The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
A) Glucose level of 120
B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates
Review Information: The correct answer is C: Long term steroid usage
Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased.
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
Review Information: The correct answer is C: echolalic
Echolalia is repeating words or phrases heard before.
The nurse has been assigned to four clients in the emergency room, each experiencing one of these conditions. Which client condition would the nurse check first?
A) Viral pneumonia with atelectasis
B) Spontaneous pneumothorax with a respiratory rate of 38
C) Tension pneumothorax with slight tracheal deviation to the right
D) Acute asthma with episodes of bronchospasm
Review Information: The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest.
A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome for this client’s care will be
A) expresses feelings appropriately through verbal interactions
B) accurately interprets events and behaviors of others
C) demonstrates improved social relationships
D) engages in meaningful and understandable verbal communication
Review Information: The correct answer is D: engages in meaningful and understandable verbal communication
The outcome must be related to the diagnosis and supporting data. Data support impaired verbal communication deficit as a nursing diagnosis. No direct data are presented related to feelings or to thinking processes, though disorganized verbalizations are typically taken to indicate disorganized thinking.
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
A) requiring the client to mop the floor
B) restricting the client’s fluids throughout the day
C) withholding privileges each time the voiding occurs
D) toileting the client more frequently with supervision
Review Information: The correct answer is D: toileting the client more frequently with supervision
With a client suffering from altered thought processes, the most appropriate nursing approach to change this behavior is by taking an active role in attending to the physical need.
The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts
Review Information: The correct answer is A: The ethical sense and feelings of justice are developing
The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment.
When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier
Review Information: The correct answer is D: There is a 25% chance a daughter will be a carrier
Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male.
Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect
Review Information: The correct answer is B: Myelination of the spinal cord is completed by this age
Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, sometime between the ages of 18 to 24 months of age.
During seizure activity which observation is the priority to enhance further direction of treatment?
A) Observe the sequence or types of movement
B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs
Review Information: The correct answer is A: Observe the sequence or types of movement
It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description.
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) The client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing
Review Information: The correct answer is D: To reduce the tendency of the client to hide objects under his or her clothing
The client may conceal weights on their body to create the illusion of increased weight gain.
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house
Review Information: The correct answer is A: Allow the child to continue normal activities
Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucus secretion and helps develop normal breathing patterns.
A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource?
A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years ago
C) The policies and procedures of the assigned agency in that state
D) The Nursing Social Policy Statement within the United States
Review Information: The correct answer is A: The state nurse practice act in which the assignment is made
The state nurse practice act is the governing document of the scope of practice in the given state.
At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"
Review Information: The correct answer is B: "How long has this been occurring?"
Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons.
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
Review Information: The correct answer is B: Cereal
Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch
Review Information: The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be expelled
The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and close the bottom of the pouch.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
A) Call the health care provider
B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen
Review Information: The correct answer is D: Administer oxygen
When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation. Starting oxygen is the priority.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids
Review Information: The correct answer is C: Check the mouth and radial pulse
The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation, then stabilize the client. The other nursing actions would follow.
The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?
A) Notify the provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings
Review Information: The correct answer is D: Record these normal findings
The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age.
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
A) avoid smoking near the client
B) turn off oxygen during meals
C) adjust the liter flow to 10 as needed
D) remind the client to keep mouth closed
Review Information: The correct answer is A: avoid smoking near the client
Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment.
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to
A) avoid overheating during physical activities
B) maintain normal activity with some restrictions
C) be cautious of others with viruses or temperatures
D) maintain routine immunizations
Review Information: The correct answer is A: avoid overheating during physical activities
Fluid loss caused by overheating and dehydration can trigger a crisis.
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
A) Large volume of urinary output with each voiding
B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated
Review Information: The correct answer is C: Frequent urination
Clients with BPH have overflow incontinence with frequent urination in small amounts day and night.
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
A) 50% increase in birth weight
B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen
Review Information: The correct answer is A: 50% increase in birth weight
Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18 months.
The nurse is caring for a post-op colostomy client. The client begins to cry, saying "I'll never be attractive again with this ugly red thing." What should be the first action taken by the nurse?
A) Arrange a consultation with a sex therapist experienced in working with colostomy clients
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care after viewing an instructional video
D) Encourage the client to discuss her feelings about the colostomy
Review Information: The correct answer is D: Encourage the client to discuss her feelings about the colostomy
One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However, the client’s personal feelings about the stoma and colostomy care, as well as the client''s specific concerns, need to be assessed to accurately identify the problem(s) to be solved. An assessment should occur before specific suggestions for dealing with the sexual concerns are given.
Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day
Review Information: The correct answer is C: A serving size at this age is about 2 tablespoons
In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake.
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears
Review Information: The correct answer is C: Auscultate heart and lungs
The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
A) bronchial breath sounds in outer lung fields
B) decreased tactile fremitus
C) hacking, nonproductive cough
D) hyper-resonance of areas of consolidation
Review Information: The correct answer is A: bronchial breath sounds in outer lung fields
Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.
A client is unconscious following a tonic-clonic seizure. What should the nurse do first?
A) check the pulse
B) administer Valium
C) place the client in a side-lying position
D) place a tongue blade in the mouth
Review Information: The correct answer is C: place the client in a side-lying position
Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep
Review Information: The correct answer is A: Maintain good nutrition
Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease
Review Information: The correct answer is B: 1in 4 risk for each child to have the disease
Cystic fibrosis has an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
A) Low hemoglobin
C) High serum creatinine
Review Information: The correct answer is A: Low hemoglobin
Although hemodialysis improves or corrects electrolyte imbalances it has no effect on improving anemia.
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support
Review Information: The correct answer is B: Looking different from their peers
Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery.
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the nurse's best response to the parent?
A) "When a child asks a question, give a simple answer."
B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."
Review Information: The correct answer is A: "When a child asks a question, give a simple answer."
During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer. When they are ready, they will ask for more detailed information.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy
Review Information: The correct answer is A: Ileostomy
Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in several hours. Because of the caustic nature of this stoma output adequate peristomal skin protection must be delivered to prevent skin breakdown.
The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?
A) Avoid climbing stairs for 3 months
B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross your legs
Review Information: The correct answer is D: Do not cross your legs
When the client is immediately post-op, hip flexion should not exceed 60 degrees, and after discharge it should not exceed 90 degrees.
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs
Review Information: The correct answer is D: Spare protein catabolism to meet metabolic needs
Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue.
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
A) Involuntary rhythmic stereotypic movements and tongue protrusion
B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension
Review Information: The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension
Hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of NMS (neuroleptic malignant syndrome).
The nurse understands that during the "tension building" phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
Review Information: The correct answer is B: helplessness
Battered individuals internalize appropriate anger of the batterer’s unfairness. They feel depressed, with a sense of helplessness when their partner explodes, in spite of their best efforts to please the batterer.
The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp
Review Information: The correct answer is D: Characteristic limp
Developmental dysplasia produces a characteristic limp in children who are walking.
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort
Review Information: The correct answer is A: Report a persistent cough to the health care provider
Persistent coughing should be reported to the health care provider as this may indicate bleeding.
A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that the most likely reason for the HSV-1 infection in this client is
B) emotional stress
C) unprotected sexual activities
D) contact with saliva
Review Information: The correct answer is A: immunosuppression
The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HSV-1. However, they are not the most likely causes in clients with HIV.