1. A client who is at 26 weeks’ gestation arrives at the clinic for her scheduled examination. Her blood pressure is 150/86. She tells the nurse that she has gained 5 pounds in the last 2 weeks. What is the priority nursing action?
Test the client’s urine for albumin.
Take the client’s body temperature.
Prepare the client for a vaginal examination.
Schedule the client for an appointment in a week.
2. A new mother refuses to look at her newborn who has a severe birth defect. What is the nurse’s most therapeutic approach?
Request that the family try to distract her.
Clarify why she should stop blaming herself for the baby’s handicap.
Reinforce the explanation of the handicap and allow time for her to discuss her fears.
Wait until she has sufficiently recovered from the stress of birth and then bring the baby to her again.
3. An African-American woman is diagnosed with primary hypertension. She asks, “Is hypertension a disease of African- American people?” What is the nurse’s best response?
“The prevalence of hypertension is about equal for women of all races.”
“The higher-risk population is composed of African- American men and women.”
“The highest-risk population consists of older Caucasian- American men and women.”
“The prevalence of hypertension is greater for African- American women than for African-American men.”
4. An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication of this type of surgery should the nurse explain to the parents to prepare them for their child’s discharge?
Violent involuntary muscle contractions
Eyes with sclerae visible above the irises
Excessive fluid accumulation in the abdomen
Fever accompanied by decreased responsiveness
5. Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse?
“It is rarely performed in children.”
“The immune system must be destroyed before a transplant can take place.”
“The hematopoietic stem cells are surgically implanted in the bone marrow.”
“It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion.”
6. During the first well-baby visit after discharge from the hospital, the parents inform the nurse that their baby has difficulty sucking and swallowing and tires easily. What should the nurse consider when assessing this infant?
Newborns tend to tire easily, especially when feeding
Decreased sucking is insignificant in the absence of cyanosis
Difficulty when feeding may be an early indication of a heart defect
Some infants retain mucus for several days that may interfere with feeding.
7. A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the clients trachea routinely. What is the rationale for this nursing intervention?
A mediastinal shift may have occurred.
Nodular lesions may demonstrate metastasis.
Tracheal edema may lead to an obstructed airway.
The cuff of the endotracheal tube may be overinflated.
8. A client is scheduled for emergency abdominal surgery. What is the priority preoperative nursing objective when caring for this client?
Recording accurate vital signs
Alleviating the client’s anxiety
Teaching about early ambulation
Maintaining the client’s nutritional status
9. When performing a newborn assessment after a vaginal birth, a nurse observes a swelling on one side of the top of the head. What clinical manifestation did the nurse identify?
Caput succedaneum that will spread across the scalp and then resolve
Fontanel that bulges when the infant cries and will close in eighteen months
Cephalohematoma that does not cross the suture line and will resolve in several weeks
Molding that results from the skull taking the shape of the vagina and will disappear in several days
10. What is most important for a nurse to do when helping a new mother on the postpartum unit develop her parenting role?
Teach her how to care for the infant.
Provide time for her and her infant to be together.
Respond to any questions she has about her infant’s behavior.
Demonstrate infant care and evaluate her return demonstration.
11. When teaching a class about parenting, the nurse asks the participants what they do when their toddlers have a temper tantrum. Which statement demonstrates one parent’s understanding of the origin of temper tantrums?
“After a temper tantrum, I discipline my child by restricting a favorite food or activity.”
“When a temper tantrum begins, I isolate and ignore my child until the behavior improves.”
“During a temper tantrum, I partially gives in to my child before the tantrum becomes excessive.”
“I try to prevent a temper tantrum by allowing my child to choose between two reasonable alternatives.”
12. A nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective?
Apples
Broccoli
Cherries
Cauliflower
13. An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit?
Initiate a program of planned interaction.
Explain the nature and routines of the unit.
Explore in depth the reasons for the admission.
Provide for the continuous presence of a staff member.
14. A parent of a 2-year-old child who was just diagnosed with cystic fibrosis expresses concern about the child’s frailty and low weight. What is the nurse’s most appropriate reply?
“Digestive enzymes will be given to help your child digest food.”
“Your child’s appetite will improve once respiratory therapy is initiated.”
“Your child’s coughing and shortness of breath prevent adequate chewing of food.”
“I suggest that you offer baby foods to your child because they are more easily digested.”
15. A client who has a phobia about dogs is about to begin systematic desensitization. The client asks what the treatment will involve. What is the nurse’s best response?
“You will be exposed to dogs until you no longer feel anxious.”
“Rewards will be given when you do not become anxious around dogs.”
“Your contact with dogs will increase while using relaxation techniques.”
“There will be in-depth discussions to identify what caused your phobia.”
16. A nursing assistant interrupts the performance of a ritual by a client with obsessive-compulsive disorder. What is the most likely client reaction?
Anxiety
Hostility
Aggression
Withdrawal
17. A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?
Facilitates vasodilation
Promotes smooth muscle relaxation
Reduces the circulating blood volume
Blocks the sympathetic nervous system
18. A health care provider prescribes famotidine (Pepcid) for a client with dyspepsia. What is important to include about this medication in a teaching program for this client?
Lowers the stress level
Neutralizes gastric acidity
Reduces gastrointestinal peristalsis
Decreases secretions in the stomach
19. The parents of a child with spasmodic croup ask why their child is receiving humidified oxygen. What effect of humidified oxygen should the nurse include in the explanation?
Minimizes tissue edema
Provides a mode for giving inhalant drugs
Increases the surface tension of the respiratory tract
Provides an environment free of pathogenic organisms
20. A nurse is caring for a client experiencing an acute episode of bronchial asthma. What outcome should be achieved?
Raising mucous secretions from the chest
Curing the client’s condition permanently
Limiting pulmonary secretions by decreasing fluid intake
Convincing the client that the condition is emotionally based
21. A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?
Oxygen
Naloxone
Calcium gluconate
Suction equipment
22. When a developmental appraisal is performed on a 6-month- old infant, which observation is most important to the nurse in light of a diagnosis of hydrocephalus?
Head lag
Positive Babinski reflex
Inability to sit unsupported
Absence of the grasp reflex
23. What behavior does a nurse expect of a newborn about 1 hour after birth?
Crying and cranky
Hyperresponsive to stimuli
Relaxed and sleeping quietly
Intensely alert with eyes wide open
24. What must the nurse emphasize to the family when preparing a child with persistent asthma for discharge?
A cold, dry environment is desirable.
Limits should not be placed on the child’s behavior.
The health problem is gone when symptoms subside.
Medications must be continued even when asymptomatic.
25. A 20-year-old college student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most appropriate response by the nurse?
“With whom have you shared your feelings of anxiety?”
“What have you identified as the cause of your anxiety?”
“It has been difficult for you. How long has this been going on?”
“Let’s talk about your problems. Are you having difficulty adjusting?”
26. A client has a surgical creation of a colostomy. What is the most effective nursing intervention to initially help the client accept the colostomy?
Introduce equipment needed to care for the colostomy.
Provide literature containing factual data about colostomies.
Ask a member of a support group to come to speak with the client.
Point out the number of important people who have had colostomies.
27. A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required?
Irritability
Hoarseness
Barking cough
Rapid respirations
28. A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery?
Use a pillow to keep the legs abducted.
Elevate the client’s affected limb on a pillow.
Turn the client using the log-rolling technique.
Place a trochanter roll along the entire extremity.
29. A nurse is caring for a client who attempted suicide. What is the most desirable short-term client outcome during this crisis situation?
Strengthening coping skills
Establishing a no-suicide contract
Learning problem-solving techniques
Recognizing why suicide was attempted
30. A 3/4-year-old child is admitted to the hospital for an appendectomy. What should the nurse use to best prepare the child for the hospital experience?
A diagram
Puppet play
A storybook
Therapeutic play
31. A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client?
Tolerance to the drug develops readily.
One third to one half the usual dose should be prescribed.
Opioids may interfere with the secretion of thyroid hormones.
Sedation will have a paradoxical effect, causing hyperactivity.
32. During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment, a CBC and a urinalysis are performed. Which laboratory finding should alert the nurse that further assessment is required?
WBC count of 9000/mm3
Hemoglobin level of 10 g/dL
Urine specific gravity of 1.020
Glucose level of 1+ in the urine
33. A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?
“Don’t worry; these tests are routine.”
“They are done to identify other health risks.”
“They determine whether surgery will be safe.”
“I don’t know; your health care provider ordered them.”
34. A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery?
Femoral pulse
Toes for mobility
Condition of the pin
Range of motion of the knee
35. A client who uses ritualistic behavior taps other clients on the shoulders three times while going through the ritual. The nurse infers that this client has a:
blurred personal identity.
poor control of sudden urges.
disturbance in spatial boundaries.
reduced ability to adapt to life’s stresses.
36. A person with a history of alcoholism states, “I have been drinking since last Friday to celebrate my son’s graduation from college.” What defense mechanism does the nurse identify the client is using?
Projection
Suppression
Identification
Rationalization
37. The parents of a child with a fever, headache, and stiff neck express concern that the child be tested for meningitis. Which test should the nurse explain to the parents is used to confirm the diagnosis of meningitis?
Myelogram
Blood culture
Lumbar puncture
Peripheral skin smear
38. A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in a Buck extension. What explanation does the nurse give the client for why the traction is being used?
Reduces muscle spasms.
Prevents soft tissue edema.
Reduces the need for cast application.
Prevents damage to the surrounding nerves.
39. A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse?
Place the client in restraints.
Sedate and place the client in a controlled environment.
Encourage the client to play Ping Pong with another client.
Set firm limits on the client’s behavior and enforce adherence to them.
40. A client in a psychiatric hospital with the diagnosis of major depression is tearful and refuses to eat dinner after a visit with a friend. What is the most therapeutic nursing action?
Allow the client to skip the meal.
Offer an opportunity to discuss the visit.
Reinforce the importance of adequate nutrition.
Provide the client with adequate quiet thinking time.
41. A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. What should the nurse determine is the most probable cause of these symptoms?
A lack of potassium
Postural hypertension
A hypoglycemic reaction
Increased extracellular fluid volume
42. A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include is the rationale for this diet?
Repairs tissues
Slows peristalsis
Corrects the anemia
Improves muscle tone
43. When planning care for a child with autism, the nurse understands that given a choice, the child with autism usually enjoys playing:
on a jungle gym.
with a cuddly toy.
with a small yellow block.
on a playground merry-go-round.
44. Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse?
50-year-old woman who is pacing around the dayroom and picking fights with other clients
25-year-old man who is making sounds and actions like a machine gun in front of the nurse’s station
45-year-old man who sits quietly in the corner of the room, watching the movements of other clients
33-year-old woman who wanders aimlessly around the unit, saying, “I just don’t know what to do. I feel so lost.”
45. Two hours after an uneventful labor and birth, a client’s uterus is four fingerbreadths above the umbilicus. After urinary catheterization, the fundus remains firm and four fingerbreadths above the umbilicus. What is the priority nursing action?
Recheck the vital signs.
Catheterize again in 1 hour.
Notify the health care provider.
Palpate the fundus every 2 hours.
46. For which clinical indicator should the nurse monitor a child with chronic hypoxia?
Clubbing of fingers
Slow, irregular respirations
Subcutaneous hemorrhages
Decreased red blood cell count
47. A family of a client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the nurse’s best response?
“Medications will mask the signs of the disease.”
“With continuous treatment, the progression of the disease usually can be controlled.”
“There will be periods when bed rest will be necessary and times when regular activity will be possible.”
“The progression generally is slow, so people with myasthenia will spend their younger life with few problems.”
48. When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship?
Increase nonverbal communication
Present an outlet for suppressed hostile feelings
Assist the client in acquiring more effective behavior
Provide the client with someone who can make decisions
49. A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbalance should the nurse monitor the client?
Hypokalemia
Hypocalcemia
Hypernatremia
Hyperglycemia
50. A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment?