwards

Explanation:

The correct answer is in the back seat of the car with the car seat facing backwards.

Question 52

The couple with the lowest risk of having a child with sickle cell disease is the one in which what is true?

The father is HbS and the mother is HbS.

The father is HbS and the mother is HbAS.

The father is HbA and the mother is HbS.

The father is HbAS and the mother is HbAS.

Correct.The answer isThe father is HbA and the mother is HbS.

Explanation:

Correct answer:The father is HbA and the mother is HbS

If the father has normal hemoglobin (HbA) and the mother has sickle cell disease (HbS), the couple has a 0% chance of having a child with sickle cell disease. If both parents have sickle disease, the couple has a 100% chance of having a child with sickle cell disease. If the father has sickle cell disease and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell disease. lf both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell disease.

Question 53

You are reading the result of a Mantoux test on a2-year- old child. The results indicate an area of induration that measures 10 mm. What do you interpret these results as?

negative

positive

inconclusive

definitive and requiring a repeat test

Correct.The answer ispositive

Explanation:

The Correct answer is:positive

Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. For high risk groups, a reaction of 5mm or more is considered positive. A reaction of 15 mm or more is positive in children 4 years of age and older who have no risk factors.

Question 54

Of the following, which is the normal blood pressure range for an adolescent?

90-100/50-65

60-80/30-60

110-120/60-80

95-110/55-70

Correct.The answer is110-120/60-80

Explanation:

The correct answer is C. Choice A is the normal range for a toddler. Choice B is normal for a newborn and Choice D, for a school-aged child.

Question 55

Which of the following theorists was mentally disturbed?

Gordon Allport.

Hans Eysenck.

Raymond Cattell.

None of the above.

Correct.The answer isNone of the above.

Explanation:

Correct answer:None of the above

None of these theorists have been identified as being mentally disturbed.Each made great contributions to the field of mental health.

Question 55

Which of the following theorists was mentally disturbed?

Gordon Allport.

Hans Eysenck.

Raymond Cattell.

None of the above.

Correct.The answer isNone of the above.

Explanation:

Correct answer:None of the above

None of these theorists have been identified as being mentally disturbed.Each made great contributions to the field of mental health.

Question 56

A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend:

petroleum jelly.

a water-soluble lubricant.

body cream or body lotion.

less-frequent intercourse.

Correct.The answer isa water-soluble lubricant.

Explanation:

The correct answer is a water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.

Question 56

A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend:

petroleum jelly.

a water-soluble lubricant.

body cream or body lotion.

less-frequent intercourse.

Correct.The answer isa water-soluble lubricant.

Explanation:

The correct answer is a water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.

Question 57

The nurse is teaching a client who heavily drinks alcohol about maintaining a healthy heart. The nurse should include which point in her teaching?

Smoke in moderation.

Use alcohol in moderation.

Consume a diet high in saturated fats and low in cholesterol.

Avoid exercise.

Correct.The answer isUse alcohol in moderation.

Explanation:

Correct answer:Use alcohol in moderation

Alcohol may be used in moderation as long as there are no other contraindications for its use. Having a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol and saturated fat.

Question 58

You are caring for a client with a chest tube. You enter the room and find that the client has turned onto the side of the tube and disconnected the tube accidentally from the machine but is still connected to the patient. The appropriate initial action is to:

Place the tube in a bottle of sterile water.

Immediately replace the chest tube system.

Call the physician.

Place a sterile dressing over the site.

Correct.The answer isPlace the tube in a bottle of sterile water.

Explanation:

The Correct answer is:Place the tube in a bottle of sterile water.

Once the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water and held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. The physician may be notified, but this is not the initial action necessary. Placing a dressing over the disconnection site will not prevent complications.

Question 59

Which of the following will MOST help an elderly, hearing impaired client admitted to the hospital?

Invite all family members to come and visit any time.

Keep the television volume at high.

Leave the door open so the patient can hear everything going on in the hall.

Limit bedside conversation to that which directly pertains to the patient.

Correct.The answer isLimit bedside conversation to that which directly pertains to the patient.

Explanation:

The correct ansCorrect answer:Limit bedside conversation to that which directly pertains to the patient

This creates the least amount of auditory disturbance for the patient. Lots of noise can be upsetting to those with hearing impairments.

Question 60

Which of the following is the most common source of airway obstruction in an unconscious victim?

A foreign object.

Saliva or mucus.

The tongue.

Edema.

Incorrect.The answer isThe tongue.

Explanation:

Correct answer:The tongue

The muscles in many cases that control the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw-thrust maneuver must be performed.

Question 61

The nurse understands a child with HIV who is classified as Category C has which of the following manifestations?

anemia

encephalopathy

cystomegalovirus

toxoplasmosis

Incorrect.The answer isencephalopathy

Explanation:

The correct answer is encephalopathy.

The clinical manifestations that are seen with the category C classification of HIV are recurrent and multiple infections, encephalopathy, kaposi's sarcoma, lymphoma and wasting syndrome. The remaining answer choices are not the best selections as these are clinical manifestations of the Category B HIV classification.

Question 62

The nurse knows that in the past, inadequate community and occupational skills often limited clients who had severe mental illness. Today, though some teaching is best done in the client's own setting, priority community-based teaching would be for what?

Conflict management skills.

ADL skills.

Job training.

Social skills training.

Incorrect.The answer isSocial skills training.

Explanation:

The correct answer is social skills training. Individuals with severe mental illness often benefit from social skills training, focusing primarily on the teaching of basic coping skills necessary to live as autonomously as possible in the community. Job training will come after the client is able to interact well with others. ADL skills are beneficial, but clients will be taught these skills in their own setting. Conflict management skills will be taught after the social skills training

Question 63

Which of the following has a a generic name of Albuterol Sulfate?

Serevent.

Brethine.

Robitussin.

Proventil.

Correct.The answer isProventil.

Explanation:

Correct answer:Proventil

Choice A has a generic name of Salmeterol. Choice B has a generic name of Terbutaline Sulfate. Choice C has a generic name of Guaifenesin.

Question 63

Which of the following has a a generic name of Albuterol Sulfate?

Serevent.

Brethine.

Robitussin.

Proventil.

Correct.The answer isProventil.

Explanation:

Correct answer:Proventil

Choice A has a generic name of Salmeterol. Choice B has a generic name of Terbutaline Sulfate. Choice C has a generic name of Guaifenesin.

Question 64

When obtaining a health history, the nurse expects a client with a diagnosis of Myasthenia Gravis to report which of the following signs or symptoms?

Low lying eyelids.

Increased headaches.

A knot on the neck.

Pain in the chest.

Incorrect.The answer isLow lying eyelids.

Explanation:

Correct answer:Low lying eyelids

A client with Myasthenia Gravis may report that his or her eyelids feel low or drooping, which is known as ptosis. Additional signs and symptoms of Myasthenia Gravis is dysphonia, enlarged thymus gland, strabismus, muscle weakness and diplopia.

Question 64

When obtaining a health history, the nurse expects a client with a diagnosis of Myasthenia Gravis to report which of the following signs or symptoms?

Low lying eyelids.

Increased headaches.

A knot on the neck.

Pain in the chest.

Incorrect.The answer isLow lying eyelids.

Explanation:

Correct answer:Low lying eyelids

A client with Myasthenia Gravis may report that his or her eyelids feel low or drooping, which is known as ptosis. Additional signs and symptoms of Myasthenia Gravis is dysphonia, enlarged thymus gland, strabismus, muscle weakness and diplopia.

Question 65

A client is discharged from a hospital's psychiatric unit. The physician writes an order for Zyprexa. As the nurse prepares the teaching plan for the Zyprexa medication, the nurse should teach the client to do what?

avoid smoking

get plenty of sunlight

avoid foods containing tyramine

eat a high protein, high carbohydrate diet

Incorrect.The answer isavoid smoking

Explanation:

The correct answer is to avoid smoking. The serum levels of antipsychotic medications, such as Zyprexa, can be decreased when an individual smokes tobacco products. When taking Zyprexa, the client should avoid exposure to direct sunlight. Avoiding foods containing tyramine would be dangerous if the client was prescribed an monoamine oxidase inhibitor (MAOI). Further, instructing the client to eat a high protein, high carbohydrate diet is not a requirement for a client who is prescribed Zyprexa. This dietary instruction is recommended for clients with bipolar disorder.

Question 66

Which must be included in a medication order?

Drug class

Possible adverse reactions

Physician's signature

Client allergies

Incorrect.The answer isPhysician's signature

Explanation:

The correct answer is physician's signature. The physician's signature must be included in a medication order. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions are not components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order.

Question 67

The nurse is assessing a client's pulse. Which pulse feature should the nurse document?

Timing in the cycle

amplitude

pitch

intensity

Incorrect.The answer isamplitude

Explanation:

The correct answer is amplitude. The nurse should document the rate, rhythm, and amplitude of a client's pulse. Pitch, timing, and intensity are not associated with pulse assessment.

Question 68

Which of the following is a brand name for Metoclopramide HCL?

Reglan.

Compazine.

Phenergan.

Nexium.

Correct.The answer isReglan.

Explanation:

Correct answer:Reglan

Choice B is a brand name for Prochlorperazine. Choice C is a brand name for Promethazine and choice D, for Esomeprazole Magnesium.

Question 69

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?

Caucasian race.

Female gender.

Obesity.

Bronchial asthma.

Correct.The answer isObesity.

Explanation:

Correct answer:Obesity

Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The clients' race, gender and bronchial asthma are not risk factors for stroke.

Question 69

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?

Caucasian race.

Female gender.

Obesity.

Bronchial asthma.

Correct.The answer isObesity.

Explanation:

Correct answer:Obesity

Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The clients' race, gender and bronchial asthma are not risk factors for stroke.

Question 70

Which leadership style is base on the belief that every member of the group should have input into the development of goals and problem solving?

autocratic leadership

laissez-faire leadership

democratic leadership

situational leadership

Incorrect.The answer isdemocratic leadership

Explanation:

The Correct answer is:democratic leadership

Autocratic leadership is focused and maintains strong control, makes decisions, and addresses all problems. The autocratic leader dominates and commands rather than seek suggestions or input. The laissez-faire leader assumes a passive, nondirective, and inactive approach and relinquishes part or all of the leadership responsibilities to group members. The situational leader uses a combination approach based on the circumstances.

Question 71

What is the best way for a client with reoccurring kidney stones to prevent further kidney stones?

Increase dairy intake.

Decrease fatty protein and carbohydrate intake.

Ingest plenty of cranberry juice.

Take vitamin D supplements.

Incorrect.The answer isIngest plenty of cranberry juice.

Explanation:

Correct answer:Ingest plenty of cranberry juiceCranberry juice increases the acidity of urine, which helps with the dissolving of kidney stones. While the other foods will add nutrients to the diet, they do not address the development of further kidney stones.

Question 72

The nurse is providing dietary teaching for the parents of a child with celiac disease. This child should avoid what?

Vegetables.

Fruits.

Prepared puddings.

Rice.

Correct.The answer isPrepared puddings.

Explanation:

Correct answer:Prepared puddings

A child with celiac disease must not consume food containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other choices do not contain gluten and are permitted when on a gluten free diet.

Question 73

The client is prescribed morphine. The client is experiencing urinary retention. The nurse understands the physician may order which of the following?

a lowered dose of morphine

a mild laxative

increased fluid intake

increased fiber intake

Incorrect.The answer isa lowered dose of morphine

Explanation:

The correct answer is: a lowered dose of morphine. If the client experiences the side effect of urinary retention due to the morphine, the physician may order a change in the dose or a lowered dosing of morphine. Also, the physician may instruct the nurse to catherize the client. The remaining answer choices are incorrect as they are orders the physician may give for other conditions such as constipation.

Question 74

The nurse documents scalp edema that crosses the lines of the skull in the newborn as what?

molding.

cephalohematoma.

cranial distention.

caput succedaneum.

Incorrect.The answer iscaput succedaneum.

Explanation:

The correct answer is caput succedaneum. Since a caput succedaneum is just superficial and beneath the scalp, the swelling can cross the suture lines. Molding is overriding of the cranial plates, and cephalohematoma does not cross the suture lines, since it results when blood is trapped beneath the periosteum. Cranial distention is not a term used in newborn assessment.

Question 74

The nurse documents scalp edema that crosses the lines of the skull in the newborn as what?

molding.

cephalohematoma.

cranial distention.

caput succedaneum.

Incorrect.The answer iscaput succedaneum.

Explanation:

The correct answer is caput succedaneum. Since a caput succedaneum is just superficial and beneath the scalp, the swelling can cross the suture lines. Molding is overriding of the cranial plates, and cephalohematoma does not cross the suture lines, since it results when blood is trapped beneath the periosteum. Cranial distention is not a term used in newborn assessment.

Question 75

A 21-year-old female is diagnosed with dysthymic disorder. When obtaining a history from the female, what information should the nurse expect?

experienced compulsive behavior

intense fear

irritability

talking excessively

Correct.The answer isirritability

Explanation:

The correct answer is irritability. In young adults and children, the symptoms noted with dysthymic disorder include irritability, depression, low self esteem, pessimism, and impaired social skills and social interactions. Talking excessively is more evident with children who have attention deficit hyperactivity disorder. Intense fear is associated with anxiety disorders. Further, compulsive behavior is not associated with individuals diagnosed with dysthymic disorder.

Question 76

The nurse is teaching accident prevention to the parents of a toddler. Which instruction is MOST appropriate for the nurse to tell the parents?

The toddler should wear a helmet when rollerblading.

Place locks on cabinets containing toxic substances.

Teach the toddler water safety.

Do not allow the toddler to use pillows when sleeping.

Incorrect.The answer isPlace locks on cabinets containing toxic substances.

Explanation:

Correct answer:Place locks on cabinets containing toxic substances

All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to climb and open doors and drawers makes poisoning a concern in this age group. Rollerblading is not an appropriate activity for toddlers. Toddlers lack the cognitive development to understand water safety. Pillows should not be placed in the crib of an infant to avoid suffocation; however, toddlers may use them.

Question 77

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for which of the following?

Nausea and vomiting.

Dyspnea and cyanosis.

Fatigue and weakness.

Thrush and circumoral pallor.

Correct.The answer isFatigue and weakness.

Explanation:

Correct answer:Fatigue and weakness

RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF, but do not result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor which reflects decreased oxygenation, are not signs of CRF.

Question 78

Which of the following is a high risk factor for diabetes mellitus?

A history of being overweight 10 pounds

Native American

A great-grandparent with diabetes

A sweet tooth

Incorrect.The answer isNative American

Explanation:

The correct answer is B. The highest risk factors include: Native Americans, obesity (BMI of 30 or higher), and an immediate family history (sibling or parent). African American and Hispanic populations are also at high risk.

Question 79

Which of the following patients would a nurse not administer Erythromycin to?

A person with multiple sclerosis.

A person with pneumonia

A person with a gun shot wound.

A person with an infection after surgery.

Correct.The answer isA person with multiple sclerosis.

Explanation:

Correct answer:A person with multiple sclerosis

An antibiotic is indicated if there is a possible infection. Multiple sclerosis is not characterized by infections.

Question 80

There are many rights to the patient when they are hospitalized. Which of the following isNOTa right to be considered with these patients?

The right to have an advanced directive.

The right to expect that medical records are confidential.

The right to consent or refuse to take part in research.

The right to bring their own personal protection devices and medications into a health care facility.

Correct.The answer isThe right to bring their own personal protection devices and medications into a health care facility.

Explanation:

The Correct answer is:The right to bring their own personal protection devices and medications into a health care facility.

The client is not allowed to bring weapons or medications into a health care facility as delegated by hospital rules, policies, and procedures. The other answers (a, b, and c) are all rights of the client.

Question 81

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called what?

Looseness of association.

Flight of ideas.

Tangential thinking.

Circumstantial thinking.

Incorrect.The answer isFlight of ideas.

Explanation:

Correct answer:Flight of ideas

Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around the subject and includes a lot of unnecessary information is exhibiting circumstantial thinking.

Question 82

The nurse is developing a plan of care for the client in a crisis state. When developing the plan, the nurse considers which of the following?

Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis.

Aclient's response to a crisis situation is individualized and what constitutes a crisis for one person may not constitute a crisis for another person.

Acrisis state indicates that the individual is suffering from a mental illness.

A crisis state indicates that the individual is suffering from an emotional illness.

Correct.The answer isAclient's response to a crisis situation is individualized and what constitutes a crisis for one person may not constitute a crisis for another person.

Explanation:

The Correct answer is:Aclient's response to a crisis situation is individualized and what constitutes a crisis for one person may not constitute a crisis for another person.

A crisis response can be described in similar terms, what constitute a crisis for one person may not constitute a crisis for another person because each person is unique. A crisis state does not mean that the person has an emotional or mental illness.

Question 83

The nurse is performing wound care. Which of the following practices violates surgical asepsis?

Holding sterile objects above the waist.

Considering a 1" edge around the sterile field as being contaminated.

Pouring solution onto a sterile field cloth.

Opening the outermost flap of a sterile package away from the body.

Incorrect.The answer isPouring solution onto a sterile field cloth.

Explanation:

Correct answer:Pouring solution onto a sterile field cloth

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other choices are practices that help ensure surgical asepsis.

Question 84

The nurse assesses a child who is dehydrated. The child has lost 15% of his body weight. The nurse suspects what of the child?

The child is not dehydrated any longer

The child has mild dehydration

The child has moderate dehydration

The child has severe dehydration

Correct.The answer isThe child has severe dehydration

Explanation:

The correct answer is the child has severe dehydration. When a child has lost 10% of his or her body weight during dehydration, this indicates the child has severe dehydration. Mild dehydration is indicated when the child has lost up to 5% of his or her body weight. Moderate dehydration is represented when the child has lost 6-9% of his or her body weight.

Question 85

After running several tests, Dr. Smith realizes that the microorganisms in his patient, Tom are rapidly multiplying. However, the microorganisms are not causing any damage. This multiplication of microorganisms is known as which of the following?

Colonization.

Infectious agent.

Particulate respirator.

Reservoir.

Correct.The answer isColonization.

Explanation:

Correct answer:Colonization

An infectious agent is an organism that can cause disease. A particulate respirator is a mask worn on the faces of medical personnel. They block organisms from entering the body. A reservoir is a place where the conditions are conducive for the growth and development of microorganisms.

Question 86

A client asks the nurse what treatments are used for xerosis. Which intervention should the nurse include in a teaching plan for the client?

Use perfumes and lotions with alcohol.

Use hot water when taking a bath.

Use a humidifier.

Apply heating pads to reduce pruritus.

Incorrect.The answer isUse a humidifier.

Explanation:

Correct answer:Use a humidifier

Xerosis, which is dry skin, is caused by heat and low humidity. Therefore, it is important to use a humidifier to add moisture to the air in order to relieve dry, itchy skin.

Question 87

An infant is startled by a loud noise. The nurse understands this reaction to the loud noise is the the result of:

Tonic neck reflex

Moro reflex

Steeping reflex

Babinski reflex

Incorrect.The answer isMoro reflex

Explanation:

The correct answer is:Moro reflex

The Moro reflex is used to determine an infant's nervous system maturity. This reflex goes away when a child reaches 4 months old. Typically, when a child hears a loud noise or reacts to a sudden change in a position, this reflex occurs.

Question 88

Which of the following is a brand name for Buspirone?

Librium.

Valium.

BuSpar.

Concerta.

Correct.The answer isBuSpar.

Explanation:

Correct answer:BuSpar

Choice A is a brand name for Chlordiazepoxide. Choice B is a brand name for Diazepam. Choice D is a brand name for Methylphenidate HCL.

Question 88

Which of the following is a brand name for Buspirone?

Librium.

Valium.

BuSpar.

Concerta.

Correct.The answer isBuSpar.

Explanation:

Correct answer:BuSpar

Choice A is a brand name for Chlordiazepoxide. Choice B is a brand name for Diazepam. Choice D is a brand name for Methylphenidate HCL.

Question 89

Which of the following phases of disaster management is primarily concerned with physical and mental health and safety of the disaster response team?

Preparedness.

Recovery.

Mitigation.

Response.

Correct.The answer isResponse.

Explanation:

Correct answer:Response

Choice A looks for the most effective way of caring for a patient once a disaster occurs. Choice B takes into consideration the actions necessary for everyone to return to a state of normalcy after a disaster. Choice C takes into consideration the actions that can help prevent the occurrence of a disaster.

Question 90

The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of what?

Protein.

Fat.

Vitamin A.

Zinc.

Incorrect.The answer isFat.

Explanation:

Correct answer:Fat

A diet containing excessive fat seems to contribute to autoimmunity - overreaction of the body against constituents of its own tissues. Immune dysfunction has been liked to deficient - not excessive - intake of protein, vitamin A and zinc.

Question 91

According to studies done on gay and lesbian families, what significant differences might be expected in parent/child and peer relationships of children raised in a gay/ lesbian household as compared with traditional heterosexual parenting?

children seem to experience no differences

children fighting more with the biological parent

children fighting more with the partner of the biological parent

children being more inclined to use drugs

Incorrect.The answer ischildren seem to experience no differences

Explanation:

The correct answer is children seem to experience no differences. No significant differences have been found. There is no evidence that children fight with the biological parent or with the partner of the biological parent significantly more in gay and lesbian families. It has not been found that children in gay and lesbian families are more inclined to use drugs.

Question 91

According to studies done on gay and lesbian families, what significant differences might be expected in parent/child and peer relationships of children raised in a gay/ lesbian household as compared with traditional heterosexual parenting?

children seem to experience no differences

children fighting more with the biological parent

children fighting more with the partner of the biological parent

children being more inclined to use drugs

Incorrect.The answer ischildren seem to experience no differences

Explanation:

The correct answer is children seem to experience no differences. No significant differences have been found. There is no evidence that children fight with the biological parent or with the partner of the biological parent significantly more in gay and lesbian families. It has not been found that children in gay and lesbian families are more inclined to use drugs.

Question 92

Which of the following is an adverse reaction of phenelzine sulfate (Nardil)?

Nausea.

Tachypnea.

Headache.

Anxiety.

Incorrect.The answer isTachypnea.

Explanation:

Correct answer:Tachypnea

Phenelzine sulfate (Nardil) is a antidepressant that belongs to the class of drugs called monoamine oxidase inhibitors (MAOI). When taking this drug, the common adverse reactions are tachypnea, tachycardia, tremors, seizures and heart block.

Question 93

Which of the following types of wounds is characterized by black, dry tissue?

Yellow wounds.

White wounds.

Red wounds.

Black wounds.

Correct.The answer isBlack wounds.

Explanation:

Correct answer:Black wounds

Wounds are divided into the following types: black wounds, yellow wounds and red wounds. Black wounds are necrotic, dry tissue that are prone to infection. In order to remove the dead tissue, surgical abridgement is used.

Question 93

Which of the following types of wounds is characterized by black, dry tissue?

Yellow wounds.

White wounds.

Red wounds.

Black wounds.

Correct.The answer isBlack wounds.

Explanation:

Correct answer:Black wounds

Wounds are divided into the following types: black wounds, yellow wounds and red wounds. Black wounds are necrotic, dry tissue that are prone to infection. In order to remove the dead tissue, surgical abridgement is used.

Question 94

A client with major depression frequently is irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach?

Firmness.

Joyfulness.

Humor.

Aloofness.

Incorrect.The answer isFirmness.

Explanation:

Correct answer:Firmness

By taking a firm approach, the nurse sets limits and establishes boundaries for the client's behavior, which helps ensure safety and gives the client a sense of control. A joyful or humorous approach may make the client feel guilty about being depressed. An aloof approach does not enable the client to initiate interpersonal contact or encourage communication.

Question 95

Nurses require leadership skills. Of the following leadership types, which relinquishes some control to the members of the group?

Democratic.

Situational.

Autocratic.

Laissez-faire.

Incorrect.The answer isLaissez-faire.

Explanation:

Correct answer:Laissez-faire

The type of leader in Choice A actively seeks input from members of the group. Situational leaders are flexible and utilize a combination of the other leadership types depending on the most effective way of completing the task. An autocratic leader dominates the group rather than seeking suggestions from the group.

Question 96

The nurse has been ordered to collect a sputum specimen from a client. The professional nurse knows which of the following will facilitate obtaining the specimen?

Having the client take three deep breaths.

Asking the client to spit into the collection container.

Limiting fluids.

Asking the client to obtain the specimen after eating.

Incorrect.The answer isHaving the client take three deep breaths.

Explanation:

The Correct answer is:Having the client take three deep breaths.

The proper procedure to collect a specimen includes rinsing the mouth out to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or inhalation respiratory treatments so the best time to collect the specimen is early a.m. upon arising.

Question 97

When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?

Constriction and divergence

Dilation and convergence

Constriction and convergence

Dilation and divergence

Correct.The answer isConstriction and convergence

Explanation:

The correct answer is:Constriction and convergence

During accommodation, the pupils should constrict and converge equally on an object. Pupils normally dilate in darkness and when a person stares at an object across a room. Divergence is never a normal response.

Question 98

The nurse is performing a psychosocial assessment on an adolescent age 14. Which emotional response is typical during early adolescence?

Frequent anger.

Cooperativeness.

Moodiness.

Combativeness.

Correct.The answer isMoodiness.

Explanation:

Correct answer:Moodiness

During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.

Question 99

The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best response for the nurse to make?

"I would not worry about it."

"This is normal. It will soon turn to real milk."

"You are coming along fine."

"You have not gotten your milk in yet."

Correct.The answer is"This is normal. It will soon turn to real milk."

Explanation:

The correct answer:"This is normal. It will soon turn to real milk."

The client is describing colostrum. Milk comes in about 72 hours after delivery. "I would not worry about it" and "you are coming along fine" do not address the question asked by the mother.

Question 99

The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best response for the nurse to make?

"I would not worry about it."

"This is normal. It will soon turn to real milk."

"You are coming along fine."

"You have not gotten your milk in yet."

Correct.The answer is"This is normal. It will soon turn to real milk."

Explanation:

The correct answer:"This is normal. It will soon turn to real milk."

The client is describing colostrum. Milk comes in about 72 hours after delivery. "I would not worry about it" and "you are coming along fine" do not address the question asked by the mother.

Question 100

The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority?

Impaired gas exchange.

Anxiety.

Decreased cardiac output.

Ineffective cardiopulmonary tissue perfusion.

Correct.The answer isImpaired gas exchange.

Explanation:

Correct answer:Impaired gas exchange

For a client with chest trauma, a diagnosis of impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other options are possible nursing diagnoses for this client, they take lower priority.