EXAM

Question 1

BSE is one of the ways to detect breast cancer earlier. The nurse is conducting a health teaching to female clients in a clinic. During evaluation the clients are asked to state what they learned. Which of the following statement made by a client needs further teaching about BSE?

Answer 1

BSE palpation is done by starting at the center going to the periphery in a circular motion.

Question 2

A 24-year old female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

Answer 2

The condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear anually.

Question 3

Ms. L reports experiencing vulvar pruritus. Upon assessment, which of her reports may indicate that she has an infection caused by Candida albicans?

Answer 3

I have a cottage cheese-like vaginal discharge.

Question 4

A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

Answer 4

Chlamydia

Question 5

The nurse is evaluating a client for breast cancer. The nurse explains the risk factors for the development of the disease. Which information should the nurse include in the teaching? Select ALL that apply.

Answer 5

• Menarche before age 12
• Giving birth to first child after age 30
• Menopause beginning after age 55

Question 6

When caring for a client with syphilis, the nurse instructs the client that syphilis may be transmitted by which type of contact?

Answer 6

Engaging in sexual intercourse

Question 7

The nurse is counselling a postmenopausal woman about her new stress incontinence. Which statement by the nurse is most important?

Answer 7

It will be important to keep that area clean and dry.

Question 8

Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following?

Answer 8

Intercostal retractions

Question 9

A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would the nurse expect to see?

Answer 9

Anasarca

Question 10

An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following?

Answer 10

Jitters

Question 11

A Roman Catholic couple has just delivered a baby with an Apgar score of 1 at 1 minute, 2 at 5 minutes, and 2 at 10 minutes. Which of the following interventions is appropriate at this time.

Answer 11

Ask the parents whether they would like the nurse to baptize the baby.

Question 12

A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment?

Answer 12

Wrinkled skin

Question 13

A mother of a preterm baby is performing kangaroo care in the neonatal nursery. Which of the following responses would the nurse evaluate as a positive neonatal outcome?

Answer 13

Licking of mother’s nipples

Question 14

A full-term neonate in the NICU has been diagnosed with congestive heart failure secondary to a cyanotic heart defect. Which of the following activities is most likely to result in a cyanotic episode?

Answer 14

Feeding

Question 15

The nurse caring for a neonate with congestive heart failure identifies which of the following nursing diagnoses as highest priority?

Answer 15

Altered tissue perfussion

Question 16

A baby is born with a suspected coarctation of the aorta. Which of the following assessments should be done by the nurse?

Answer 16

Check blood pressure in all four limbs.

Question 17

The nurse is developing a teaching plan for parents of an infant with a tetralogy of Fallot. In which of the following positions should parents be taught to place the infant during a “blue”, or “tet,” spell?

Answer 17

Knee-chest

Question 18

A preterm infant has patent ductus arteriosus (PDA). Which of the following explanations should the nurse give to the parents about the condition?

Answer 18

Oxygenated blood is reentering the pulmonary system.

Question 19

A 3-year-old child was brought to the pediatric clinic after a sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first.

Answer 19

Notify the healthcare provider of the child’s status

Question 20

A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

Answer 20

Most, productive cough

Question 21

You were a floor nurse who took care of baby M status post tonsillectomy. You noticed that the child is frequently swallowing something. What will be your most immediate intervention?

Answer 21

Turn the patient to side

Question 22

You provided health teaching to Mrs. D, baby M’s mother, regarding appropriate food items that she can offer to her child after tonsillectomy. Which of the following responses of Mrs. D indicated that she had understood your health teaching?

Answer 22

I can offer him clear, cool liquids like Jell-O.

Question 23

A nurse is preparing a discharge teaching plan for a teenager with asthma. Which of the following health promotion activities should the nurse include?

Answer 23

Incorporate physical exercise as tolerated into the treatment plan.

Question 24

The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. the parents ask what they should expect. Select the nurse’s best response.

Answer 24

Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved.

Question 25

A male child who has been treated for chronic renal failure (CRF) is ready for discharge. Nurse Billy should reinforce which dietary instruction?

Answer 25

Increase your carbohydrate intake.

Question 26

An adolescent patient with a positive rapid antibody test result from human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Answer 26

Remind the patient about the need to return for retesting to verify the results.

Question 27

A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?

Answer 27

Blood cultures

Question 28

A nurse is conducting a interview to an 11-year old client upon admission. What complaints will she expect to hear in a client with Crohn’s disease?

Answer 28

Rectal cramping and bleeding

Question 29

An adolescent patient is scheduled for surgery to have his appendix out due to acute appendicitis. The patient says: “I don’t think I need surgery now because I feel better.” A nurse should respond as follows:

Answer 29

I will call your doctor to explain the procedure to you.

Question 30

The nurse is planning to conduct a health teaching to a group of adolescents. Which of the following should included when developing a teach plan to prevent urinary tract infection? Select all the apply.

Answer 30

• Maintain adequate fluid intake
• Emptying bladder with urination
• Regulation of blood volume and pressure

Question 31

A school nurse is educating the parents on measures to prevent poststreptococcal glomerulonephritis in children. She will likely tell them which of the following as the best way to prevent this?

Answer 31

Encourage the child to take all the antibiotics if diagnosed with strep throat

Question 32

You obtain a history from the mother of a child with glomerulonephritis about how he became ill. Which of the following would you expect her to tell you she noticed?

Answer 32

dark brown urine

Question 33

Mr. and Mrs. Smith’s child has hemophilia; which of the following actions would you instruct them to avoid?

Answer 33

Lowering the injured area

Question 34

Mrs. Baker was instructed by the nurse on foods to encourage her child’s diet concerning the latter’s iron deficiency anemia; which of the following if stated by the mother would indicate the need for further instructions

Answer 34

Yellow vegetables

Question 35

The long-term complications seen in thalassemia major are associated to which of the following?

Answer 35

Hemochromatosis

Question 36

The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is blood pressure that is

Answer 36

lower in the legs than in the arms

Question 37

When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting:

Answer 37

increase the return of venous blood back to heart

Question 38

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?

Answer 38

stupor

Question 39

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as:

Answer 39

neurological emergency

Question 40

During teaching, the nurse should advise the family of the child newly-diagnosed with Grave’s disease to:

Answer 40

Promote interaction with one friend instead of a group

Question 41

You are going over insulin administration education with a patient’s mother. Which statement by her raises concern?

Answer 41

When she is sick I will hold her insulin.

Question 42

A patient with a history of diabetes is exhibiting sweating and slurred speech. What do you suspect is the cause?

Answer 42

hypoglycemia

Question 43

A 15 year old, who is type 1 diabetic, reports that she almost “passes out” during gym class. What information would you pass assess from the teenager?

Answer 43

Her eating habits prior to gym class

Question 44

The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in Pavlik harness. The nurse would teach the parents to:

Answer 44

Fit the diaper under then straps

Question 45

The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:

Answer 45

I should use a pillow to elevate my child’s foot as he sleeps

Question 46

While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child’s left thigh is swollen. What should the nurse do next?

Answer 46

Assess the neurologic status of the toes.

Question 47

A patient is seen at the Emergency Department after falling on the right arm and shoulder. It will be most important for the nurse to determine

Answer 47

whether the right arm is shorter than the left

Question 48

When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?

Answer 48

Bend forward at the waist with arms hanging freely

Question 49

Which of these clinical manifestation would cause the nurse to suspect that Patient SAM is diagnosed with systemic lupus erythematosus?

Answer 49

joint edema and ternderness

Question 50

Patient SAM is diagnosed with systemic lupus erythematosus. Which of the instruction would be included in the teaching plan for the client?

Answer 50

You have to wear large-brimmed hats when exposed to the sun.