1. The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it alright
if I give him two baby aspirins?" How should the nurse respond
a. "You seem concerned about giving drugs to your child"
b. "It is all right to give him baby aspirin when he hurts himself.
c. "Aspirin may cause more bleeding. Give him acetaminophen instead"
d. "He should be given acetaminophen every day. It will help with the bleeding".
Response Feedback:
- Aspirin has an anticoagulant effect, and it may harm a child with bleeding problems; in
addition, aspirin is contraindicated for all children because of its relationship to Reye
syndrome. This response does not answer the mothers questions; it may cause the
other to feel defensive. Aspirin is contraindicated because of the anticoagulant effect.
Acetaminophen cannot prevent bleeding episodes; it is an analgesic.
2. Select the most therapeutic manner for a nurse working with a patient beginning
treatment for alcohol addiction.
a. Empathetic & supportive
b. Cool and distant
c. Skeptical & guarded
d. Confrontational
Response Feedback:
- Empathy is the experience of understanding another person's thoughts, feelings, and
condition from his or her point of view, rather than from one's own.
3. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days
ago. The patient now says, "This medicine isn't working." The nurse's best intervention
would be to:
a. Assess the patient for any symptoms of improvement.
b. Explain the time lag before antidepressants relieve symptoms.
c. Reassure the patient that the medication will be effective soon.
d. Discuss with the health care provider the need to increase the dose.
Response Feedback:
- It takes several weeks or longer before an antidepressant is fully effective.
4. A pediatric nurse health educator provides a teaching session to the nursing students
regarding hemophilia. Which of the following information regarding this disorder would
the nurse plan to include in the discussion?
a. Hemophilia is a Y-linked hereditary disorder
b. Males inherit hemophilia from their fathers
c. Hemophilia B results from an abundance of Factor IX
d. Hemophilia A results from a deficiency of Factor VIII
Response Feedback:
- Hemophilia is inherited in a recessive manner via a genetic defect on the X
chromosome. Males inherit hemophilia from their mothers. Hemophilia B results from a
deficiency of Factor IX.
5. A nurse is caring for a patient diagnosed with an opioid overdose. What focused
assessment has the highest priority?
a. Neurologic
b. Cardiovascular
c. Hepatic
d. Respiratory
Response Feedback:
- Opioid overdose causes respiratory depression. Respiratory depression is the primary
cause of death among opioid abusers. The assessment of the other body systems is
relevant but not the priority.
6. The nurse has been asked to administer a coping measurement instrument to a patient.
What education would the nurse present to the patient related to this tool?
a. "This tool will let us compare your stress to other patients in the hospital"
b. "This tool is short because it only measures the negative stressors you are
experiencing"
c. "You will need to ask your parents about stressors you had as a child to complete
this tool"
d. "This tool will help assess recent positive and negative events you are
experiencing."
Response Feedback:
- This tool will help assess recent positive and negative events you are experiencing.
7. Which of the following goals would the health care provider identify as realistic for a
patient with a substance abuse problem?
a. Focus on how cravings can be eliminated by enhancing willpower.
b. Use the substance only in moderation and in certain situations
c. Explore genetic anomalies associated with substance abuse.
d. Identify situations that trigger a desire to use the substance.
Response Feedback:
- The most realistic goal for a patient with a substance abuse problem is to avoid people,
places, and events that can trigger substance use. Continued substance abuse is
associated with a lack of effective coping skills rather than a lack of willpower. Realistic
goals that support the patient’s dignity will provide the greatest opportunity for success.
Most patients with a substance abuse problem will not be able to use the substance in
moderation.
8. A client brought to the emergency room (ER) states he has accidentally been taking two
times his usual dose of Warfarin (Coumadin) for the past week. After noting the client
has no evidence of obvious bleeding, the nurse plans to do which of the following:
a. Prepare to administer an antidote.
b. Draw a blood sample for type and cross match to transfuse the client
c. Draw a blood sample for an activated thromboplastin time (aPTT) level
d. Draw a blood sample for prothrombin time (PT) and international
normalized ratio (INR).
Response Feedback:
- Based on nursing process the nurse must assess the patient's PT and INR level. The PT
measures the adequacy of the extrinsic system-clotting mechanism. INR is a
standardized result used to analyze effectiveness of the warfarin (Coumadin). The nurse
cannot administer an antidote without determining results of the PT and INR. Type and
Crossmatch is needed to begin a transfusion with a blood product. aPTT-measures
intrinsic system-used to monitor therapeutic ranges for heparin.
9. The nurse is assessing a client who has had a current history of alcohol dependence for
signs of major withdrawal. What findings would the nurse expect to find?
a. Cold, clammy skin, decreased body temperature
b. Hypotension, bradycardia
c. Anxiety and increased appetite
d. Tachycardia, severe diaphoresis
Response Feedback:
- Tachycardia and severe diaphoresis are associated with major withdrawal from alcohol.
10. Following myocardial infarction, a hospitalized patient is encouraged to practice frequent
leg exercises and ambulate in the hallway as directed by his physician. Which of the
following choices reflects the purpose of exercise for this patient?
a. Increases fitness and prevents future heart attacks
b. Prevents bedsores
c. Prevents DVT (deep vein thrombosis)
d. Prevents constipation
Response Feedback:
- A DVT is the most common complication of being hospitalized. By encouraging
ambulation it will prevent other complications: bedsores and constipation. By ambulating
and staying active fitness will prevent future heart attacks.
11. A nurse sits with a depressed client twice a day, although there is little verbal
communication. One afternoon, the client asks, “Do you think they'll ever let me out of
here?” What is the nurse's best response?
a. We should ask your doctor
b. Everyone says you're doing fine
c. Do you think you are ready to leave?
d. How do you feel about leaving here?
Response Feedback:
- How do you feel about leaving here, this response is an open ended question inviting the
patient to explore their feelings about leaving the facility
12. The spouse of a patient diagnosed with bipolar disorder asks what evidence supports
the possibility of genetic transmission of bipolar disorders. Which response should the
nurse provide?
a. "Patient's with bipolar disorder have higher rates of relatives who respond in an
exaggerated way to daily stress."
b. "More individuals with bipolar disorder come from high socioeconomic and
educational backgrounds."
c. A higher rate of relatives with bipolar disorder is found among patients
with bipolar disorder.
d. "A high proportion of patients with bipolar disorders are found among creative
writers."
Response Feedback:
- Bipolar disorder is one of the most highly heritable disorders. Genetic variation accounts
for most of the population risk of illness.
13. A patient who has a history of chronic back pain requires a higher dose of an opioid
medication in order to achieve adequate pain relief. The health care provider suspects
that these findings are a result of which of the following?
a. Addiction
b. Pseudoaddiction
c. Tolerance
d. Dependence
Response Feedback:
- Tolerance is a person’s diminished response to a drug that is the result of repeated use.
14. A nurse is collecting data from a pregnant client in the second trimester of pregnancy
who was admitted to the maternity unit with a suspected diagnosis of abruptio placenta.
Which findings is associated with abruptio placenta?
a. Non tender uterus
b. Decreased uterine resting tone
c. A hard, "board-like" abdomen
d. Painless, bright red vaginal bleeding
Response Feedback:
- Assessment for abruptio placenta includes uterine pain, tenderness or both, uterine
rigidity (board like abdomen), severe abdominal pain, signs of fetal distress, and signs of
maternal shock if the bleeding is excessive.
15. Which of the following would lead the nurse to suspect that a child with meningitis has
developed disseminated intravascular coagulation (DIC)?
a. Petechie and purpuric skin rash
b. Edema and hemarthrosis
c. Cyanosis and pallor
d. Dyspnea on exertion
Response Feedback:
- DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous
bleeding into tissues. An abnormal coagulation phenomenon causes the condition.
16. The student nurse recognizes that positive coping behaviors include all of the following
except? (Select all that apply)
a. Art Therapy
b. Compartmentalizing
c. Counseling
d. Social Support
e. Substance Abuse
Response Feedback:
- Art therapy, counseling and social support are all examples of positive coping behavior.
Compartmentalizing and substance abuse are examples of maladaptive coping
behaviors.
17. The nurse is preparing a client to receive epidural anesthesia. What lab finding is
considered abnormal and need to be reported to the physician
a. White blood cells (WBCs): 10,000/mm3
b. Glucose: 78 gm/dL
c. Hemoglobin: 13.2 g/dL
d. Platelets: 90,000/µL
Response Feedback:
- Normal platelet count: 150,000-400,000
18. What imbalance places the client in heart failure, taking Digoxin (lanoxin) at greatest risk
of toxicity and associated dysrhythmias?
a. Anemia
b. Leukocytosis
c. Hypokalemia
d. hypoalbuminemia
Response Feedback:
- hypokalemia can place the patient taking Digoxin at risk for dig toxicity and dysrhythmias
19. A client with a deep vein thrombosis experiences acute chest pain and dyspnea. The
nurse should perform which of the following? (Select all that apply)
a. Elevate the head to the bed
b. Check the pulse in the affected extremity
c. Flex the client's knees and place in a supine position
d. Notify the physician of the situation
e. Assess for signs of hypoxemia and monitor the pulse oximetry value
Response Feedback:
- Elevate the head of the bed to assist ventilation. Immediately report complaints of chest
pain and shortness of breath to the physician.
20. Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of
the following statements concerning this life threatening complications are true except:
a. The rapidity of onset is determined by the intensity of the trigger and is related to
the condition of the patient's liver, bone marrow and endothelium
b. The most critical intervention for DIC is the early identification and treatment of
the underlying disorder
c. The most critical intervention for DIC is the early identification and treatment of
the underlying disorder
d. Though a coagulopathy is present, excessive blood loss rarely results in
hemorrhagic shock
Response Feedback:
- Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic
shock. This statement is NOT true. Hemorrhagic shock is a definite possibility with
extreme blood loss. All of the other statements are true.
21. A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term
care facility has had several episodes of wandering away from home. Which action will
the nurse include in the plan of care?
a. Reorient the patient several times daily.
b. Have the family bring in familiar items.
c. Place the patient in a room close to the nurses' station.
d. Ask the patient why the wandering episodes have occurred
Response Feedback:
- Place the patient in a room close to the nurses' station. Patients at risk for problems with
safety require close supervision. Placing the patient near the nurse's station will allow
nursing staff to observe the patient more closely.
22. The nurse understands that the teaching plan for a patient taking lithium should include
instructions to:
a. Drink twice the usual daily amount of fluid.
b. Double the lithium dose if diarrhea or vomiting occurs.
c. Maintain normal salt and fluids in the diet.
d. Avoid eating aged cheese, processed meats and red wine.
Response Feedback:
- Less salt may cause your lithium level to rise. More salt may cause your lithium level to
fall.
23. A person was online continuously for over 24 hours, posting rhymes on official
government websites and inviting politicians to join social networks. The person has not
slept or eaten for 3 days. What features of mania are evident?
a. Increased muscle tension and anxiety.
b. Cognitive deficits and paranoia.
c. Vegetative signs and poor grooming.
d. Poor judgment and hyperactivity.
Response Feedback:
- Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government
websites) are a characteristic of manic episodes.
24. A patient diagnosed with depression begins serotonin reuptake inhibitor (SSRI)
antidepressant therapy. The nurse should provide teaching to the patient and
family about
a. Maintaining a tyramine-free diet.
b. Reporting increased suicidal thoughts.
c. Minimizing exposure to bright sunlight.
d. Restricting sodium intake to 1 gram daily.
Response Feedback:
- Selective Serotonin Reuptake Inhibitors [SSRIs] may cause worsening of suicidal ideas
in vulnerable patient
25. A child is experiencing severe thrombocytopenia. Which of the following
interventions should the nurse take to prevent complications from treatment?
(Select all that apply).
a. Avoid injections and associated skin punctures.
b. Perform frequent hand hygiene.
c. Limit visitors.
d. Monitor the platelet count
e. Avoid taking rectal temperatures
Response Feedback:
- A child with hemophilia is at risk for bleeding and or hemorrhage. Avoiding injections and
associated skin punctures, monitoring platelet count and avoid taking rectal
temperatures will prevent complications of bleeding and hemorrhage.
26. A patient says to the nurse, "My life doesn't have any happiness in it anymore. I
once enjoyed holidays, but now they're just another day." The nurse documents
this report as an example of:
a. Anhedonia
b. Anergia
c. Euphoria
d. Dysthymia
Response Feedback:
- Anhedonia is a main symptoms of major depressive disorder (MDD). It is the loss of
interest in previously rewarding or enjoyable activities. Dysthymia (also known as
persistent depressive disorder)-the only depressive disorder where symptoms are
present for at least two years, and typically longer. Euphoria is the experience (or affect)
of pleasure or excitement and intense feelings of well-being and happiness. Anergiaabnormal lack of energy.
27. A patient who has severe Alzheimer's disease (AD) is being admitted to the
hospital for surgery. Which intervention will the nurse include in the plan of care?
a. Encourage the patient to discuss events from the past.
b. Maintain a consistent daily routine for the patient's care.
c. Reorient the patient to the date and time every 2 to 3 hours.
d. Provide the patient with current newspapers and magazines
Response Feedback:
- Providing a consistent routine will decrease anxiety and confusion for the patient.
28. The physician has ordered several laboratory tests to help diagnose an infant's
bleeding disorder. Which of the following tests, if abnormal, would the nurse
interpret as most likely to indicate hemophilia
a. Bleeding time
b. Tourniquet test
c. Clot retraction test
d. Partial thromboplastin time (PTT)
Response Feedback:
- PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting
factors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient,
resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test
measures vasoconstriction and platelet function; and the clot retraction test measures
capillary fragility. All of these are unaffected in people with hemophilia.
29. A nurse plans to evaluate a newly admitted depressed client's potential for
suicide. What is the best approach to obtain this information?
a. Question the client about plans for the future
b. Inquire whether the client is now considering suicide
c. Discuss suicide with other clients while the client is in the group.
d. Ask family members whether the client has ever attempted suicide
Response Feedback:
- Directness is the best approach at the first interview because this sets the focus and
concern and lets the nurse know what the client is feeling now. A. At this point the client
is most likely unable to think past to present, much less deal with future plans. C. This is
an indirect approach, initially the direct approach is best. D This is one resource for
input, but regarding suicide, it is best to approach the client directly.
30. A child with hemophilia states that he wants to participate in sports. Which sport
should the nurse recommend as most appropriate for the child?
a. Biking
b. Swimming
c. Baseball
d. Fencing
Response Feedback:
- Biking, baseball, and fencing pose a risk of bleeding for the child. Swimming is the ideal
sport for this child because it is a non-contact sport.
1. The spouse of a client who had a brain attack seems unable to accept the concept
that the client must be encouraged to participate in self-care. What is the best
response by the nurse?
a. Tell the spouse to let the client do things independently.
b. Allow the spouse to assume total responsibility for the client's care.
c. Explain that the nursing staff has full responsibility for the client's activities.
d. Ask the spouse for assistance in planning those activities most helpful to
the client.
Response Feedback:
- To foster communication and cooperation, family members should be involved in
planning and implementing care.
2. When the nurse is administering a vesicant chemotherapeutic agent
intravenously, an important consideration is to:
a. Infuse the medication over a short period of time.
b. Stop the infusion if swelling is observed at the site.
c. Administer the chemotherapy through a small-bore catheter.
d. Hold the medication unless a central venous line is available.
Response Feedback: Swelling at the site may indicate extravasation. and the IV should be
stopped immediately. The medication should generally be given slowly to avoid irritation of the
vein. The size of the catheter is not as important as administration of vesicants into a running IV
line to allow dilution of the chemotherapy drug. These medications can be given through
peripheral lines. although central vascular access devices (CVADs) are preferred.
3. The student nurse assesses for evidence of negative symptoms of schizophrenia
in a newly admitted client. Which symptom is considered negative?
a. Delusions
b. Hallucinations
c. Flat affect
d. Loose associations
Response Feedback:
- Flat affect, anhedonia, social withdrawal are negative symptoms of schizophrenia. The
other symptoms are positive.
4. The nurse is providing care for a patient who has been admitted to the hospital
with a head injury and who requires regular neurologic vital signs. Which of the
following assessments will be components of the patient's score on the Glasgow
Coma Scale (GCS)? Select all that apply.
a.
b.
c.
d.
e.
Judgement
Eye opening
Abstract reasoning
Best verbal response
Best motor response
Response Feedback:
- The 3 dimensions of the GCS are eye opening, best verbal response and best motor
response.
5. A patient with a diagnosis of lung cancer is receiving chemotherapy and reports
nausea and loss of appetite resulting in decreased food intake. What should the
nurse recommend to promote adequate nutrition?
a. Eat small meals throughout the day.
b. Eat only when feeling hungry.
c. Eat only favorite foods to increase appetite.
d. Eat large meals but less frequently throughout the day.
Response Feedback:
- Large meals can seem overwhelming or unappealing. This can happen when you have a
decreased appetite or early satiety (feel full shortly after you start eating). Small frequent
meals are ideal for patients receiving chemotherapy to lessen nausea and vomiting.
6. After 2 weeks of receiving lithium therapy a client diagnosed with mania becomes
depressed. It is MOST important for the nurse to take which action?
a. Explore with the client the reasons the client appears depressed.
b. Monitor the client for suicidal behavior.
c. Contact the health care provider to discuss the addition of an antidepressant.
d. Continue the current treatment plan.
Response Feedback:
- Safety needs are priority.Full therapeutic effect may not be seen for 2-3 weeks; creates
behavioral changes due to mood-stabilizing effect of medication; might create
depression; take with meals; encourage fluid intake of 2500-3000 mL/day and adequate
salt intake.
7. The mother of a 1-month-old infant tells the nurse she worries that her baby will get
meningitis like her oldest son did when he was an infant. The nurse should base her
responses on which statement?
a. Meningitis rarely occurs during infancy due to maturity of the newborn's immune
system.
b. Often a genetic predisposition within families to meningitis is found and should be
a consideration in the assessment.
c. Vaccination to prevent Haemophilus Influenza type B meningitis has
decreased the frequency of this disease in children.
d. Vaccinations are available to prevent all types of meningitis and should be
scheduled during the first pediatric visit.
Response Feedback:
- The mother of a 1-month-old infant tells the nurse she worries that her baby will get
meningitis like her oldest son did. This is an opportunity for the nurse to provide the
client with evidenced-based nursing about meningitis and the role of the Haemophilus
influenza type B. The nurse should stress the importance of adhering to the
immunization schedule to protect the child against serious childhood diseases.
8. A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical
findings indicate positive signs and symptoms associated with schizophrenia
a. Flat affect, decreased spontaneity, asocial behavior
b. Withdrawal, poverty of speech, inattentiveness
c. Hyperactivity, auditory hallucinations, loose associations
d. Hypomania, labile mood swings, episodes of euphoria
Response Feedback:
- Positive signs and symptoms of schizophrenia are: hallucinations, delusions, racing
thoughts, catatonic behaviors, disorganized speech, unpredictable agitation or silliness.
Negative signs and symptoms are: apathy, lack of emotion, poor or nonexistent social
functioning, disorganized thoughts & difficulty concentrating,
9. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures.
The client's speech pattern is rapid, and affect is belligerent. Based on these
observations, which is the nurse's immediate priority of care?
a. Provide safety for the client and other clients on the unit.
b. Provide the clients on the unit with a sense of comfort and safety.
c. Assist the staff in caring for the client in a controlled environment.
d. Offer the client a less stimulating area in which to calm down and gain control.
Response Feedback:
- Safety of the client and other clients is the immediate priority.. The correct option is the
only one that addresses the safety needs of the client as well as those of the other
clients.
10. A nurse is caring for a client with a head injury. The client reports having a headache
and is slightly confused. The client's sodium is 120 mEq/L. What order should the nurse
expect from the physician?
a.
b.
c.
d.
Administration of antidiuretic hormone (ADH).
Administration of normal saline solution.
Restriction of sodium intake.
Administration of D5W solution.
Response Feedback:
- The earliest sign of increased intracranial pressure (ICP) is change in level of
consciousnesses and/or headache. Osmotic diuretics (normal saline solutions) decrease
interstitial volume and decrease ICP. Sodium levels and serum osmolality must be
closely monitored because this will indicate if hypernatremia or hyponatremia is present.
The patient's sodium levels should be between 135-145 mEq/L. Administering D5W can
lead to further brain injury. ADH-regulates renal excretion of water but not Sodium.
11. A 55 year old client tells the nurse she does not have mammograms because
there us no history of breast cancer in her family. What is the nurse's best
response?
a. "You are correct. Breast cancer is an inherited type of malignancy and your
family history indicates a low risk for you."
b. "Performing breast self-examinations monthly at home is sufficient screening for
someone with your family history."
c. "Your breasts are no longer as dense as they were when you were younger, your
risk for breast cancer is now decreased. "
d. "Breast cancer can be found more frequently in families; however, the risk
for general, non-familial breast cancer increases with age."
Response Feedback:
- Only a small percentage of cancers, including breast cancer, are hereditary or familial.
The far more critically important risk factor for breast cancer in women is advancing age.
Although performance of monthly self-breast examination is good, for a woman of this
age, if should be done in conjunction with a yearly mammogram.
12. The nurse recognizes the following as risk factors for stroke? (Select all that
apply.)
a. Frequent exercise (5 times/week)
b. Hormone replacement therapy
c. Previous transient ischemic attacks (TIA)
d. History of hypertension
e. Atrial fibrillation
Response Feedback: History of hypertension, A. Fib, previous TIAs, and hormone replacement
therapy are risk factors for stroke.
13. The nurse is obtaining a health history for a client admitted to the hospital after
experiencing a brain attack. Which disorder does the nurse identify as a
predisposing factor for an embolic stroke?
a. Cerebral Aneurysm
b. Psychotropic drug use
c. Atrial fibrillation
d. Seizures
Response Feedback:
- Atrial fibrillation can cause stasis of blood in the left atrium, which can cause clot
development. Clots can dislodge, allowing emboli to travel to the cerebral circulationimpairing blood flow to the brain. Cerebral aneurysm can interrupt cerebral blood flow
wither by cerebral hemorrhage or cerebral blood clots. Seizures and/or psychotropic
drug use do not put patients at high risk for an embolic stroke.
14. A patient with a history of schizophrenia is brought to the emergency department.
The patient is agitated and demonstrates generalized muscle rigidity.
Temperature, heart rate, and respiratory rate are elevated. These assessment
findings are consistent with which of the following adverse effects of
antipsychotic medications?
a. Tardive dyskinesia
b. Parkinsonism
c. Serotonin syndrome
d. Neuroleptic malignant syndrome
Response Feedback:
- Parkinsonism and Tardive dyskinesia are commonly seen with conventional
antipsychotics. Does not include muscle rigidity and elevated vital signs. Serotonin
Syndrome-caused by SSRI's which are used to treat depression. A patient with a history
of schizophrenia, presents with agitation, generalized muscle rigidity and an elevated
temperature, tachycardia & tachypnea has the classic signs of neuroleptic malignant
syndrome (NMS). NMS-acute, life threatening medical emergency, occurs in 0.2%-1%
patients taking conventional antipsychotics. Characterized by: reduced consciousness,
muscle rigidity, hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis,
and drooling.
15. A nurse is planning care for a child with acute meningitis.Based on the mode of
transmission of this infection, which of the following would be included in the
plan of care?
a. Maintain enteric precautions with gowns and gloves.
b. Maintain neutropenic precautions by masking and gowning visitors.
c. No precautions are required as long as antibiotics have been started.
d. Maintain respiratory isolation precautions for at least 24 hours after the
initiation of antibiotics.
Response Feedback:
- A major priority of nursing care for a child suspected of having meningitis is to administer
the prescribed antibiotic as soon as it is observed. The child is also placed on respiratory
isolation for at least 24 hours while culture results are obtained and the antibiotic is
having effect.
16. The nurse should plan to implement which intervention in the care of a client
experiencing neutropenia as a result of chemotherapy?
a. Restrict all visitors.
b. Restrict fluid intake.
c. Teach the client and family about meticulous hand hygiene.
d. Insert an indwelling catheter to prevent skin breakdown.
Response Feedback:
- In the neutropenic client, meticulous hand hygiene education is implemented for the
client, family, visitors, and staff. Not all visitors are restricted, but the client is protected
from persons with known infections. Fluids should be encouraged. Invasive measures
such as an indwelling urinary catheter should be avoided to prevent infections.
17. A patient diagnosed with schizophrenia states, "I am the Buddha!" Which type of
psychotic symptom is the patient demonstrating?
a. Religiosity
b. Magical thinking
c. Delusion of grandeur
d. Delusion of persecution
Response Feedback:
- Delusion of grandeur is one of the most common delusions. A delusion may be a
response to anxiety or reflect areas of concern for a person, for example, someone with
poor self-esteem may believe they are Buddha, allowing him to feel more powerful.
18. A patient is diagnosed with schizophrenia paranoid type and is admitted in the
psychiatric unit. Which of the following nursing interventions would be most
appropriate?
a. Establishing a therapeutic relationship
b. Encouraging involvement in group activities
c. Spending more time with Ramsay
d. Waiting until Ramsay initiates interaction
Response Feedback:
- A nonthreatening, non demanding relationship helps decrease the mistrust that is
common in a client with paranoid schizophrenia. Encouraging involvement in group
activities and spending more time with the client would be threatening for a client who is
suspicious of other people’s motives. This client is unlikely to initiate interaction; the
nurse is responsible for initiating a relationship with the client.
19. A pregnant woman arrives at the emergency department (ED) with abruptio
placenta and eclampsia at 34 weeks' gestation. She's at risk for which of the
following blood dyscrasias?
a. Idiopathic thombocytopenia purpura (ITP)
b. HELLP - Hemolysis, Elevated liver enzymes, low platelets
c. Heparin-associated thrombosis and thrombocytopenia (HATT)
d. PT and INR
Response Feedback:
- HELLP Syndrome is characterized by hemolysis, elevated liver enzymes, and low
platelets, increased risk with eclampsia. ITP is an autoimmune disorder which
antiplatelet antibodies decrease the life span of platelets.Thrombocytopenia is vague.
HATT-the question does not indicate that the patient is taking heparin. PT INR is drawn
to check Warfarin
20. The nurse in the outpatient clinic is caring for a 50-year-old who smokes heavily.
To reduce the patient’s risk of a lung cancer diagnosis, what action will be best for
the nurse to take?
a. Educate the patient about the seven warning signs of cancer.
b. Plan to monitor the patient's carcinoembryonic anitgen (CEA) level.
c. Teach the patient about the use of annual chest x-rays for lung cancer screening.
d. Discuss the risks associated with cigarettes and recommend a smoking
cessation program.
Response Feedback:
- Education about the risks associated with cigarette smoking is recommended at every
patient encounter, since cigarette smoking is associated with multiple health problems.
It is important to recommend a smoking cessation program to help the patient quit. A
tumor must be at least 0.5 cm large before it is detectable by current screening methods
and may already have metastasized by that time. Oncofetal antigens such as CEA may
be used to monitor therapy or detect tumor reoccurrence but are not helpful in screening
for cancer. The seven warning signs of cancer are actually associated with fairly
advanced disease.
21. A client who had a stroke combs her hair only on the right side of her head and
washes only the right side of her face. How does the nurse interpret these
actions?
a. Left-sided neglect.
b. Limited visual perception of the left fields.
c. Paralysis or contractures on the right side.
d. Poor left-sided motor control.
Response Feedback:
- Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They
often neglect the left side of their bodies.Paralysis/contractures on the right side is not
the correct answer because she is actively using her right side. It is not due to visual
perception of the left fields. The client is neglecting her left side.
22. Magnesium sulfate is given to women with preeclampsia and eclampsia to:
a. Shorten the duration of labor and lower blood pressure.
b. Improve patellar reflexes and increase respiratory rate
c. Prevent a boggy uterus and lessen the flow of lochia.
d. Prevent and treat seizures.
Response Feedback:
- Magnesium sulfate is given to women who have preeclampsia to decrease the risk of
eclamptic seizures.
23. A lumbar puncture is performed on a child suspected of having bacterial meningitis.
CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and
determines that which of the following results would verify the diagnosis? (Select all that
apply)
a. Clear cerebral spinal fluid (CSF)
b. Cloudy cerebral spinal fluid (CSF)
c. Increased glucose
d. Elevated protein
Response Feedback:
- A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture.
In the case of bacterial meningitis, findings usually include an elevated pressure,
turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased
glucose levels.
24. The nurse would incorporate which of the following into the plan of care as a
primary prevention strategy for reduction of the risk for cancer?
a. Yearly mammography for women aged 40 years and older.
b. Using skin protection during sun exposure while at the beach.
c. Colonoscopy at age 50 and every 10 years as follow up.
d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50
and over.
Response Feedback: Primary prevention :
- Sunscreen can protect against UVB rays and sometimes UVA rays. Secondary
prevention: mammography, colonoscopy, yearly PSA and digital rectal exam
25. A nurse is planning care for a child with acute bacterial meningitis.Based on the
mode of transmission of this infection, which of the following would be included
in the plan of care?
a. Maintain enteric precautions with gowns and gloves.
b. No precautions are required as long as antibiotics have been started.
c. Maintain neutropenic precautions by masking and gowning visitors.
d. Maintain respiratory isolation precautions for at least 24 hours after the
initiation of antibiotics.
Response Feedback:
- A major priority of nursing care for a child suspected of having meningitis is to administer
the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory
isolation for at least 24 hours while culture results are obtained and the antibiotic is
having effect.
26. A patient who has had auditory hallucinations for many years tells the nurse that
the voices prevents his participation in a social skills training program at the
community health center. Which intervention by the nurse is most appropriate
a. Let the patient analyze the content of the voices.
b. Teach the patient to use thought stopping techniques.
c. Advise the patient to participate in the program when the voices cease.
d. Advise the patient to take his medications as prescribed.
Response Feedback:
- Clients with long-lasting auditory hallucinations can learn to use thought stopping
measures to accomplish tasks. Analyzing the content of the voices may be indicated
when hallucinations first occur to establish whether the voices are threatening to the
client or instructing him to harm others. However, focusing on their content at this point
would reinforce this symptom. The voices have lasted many years; the client should
participate despite the voices. There is no indication that the client is not taking
medication as prescribed.
27. What is an important aspect of nursing care for a client exhibiting psychotic
patterns of thinking and behavior?
a. Help keep the client oriented to reality.
b. Encourage the client to discuss why interacting with other people should be
avoided.
c. Involve the client in activities throughout the day.
d. Help the client understand that it is harmful to withdraw from situations.
Response Feedback:
- Keeping the withdrawn client oriented to reality prevents further withdrawal into a private
world.
28. What clinical manifestations is the most serious indication of impending
assaultive behavior by a client experiencing psychosis on a mental health unit?
a. Touches people excessively.
b. Experiences command hallucinations.
c. Exhibits a sudden withdrawal.
d. Uses profane language.
Response Feedback:
- Command hallucinations are dangerous because they may influence the client to
engage in behaviors dangerous to self and others.Although profane language may be a
cause for concern, it is not as dangerous as command hallucinations. Although
excessive touching of others may be a cause for concern, it is not as dangerous as
command hallucinations. Although withdrawn behavior is a cause for concern it is not as
dangerous as command hallucinations.
29. A client brought to the emergency room (ER) with a history of an embolic stroke and
states he has accidentally been taking two times his usual dose of Warfarin (Coumadin)
for the past week. After noting the client has no evidence of obvious bleeding, the nurse
plans to do which of the following:
a. Draw a blood sample for an activated thromboplastin time (aPTT) level.
b. Prepare to administer an antidote.
c. Draw a blood sample for type and cross match to transfuse the client.
d. Draw a blood sample for prothrombin time (PT) and international
normalized ratio (INR).
Response Feedback:
- Based on nursing process the nurse must assess the patient's PT and INR level. The PT
measures the adequacy of the extrinsic system-clotting mechanism. INR is a
standardized result used to analyze effectiveness of the warfarin (Coumadin). The nurse
cannot administer an antidote without determining results of the PT and INR. Type and
Crossmatch is needed to begin a transfusion with a blood product. aPTT-measures
intrinsic system-used to monitor therapeutic ranges for heparin.
30. A nurse in the emergency department (ER) is assessing a 10-month-old infant
who is injured in an automobile collision. The infant, who is quiet but does not
appear lethargic, has a large hematoma on the left temporal area. What sign of
neurological involvement is the most critical to identify?
a. Heart rate of 110 beats/minute
b. Babinski reflex
c. Temperature of 98.9 F (37.6 C)
d. Persistent vomiting
Response Feedback:
- Vomiting frequently accompanies a head injury because of increased intracranial
pressure and stimulation of the vomiting reflex. A temperature of 98.9 F (37.6 C),
presence of Babinski reflex, and a heart rate of 110 beats/min are all expected
findings in a 10-month-old infant.