The initial response by the nurse to a delusional client who refuses to eat because of a belletrist 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) “O’Hare safe here. I won’t let anyone poison you. ” A: “You think that someone wants to poison you? ‘ This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt. .. A client has just been admitted with portal hypertension. Which nursing diagnosis would BEA priority in planning care? A) Altered nutrition: less than body requirements B) potential complication hemorrhage C) Ineffective individual coping D) Fluid volume excess B: Potential complication hemorrhage , Esophageal avarice are dilated and tortuous vessels of the esophagi that are at high risk for rupture if portal circulation pressures rise. 3..
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 4 month-old who cries during examination D) A 30 month-old only drinking from a Sappy cup The correct answer is D: A 30 month-old only drinking from a sappy cup A 30 month-old should be able to drink from a cup without a cover. . Which of the following conditions assessed by the nurse would contraindicate the use of penetration (Connecting)? A) Neurological syndrome B) Acute extramarital syndrome C) Glaucoma, prismatic hypertrophy D) Parkinson disease, atypical tremors The correct answer is C: Glaucoma, prismatic hypertrophy Glaucoma and prismatic hypertrophy are contraindications to the use of minestrone (Connecting) as the drug is an interscholastic agent. . A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) insecurity C) Dependence D) Lack of trust The correct answer is C: Dependence The client role fosters dependency. Adolescents may react to dependency with rejection, inconsiderateness, or withdrawal. 6. The nurse is caring for a client with cirrhosis of the liver with cities.
When instructing nursing assistants in the care of the client, the nurse should emphasize that A) The client should remain on bed rest in a semi-Fowler;s sections B) The client should alternate ambulation with bed rest with legs elevated C) The client may ambulate and sit in chair as tolerated D) The client may ambulate as tolerated and remain in semi-Fowlers position in bed The correct answer is B: The client should alternate ambulation with bed rest with legs elevated Encourage alternating periods ambulation and bed rest with legs elevated to mobile edema and cities.
Encourage and assist the client with gradually increasing periods of ambulation. 7. 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: Looking different from their peers, Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others.
Treatment of scoliosis is long-term and involves bracing and/or surgery. 8th 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) Calculate heart and lungs D) Examine the ears C: Calculate heart and lungs, The nurse should calculate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order. . Which oftenest 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 ACH day C: A serving size at this age is about 2 tablespoons, In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake. 0. 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: Long term steroid usage, Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased. 1 1 . Which of the following nursing assessments indicate immediate discontinuance of an antispasmodic 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) Hyperplasia, severe muscle rigidity, malignant hypertension D: Hyperplasia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of MS (narcoleptic malignant syndrome). 12. A client with HIVE infection has a secondary herpes simplex type 1 (HAS-I ) infection.
The nurse knows that the most likely cause of the HAS-I infection in his client is A) Mispronunciation B) Emotional stress C) Unprotected sexual activities D) Contact with saliva A: Mispronunciation , The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HAS-I . However they are not the most likely cause in clients with HIVE. 13. 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 health care provider B) Palpate the anterior fontanel C) Feel the posterior fontanel D) Record these normal findings D: Record these normal findings, The question is D. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age. 14. 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? The correct answer is B: “How long has this been occurring? ” Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons. 15. 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 The correct answer is D: Toileting the client more frequently with supervision With altered thought processes the most appropriate nursing approach to alter the behavior is by attending to the physical need. 16. The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece trainable story pouch. Which is the correct intervention?
A) Piercing the plastic of the story 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 story pouch to low the flatus to escape D) Assisting the client to ambulate to reduce the flatus in the pouch B: Opening the bottom of the pouch, allowing the flatus to be expelled The only correct way to vent the flatus from a 1 piece trainable story pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and dose the bottom of the pouch. 7. 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: Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron. 18. 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: There is a 25% chance a daughter will be a carrier, Hemophilia A is a sex- linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male. 19.
When teaching a client with chronic obstructive pulmonary disease about oxygen by canals, the nurse should also instruct the client’s family to A) Avoid smoking near the client the liter flow to 10 as needed B) Turn off oxygen during meals C) Adjust D) Remind the client to keep mouth closed A: Avoid smoking near the client, Since oxygen supports combustion, there is risk of fire if anyone smokes near the oxygen equipment. 20th nurse is caring for a post-pop 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 by the nurse?
A) Arrange a consultation with a sex therapist B) Suggest sexual positions that hide the colostomy C) Invite the partner to participate in colostomy care D) Determine the client’s understanding of her colostomy D: Determine the client”s understanding of her colostomy, One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer Seibel. However, the specific concern of the client needs to be assessed before specific suggestions for dealing with the sexual concerns are given. 21 . 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 The correct answer is D: Engages in meaningful and understandable verbal communication Data support impaired verbal communication deficit. The outcome must be related to the diagnosis and supporting data. No data is presented related to feelings or to thinking processes. 22.
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 catabolic to meet metabolic needs D: Spare protein catabolic to meet metabolic needs Because of the burn injury, the child has increased metabolism and catabolic. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided.
Proteins are then used to restore tissue. 23 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: The ethical sense and feelings of justice are developing, The child is developing a sense of justice and a desire to do what is right.
At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. 24. 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: Maintaining good nutrition, Nurses can seer. ‘e a pivotal role in providing nutritional education and case management interventions.
Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies. 25. A client continually repeats phrases that others have just said. The nurse recognizes this behavior as A) Autistic B) Sporadic C) Chocoholic D) Catatonic C:Chocoholic – repeating words heard. 26. A client is admitted for hemophilia’s.
Which abnormal lab value would the nurse anticipate not being improved by hemophilia’s? A) Low hemoglobin B) Hyperthermia C) High serum creating D) Hyperemia The correct answer is A: Low hemoglobin Although hemophilia’s improves or corrects electrolyte imbalances it has not effect on improving anemia. 27. 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 reviver 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 The correct answer is A: Report a persistent cough to the health care provider Persistent coughing should be reported to the health care provider as this may indicate bleeding. 28. 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) line 4 chance for each child to carry that trait B) line 4 risk for each child to have the disease C) line 2 chance of avoiding the trait and disease D) line 2 chance that each child will have the disease B: 1 in 4 risk for each child to have the disease, Cystic Fibrosis is an autocross recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance Of carrying the trait and a 25% chance Of having neither the trait or the disease. 8. ” The nurse is performing an assessment on a client with pneumatically ammonia. Which finding would the nurse anticipate? A) Bronchial breath sounds in outer lung fields B) Decreased tactile fruits C) Hacking, nonproductive cough D) Hypertension’s of areas of consolidation A: Bronchial breath sounds in outer lung fields, Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields. 29 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: Protect the client from injury, It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description. 30. 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) Amelioration 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: Amelioration of the spinal cord is completed by this age Voluntary control of the sphincter muscles can be gradually achieved due to the complete amelioration of the spinal cord, sometime between the ages of 1 8 to 24 months of age. 31 . A client complaining of severe shortness of breath is diagnosed with congestive heart failure.
The nurse observes a falling pulse geometry. 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 Fowlers D) Administer oxygen D: Administer oxygen, When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation. Starting oxygen is a priority. 32. The nurse is caring for a client with benign prismatic hypertrophy.
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: Frequent urination Clients with Benign Prismatic Hypertrophy have overflow incontinence with request urination in small amounts day and night. 33. 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: “When a child asks a question, give a simple answer. ” During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer.
When they are ready, they will ask about the other pieces. 34. A 3 year-old child is treated in the emergency department after ingestion of 1 ounce off liquid narcotic. What action should the nurse do 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: Check the mouth and radial pulse, The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation; then stabilize the client.
The other nursing actions will follow. 35. 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) So 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: To reduce the tendency of the client to hide objects under his or her clothing The client may conceal weights on their body to increase weight gain. 36. 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 D) Maintain routine immunization temperatures A: Avoid overheating, Fluid loss caused by overheating and dehydration can trigger a crisis. . 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) Explosive B: Helplessness, The battered individual internalizes appropriate anger at the batterer’s unfairness and instead feels depressed with a sense of helplessness, when the partner explodes in spite of best efforts to please the batterer. 8. A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is f most concern to the nurse? A) 50% increase in birth weight 8) Head circumference greater than chest C) Crying when the parents leave D) Able to stand up briefly in play pen A: 50% increase in birth weight, Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18 months. 39.
The nurse has been assigned to these clients in the emergency room. Which client would the nurse go check first? A) Viral pneumonia with tattletales B) Spontaneous pneumonia with a respiratory rate of 38 C) Tension pneumonia with slight tracheal deviation to the right D) Acute asthma with episodes of bronchiole’s C: Tension pneumonia with slight tracheal deviation to the right Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a intestinal shift.
In tension pneumonia the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypertension, pain in the affected side, and occasions with a high risk of cardiac tampon and cardiac arrest. 40. The nurse is assessing a 4 year-old for possible developmental dysphasia f the right hip. Which finding would the nurse expect?