(Answers and rationales follow all questions)
Fundamentals of Nursing
1.
A 62-year-old client recently retired after working 30 years as a bank manager.
Which statement to a nurse during a clinic visit best suggests that the client is achieving the developmental stage of “integrity versus despair”?
A.
“Now that I have some free time, I want to treat my wife to a trip to
Hawaii.”
B.
“I seem to be staying in bed longer and longer each day. There isn’t a reason to get up now.”
C.
“I am noticing the little aches and pains more; before I was just too busy to notice them.”
D.
“I get calls a few times a week for advice; my coworkers still value my suggestions.”
Maternity
2.
Before beginning a newborn physical assessment, a nurse reviews the newborn’s medical record and sees this notation: “31 weeks gestation.” Considering this information, the nurse determines that a physical assessment of the infant should reveal:
A.
Flexion of all four extremities
B.
The ability to suck
C.
The absence of lanugo
D.
Vernix covering the infant
Pediatrics
3.
A nurse is planning care for a child following removal of brain tumor. The child is confused, disoriented, and restless. Which nursing diagnosis should receive the highest priority?
A.
Sensory perceptual alterations related to neurological surgery
B.
Self-care deficit related to confusion and restlessness
C.
Impaired verbal communication related to confusion
D.
Risk for injury related to disorientation and restlessness

Neurological Disorders (Adult)
4.
A nurse is caring for a client with a spinal cord injury at the level of the sixth cervical vertebra. The client is at risk for the complication of autonomic dysreflexia. For which associated symptoms should a nurse monitor the client?
SELECT ALL THAT APPLY.
A.
Sweating
B.
Headache
C.
Hypotension
D.
Blurred vision
E.
Anxiety
F.
Tachycardia
Musculoskeletal/Integumentary Disorders (Adult)
5.
When analyzing the serum laboratory report for a client diagnosed with lung cancer that has metastasized to the pelvic bone, which finding should a nurse anticipate?
A.
Elevated calcium
B.
Decreased hemoglobin
C.
Elevated creatinine (Scr)
D.
Elevated creatine kinase (CK)
Oncological/ Immune/Hematological Disorders (Adult)
6.
A nurse teaches a 55-year-old strict vegetarian that, to decrease the risk of developing megaloblastic anemia, the client should:
A.
Undergo a Schilling test
B.
Increase intake of foods high in iron
C.
Supplement the diet with vitamin B12
D.
Have a monthly hemoglobin level drawn

Cardiovascular Disorders (Adult)
7.
A nurse is evaluating the blood pressure (BP) results for multiple clients with cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that the client’s mean arterial pressure (MAP) is abnormal and warrants notifying the physician?
A.
94/60 mm Hg
B.
98/36 mm Hg
C.
110/50 mm Hg
D.
140/78 mm Hg
Respiratory Disorders (Adult)
8.
A nurse is evaluating discharge teaching that has been completed for a client following total laryngectomy. Which statement made by the client indicates that the client does not accept or understand the teaching?
A.
“I will be sure to carry an extra supply of facial tissue with me.”
B.
“I probably will not be able to go swimming.”
C.
“I will schedule an appointment for closure of my tracheostomy.”
D.
“I will check the batteries on our smoke detectors.”
Endocrine Disorders (Adult)
9.
A nurse is documenting nursing diagnoses for a client with elevated growth hormone (GH) levels. Which nursing diagnosis is least likely to be included in the client’s plan of care?
A.
Fluid volume deficit related to polyuria
B.
Insomnia related to soft tissue swelling
C.
Impaired communication related to speech difficulties
D.
Disturbed body image related to undersized hands, feet, jaw, and soft body tissue

GI/GU Disorders (Adult)
10.
A nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client’s medical record?
A.
Abdominal pain and bloody diarrhea
B.
Weight gain and elevated blood glucose
C.
Abdominal distension and hypoactive bowel sounds
D.
Heartburn and regurgitation
Sensory Disorders (Adult)
11.
A nurse obtains information for a 75-year-old client and concludes that some findings are not age-related and require further follow-up because the client is at risk for falls. Which report by the client represents a non-age-related finding that requires additional investigation?
A.
Reports experiencing a decreased ability to see at night
B.
Reports seeing halo around lights
C.
Reports having difficulty distinguishing some colors
D.
Reports diminished visual acuity
Psychiatric and Mental Health (Adult)
12.
A client, who switched to paroxetine (Paxil) several days ago after taking imipramine (Tofranil) for several years, presents with tachycardia, hypertension, fever, sweating, and confusion. A nurse notifies the health care provider, suspecting the client is experiencing:
A. Neuroleptic malignant syndrome
B. Discontinuation syndrome
C. Serotonin syndrome
D. Extrapyramidal symptoms

Answers
1.
D: “Integrity versus despair” is Erikson’s stage of development from 65 years of age and older. Indicators of positive resolution include statements of acceptance of worth and uniqueness of one’s own life.
2. D: The preterm infant, 24-36 weeks gestation, typically is covered with vernix caseosa, a waxy, white substance secreted by the fetus’s sebaceous glands in utero.
Lanugo is usually extensive in a 31-week infant, covering the back, forehead, and sides of the face. The sucking and swallowing reflexes are absent in an infant younger than 33 weeks gestation. The preterm infant’s posture is characterized by very little, if any, flexion of the extremities.
3.
A: At the age of 1 year, a child’s fears of separation are great because the child is facing the developmental task of trusting others. Options 3 and 4 may be issues if the child was older. No data in the question allow one to determine that siblings exist.
4. A, B, D, E: Autonomic dysreflexia results from uncontrolled sympathetic nervous system discharges causing vasodilation and hypertension. Sweating, headache, blurred vision, and anxiety occur secondary to the hypertension. Hypertension (not hypotension) is a symptom of autonomic dysreflexia. Bradycardia (not tachycardia) is secondary to vagal parasympathetic stimulation.
5. A: Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones. A low hemoglobin is seen with bleeding, insufficient intake of iron, or with renal disease. An elevated Scr is seen with renal disease. An elevated CK would be seen with muscle damage.
6.
C: Megaloblastic anemia is caused by deficiency of vitamin B12 or folic acid. A vegetarian can prevent a deficiency with oral vitamin supplements or fortified soy milk. The U.S. Department of Agriculture’s Dietary Guidelines for Americans 2005 also recommend that people over age 50, whether or not they are vegetarian, consume vitamin B12 in its crystalline form (i.e., fortified foods or supplements).
7. B: A MAP of less than 60 mm Hg indicates that there is inadequate perfusion to organs. The mean arterial pressure is calculated by the sum of the SBP + 2DBP and then divided by 3 (MAP = (SDP + 2DBP)/3). Thus, the MAP of 98/36 mm Hg is (98
+ 72)/3 = 56.7.
8.
C: The client’s tracheostomy is permanent because the larynx and part of the trachea are removed. Stating to schedule an appointment for closure of the tracheostomy indicates the client does not accept or understand the teaching.
9. D: GH excess causes overgrowth of the bones and soft tissues, resulting in a disturbance in body image.

10.
A: The primary symptoms of ulcerative colitis are bloody diarrhea and abdominal pain. Weight loss often occurs in severe cases. Bowel sounds are often hyperactive.
Heartburn and regurgitation are not symptoms of this disease.
11. B: Seeing halos is not a normal age-related vision change. Halos are classic symptoms of glaucoma.
12.
C: Tachycardia, hypertension, fever, sweating, and confusion indicate serotonin syndrome, a potentially fatal condition that may occur with concurrent use of other medications that increase serotonin.
Reference
Ohman, K. (2010). Davis’s Q&A for the NCLEX-RN Examination.
Philadelphia, PA: F.A. Davis
Company.