The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?
A) Hypertonic neuro reflex
B) Immediate CNS depression
C) Lethargy and sleepiness
D) Jitteriness at 24-48 hours
Review Information: The correct answer is D: Jitteriness at 24-48 hours
Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.
The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority?
A) Show her films on the physiology of lactation
B) Give the client several illustrated pamphlets
C) Assist her to position the newborn at the breast
D) Give her privacy for the initial feeding
Review Information: The correct answer is C: Assist her to position the newborn at the breast
While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?
A) A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
B) A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
C) A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
D) A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement
Review Information: The correct answer is B: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.
A client arrived in the USA from a developing country 1 week ago. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS. There is a history of these findings: unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of
A) Acute tuberculosis with a productive cough of discolored sputum for over three months
B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen
C) Pseudomembranous colitis and C. difficile
D) Exacerbation of polyarthritis with severe pain
Review Information: The correct answer is A: Acute tuberculosis with a productive cough of discolored sputum for over three months
The client being admitted has the classic findings of pulmonary tuberculosis. Of the available choices, the client in option A would be the most appropriate roommate. It is acceptable to put clients with similar diagnoses in the same room when no other alternative exists. Clients are considered contagious until the cough is eliminated with medications, which initially is a combination of 4 simultaneous drugs.
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?
A) Tuberculin skin testing
B) Sputum culture
C) White blood cell count
D) Chest x-ray
Review Information: The correct answer is B: Sputum culture
The sputum culture is the most accurate method for determining the presence of active TB.
The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
A) the skin
B) the lungs
C) the muscles
D) bowel and bladder
Review Information: The correct answer is A: the skin
A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
A) Capillary refill less than 3 seconds
B) Pale mucous membranes
C) Respirations 36 breaths per minute
D) Complaints of fatigue when ambulating
Review Information: The correct answer is A: Capillary refill less than 3 seconds
Since the hemoglobin and hematocrit are normal for an adult female, addition assessments should be normal. This capillary refill time is normal.
A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?
Review Information: The correct answer is A: MMR
Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body''s ability to form antibodies.
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
A) irrigate it as ordered with distilled water
B) irrigate it as ordered with normal saline
C) place the end of the tube in water to see if the water bubbles
D) withdraw the tube several inches and reposition it
Review Information: The correct answer is B: irrigate it as ordered with normal saline
Nasogastric tubes are only irrigated with normal saline to maintain patency.
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
A) Reduced oxygen capacity of cells due to lack of iron
B) An imbalance between red cell destruction and production
C) Depression of red and white cells and platelets
D) Inability of sickle shaped cells to regenerate
Review Information: The correct answer is B: An imbalance between red cell destruction and production
Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
A) Sexually transmitted infection
B) Exposure to teratogens
C) Maternal hypertension
D) Chromosomal abnormalities
Review Information: The correct answer is C: Maternal hypertension
Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
B) acidic byproducts
C) vomiting and dehydration
Review Information: The correct answer is A: tachypnea
Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.
The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
A) Impaired skin integrity related to dependent edema
B) Activity intolerance related to oxygen supply and demand imbalance
C) Constipation related to immobility
D) Risk for infection related to ineffective mobilization of secretions
Review Information: The correct answer is B: Activity intolerance related to oxygen supply and demand imbalance
This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.
The nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?
A) The mother feels calmer and talks to the baby while nursing
B) The mother awakens the newborn to feed whenever it falls asleep
C) The newborn falls asleep after 3 minutes at the breast
D) The newborn refuses the supplemental bottle of glucose water
Review Information: The correct answer is A: The mother feels calmer and talks to the baby while nursing
Early evaluation of successful breastfeeding can be measured by the client''s voiced confidence and satisfaction with the infant.
In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
A) assess the brachial pulses
B) breathe once every 5 compressions
C) use both hands to apply chest pressure
D) compress 80-90 times per minute
Review Information: The correct answer is B: breathe once every 5 compressions
For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
Which action is most likely to ensure the safety of the nurse while making a home visit?
A) Observe no evidence of weapons in the home during the visit
B) Prior to the visit, review the client's record for any previous entries about violence
C) Remain alert at all times and leave if cues suggest the home is not safe
D) Carry a cell phone, pager and/or hand held alarm for emergencies
Review Information: The correct answer is C: Remain alert at all times and leave if cues suggest the home is not safe
No person or equipment can guarantee nurses'' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards and sources of assistance. Become acquainted with neighbors. Be alert and confident while parking the car, walking to the client''s door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
Review Information: The correct answer is B: Rude
Native Americans consider direct eye contact to be impolite or aggressive among strangers.
For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rho (D) immune globulin within 72 hours of birth?
A) Rh negative mother with Rh positive baby
B) Rh negative mother with Rh negative baby
C) Rh positive mother with Rh positive baby
D) Rh positive mother with Rh negative baby
Review Information: The correct answer is A: Rh negative mother with Rh positive baby
An Rh- mother who delivers an Rh+ baby may develop antibodies to the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has occurred. TheFor which of the following mother-baby pairs should the nurse review the Coomb''s'' test in preparation for administering Rho(D) immune globulin is given to block antibody formation in the mother.
A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings suggests to the nurse that the infant has fetal alcohol syndrome?
A) Growth retardation is evident
B) Multiple anomalies are identified
C) Cranial facial abnormalities are noted
D) Prune belly syndrome is suspected
Review Information: The correct answer is C: Cranial facial abnormalities are noted
Characteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome.
The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that
A) The child is within the age group most susceptible to SIDS
B) The peak age for occurrence of SIDS is 8 to 12 months of age
C) The apnea monitor is not effective on a child in this age group
D) 95% of SIDS cases occur before 6 months of age
Review Information: The correct answer is D: 95% of SIDS cases occur before 6 months of age
Peak age of SIDS occurrence is 2 to 4 months and 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.
The nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's syndrome?
Review Information: The correct answer is C: varicella
Varicella (chicken pox) and influenza are viral illnesses that have been identified as increasing the risk for Reye''s syndrome. Use of aspirin is contraindicated for children with these infections.
The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first?
A) Explain the stages of death and dying to the family
B) Recommend an easy-to-read book on grief
C) Assess the family's patterns for dealing with death
D) Ask about their religious affiliations
Review Information: The correct answer is C: Assess the family''s patterns for dealing with death
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that the client and their family''s needs are adequately identified in order to select the best nursing care approaches.
A nurse is teaching a class for new parents at a local community center. The nurse would stress that _______ is most hazardous for an 8 month-old child.
A) riding in a car
B) falling off a bed
C) an electrical outlet
D) eating peanuts
Review Information: The correct answer is D: eating peanuts
Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.
What is the major purpose of community health research?
A) Describe the health conditions of populations
B) Evaluate illness in the community
C) Explain the health conditions of families
D) Identify the health conditions of the environment
Review Information: The correct answer is A: Describe the health conditions of populations
Community health focuses upon aggregate population care.
The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?
A) pulse oximetry of 85%
C) crackles in lungs
Review Information: The correct answer is A: pulse oximetry of 85%
An oxygen saturation of 88% or less indicates hypoxemia and requires the nurse''s immediate attention.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
A) Moist mucous membranes
B) Urinary frequency
C) Poor skin turgor
D) Increased blood pressure
Review Information: The correct answer is C: Poor skin turgor
The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.
The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
Review Information: The correct answer is C: sodium
The client with Meniere''s disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.
The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor?
A) The increased homeless population in major cities
B) The rise in reported cases of positive HIV infections
C) The migration patterns of people from foreign countries
D) The aging of the population located in group homes
Review Information: The correct answer is B: The rise in reported cases of positive HIV infections
Between 1985 and 2002 there has been a significant increase in the reported cases of TB. The increase was most evident in cities with a high incidence of positive HIV infection. Positive HIV infection currently is the greatest known risk factor for reactivating latent TB infections.
As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
B) scuba diving
Review Information: The correct answer is B: scuba diving
The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
A) Fecal impaction
B) Infrequent voiding
C) Stress incontinence
D) Burning with urination
Review Information: The correct answer is A: Fecal impaction
The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.
Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
A) Consider a liquid supplement to increase calories
B) Discuss consequences of an unbalanced diet with the child
C) Provide fruit, vegetable and protein snacks
D) Encourage the child to keep a daily log of foods eaten
Review Information: The correct answer is B: Discuss consequences of an unbalanced diet with the child
It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
A) lung sounds
B) urine output
C) level of alertness
Review Information: The correct answer is C: level of alertness
Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill?
A) Stubborn behavior
B) Rejection of parents
C) Frustration with adults
D) Assertion of control
Review Information: The correct answer is D: Assertion of control
Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child''s progress from dependency to autonomy and independence.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be high
A) calorie, low fat, low sodium
B) protein, low fat, low carbohydrate
C) protein, high calorie, unrestricted fat
D) carbohydrate, low protein, moderate fat
Review Information: The correct answer is C: protein, high calorie, unrestricted fat
The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
A) Complaints of numbness and tingling in feet
B) Wheezing noted when lung sound auscultated
C) Excessive perspiration
D) Difficulty sleeping
Review Information: The correct answer is A: Complaints of numbness and tingling in feet
A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
A) A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
C) A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Review Information: The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
This client has an actual complication. The others present with findings of potential complications.
The nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis?
A) The number of persons in a population who develop hepatitis B during a specific period of time
B) The total number of persons in a population who have hepatitis B at a particular time
C) The percentage of deaths resulting from hepatitis B during a specific time
D) The occurrence of hepatitis B in the population at a particular time
Review Information: The correct answer is A: The number of persons in a population who develop hepatitis B during a specific period of time
This is the correct definition of incidence of the disease.
An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?
A) "Spiritual healing is emphasized and the mind contributes to the cure."
B) "The primary belief is that dietary practices result in health or illness."
C) "Fasting and prayer are initial actions to take in physical injury."
D) "Meditation is intensive in the initial 48 hours and daily thereafter."
Review Information: The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure."
For the Christian Scientist, a mind cure uses spiritual healing methods. For the believer, medical treatments may interfere with drawing closer to God.
The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes
A) the airway to become narrow and obstructs airflow."
B) air to be trapped in the lungs because the airways are dilated."
C) the nerves that control respiration to become hyperactive."
D) a decrease in the stress hormones which prevents the airways from opening."
Review Information: The correct answer is A: the airway to become narrow and obstructs airflow."
Asthma is defined as airway obstruction or a narrowing that is characterized by bronchial irritability after exposure to various stimuli.
The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is
A) "The top layer of the skin is destroyed."
B) "The skin layers are swollen and reddened."
C) "All layers of the skin were destroyed in the burn."
D) "Muscle, tissue and bone have been injured."
Review Information: The correct answer is C: "All layers of the skin were destroyed in the burn."
A third degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.