Part One You will have two hours and 30 minutes to complete Part One.
1. After delivering her second child, the client tells the nurse that she wants to breast-feed. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle-fed after 3 days of trying to nurse. Which of the following responses would best support this client's breast-feeding efforts?
A."I'll make sure that you're seen by the lactation consultant before you're discharged. "
B."It's important to room-in with your neonate so that you can respond to her nursing: cues, "
C."Don't worry, every baby is different, and I'm sure that you'll be successful this time. "
D."Breast-feeding is possible but you must be committed to it. "
A B C D
B
One way to help support this client's wishes to breast-feed is to instruct her to room-in with her neonate so she can respond to the neonate's cues. Sending the neonate to the nursery lessens the mother's ability to learn her neonate's breast-feeding cues. The other options don't support the client's need for guidance.
2. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?
A.Clear the client's airway.
B.Make the client comfortable.
C.Start eardiopulmonary resuscitation.
D.Stop the feeding and remove the NG tube.
A B C D
A
A living will states that no lifesaving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated and removing the NG tube would exacerbate the situation.
3. A client admitted for a hysterectomy has a secondary diagnosis of Ménière s disease. Which of the following nursing interventions should the nurse include in the client's plan of care to decrease the effects of tinnitus?
A.Reduce the amount of glucose and cholesterol in the diet.
B.Encourage the client to listen to the radio with earphones.
C.Encourage a weight-reduction diet.
D.Administer antihypertensive medications as ordered.
A B C D
B
Listening to the radio with earphones is one way to override the buzzing sound in the ears caused by tinnitus. Diet regulation may affect the occurrence of attacks of Ménière's but not the effects of tinnitus. The client wouldn't take antihypertensive medications for this disorder.
4. A 45-year-old auto mechanic comes to the physician's office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by
A.inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris.
B.suggesting he take aspirin for relief because it's probably early rheumatoid arthritis.
C.validating his complaint but assuming it's an adverse effect of his vocation.
D.asking him if he has been diagnosed or treated for carpal tunnel syndrome.
A B C D
A
Anyone with psoriasis vulgaris who reports joint pain should be evaIuated for psoriatic arthritis. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis, which can be painful and cause deformity. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints.
5. A client is admitted to the hospital with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in
A.vitamin Ａ.
B.vitamin Ｂ6.
C.vitamin Ｂ12.
D.vitamin Ｃ.
A B C D
C
Injury to the gastric mucosa causes gastric atrophy and impaired function of the parietal cells. This results in reduced production of intrinsic factor, which is necessary for the absorption of vitamin B12. Eventually, pernicious anemia will occur.
6. Which vaginal infection doesn't require treatment for sexual partners?
A.Neisseria gonorrhoeae.
B.Candida albicans.
C.Trichomonas vaginalis.
D.Chlamydia trachomatis.
A B C D
B
C. albicans is treated with nystatin (Mycostatin) and doesn't require treatment for sexual partners. N. gonorrhoeae, T. vaginalis, and C. trachomatis are sexually transmitted diseases that require that partners be treated.
7. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include
A.diminished or absent breath sounds on the affected side.
B.paradoxical chest wall movement with respirations.
C.tracheal deviation to the unaffected side.
D.muffled or distant heart sounds.
A B C D
A
In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade.
8. Which of the following functions would the nurse expect to be unrelated to the placenta?
A.Production of estrogen and progesterone.
B.Detoxification of some drugs and chemicals.
C.Exchange site for food, gases, and waste.
D.Production of maternal antibodies.
A B C D
D
Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.
9. While performing rounds, a nurse finds that a client is receiving the wrong IV solution. The nurse's initial response should be to
A.remove the IV catheter and call the physician.
B.write up an incident report describing the mistake.
C.slow the IV flow rate and hang the appropriate solution.
D.wait until the next bottle is due and then change to the proper solution.
A B C D
C
When a client is getting the wrong IV solution, the nurse should maintain the access and start the proper solution. Removing the catheter is unnecessary and subjects the client to unnecessary needlesticks. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. An incident report describing the specific error should be completed after the correct solution has been started.
10. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
A.Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours.
B.Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours.
C.A 5-to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling.
D.A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling.
A B C D
A
Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
11. A client who has a potassium level of 6 mEq/L should be treated with
A.antacids.
B.IV fluids.
C.fluid restriction.
D.sodium polystyrene sulfonate (Kayexalate).
A B C D
D
Sodium polystyrene sulfonate (Kayexalate) is a resin that pulls potassium into the bowel and is excreted with defecation. Antacids, IV fluids, and restriction of fluids won't reduce the potassium level.
12. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember?
A.Use cosmetic camouflage techniques.
B.Protect the graft from direct sunlight.
C.Continue physical therapy.
D.Apply lubricating lotion to the graft site.
A B C D
B
To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three interventions are all helpful to the client and his recovery but are less important.
13. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is
A.impending coma.
B.manipulating behavior.
C.suppression.
D.perceptual disorders.
A B C D
D
Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.
14. The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using
A.antiembolism stockings.
B.oxygen.
C.diuretics.
D.anticoagulants.
A B C D
C
Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess.
15. A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia, and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should
A.place a heating pad around the affected calf.
B.elevate the affected leg as high as possible.
C.keep the affected leg level or slightly dependent.
D.shave the affected leg in anticipation of surgery.
A B C D
C
While the physician makes treatment decisions, the nurse should maintain the client on bedrest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks.
16. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
A.Infection of the lung.
B.Kinked or obstructed chest tube.
C.Excessive water in the water-seal chamber.
D.Excessive chest tube drainage.
A B C D
B
Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage.
17. A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by
A.disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container.
B.wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.
C.draining urine from the drainage bag into a sterile container.
D.clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.
A B C D
B
Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.
18. Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of
A.antisocial behavior.
B.manipulation.
C.poor boundaries.
D.passive-aggressive behavior.
A B C D
C
The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
19. Which laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto's thyroiditis?
Normal thyroid function tests are as follows: T4, 5 to 12 μg/dL; T3, 65 to 195 μg/dL; TSH 0.3 to 5.4μIU/mL. With Hashimoto's thyroiditis, T4 and T3 levels are typically subnormal and TSH is elevated. With primary hyperthyroidism, T4 and T3 levels are elevated and TSH is subnormal (options A and B). With hypothyroidism, T4 is subnormal and T3 and TSH levels are elevated (option C).
20. What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior?
A.Ineffective coping.
B.Imbalanced nutrition: Less than body requirements.
C.Imbalaneed nutrition: More than body requirements.
D.Interrupted family processes.
A B C D
A
The client's coping skills are ineffective when anxiety increases. The other diagnoses don't correspond to the observed behavior.
21. A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today. " The nurse is using which therapeutic technique?
A.Restating.
B.Making observations.
C.Exploring.
D.Focusing.
A B C D
D
The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation.
22. The nurse is caring for a client who recently underwent a total hip replacement. The nurse should
A.ease the client onto a low toilet seat.
B.allow the client's legs to be crossed at the knees when out of bed.
C.use soft chairs when the client is sitting out of bed.
D.limit client hip flexion when sitting.
A B C D
D
Instruct the client to limit hip flexion to 90 degrees while sitting. Supply an elevated toilet seat so the client can sit without having to flex his hip more than 90 degrees. Instruct the client not to cross his legs, to avoid dislodging or dislocating the prosthesis. Caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable.
23. Which of the following observations signals the onset of puberty in male adolescents?
A.Appearance of pubic hair.
B.Appearance of axillary hair.
C.Testicular enlargement.
D.Nocturnal emissions.
A B C D
C
Testicular enlargement signifies the onset of puberty in the male adolescent. Then sexual development progresses, causing the appearance of pubic hair and axillary hair and the onset of nocturnal emissions.
24. A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μL. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150mL/hr. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?
A.Oral.
B.IV.
C.IM.
D.Subcutaneous (SC).
A B C D
C
With a platelet count of 22,000/μL, the client bleeds easily. Therefore, the nurse should avoid using the IM route because the area is highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. The client already has an IV access, so it would be the best route, especially because IV morphine is effective almost immediately. Oral and SC routes are preferred over IM, but they're less effective for acute pain management than IV.
25. The nurse is teaching the parents of a school-age child. Which teaching topic should take priority?
A.Preventing accidents.
B.Keeping a night light on to allay fears.
C.Explaining normalcy of fears about body integrity.
D.Encouraging the child to dress without help.
A B C D
A
Accidents are the major cause of death and disability during the school age years. Therefore accident prevention should take priority when teaching parents of school-age children. Preschool children are afraid of the dark, have fears concerning body integrity, and should be encouraged to dress without help (with the exception of tying shoes), but none of these should take priority over accident prevention.
26. A client with three children who is still in her childbearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon's preoperative teaching when the client states,
A."If I should become pregnant again, the child would be delivered by cesarean delivery. "
B."If I have another child, the procedure may need to be repeated. "
C."This surgery may render me incapable of conceiving another child. "
D."This procedure is accomplished in two separate surgeries. "
A B C D
B
Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair may need to be repeated. These clients don't necessarily have to have a cesarean delivery if they become pregnant, and this procedure doesn's render them sterile. This procedure is completed in one surgery.
27. The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury?
A.Bend over the object you're lifting.
B.Narrow the stance when lifting.
C.Push or puI1 an object using your arms.
D.Stand close to the object you're lifting.
A B C D
D
Standing close to an object being lifted moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload.
28. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to
A.avoid shopping for large amounts of food.
B.control eating impulses.
C.identify anxiety-causing situations.
D.eat only three meals per day.
A B C D
C
Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.
29. When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening?
A.Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed.
B.Listen for a clicking sound as the child abducts the hips.
C.Have the child run the heel of one foot down the shin of the other leg while standing.
D.Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders.
A B C D
A
To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the child to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. The nurse would listen for a clicking sound while the child abducts the hips when screening for developmental dysplasia of the hip. The heel-to-shin test evaluates cerebellar function. Having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve Ⅺ.
30. The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
A.Give the medication on an empty stomach.
B.Warn the client that he'll experience mouth dryness.
C.Schedule the medication before meals.
D.Administer the medication for complaints of muscle weakness or difficulty swallowing.
A B C D
C
Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. Pericardiocentesis is performed on a client with cardiac tamponade. This procedure would be deemed effective if
A.aspirated blood clots rapidly.
B.blood pressure decreases.
C.blood pressure increases.
D.heart sounds become muffled.
A B C D
C
Cardiac tamponade is associated with decreased cardiac output, resulting in decreased blood pressure. Removing a small amount of blood may improve cardiac output and blood pressure. Pericardial blood doesn't clot rapidly because it's defibrinated by cardiac motion within the cardiac sac. If blood clots rapidly, the needle may have entered the heart. Clients with cardiac tamponade may have muffled heart sounds. If pericardiocentesis is effective, heart sounds become normal.
2. When administering gentamicin to a preschooler, which of the following monitoring schedules is best for determining the drug's effectiveness?
A.A serum trough level every morning.
B.A serum peak level after the second dose.
C.A serum trough and peak level around the third dose.
D.Serial serum trough levels after three doses (24 hours).
A B C D
C
Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. A serum peak and trough level (taken half an hour before the dose and half an hour after the dose has been administered) around the third dose (the third dose provides enough medication build up in the blood stream to be measured) is the most accurate way to determine the correct serum values. A trough level every morning, a serum peak level after the second dose, and serial serum trough levels won't provide sufficient data about the effectiveness of the antibiotic.
3. When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following?
A.Fetal hypoxia.
B.The contraction pattern.
C.The status of a trapped cord.
D.Maternal comfort.
A B C D
A
These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.
4. The nurse is interviewing a client who is currently under the influence of a controlled substance and shows signs of becoming agitated. What should the nurse do?
A.Use confrontation.
B.Express disgust with the client's behavior.
C.Be aware of hospital security.
D.Communicate a scolding attitude to intimidate the client.
A B C D
C
The nurse, for her own protection, should be aware of hospital security and other assisting personnel. The other options may cause a relatively docile client to become belligerent.
5. A client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distention, it's typically due to
A.a neck tumor.
B.an electrolyte imbalance.
C.dehydration.
D.fluid overload.
A B C D
D
Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the veins to distend and can be seen most obviously in the neck veins. An electrolyte imbalance may result in fluid overload, but it doesn't directly contribute to jugular vein distention.
6. Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol's solution) and propylthiouracil (PTU). The nurse would expect the client's symptoms to subside
A.in a few days.
B.in 3 to 4 months.
C.immediately.
D.in 1 to 2 weeks.
A B C D
D
Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for surgery. Potassium iodide reaches its maximum effect in 1 to 2 weeks. PTU blocks the conversion of thyroxine to triiodothyronine, the more biologically active thyroid hormone. PTU effects are also seen in 1 to 2 weeks. To relieve symptoms of hyperthyroidism in the interim, clients are usually given a beta-adrenergic blocker such as propranolol.
7. Which signs and symptoms are associated with an acoustic neuroma?
A.Amenorrhea and obesity.
B.Acromegaly.
C.Ataxia and intention tremor.
D.Unilateral hearing loss and tinnitus.
A B C D
D
Unilateral hearing loss that occurs over an extended time and tinnitus are classic signs and symptoms of an acoustic neuroma. Amenorrhea, obesity, and acromegaly are signs of a pituitary tumor. Ataxia and intention tremors are seen with a cerebellar brain tumor.
8. The nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior?
A.By designating times during which the client can focus on the behavior.
B.By urging the client to reduce the frequency of the behavior as rapidly as possible.
C.By calling attention to or attempting to prevent the behavior.
D.By discouraging the client from verbalizing anxieties.
A B C D
A
The nurse should designate times during which the client can focus on compulsive behavior or obsessive thoughts. Frequency of the compulsive behavior should be reduced gradually, not rapidly. The nurse shouldn't call attention to or prevent the behavior; doing so may cause pain and terror in the client. Encouraging the client to verbalize anxieties may help distract his attention from the compulsive behavior.
9. The nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to
A.take sleeping pills for a restful night's sleep.
B.try to get more rest by going to bed earlier.
C.take her prenatal vitamins.
D.tell her not to worry because the fatigue will go away soon.
A B C D
B
She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now.
10. The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is
A.sedation.
B.diarrhea.
C.vertigo.
D.urticaria.
A B C D
B
Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as commonly as diarrhea.
11. The nurse is assessing an 8-month-old during a wellness checkup. Which of the following is a normal developmental task for an infant this age?
A.Sitting without support.
B.Saying two words.
C.Feeding himself with a spoon.
D.Playing patty-cake.
A B C D
A
According to the Denver II Developmental Screening test, most infants should be able to sit unsupported by age 7 months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10- month-old should be able to play patty-cake.
Directions. The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number. While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped. " How should the nurse respond?
12. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.
对 错
A
13. Report suspicions of abuse to the local authorities.
对 错
B
14. Assist the client in developing a safety plan for times of increased violence.
对 错
A
15. Call the client's husband to discuss the situation.
对 错
B
16. Tell the client that she needs to leave the abusive situation as soon as possible.
对 错
B
17. Provide the client with telephone numbers of local shelters and safe houses.
对 错
A
The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected to be victims of abuse should be counseled on a safety plan, which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse should not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Nurses do, however, have a duty to report cases of actual or suspected abuse in children or elderly clients. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a non-threatening manner that promotes trust, rather than ordering her to break off her relationship.
18. A 10-year-old diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which of the following is a part of the child's care?
A.Taking vital signs every 4 hours and obtaining daily weight.
B.Obtaining a blood sample for electrolyte analysis every morning.
C.Checking every urine specimen for protein and specific gravity.
D.Ensuring that the child has accurate intake and output and eats a high-protein diet.
A B C D
A
Because major complications--such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation--can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. These are less important nursing measures in this situation.
19. A client with myocardial infarction and cardiogenic shock is placed in an intra-aortic balloon pump (IABP). If the device is functioning properly, the balloon inflates when the
A.triseupid valve is closed.
B.pulmonic valve is open.
C.aortic valve is closed.
D.mitral valve is closed.
A B C D
C
An IABP inflates during diastole when the tricuspid and mitral valves are open and the aortic and pulmonic valves are closed.
20. The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can
A.prepare the child by positive self-talk.
B.establish a time limit to get ready for the procedure.
C.hold and rock him and give him a security object.
D.count and sing with the child.
A B C D
C
The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; but the success of these tactics depends on the child.
21. Lochia normally progresses in which pattern?
A.Rubra, serosa, alba.
B.Serosa, rubra, alba.
C.Serosa, alba, rubra.
D.Rubra, alba, serosa.
A B C D
A
As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.
22. A client is experiencing an early postpartum hemorrhage. Which action is inappropriate?
A.Inserting an indwelIing urinary catheter.
B.Fundal massage.
C.Administration of oxytoxics.
D.Pad count.
A B C D
D
By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytoxics may be ordered to promote sustained uterine contraction.
23. A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should do which of the following?
A.Give the baby a pacifier to help soothe him.
B.Lie the baby in the prone position.
C.Place the infant's arms in soft elbow restraints.
D.Avoid touching the suture line, even to clean.
A B C D
C
Soft restraints from the upper arm to the wrist prevent the infant from touching his lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers, suction catheters, and small spoons shouldn't be placed in a baby's mouth after cleft palate repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can widen the scar.
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