The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?
A) Clear the area of any hazards
B) Place the child on its side
C) Restrain the child
D) Give the prescribed anticonvulsant
Review Information: The correct answer is B: Place the child on its side
Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent airway and oxygenation must be assured.
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
A) High Fowler's
C) Left lateral
D) Low Fowler's
Review Information: The correct answer is A: High Fowler''s
Sitting in a chair or resting in a bed in high Fowler''s position decreases the cardiac workload and facilitates breathing.
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
Review Information: The correct answer is A: Direct sunlight
Phenothiazine increases sensitivity to the sun, making clients especially susceptible to sunburn. The nurse should recommend that clients treated with phenothiazines use sunblock consistently.
A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-emotional growth and development due to
A) loss of control
D) lack of trust
Review Information: The correct answer is C: dependence
The client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal.
The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in the 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes
Review Information: The correct answer is C: Takes frequent rest periods while playing
Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children.
Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
Review Information: The correct answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique.
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?
A) Teaching the child self care skills
B) Preparing for independent toileting
C) Promoting the child's optimal development
D) Helping the family decide on long term care
Review Information: The correct answer is C: Promoting the child''s optimal development
The primary goal of nursing care for a developmentally challenged child is to promote the child''s optimum development.
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sippy cup
Review Information: The correct answer is D: A 30 month-old only drinking from a sippy cup
A 30 month-old should be able to drink from a cup without a cover.
Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene
Review Information: The correct answer is B: Excessive fluoride intake
The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel''s porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
A) reports of difficulty falling and staying asleep
B) expression of persistent suicidal thoughts
C) lack of enjoyment in usual pleasures
D) reduced senses of taste and smell
Review Information: The correct answer is C: lack of enjoyment in usual pleasures
Lack of enjoyment in usual pleasures is the definition of “anhedonia,” which is a common finding in depression.
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
A) administer pain medication
B) suction excessive tracheobronchial secretions
C) assist client to turn, deep breathe and cough
D) monitor oxygen saturation
Review Information: The correct answer is B: suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway which is always the priority nursing intervention.
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
C) Maintaining bed rest with bathroom privileges
D) Performing chest physiotherapy twice a day
Review Information: The correct answer is B: Increasing oral fluid intake to 3000 cc per day
Secretion removal is enhanced with adequate hydration which thins and liquefies secretions.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken
Review Information: The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting foods that are high in calories and nutrients, to provide more nourishment with less chewing. Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw movements when eating, suggest that foods be pureed.
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
A) Elevate the leg on 2 pillows
B) Apply support stockings
C) Apply warm compresses
D) Maintain complete bed rest
Review Information: The correct answer is A: Elevate the leg on 2 pillows
The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation.
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
A) They occur about 2 years earlier than for males.
B) They begin about the same time for males.
C) They begin just prior to the onset of puberty.
D) They are characterized by an increase in height of 4 inches each year.
Review Information: The correct answer is A: They occur about 2 years earlier than for males.
Normally, females in their teenage years experience a growth spurt about 2 years earlier than their male peers.
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess
Review Information: The correct answer is B: Potential complication hemorrhage
Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
A) congenital cardiac defects
B) an acute febrile illness
C) prolonged hypoxemia
D) severe multiple trauma
Review Information: The correct answer is C: prolonged hypoxemia
Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia. Children usually have both cardiac and respiratory arrest.
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention
Review Information: The correct answer is B: Explain that this behavior is expected
During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
A) Compulsive behavior
B) Sense of impending doom
C) Fear of flying
D) Predictable episodes
Review Information: The correct answer is B: Sense of impending doom
The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
A) Speak directly to the interpreter while presenting information and use pauses for questions
B) Talk to the interpreter in advance and leave the client and interpreter alone
C) Include a family member and direct communications to that person
D) Face the client while presenting the information as the interpreter talks in the native language
Review Information: The correct answer is D: Face the client while presenting the information as the interpreter talks in the native language
Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, face the client and present the information to the client, allow the interpreter to translate the content. Facing the client allows non-verbal communication to take place between the client and nurse.
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."
Review Information: The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.
The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?
Review Information: The correct answer is D: Safety
Safety is a care priority for all inpatients, and a depressed client is at acute risk for self-destructive behavior. Precautions to prevent suicide must be a part of the nursing care plan.
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
A) Encourage the client to cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions
Review Information: The correct answer is A: Encourage the client to cough and deep breathe every 2 hours
Respiratory infections are common because of fluid in the retro-peritoneum pushing up against the diaphragm, causing shallow respirations. Coughing and deep breathing every 2 hours will diminish the occurrence of this complication.
The nursing care plan for a client with decreased adrenal function should include
A) encouraging activity
B) placing client in reverse isolation
C) limiting visitors
D) measures to prevent constipation
Review Information: The correct answer is C: limiting visitors
Any exertion, either physical or emotional, places additional stress on the adrenal glands which could precipitate an Addisonian crisis. The plan of care should protect this client from the physical and emotional exertion of visitors.
Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
A) Neuro malignant syndrome
B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy
D) Parkinson's disease, atypical tremors
Review Information: The correct answer is C: Glaucoma, prostatic hypertrophy
Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) because the drug is an anticholinergic agent. Cogentin is used to treat the side effects of antipsychotic medications.
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences
Review Information: The correct answer is B: They are able to think logically in organizing facts
The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."
Review Information: The correct answer is A: "Eat a balanced diet for your age."
A diet for a teenager with acne should be a well balanced diet for their age. There are no recommended additions and subtractions from the diet.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games
Review Information: The correct answer is B: Separation from parents
Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.
Which of these variations in the newborn results from the presence of maternal hormones?
A) Engorgement of the breasts
B) Mongolian spots
C) Edema of the scrotum
Review Information: The correct answer is A: Engorgement of the breasts
Breast engorgement occurs in both sexes as a result of the withdrawal of maternal hormones after birth.
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns
Review Information: The correct answer is D: Observe swallowing patterns
The nurse should observe for increased swallowing frequency, which would signal hemorrhage.
A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
Review Information: The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner
Drain cleaner is very alkaline. Orange juice is acidic and will help to neutralize this substance.
A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy
Review Information: The correct answer is C: Anticipation of the birth
Directing activities toward preparation for the newborn''s needs and personal adjustment are indicators of appropriate emotional response in the third trimester.
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
A) perform defibrillation
B) administer epinephrine as ordered
C) assess for presence of pulse
D) institute CPR
Review Information: The correct answer is C: assess for presence of pulse
Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client’s pulse.
A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic
Review Information: The correct answer is A: Counsel the woman to consent to HIV screening
The client''s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to
A) Notify the primary care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
Review Information: The correct answer is A: Notify the primary care provider immediately
Not only does the client report suicidal intent, he had formulated a plan and taken steps to implement it. The primary care provider and the rest of the health care team will arrange for treatment given the client’s serious risk for self-destructive behavior. Hospitalization and most probably work with the family are indicated. The nurse should never agree to help a client “keep secrets” from the health care team.
A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?
D) clove hitch
Review Information: The correct answer is A: elbow
The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.
Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs
Review Information: The correct answer is A: Sports and games with rules
The purpose of play for the 7 year-old is developing cooperation. Rules are very important. Logical reasoning and social skills are developed through play.
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client
A) should remain on bed rest in a semi-Fowler's position
B) should alternate ambulation with bed rest with legs elevated
C) may ambulate and sit in chair as tolerated
D) may ambulate as tolerated and remain in semi-Fowlers position in bed
Review Information: The correct answer is B: should alternate ambulation with bed rest with legs elevated
Encourage alternating periods ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client with gradually increasing periods of ambulation.
The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A) urinary output of 30 ml per hour
B) no complaints of thirst
C) increased hematocrit
D) good skin turgor around burn
Review Information: The correct answer is A: urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest overload.
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds:
A) "The complaints of at least 3 common findings."
B) "The absence of any opportunistic infection."
C) "CD4 lymphocyte count is less than 200."
D) "Developmental delays in children."
Review Information: The correct answer is C: "CD4 lymphocyte count is less than 200."
CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these – the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.