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Question 1

A child diagnosed with deficiency of growth hormone who needs replacement drug therapy comes to the clinic for treatment. Which one of the following nursing diagnoses would be most appropriate for this client?

1. Imbalanced nutrition: More than body requirements
2. Disturbed body image
3. Diversional activity deficit
4. Decreased cardiac output

Answer 1

2. Disturbed body image

Children with growth hormone deficiency are smaller than their peers and frequently experience problems with self-esteem and body image. Option 1 would be the opposite problem of what the client is experiencing. The nursing diagnoses in options 3 and 4 are unrelated to the client in this question.

Question 2

The nursing unit is understaffed and a nurse from the surgical intermediate care unit has been floated to the unit for the day shift. Which of the following two clients should the nurse assign to this RN float nurse? Select all that apply.

1. A client newly admitted with exacerbation of heart failure
2. A client newly diagnosed with type 2 diabetes mellitus
3. A client who underwent emergency appendectomy during the night
4. A client with nephrolithiasis scheduled for lithotripsy later in the morning
5. A client admitted with thyrotoxicosis

Answer 2

3. A client who underwent emergency appendectomy during the night
4. A client with nephrolithiasis scheduled for lithotripsy later in the morning

The intermediate care surgical nurse should be most comfortable assuming the care of surgical clients. Heart failure, diabetes, and thyrotoxicosis are medical problems, and the client with diabetes will also require extensive teaching. The client with nephrolithiasis may also require teaching about the procedure, but since the client will undergo moderate sedation, the nurse would be completing typical preoperative care.

Question 3

The nurse would conclude that hypomagnesemia has not resolved if which of the following neuromuscular signs is still present after treatment?

1. Paralysis
2. Tetany
3. Flaccidity
4. Decreased reflexes

Answer 3

2. Tetany

Effects of hypomagnesemia are mainly due to increased neuromuscular responses. Paralysis, flaccidity, and decreased reflexes may be present with hypermagnesemia.

Question 4

A client presents to the Emergency Department with a complaint of chest pain. Which serum laboratory test does the nurse check off on the laboratory slip as part of a protocol order to rule out an acute myocardial infarction?

1. LDH4
2. Troponin
3. Amylase
4. CK-MM

Answer 4

2. Troponin

Troponin is a sensitive test that indicates damage to the myocardial cells. A CK-MM isoenzyme elevation would indicate skeletal muscle damage. The LDH4 isoenzyme is utilized to determine hepatic function and amylase is a digestive enzyme.

Question 5

The nurse is planning for a multidisciplinary team meeting concerning a client with bipolar disorder. In discussing the client’s safety needs, the nurse would be sure to include:

1. Placement of the client in a four-bed room.
2. The client’s risk level for self-harm.
3. Unrestricted visitors.
4. The need of the client to participate daily in many concentrated activities.

Answer 5

2. The client’s risk level for self-harm.

Question 6

A nurse is teaching a female client newly diagnosed with Helicobacter pylori infection. The nurse anticipates that which of the following medications will not be used after learning the client is pregnant?

1. Metronizadole
2. Amoxicillin
3. Clarithromycin
4. Ciprofloxacin

Answer 6

4. Ciprofloxacin

Question 7

The nurse admitting a client with a history of trigeminal neuralgia (tic Douloureux) would question the client about which of the following manifestations?

1. Facial droop accompanied by numbness and tingling
2. Stabbing pain that occurs with twitching of part of the face
3. Aching pain and ptosis of the eyelid
4. Burning pain and intermittent facial paralysis

Answer 7

2. Stabbing pain that occurs with twitching of part of the face

Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth.

Question 8

Which of the following would be an appropriate intervention for the nurse to include in a plan of care for a client with clinical diagnosis of bulimia?

1. Assess for laxative and diuretic possession.
2. Supervise mealtimes to ensure eating.
3. Observe for ritualistic eating patterns.
4. Reward nonpurging behavior with a favorite snack.

Answer 8

1. Assess for laxative and diuretic possession.

Abuse of laxatives and diuretics is a frequent purging behavior for bulimic clients. Options 2 and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a reward.

Question 9

A client has a strong family tendency toward hypertension. He denies that he will get hypertension because he watches what he eats, gets plenty of exercise, and keeps his weight within normal range. When implementing the plan of care, the nurse would do which of the following?

1. Praise the client and reassure him that these actions will prevent him from becoming hypertensive.
2. Emphasize that no matter what he does, the client will eventually develop hypertension because of his family history.
3. Recognize the client’s efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications.
4. Recommend that the client request antihypertensive medications prophylactically because of his family history.

Answer 9

3. Recognize the client’s efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications.

Lifestyle modifications and recognition of risk factors are important parts of prevention of long-term complications. Family history is a very strong risk factor but encouraging the client to maintain his current lifestyle and following up with health screening would be the best plan of action. False reassurance that he will never be hypertensive and prophylactic antihypertensive medications are inappropriate.

Question 10

A parent asks the nurse what to do with rough edges of her child’s cast, which are beginning to cause excoriation on the child’s skin. Which of the following responses by the nurse describes the appropriate action to take?

1. “Perform good skin care to the skin around the cast edges, with a protective barrier like Vaseline.”
2. “Call the physician to have the rough edges of the cast cut away.”
3. “Tape a soft towel to the edge of the cast to provide some protection from the rough edges.”
4. “Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast.”

Answer 10

4. “Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast.”

When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be covered to prevent skin irritation. This can be done by petaling the cast edges with strips of adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the outside of the cast.

Question 11

A 3-month-old infant is diagnosed with leukemia. Which of the following does the nurse anticipate will be part of the plan of care for this infant?

1. The baby will be placed in isolation.
2. Leukemia is familial and other children should be assessed.
3. All immunizations will be withheld during exacerbations.
4. The baby will be NPO during chemotherapy

Answer 11

3. All immunizations will be withheld during exacerbations.

Immunizations should be withheld during leukemia exacerbations because the immune system is compromised and the client cannot manage an appropriate response to the immunization. There is no need to place the client in isolation without added evidence of immunosuppression (option 1). Options 2 and 4 are irrelevant to the issue of the question.

Question 12

The registered nurse (RN) is assigned to the postpartum unit. Which task could the RN safely delegate to a beginning student nurse?

1. Ambulate a client who delivered by cesarean 2 days ago.
2. Complete the admission assessment on a newly delivered client.
3. Call the physician to report a low hemoglobin level.
4. Verify a unit of blood prior to transfusion.

Answer 12

1. Ambulate a client who delivered by cesarean 2 days ago.

Question 13

A client presents to the Emergency Department with a stab wound to the right upper abdominal quadrant. The client’s vital signs are BP 85/60, pulse 125, and respiratory rate of 28 breaths/minute. The nurse should immediately suspect damage to what organ?

1. Stomach
2. Liver
3. Large intestine
4. Kidney

Answer 13

2. Liver

The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding. The other organ systems would not be located in this area.

Question 14

The client is scheduled for a barium enema and is expressing concern that the barium will not be evacuated and a bowel obstruction will occur. What would be the best response for the nurse to make to the client?

1. “Don’t worry. The physicians will make sure that all of the barium is out of your bowel before you return to the unit.”
2. “You will be given extra fluids, laxatives, and an enema if you have not expelled the barium within 24 hours.”
3. “The barium they are using will not cause an obstruction.”
4. “Should I have the test rescheduled for when you are less concerned about it?”

Answer 14

2. “You will be given extra fluids, laxatives, and an enema if you have not expelled the barium within 24 hours.”

Question 15

The nurse is conducting an educational group on an inpatient unit. One of the clients has not spoken during the group. An effective therapeutic response by the nurse would include:

1. Allowing the client to remain present but nonparticipative.
2. Explaining to the client that everyone in the group needs to participate.
3. Asking the rest of the group members how they feel about this member not sharing.
4. Stopping the group and asking the client to leave.

Answer 15

1. Allowing the client to remain present but nonparticipative.

Question 16

As part of the ongoing assessment of a client who has an electrical burn, a CBC, electrolyte panel, and renal panel were ordered. The nurse would expect to find which of the following results?

1. Potassium level 5.9
2. Potassium level 2.8
3. Hematocrit of 28
4. WBC 4,000

Answer 16

1. Potassium level 5.9

After burn injuries, an elevated potassium level (normal 3.5-5.1 mEq) is expected because of cellular tissue damage with release of intracellular potassium into the bloodstream. The potassium level would not fall. The hematocrit will be elevated (not decreased) due to hemoconcentration. The white blood cell count will be elevated as part of the inflammatory response to injury.

Question 17

A client with congestive heart failure (CHF) has been advised to follow a 2-gram sodium diet. Which statement by the client indicates to the nurse that diet teaching has been effective?
1. “If I stop adding table salt, I shouldn’t have any problems.”
2. “I need to avoid eating processed foods and canned meats and vegetables.”
3. “I can still use a small amount of table salt in cooking.”
4. “I only have to worry about salty-tasting foods like potato chips.”

Answer 17

2. “I need to avoid eating processed foods and canned meats and vegetables.”

In a 2-gram sodium diet, clients should be taught to read food labels for hidden sodium content. In a 2-gram sodium diet, foods high in sodium content should be eliminated. It is not enough to stop adding salt while cooking. Added salt while cooking is allowed in a 4-gram sodium diet, not a 2-gram sodium diet. In a 2-gram sodium diet, foods high in sodium content should be eliminated but other measures are also needed, such as not adding salt while cooking.

Question 18

After delivery, a Chinese client states she needs to restore the balance between hot and cold forces in her body and refuses to bathe. The most appropriate nursing intervention is to:

1. Show her a videotape on postpartum self-care
2. Recognize her cultural beliefs and respect her wishes
3. Discuss postpartum complications related to poor personal hygiene
4. Request a psychiatric consult for this client.

Answer 18

2. Recognize her cultural beliefs and respect her wishes

Question 19

The nurse is preparing a client for discharge who will be takin lithium carbonate. Which of the following statements indicates that the client is feeling comfortable with being discharged on an antimanic medication?

1. “I don’t want to take the medicine you will give me, but you said I have to”
2. “I know that if I take my lithium every day I won’t have to come to the hospital again”
3. “I have a hard time taking this medicine and I don’t like the shaking, but I will take it every day with meals, and have my blood tests done, and come back to the clinic next month for my check-up like you said”
4. “Even though I don’t like taking medicine, I will take lithium daily with meals and have my blood tests on the dates I marked on my calendar. I should be able to do my normal things every day, and in a few weeks I won’t feel shaky anymore”

Answer 19

4. “Even though I don’t like taking medicine, I will take lithium daily with meals and have my blood tests on the dates I marked on my calendar. I should be able to do my normal things every day, and in a few weeks I won’t feel shaky anymore”

Question 20

A client has just finished a dose of intravesicular chemotherapy as treatment for bladder cancer. When giving instructions to the unlicensed assistive personnel (UAP) who will give routine care to this client, what statement should the nurse make?

1. “Be sure the client flushes the toilet after each use.”
2. “Cleanse the toilet with bleach after each use for the next 6 hours.”
3. “Ask the client to wipe the toilet seat with tissue after each bathroom use.”
4. “Assist the client to the bathroom and wear sterile gloves for pericare.”

Answer 20

2. “Cleanse the toilet with bleach after each use for the next 6 hours.”

For 6 hours following intravesicular chemotherapy, the toilet should be disinfected after each use. This will help ensure that the biohazard of excreted chemotherapy drug is contained. The toilet may also be double-flushed. Options 1 and 3 are insufficient, while option 4 is unnecessary and does not address the biohazardous aspect of chemicals remaining in the toilet.

Question 21

The nurse is caring for a young child who has mitt restraints. Which of the following priority actions needs to be done regularly to ensure that the child’s needs are met?

1. Check adequacy of circulation and skin condition.
2. Check that the tongue blades in pockets are intact and ends are covered or padded.
3. Ensure that the straps are tied to nonmovable parts of the crib.
4. Check that the call bell is pinned to the child’s gown.

Answer 21

1. Check adequacy of circulation and skin condition.

Question 22

The client is to undergo an extensive process of allergy testing as an outpatient. The nurse would complete which of the following as a priority intervention during the initial testing?

1. Have emergency equipment available in the event of an anaphylactic reaction.
2. Instruct the client to wear a t-shirt to assure easy access to the skin testing sites.
3. Give discharge instructions prior to testing since the client will be able to go home immediately after the testing.
4. Set up the room before the client enters the examination area.

Answer 22

1. Have emergency equipment available in the event of an anaphylactic reaction.

Question 23

A client who has been experiencing panic attacks asks why the physician has ordered several laboratory tests. The nurse’s answer should incorporate which of the following pieces of information?

1. Laboratory tests can differentiate between true anxiety and the anxiety associated with depression.
2. Laboratory tests can determine the specific cause of the panic attacks.
3. Physiologic symptoms associated with panic disorders often mimic medical disorders.
4. Symptoms of panic disorders are usually related to hypochondriasis.

Answer 23

3. Physiologic symptoms associated with panic disorders often mimic medical disorders.

Symptoms associated with a number of medical conditions are very similar to the symptoms associated with panic attacks. When a medical condition is present, it should be identified and treated. The other options are inaccurate responses to the client’s question.

Question 24

A female client has been taking norethindrone (Micronor) oral contraceptive pills. Which of the following items is most likely to be found in her health history?

1. Superficial phlebitis
2. Currently breastfeeding
3. Dysmenorrhea
4. Menarche at age 18

Answer 24

2. Currently breastfeeding

Norethindrone (Micronor) contains only progestin and no estrogen. Because estrogen may decrease lactation, progestin-only pills are commonly used in lactating women. The other options do not address the issue of contraception during lactation.

Question 25

The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, the most important nursing intervention will be which of the following?

1. Maintain cervical spine precautions.
2. Assess for facial lacerations.
3. Remove clothing.
4. Perform a mental status exam.

Answer 25

1. Maintain cervical spine precautions.

It is essential that the client’s spinal cord be immobilized to prevent further injury and loss of function. Assessing for lacerations, exposure of the client, and performing a full mental status exam are all part of the secondary assessment.

Question 26

Which breakfast option indicates to the nurse that the client with coronary artery disease requires further diet instruction?

1. Orange juice, shredded wheat, skim milk, toast with jelly
2. Grapefruit juice, oatmeal, 1% milk, bagel with jelly
3. Canned peaches, egg omelet, whole milk, fruited yogurt
4. Applesauce, bagel with margarine, egg-white omelet, skim milk

Answer 26

3. Canned peaches, egg omelet, whole milk, fruited yogurt

The American Heart Association recommends a diet with reduced saturated fats and cholesterol for clients with coronary artery disease. Canned peaches are high in concentrated sugars, which increase triglyceride levels. Egg yolks are high in cholesterol and whole milk is high in saturated fats. The other options reflect appropriate food selections that are low in saturated fat and cholesterol content.

Question 27

The nurse would encourage the new mother to use which breast-feeding position to enable the mother to have optimal control of the newborn’s head while giving the mother a full view of the infant’s cheeks and jaw?

1. Lying-down position
2. Cradle position
3. Clutch (football) position
4. Across-the-lap position

Answer 27

3. Clutch (football) position

The football, or clutch, position provides the mother with more control of the newborn’s head and full view of face. The lying-down position is usually done in bed (option 1). The cradle position often causes the newborn’s head to wobble around on the mother’s arm (option 2). Options 1, 2, and 4 do not allow full view of the infant’s face.