At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should
A) Inform the client that she must wait until the program ends at 5:00 pm to leave
B) Give the client simple information about what she will be doing
C) Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
D) Firmly direct the client to her assigned group activity
Review Information: The correct answer is C: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
Comforting and distraction, key approaches in validation therapy are the kindest and most effective for clients who have advancing dementia. The distressed, disoriented client should be gently oriented to reduce fear and increase the sense of safety and security, but reorientation often is ineffective when the client has moderate dementia and/or is upset. Environmental changes provoke stress and fear, especially in clients suffering from Alzheimer’s disease.
At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
A) Say 2 words
B) Pull up to stand
C) Sit without support
D) Drink from a cup
Review Information: The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8 months.
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behaviors are warning signs to indicate that the client may be
A) headed for relapse
B) feeling hopeless
C) approaching recovery
D) in need of increased socialization
Review Information: The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
A) Anxiety, unconscious anger, and hostility
B) Guilt, indecisiveness, poor self-concept
C) Psychomotor retardation or agitation
D) Meticulous attention to grooming and hygiene
Review Information: The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that the family can attend."
Review Information: The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern. Other information of interest is that cystic fibrosis is an autosomal recessive disease. For these parents there is a 25% chance that each pregnancy will result in a child with cystic fibrosis.
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball
Review Information: The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.
Post-procedure nursing interventions for electroconvulsive therapy include
A) applying hard restraints if seizure occurs
B) permitting client to sleep for 4 to 6 hours
C) remaining with client until oriented
D) expecting long-term memory loss
Review Information: The correct answer is C: remaining with client until oriented
The client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care. The time frame will vary, but it will not take several hours.
A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly “bothers” other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
Review Information: The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention. The other options would over-tax the client’s level of self-control.
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
Review Information: The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.
First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?
A) The pediatrician must examine the baby
B) Emergency equipment should be available
C) This breathing pattern is normal
D) A future referral may be indicated
Review Information: The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the
A) Yang, the positive force that represents light, warmth, and fullness
B) Yin, the negative force that represents darkness, cold, and emptiness
C) use of improper hot foods, herbs and plants
D) a failure to keep life in balance with nature and others
Review Information: The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness
Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.
Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure
Review Information: The correct answer is D: Note patterns of increased blood pressure
Evaluation for hypertension is a key assessment in the course of the disease.
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
A) Maintaining and preserving function
B) Anticipating side effects of therapy
C) Supporting coping with limitations
D) Ensuring compliance with medications
Review Information: The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture, and active and passive range of motion exercises are important interventions for maintaining function of affected joints.
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
A) Stand on 1 foot
B) Catch a ball
C) Skip on alternate feet
D) Ride a bicycle
Review Information: The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.
A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?
A) The alveoli will degenerate
B) Chronic bronchoconstriction of the large airways will occur
C) Lung remodeling and permanent changes in lung function will result
D) The client will experience frequent bouts of pneumonia
Review Information: The correct answer is C: Lung remodeling and permanent changes in lung function will result
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help reinforce the need for daily management of the disease whether or not the client "feels better."
A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
A) 9 month-old who stays with a sitter 5 days a week
B) 20 month-old who has just learned to climb stairs
C) 10 year-old who occasionally stays at home unattended
D) 15 year-old who likes to repair bicycles
Review Information: The correct answer is B: 20 month-old who has just learned to climb stairs
Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.
When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?
Review Information: The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.
The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?
A) Aerobic exercise classes
B) Transportation for shopping trips
* C) Reminiscence groups
D) Regularly scheduled social activities
Review Information: The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of elders as ego integrity vs despair.
Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects?
A) Red reflex test
B) Visual acuity
C) Pupil response to light
D) Cover test
Review Information: The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home
B) Medication compliance
C) Exposure to hot temperatures
D) Alcohol use
Review Information: The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of schizophrenia. Compliance with daily doses is a critical assessment finding.
A mother asks the nurse if she should be concerned about her child’s tendency to stutter. What assessment data will be most useful in counseling the parent?
A) Age of the child
B) Sibling position in family
C) Stressful family events
D) Parental discipline strategies
Review Information: The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
A) Oral ingestion
B) Topical contact
D) Eye splashes
Review Information: The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position
Review Information: The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
A) Monitor for hyperkalemia
B) Place in protective isolation
C) Precautions with position changes
D) Administer diuretics as ordered
Review Information: The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, clients are at high risk for pathological fractures.
A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client?
A) "No, it would be best if you brought the client some reading material that she could read at night."
B) "No, your presence may cause the client to become more anxious."
C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
D) "Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?"
Review Information: The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.
A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?
A) transparent dressing
B) dry sterile dressing with antibiotic ointment
C) wet to dry dressing
D) occlusive moist dressing
Review Information: The correct answer is D: occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
A) "My child has lost 3 pounds in the last month."
B) "Urinary output seemed to be less over the past 2 days."
C) "All the pants have become tight around the waist."
D) "The child prefers some salty foods more than others."
Review Information: The correct answer is C: "All the pants have become tight around the waist."
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
A) Schedule the therapy thirty minutes after meals
B) Teach the child not to cough during the treatment
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy
Review Information: The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.
In a child with suspected coarctation of the aorta, the nurse would expect to find
A) strong pedal pulses
B) diminishing carotid pulses
C) normal femoral pulses
D) bounding pulses in the arms
Review Information: The correct answer is D: bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities resulting in increased pressure and pulses.
The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?
A) Activity intolerance caused by fatigue related to chronic tissue hypoxia
B) Impaired mobility related to chronic obstructive pulmonary disease
C) Self care deficit caused by fatigue related to dyspnea
D) Ineffective airway clearance related to increased bronchial secretions
Review Information: The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia
Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
A) Increase fluid intake to prevent dehydration
B) Place client on a pressure reducing support surface
C) Use skin care products designed for use with incontinence
D) Increase caloric intake to aid healing
Review Information: The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
A) Change the baby to whole milk
B) Add chocolate syrup to the bottle
C) Continue with the present formula
D) Offer fruit juice frequently
Review Information: The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.
A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?
A) "The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change."
B) "Perhaps, if you understood the need to abuse, you could stop the violence."
C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"
D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Review Information: The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.
A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it
A) contains less lactose
B) is higher in calories/ounce
C) provides antibodies
D) has less fatty acid
Review Information: The correct answer is C: provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.
The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is
A) "Although the results are here, your doctor will explain them later."
B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."
Review Information: The correct answer is B: "Your child has fewer red blood cells that carry oxygen."
The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.
A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to
A) ask the client about the refusal of certain pain medications
B) talk with the client's family about the situation
C) report the situation to the primary care provider
D) document the situation in the notes
Review Information: The correct answer is A: ask the client about the refusal of certain pain medications
Beliefs regarding pain are one of the oldest culturally-related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
A) Hyperextension of the neck with passive shoulder flexion
B) Flexion of the hip and knees with passive flexion of the neck
C) Flexion of the legs with rebound tenderness
D) Hyperflexion of the neck with rebound flexion of the legs
Review Information: The correct answer is B: Flexion of the hip and knees with passive flexion of the neck
This is known as a positive Brudzinski’s sign (flexion of hip and knees with passive flexion of the neck). A positive Kernig’s sign, the inability to extend the knee to more than 135 degrees without pain behind the knee while the hip is flexed, usually establishes the diagnosis of meningitis.
The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?
Review Information: The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
A) When a family member offers information about their loved one
B) When the client threatens self-harm and harm to others
C) When the provider decides the family has a right to know the client's diagnosis
D) When a visitor insists that the visitor has been given permission by the client
Review Information: The correct answer is B: When the client threatens self-harm and harm to others
Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public. (Tarasoff decision,1974)
At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
A) Feelings of increasing anxiety related to paranoia
B) Social isolation related to altered thought processes
C) Sensory perceptual alteration related to withdrawal from environment
D) Impaired verbal communication related to impaired judgment
Review Information: The correct answer is B: Social isolation related to altered thought processes
Hostile alertness and absence of involvement with people are findings supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggest altered thinking processes.