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218 Cards in this Set

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1. The plan of care for a pregnant teen should include teaching regarding which of the following concerning dental care?

1. Use toothpaste with baking soda to decrease plaque buildup.
2. Avoid the use of local anesthetics during dental work.
3. Expect to lose at least one tooth because of calcium and phosphorus leaving the teeth to nourish the fetus.
4. Tell the dentist office staff that she is pregnant.
Answer: 4
Rationale: Baking soda may irritate the gums, which are more likely to bleed because of hormonal changes of pregnancy. Local anesthetics for minor dental work should not have adverse effects on the fetus. Option 3 is inaccurate information. The dental staff needs to know about the pregnancy so that care is taken during examinations and x-ray studies are avoided.
2. A pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client’s partner and tells the partner to:

1. Dorsiflex the client’s foot while flexing the knee.
2. Dorsiflex the client’s foot while extending the knee.
3. Plantarflex the client’s foot while flexing the knee.
4. Plantarflex the client’s foot while extending the knee.
Answer: 2
Rationale: Leg cramps often occur when the pregnant woman stretches her leg and plantarflexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping.
3. A client being prepared for a cesarean delivery is brought to the delivery room. To maintain optimal perfusion of oxygenated blood to the fetus, the nurse places the client in a:

1. Trendelenburg position
2. Semi-Fowler’s position
3. Supine position with a wedge under the right hip
4. Prone position
Answer: 3
Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, therefore decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler’s or prone position is not practical for this type of abdominal surgery.
4. A nurse is asked to assist the primary health care provider in performing Leopold maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
1. Locate fetal heart tones
2. Have the client drink 8 ounces of water
3. Warm the sonogram gel
4. Have the client empty her bladder
Answer: 4
Rationale: An empty bladder contributes to a woman’s comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed prior to a sonogram (ultrasound). Often, Leopold’s maneuvers are performed to aid the examiner in locating the fetal heart tones.
5. A woman in active labor has contractions every 2 to 3 minutes lasting 45 seconds. The fetal heart rate between contraction is 100 beats per minute. Based on these findings, the priority nursing intervention is to:

1. Notify the registered nurse (RN) immediately.
2. Encourage relaxation and breathing techniques between contractions.
3. Continue monitoring labor and fetal heart rate.
4. Monitor maternal vital signs.
Answer: 1
Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse would immediately contact the RN, who in turn would contact the physician. Options 2, 3, and 4 will delay necessary and immediate interventions.
6. A nurse is assigned to assist in caring for a client being admitted to the birthing center in early labor. On admission, the nurse would initially:

1. Check pelvic adequacy.
2. Administer an analgesic.
3. Estimate fetal size.
4. Determine maternal and fetal vital signs.
Answer: 4
Rationale: To evaluate a woman's physical well-being, the temperature, pulse, respirations, and blood pressure, as well as the fetal heartbeat, are checked. Option 2 is incorrect because it would be too premature for an analgesic. Medication given too early tends to slow or stop labor contractions. Options 1 and 3 are incorrect. These assessments should be done by the physician or a nurse midwife during prenatal visits.
7. Leopold’s maneuvers will be performed on a pregnant client. The client asks the nurse about this procedure. The nurse responds knowing that this procedure:

1. Determines the “lie” and “attitude” of the fetus
2. Is a systemic method for palpating the fetus through the maternal back
3. Is a systemic method for palpating the fetus through the maternal abdominal wall
4. Measures the height of the maternal fundus
Answer: 3
Rationale: Leopold’s maneuvers comprise a systemic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 4 are incorrect.
8. After delivery, a nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted:

1. At the level of the umbilicus
2. Above the level of the umbilicus
3. One fingerbreadth above the symphysis pubis
4. To the right of the abdomen
Answer: 1
Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder.
9. A nurse is caring for a postpartum client. Four hours postpartum, the client’s temperature is 102˚ F (38.9˚ C). The appropriate nursing action would be to:

1. Continue to monitor the temperature.
2. Notify the registered nurse, who will then contact the physician.
3. Apply cool packs to the abdomen.
4. Remove the blanket from the client’s bed.
Answer: 2
Rationale: In the postpartum period, the mother’s temperature may be elevated during the first 24 hours as a result of dehydration. However, if the temperature is more than 2˚ F above normal, this may indicate infection, and the physician will need to be notified.
10. A nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which of the following would best indicate a hematoma?
1. Complaints of a tearing sensation
2. Complaints of lower abdominal discomfort
3. Changes in vital signs
4. Signs of heavy bruising
Answer: 3
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 1 and 2 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.
11. A nurse is assisting in planning care for the postpartum woman who has small vulvar hematomas. To assist in reducing the swelling, the nurse should:

1. Check the vital signs every 4 hours.
2. Prepare a heat pack for application to the area.
3. Measure the fundal height every 4 hours.
4. Prepare an ice pack for application to the area.
Answer: 4
Rationale: Application of ice will reduce swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 will not reduce the swelling.
11. A client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client’s systolic blood pressure (BP) drops 20 points, the diastolic BP drops 10 points, and the pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse would plan to:

1. Monitor fundal height.
2. Apply perineal pressure.
3. Prepare the client for surgery.
4. Reassure the client.
Answer: 3
Rationale: The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Options 1, 2, and 4 would not assist in controlling the bleeding in this emergency situation.
12. A male neonate has just been circumcised. The nurse would expect the surgical site to appear:

1. Pink, without drainage
2. Reddened, with a small amount of bloody drainage
3. Reddened, with a large amount of bloody drainage that requires a dressing change every 30
minutes
4. Reddened, with a small amount of yellow exudate on the glans
Answer: 2
Rationale: The glans penis is normally dark red. Following circumcision, a small amount of bloody drainage is expected. During the normal healing process, the glans become covered with a yellow exudate. If excessive bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a sterile gauze pad. If bleeding is not controlled, the physician is notified because a blood vessel may need to be ligated.
13. A pregnant human immunodeficiency virus (HIV)–positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. The nurse determines that additional guidance is needed if the woman states that she will:

1. Be sure to wash her hands before and following bathroom use.
2. Be sure to wash her hands before feeding the newborn.
3. Breast-feed, especially for the first 6 weeks postpartum.
4. Administer the prescribed antiviral medication to the newborn for the first 6 weeks after
delivery.
Answer: 3
Rationale: The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum periods. HIV transmission can occur during breast-feeding; thus, HIV-positive clients are encouraged to bottle feed their neonates. Antiviral medications will be prescribed for the neonate for the first 6 weeks of life. The principles related to hand washing need to be taught to the mother.
14. A pregnant woman has a positive history of genital herpes, but has not had lesions during this pregnancy. The nurse plans to provide which of the following information to the client?

1. “You will be isolated from your newborn following delivery.”
2. “You will be evaluated at the time of delivery for herpetic genital tract lesions, if present, a cesarean delivery will be needed.”
3. “There is little risk to your neonate during this pregnancy, birth, and following delivery.”
4. “Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at birth.”
Answer: 2
Rationale: If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery.
15. A nurse administers erythromycin ointment (0.5%) to the newborn’s eyes, and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to:

1. Minimize the spread of microorganisms to the neonate from invasive procedures during labor.
2. Protect the neonate's eyes from possible infections acquired while hospitalized.
3. Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.
4. Prevent cataracts in the neonate born to a woman who is susceptible to rubella.
Answer: 3
Rationale: Erythromycin ophthalmic ointment (Ilotycin ophthalmic) 0.5% is used as a prophylactic treatment of ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 4 are not the purposes of administering this medication to the newborn infant
16. A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse makes which statement to the client?

1. “Your newborn needs vitamin K to develop immunity.”
2. “The vitamin K will protect your newborn from becoming jaundiced.”
3. “Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding.”
4. “Newborns have sterile bowels and the vitamin K will colonize the bowel with the necessary bacteria.”
Answer: 3
Rationale: Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. It promotes liver formation of the clotting factors II, VII, IX, and X. Newborn infants are vitamin K–deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn infant’s bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
17. A nurse is assigned to assist in caring for a neonate born to a mother with acquired immunodeficiency syndrome (AIDS). The nurse understands that which of the following should be included in the plan of care?

1. Instruct breast-feeding mothers regarding treatment of their nipples with an antifungal cream.
2. Monitor the neonate’s vital signs routinely.
3. Maintain standard precautions at all times while caring for the neonate.
4. Initiate referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate.
Answer: 3
Rationale: The neonate born of a mother with AIDS must be cared for with strict attention to universal precautions. This prevents the transmission of the infection from the neonate, if infected, to others, and prevents the transmission of other infectious agents to the possibly immunocompromised neonate. A mother with AIDS should not breast-feed. Options 2 and 4 are not specifically associated with the care of a potentially AIDS infected neonate.
18. A nurse in the newborn nursery receives a telephone call to prepare for the admission of a 43-week-gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse’s highest priority should be to:

1. Connect the resuscitation bag to the oxygen outlet.
2. Turn on the apnea and cardiorespiratory monitor.
3. Set up the intravenous line with 5% dextrose in water.
4. Set up the radiant warmer control temperature at 36.5 C (97.6 degrees F).
Answer: 1
Rationale: The highest priority on admission to the nursery for a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of somewhat lower priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an IV with 5% dextrose in water would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.
19. A nurse is caring for a post-term neonate immediately after admission to the nursery. The priority nursing action would be to monitor:

1. Urinary output
2. Total bilirubin levels
3. Blood glucose levels
4. Hemoglobin and hematocrit
Answer: 3
Rationale: The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action. Hemoglobin and hematocrit levels are monitored because the post-term neonate exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
20. A nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection?

1. A darkened drying stump
2. A moist cord with discharge
3. A purple stump that shows pinkness around the base
4. A purple stump that shows some moistness at the base
Answer: 2
Rationale: Signs of infection at the umbilical cord are moistness, oozing, discharge, and a reddened base. If signs of infection occur, the health care provider is notified. Antibiotic treatment may be necessary.
21. A nurse is caring for a 5-year-old child who has been placed in traction following a fracture to the femur. Which of the following is the most appropriate activity for this child?

1. Large picture books
2. A radio
3. A sports video
4. Finger paints
Answer: 4
Rationale: In the preschooler, play is simple and imaginative, and includes activities such as dressing up, finger paints, clay, pasting, and simple board and card games. Large picture books are most appropriate for the infant. A radio and sports video are most appropriate for the adolescent.
22. The mother of a 16-year-old child tells the nurse that she is concerned because the child sleeps until noon every weekend, and whenever the child has a day off from school. The appropriate nursing response is which of the following?

1. “The child should have a blood test to check for anemia.”
2. “Adolescents love to sleep late in the morning.”
3. “The child shouldn’t be staying up so late at night.”
4. “If the child eats properly, that shouldn’t be happening.”
Answer: 2
Rationale: Sleep patterns in the adolescent vary according to individual need. Adolescents love to sleep late in the morning but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school. Options 1, 3, and 4 are incorrect.
23. A 16-year-old child is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which of the following interventions is most appropriate to facilitate normal growth and development?

1. Allow the family to bring in favorite computer games.
2. Encourage the parents to room in with the child.
3. Encourage the child to rest and read.
4. Allow the child to participate in activities with other individuals in the same age group when the condition permits.
Answer: 4
Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the peer group will support their ill friend. Options 1, 2, and 3 isolate the child from the peer group.
24. A 2-year-old child is treated in the emergency room for a burn to the chest and abdomen. The child sustained the burn from grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reinforces safety principles with the parents before discharge. Which statement, if made by the parents, indicates an understanding of the measures to provide safety in the home?

1. “I guess my children need to understand what the word ‘hot’ means.”
2. “We will install a safety gate as soon as we get home so the children can’t get into the kitchen.”
3. “We will be sure that the children stay in their rooms when we work in the kitchen.”
4. “We will be sure not to leave hot liquids unattended.”
Answer: 4
Rationale: Toddlers, with their increased mobility and developing of motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove; pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. Options 1, 2, and 3 do not reflect an adequate understanding of the principles of safety.
25. A nurse is reinforcing instructions with an adolescent with a history of seizures, who is on an anticonvulsant medication. Which of the following statements, if made by the adolescent, indicates an understanding of the instructions?

1. “I will never be able to drive a car.”
2. “My anticonvulsant medication will clear up my skin.”
3. “I can’t drink alcohol while I am taking my medication.”
4. “If I forget my morning medication, I can take just two pills at bedtime.”
Answer: 3
Rationale: Alcohol will lower the seizure threshold and should be avoided. Adolescents can obtain a driver’s license, in most states, when they are seizure-free for 1 year. Anticonvulsants cause acne and oily skin; therefore, a dermatologist may need to be consulted. If an anticonvulsant medication is missed, the physician should be notified.
26. A nurse is collecting data on a child admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by:

1. Testing the child’s urine for specific gravity
2. Obtaining a family history of psychiatric illness
3. Obtaining a history regarding factors that might precipitate seizure activity
4. Asking the child what happens during a seizure
Answer: 3
Rationale: Fever and infections increase the body’s metabolic rate. This can cause seizure activity in children under the age of 5 years old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injury, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.
27. A nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is:

1. A chronic disability characterized by a difficulty in controlling the muscles
2. An infectious disease of the central nervous system
3. An inflammation of the brain as a result of a viral illness
4. A congenital condition that results in moderate to severe retardation
Answer: 1
Rationale: Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
28. A nurse is caring for a child with cerebral palsy. The primary goal to be included in the plan of care is to:

1. Eliminate the cause of the disease.
2. Prevent the occurrence of emotional disturbances.
3. Maximize the child’s assets and minimize the limitations caused by the disease.
4. Improve muscle control and coordination.
Answer: 3
Rationale: The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child’s abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances. if possible, but not to prevent them, because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child’s assets and minimize the limitations caused by the disease.
29. A nurse is assigned to care for an 8-year-old child with a basilar skull fracture. Which of the following physician orders written in the child’s medical record would the nurse question?

1. Restrict fluid intake.
2. Keep an intravenous (IV) line patent.
3. Insert an indwelling urinary catheter.
4. Suction PRN.
Answer: 4
Rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the nature of the injury, the suction catheter may be introduced into the brain. The child may need a urinary catheter for accurate monitoring of I&O. Fluids are restricted to prevent fluid overload. An IV line is maintained to administer fluids or medications if necessary.
30. A lumbar puncture is performed on a child suspected of having bacterial meningitis and cerebrospinal fluid (CSF) is obtained for analysis. The nurse understands that which of the following results would verify the diagnosis?

1. Cloudy CSF with low protein and low glucose levels
2. Cloudy CSF with high protein and low glucose levels
3. Clear CSF with high protein and low glucose levels
4. Decreased pressure and cloudy CSF with high protein level
Answer: 2
Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy CSF, high protein level, and low glucose level.
31. Following tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to:

1. Administer the prescribed antiemetic.
2. Turn the child to the side.
3. Notify the registered nurse (RN.
4. Maintain an NPO status.
Answer: 2
Rationale: Following tonsillectomy, if bleeding occurs, the child is turned to the side and the RN is notified, who will then contact the physician. An NPO status would be maintained and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.
32. Following tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child?

1. Cool cherry Kool-Aid
2. Vanilla pudding
3. Cold ginger ale
4. Jell-O
Answer: 4
Rationale: Following tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Red liquids need to be avoided because they give the appearance of blood if the child vomits. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding.
33. A nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse makes which response to the mother?

1. “In 1 week.”
2. “In 3 weeks.”
3. “Two days following surgery.”
4. “When the physician says it’s OK.”
Answer: 2
Rationale: Rough, scratchy foods or spicy foods are to be avoided for 3 weeks. Citrus juices, which irritate the throat, need to be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. The mother is instructed to add full liquids on the second day and soft foods as the child tolerates them.
34. A nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates a need for further instruction?

1. “I will place a steam vaporizer in my child’s room.”
2. “I will place my child in a closed bathroom and allow my child to inhale steam from the running water.”
3. “I will place a cool mist humidifier in my child’s room.”
4. “I will take my child out into the cool, humid night air.”
Answer: 1
Rationale: Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective in reducing mucosal edema. Cool mist humidifiers are recommended over steam vaporizers, which present a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.
35. A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. On admission, the nurse prepares to ask the mother which question to elicit information specific to the development of RF?

1. “Did the child have a sore throat or an unexplained fever within the last 2 months?”
2. “Has the child had any nausea or vomiting?”
3. “Has the child complained of headaches?”
4. “Has the child complained of back pain?”
Answer: 1
Rationale: RF characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 2, 3, and 4 are unrelated RF.
36. Acetylsalicylic acid (Aspirin) is prescribed for the child with rheumatic fever. The nurse would question this order if the child had documented evidence of which of the following?

1. A viral infection
2. Joint pain
3. Facial edema
4. Arthralgia
Answer: 1
Rationale: Anti-inflammatory agents, including aspirin, may be prescribed for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections such as the flu. Options 2 and 4 are clinical manifestations of RF. Facial edema may be associated with the development of a cardiac complication.
37. A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results, knowing that which laboratory study would assist in confirming the diagnosis of RF?

1. White blood cell count
2. Red blood cell count
3. Immunoglobulin
4. Antistreptolysin O titer
Answer: 4
Rationale: A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. Additionally, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 3 will not assist in confirming the diagnosis of RF.
38. A nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. The nurse tells the mother that:

1. It is an acquired cell-mediated immunodeficiency disorder.
2. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
3. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.
4. Is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.
Answer: 4
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 2 describes rheumatic fever. Option 3 describes systemic lupus erythematosus.
39. A nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child’s record for the laboratory results of the urine test and would most likely expect to note which of the following?

1. Hematuria
2. Proteinuria
3. Bacteriuria
4. Glucosuria
Answer: 3
Rationale: Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 2, and 4 are not characteristically noted in this condition.
40. A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. A nurse is asked to assist in preparing a plan of care for this child and makes suggestions, knowing that this surgery is taking place at a time when:

1. Fears of separation and mutilation are great.
2. Sibling rivalry will cause regression to occur.
3. Embarrassment of voiding irregularities is common.
4. Concern over size and function of the penis is present.
Answer: 1
Rationale: At the age of 1 year, a child’s fears of separation and mutilation are great, because the child is facing the developmental task of trusting others. As the child gets older, fears about virility and reproductive ability may surface. The question does not provide enough data to determine that siblings exist. Options 3 and 4 may be issues if the child were older.
41. An 18-month-old child is being discharged following surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?

1. Encourage toilet training to ensure that flow of urine is normal
2. Restrict fluid intake to reduce urinary output for the first few days
3. Avoid tub baths until the stent has been removed
4. Leave the diapers off to allow the site to heal
Answer: 3
Rationale: Following hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent contamination of the surgical site. Fluids should be encouraged to maintain hydration. Toilet training should not be an issue during this stressful period.
42. A nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

1. “Circumcision has been delayed to save tissue for surgical repair.”
2. “Catheterization will be necessary if my infant does not void.”
3. “Caution should be used when straddling my infant on a hip.”
4. “Vital signs should be taken daily to check for bladder infection.”
Answer: 1
Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 2, 3, and 4 are unrelated to this disorder.
43. Corticream is prescribed by the physician for a child with atopic dermatitis (eczema) and the nurse instructs the mother how to apply the cream. The nurse tells the mother to:

1. Avoid cleansing the area before applying the cream
2. Apply the cream over the entire body
3. Apply a thin layer of cream and rub into the area thoroughly
4. Apply a thick layer of cream in affected areas only
Answer: 3
Rationale: Corticream is a topical corticosteroid. It should be applied sparingly and rubbed into the area thoroughly. The affected area should be cleansed gently before application. It should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.
44. A nurse assists in providing an instructional session to parents regarding impetigo. Which statement by a parent indicates a need for further instruction?

1. “It is most common in humid weather.”
2. “It begins in an area of broken skin, such as an insect bite.”
3. “It is extremely contagious.”
4. “Lesions are most often located on the arms and chest.”
Answer: 4
Rationale: Impetigo is most common during hot, humid summer months. It begins in an area of broken skin, such as an insect bite. It may be caused by Staphylococcus aureus, group A beta-hemolytic streptococci, or a combination of these bacteria. It is extremely contagious. Lesions are usually located around the mouth and nose, but may be present on the extremities.
A nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment and the mother asks the nurse when the child can return to school. The nurse tells the mother that the child can return to school:

1. Twenty-four hours after using antibiotic ointment
2. Forty-eight hours after using antibiotic ointment
3. One week after using antibiotic ointment
4. Ten days after using antibiotic ointment
Answer: 2
Rationale: The child should not attend school for 24 to 48 hours after the initiation of systemic antibiotics or 48 hours after using antibiotic ointment. The school should be notified of the diagnosis. Therefore, options 1, 3, and 4 are incorrect.
A 6-year-old child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. The nurse makes which appropriate response to the grandmother?

1. “I have a vase in the utility room and I will get it for you.”
2. “The flowers from your garden are beautiful, but should not be placed in the child’s room at this time.”
3. “I will get the vase and wash it well before you put the flowers in it.”
4. “When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible.”
Answer: 2
Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas organisms, to which these children are very susceptible. Additionally, fruits and vegetables that are not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises.
A nurse is reviewing the health record of a 10-year-old child suspected of having Hodgkin’s disease. Which of the following would the nurse expect to note documented in the record that is most characteristic of this disease?

1. Painful, enlarged inguinal lymph nodes
2. Fever and malaise
3. Painless, firm, and movable adenopathy in the cervical area
4. Anorexia and weight loss
Answer: 3
Rationale: Clinical manifestations specifically associated with Hodgkin’s disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin’s disease, these manifestations are seen in many disorders.
A 4-year-old child is hospitalized with a suspected diagnosis of Wilms’ tumor. The nurse assists in developing a plan of care and suggests avoiding which of the following?

1. Palpating the abdomen for a mass
2. Checking the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension
Answer: 1
Rationale: A Wilms’ tumor is a tumor of the kidney. If Wilms’ tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and cause the spread of the cancerous cells. Fever, hematuria, and hypertension are clinical manifestations associated with Wilms’ tumor.
The mother brings her 6-year-old child to the clinic because the child has developed a rash on the trunk and on the scalp. The mother reports that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox, and the mother inquires about the communicable period associated with chickenpox. The nurse plans to base the response on which of the following?

1. The communicable period is unknown.
2. The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.
3. The communicable period is 10 days before the onset of symptoms to 15 days after the rash appears.
4. The communicable period ranges from 2 weeks or less up to several months.
Answer: 2
Rationale: The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions. In roseola, the communicable period is unknown. Option 3 describes rubella. Option 4 describes diphtheria.
The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further instructions?

1. “We need to maintain respiratory precautions and a quiet environment for at least 2 weeks.”
2. “Coughing spells may be triggered by dust or smoke.”
3. “We need to encourage an adequate fluid intake.”
4. “Good hand washing techniques must be instituted to prevent spreading the disease to others.”
Answer: 1
Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 2, 3, and 4 are components of home care instructions.
A 6-month-old infant receives a DTaP (diphtheria, tetanus, and acellular pertussis) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. The nurse tells the mother to:

1. Leave the injection site alone because this always occurs
2. Bring the infant back to the clinic
3. Apply an ice pack to the injection site
4. Monitor the infant for a fever
Answer: 3
Rationale: Occasionally, tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with ice packs for the first 24 hours, followed by warm compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 4 may be an appropriate intervention but is not specific to the issue of the question.
A nursing student is assigned to help administer immunizations to children in a clinic. The nursing instructor asks the student about the contraindications to receiving an immunization. The student responds correctly by telling the instructor that a contraindication for receiving an immunization is if a child has:

1. A cold
2. Otitis media
3. Mild diarrhea
4. A severe febrile illness
Answer: 4
Rationale: A severe febrile illness is a reason to delay immunization, but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea are not contraindications to immunization.
A nurse reinforces instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which statement by a client indicates a need for further instructions?

1. “I need to use sunscreen when participating in outdoor activities.”
2. “I need to examine my body monthly for any lesions that may be suspicious.”
3. “I need to wear a hat, opaque clothing, and sunglasses when in the sun.”
4. “I need to avoid sun exposure before 11 am and after 3 pm.”
Answer: 4
Rationale: The client should be instructed to avoid sun exposure between the hours of 11 am and 3 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions.
A nurse reviews a client’s chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during data collection

1. Swelling of the skin near the parotid gland
2. Red, shiny skin around the nail bed
3. White, silvery patches on the elbows
4. White, taut skin in the popliteal area
Answer: 2
Rationale: Paronychia or infection around the nail is characterized by red, shiny skin, often associated with painful swelling. These infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. Often, these become secondarily infected with bacteria or fungus, which later involves the nail. Options 1, 3, and 4 are incorrect descriptions of this disorder.
A nurse reinforces instructions to a client diagnosed with impetigo. Which statement by the client indicates a need for further instructions?

1. “I need to continue with the antibiotics as prescribed.”
2. “I need to separate my dishes and wash them separately from the dishes of other household members.”
3. “I can wash my laundry with other household members’ items.”
4. “I need to wash my hands thoroughly and frequently throughout the day.”
Answer: 3
Rationale: Thorough hand washing, separating laundry, and separate washing of the client’s dishes is required because this infection is contagious as long as skin lesions are present. Antibiotics are administered and should be continued, as prescribed.
A client arrives at the emergency room and has experienced frostbite to the right hand. Which of the following would the nurse note on data collection of the client’s hand?

1. A fiery red skin with edema in the nail beds
2. A pink edematous hand
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch
Answer: 4
Rationale: Findings in frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Gangrene can develop in 9 to 15 days.
A nurse is assigned to assist in caring for a client with frostbite of the toes. Which of the following would the nurse anticipate to be prescribed for this condition?

1. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs
2. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes
3. Rapid and continuous rewarming of the toes when flushing occurs
4. Rapid and continuous rewarming of the toes in cold water for 45 minutes
Answer: 1
Rationale: Frost bite is ideally treated with rapid and continuous rewarming of the tissue in a water bath for 15 to 20 minutes, or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite.
An evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note when checking the client’s sacral area?

1. Skin is intact
2. Partial-thickness skin loss of the epidermis
3. A deep crater-like appearance
4. The presence of sinus tracts
Answer: 2
Rationale: In a stage II pressure ulcer, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and may look like an abrasion, blister, or shallow crater. The skin is intact in stage I. A deep, crater-like appearance occurs in stage III, and sinus tracts develop in stage IV.
A 32-year-old female client has a history of fibrocystic disorder of the breasts. The nurse gathering data from the client asks whether the breast lumps are more noticeable:

1. In the spring months
2. In the autumn
3. After menses
4. Before menses
Answer: 4
Rationale: The nurse asks the client with fibrocystic breast disorder about worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Options 1, 2, and 3 do not provide significant data regarding this disorder.
A client has undergone mastectomy. The nurse interprets that the client is making the best adjustment to the loss of the breast if which of the following behaviors is observed?

1. Participating in the care of the surgical drain
2. Reading postoperative care booklet
3. Refusing to look at wound
4. Asking for pain medication when needed
Answer: 1
Rationale: The client demonstrates the best adjustment by participating in his or her own care. This would include care of surgical drains that would be in place for a short time after discharge. Asking for pain medication is also an action-oriented option, but it does not relate to acceptance of the loss of the breast. Reading the postoperative care booklet is useful, but is not the best of the options presented. Refusing to look at the wound indicates a lack of adjustment to the loss.
A client is preparing for discharge after undergoing a radical vulvectomy. The nurse plans to tell the client that which activity is acceptable after discharge because it will not precipitate complications?

1. Sexual activity
2. Walking
3. Sitting for lengthy periods
4. Driving a car
Answer: 2
Rationale: The client should resume activity slowly, and walking is a beneficial activity. The client should be instructed to rest when fatigue occurs. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged standing or sitting. Sexual activity is prohibited for 4 to 6 weeks after surgery.
A client has undergone vaginal hysterectomy. The nurse avoids which of the following in the care of this client?

1. Removal of antiembolism stockings twice daily
2. Assisting with range-of-motion leg exercises
3. Elevating the knee on the Gatch bed
4. Checking placement of pneumatic compression boots
Answer: 3
Rationale: The client is at risk of deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Range-of-motion exercises, antiembolism stockings, and pneumatic compression boots are all helpful. The nurse should avoid using the knee Gatch in the bed, which inhibits venous return, thus placing the client more at risk for deep vein thrombosis or thrombophlebitis.
A client suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse plans to tell the client that preparation for the ultrasound includes which of the following?

1. NPO prior to the procedure
2. A light breakfast only
3. Drinking six to eight glasses of water without voiding before the test
4. Wearing comfortable clothing and shoes for the procedure
Answer: 3
Rationale: A pelvic ultrasound requires the ingestion of large volumes of water just prior to the procedure. A full bladder is necessary so that this organ will be visualized as such and not mistaken as a possible pelvic growth. An abdominal ultrasound may require that the client abstain from food or fluid for several hours before the procedure. Option 4 is unrelated to this specific procedure.
A client is diagnosed as having a bowel tumor and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy?

1. Magnetic resonance imaging (MRI)
2. Computerized tomography (CT) scan
3. Abdominal ultrasound
4. Biopsy of the tumor
Answer: 4
Rationale: A biopsy is done to determine whether a tumor is malignant or benign. An MRI, CT scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy.
A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which characteristic of the disorder?

1. Malignant exacerbation in the number of leukocytes
2. Altered red blood cell production
3. Altered production of lymph nodes
4. Malignant proliferation of plasma cells and tumors within the bone
Answer: 4
Rationale: Multiple myeloma is a neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Option 1 describes the leukemic process. Options 2 and 3 are not characteristics of multiple myeloma.
A nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which of the following would the nurse expect to specifically note with this diagnosis?

1. Decreased number of plasma cells in the bone marrow
2. Increased white blood cells
3. Increased calcium level
4. Decreased blood urea nitrogen (BUN) level
Answer: 3
Rationale: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia as a result of the release of calcium from the deteriorating bone tissue, and an elevated BUN level. An increased white blood cell count may or may not be present and is not specifically related to multiple myeloma.
A nurse is assisting in developing a plan of care for the client with multiple myeloma. A priority nursing intervention for a client with multiple myeloma is which of the following?

1. Coughing and deep breathing
2. Encouraging fluids
3. Monitoring the red blood cell count
4. Providing frequent oral care
Answer: 2
Rationale: Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids in adequate amounts to maintain an output of 1.5 to 2.0 L/day. Clients require about 3 L of fluid per day. The fluid is needed not only to dilute the calcium, but also to prevent protein from precipitating in the renal tubules. Options 1, 3, and 4 may be a component of the plan of care, but are not the priority in this client.
A nursing instructor asks a nursing student about the characteristics of Hodgkin's disease. The instructor determines that the student needs to read about the characteristics of this disease if the student states that which of the following is an associated characteristic?

1. Presence of Reed-Sternberg cells
2. Involvement of lymph nodes, spleen, and liver
3. Occurs most often in older adults
4. Prognosis depends on the stage of the disease
Answer: 3
Rationale: Hodgkin's disease is a disorder of young adults and primarily occurs between the ages of 20 to 40. Options 1, 2, and 4 are characteristics of this disease.
A nurse is assisting in conducting a health promotion program regarding testicular cancer to community members. The nurse determines that further teaching is needed if a community member states that which of the following is a sign of testicular cancer?

1. Painless testicular swelling
2. Heavy sensation in the scrotum
3. Alopecia
4. Back pain
Answer: 3
Rationale: Alopecia is not a finding in testicular cancer. It may however occur as a result of radiation or chemotherapy. Options 1, 2, and 4 are findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes.
A nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurs with the chemotherapy?

1. Anemia
2. Decreased platelets
3. Decreased leukocyte count
4. Increased uric acid level
Answer: 4
Rationale: Hyperuricemia is especially common following treatment for leukemias and lymphomas, because the therapy results in massive cell destruction. Although options 1, 2, and 3 may also be noted, an increased uric acid level is specifically related to cell destruction.
A client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The nurse would immediately:

1. Call the physician.
2. Pick up the implant with gloved hands and flush down the toilet.
3. Reinsert the implant into the vagina immediately.
4. Pick up the implant with long-handled forceps and place into a lead container.
Answer: 4
Rationale: A lead container and long-handled forceps should be kept in the client’s room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it into the lead container. Options 1, 2, and 3 are inaccurate interventions.
A nurse is assisting in developing a plan of care for a client experiencing hematological toxicity as a result of chemotherapy. The nurse suggests including which of the following in the plan of care?

1. Restricting all visitors
2. Restricting fluid intake
3. Inserting an indwelling urinary catheter to prevent skin breakdown
4. Restricting fresh fruits and vegetables in the diet
Answer: 4
Rationale: In a client experiencing hematological toxicity, a low-bacteria diet is implemented. This includes avoiding fresh fruits and vegetables and thorough cooking of all foods. Not all visitors are restricted, but the client is protected from people with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.
A nurse is reviewing the laboratory results of a client receiving chemotherapy and notes that the platelet count is 10,000/mm3. Based on this laboratory value, the priority action is to monitor which of the following?

1. Level of consciousness
2. Temperature
3. Bowel sounds
4. Skin turgor
Answer: 1
Rationale: A high risk of hemorrhage exists when the platelet count is lower than 20,000/mm3. Fatal central nervous system (CNS) hemorrhage or massive gastrointestinal (GI) hemorrhage can occur when the platelet count is lower than 10,000/mm3. The client should be monitored for changes in level of consciousness, which may be an early indication of an intracranial hemorrhage. Option 2 is a priority when the WBC count is low and the client is at risk for an infection. Although options 3 and 4 are important, they are not the priority in this situation.
A nurse is caring for a postoperative client who had a pelvic exenteration. The physician has changed the client's diet from NPO to clear liquids. The nurse checks which of the following before administering the clear liquids?

1. Ability to ambulate
2. Specific gravity of the urine
3. Incision appearance
4. Bowel sounds
Answer: 4
Rationale: The client is kept NPO until peristalsis returns, usually in 4 to 6 days postoperatively. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. It is most important to monitor for bowel sounds prior to feeding the client. Options 1, 2, and 3 are unrelated to the issue of the question.
A client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which of the following findings would the nurse most likely expect to note documented in the client’s record?

1. Weakness
2. Fatigue
3. Weight gain
4. Enlarged lymph nodes
Answer: 4
Rationale: Hodgkin’s disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur, but is not significantly related to the disease.
A nurse is assisting in providing a teaching session to a community group regarding the risks and causes of bladder cancer. The nurse determines that additional teaching is needed if a member of the community group states that which of the following is associated with this type of cancer?

1. It most often occurs in women
2. It is generally seen in clients older than age 40
3. Environmental health hazards have been attributed as a cause
4. Using cigarettes, artificial sweeteners, and coffee drinking can increase the risk
Answer: 1
Rationale: The incidence of bladder cancer is three times greater in men than in women and affects the white population twice as often as the black population. Options 2, 3, and 4 are associated with the incidence of bladder cancer.
A nurse is reviewing the history of a client with bladder cancer. The nurse would expect to note which most common symptom of this type of cancer documented in the record?

1. Frequency of urination
2. Urgency on urination
3. Hematuria
4. Dysuria
Answer: 3
Rationale: The most common symptom in clients with cancer of the bladder is hematuria. The client may also experience irritative voiding symptoms such as frequency, urgency, and dysuria and these symptoms are often associated with cancer in situ.
A nurse is inspecting the stoma of a client following a ureterostomy. Which of the following would the nurse expect to note?

1. A pale stoma
2. A red and moist stoma
3. A dry stoma
4. A dark-colored stoma
Answer: 2
Rationale: After ureterostomy, the stoma should be red and moist. A pale stoma may indicate an inadequate amount of vascular supply. A dry stoma may indicate body fluid deficit. Any sign of darkness or duskiness in the stoma may mean loss of vascular supply and must be corrected immediately or necrosis can occur.
Cytarabine HCl (Cytosar) is prescribed for the client with acute lymphocytic leukemia. The nurse plans care knowing that this is a:

1. Cell cycle phase–nonspecific medication
2. Hormone medication
3. Cell cycle phase–specific medication
4. A medication that affects cells in any phase of the reproductive cell cycle
Answer: 3
Rationale: Cytarabine is an antimetabolite. Antimetabolites are classified as cell cycle phase–specific. Alkylating medications affect all phases of the cell reproductive cycle. Hormone medications suppress the immune system and block normal hormones in hormone-sensitive tumors
A nurse is assisting in preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which of the following instructions should be included in the plan?

1. Soak feet in hot water.
2. Apply a moisturizing lotion to dry feet. but not between the toes.
3. Always have a podiatrist cut your toenails; never cut them yourself.
4. Avoid using a mild soap on the feet.
Answer: 2
Rationale: The client should use a moisturizing lotion on his or her feet and avoid applying lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut toenails straight and even with the toe itself, and would consult a podiatrist if the toenails were thick, hard to cut, or if vision is poor. The client should be instructed to wash the feet daily using a mild soap.
A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates a need for further teaching?

1. “I need to drink diet soft drinks.”
2. “I'll eat a balanced meal plan.”
3. “I need to buy special dietetic foods.”
4. “I'll snack on fruit instead of cake.”
Answer: 3
Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.
A nurse reinforces instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse determines accurate understanding of measures to prevent diabetic ketoacidosis (DKA) when the client says:

1. “I will stop taking my insulin if I’m too sick to eat.”
2. “I will decrease my insulin dose during times of illness.”
3. “I will notify my physician if my blood glucose level is higher than 250 mg/dL.”
4. “I will adjust my insulin dose according to the level of glucose in my urine.”
Answer: 3
Rationale: During illness, the client should monitor the blood glucose level and should notify the physician if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the physician’s advice.
A sexually active 20-year-old client has developed viral hepatitis. Which of the following statements if made by the client would indicate a need for teaching?

1. “A condom should be used for sexual intercourse.”
2. “I can never drink alcohol again.”
3. “I won’t go back to work right away.”
4. “My close friends should get the vaccine.”
Answer: 2
Rationale: To prevent transmission of hepatitis, a condom is advised during sexual intercourse as well as vaccination of the partner or close friends. Alcohol should be avoided for 1 year, because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that the liver function has returned to normal. The client’s activity is increased gradually.
A client is admitted to the hospital with severe jaundice and is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room, but will not enter the hall. Which of the following problems most likely is the reason for the client’s reluctance to walk in the hall?

1. Fear of catching another disease
2. Not wanting to overexert and get overtired
3. Feeling self conscious about appearance
4. Unfamiliarity with the hospital
Answer: 3
Rationale: Clients with jaundice frequently have a body image disturbance because of a change in appearance. This can be manifested in negative verbal or nonverbal behavior. Options 1, 2, and 4 are unrelated to the data in the question.
A client with viral hepatitis has no appetite and food makes the client nauseated. Which nursing intervention would be most appropriate?

1. Explain that high-fat diets are usually better tolerated.
2. Encourage foods low in calories.
3. Explain that the majority of calories need to be consumed in the evening hours.
4. Monitor for fluid and electrolyte imbalances.
Answer: 4
Rationale: If nausea persists, the client will need to be assessed for fluid and electrolyte imbalances. It is important to explain to the client that the majority of calories should be eaten in the morning hours, because nausea most often occurs in the afternoon and evening. Clients should select a diet high in calories, because energy is required for healing. Changes in bilirubin interfere with fat absorption, so low fat-diets are better tolerated.
A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. The nurse would plan to include which most important risk factor for colorectal cancer in the material?

1. Age of 20 years
2. High-fiber, low-fat diet
3. Distant relative with colorectal cancer
4. Personal history of ulcerative colitis or gastrointestinal polyps
Answer: 4
Rationale: Common risk factors for colorectal cancer include age over 40 years, first-degree relative with colorectal cancer, high-fat, low-fiber diet, and history of bowel problems such as ulcerative colitis or familial polyposis.
A hospitalized client with gastroesophageal reflux disease (GERD) is complaining of chest discomfort that feels like heartburn following a meal. After administering a prescribed antacid, the nurse would encourage the client to lie in which position?

1. Supine, with the head of bed flat
2. On the stomach, with the head flat
3. On the left side, with the head of bed elevated 30 degrees
4. On the right side, with the head of bed elevated 30 degrees
Answer: 3
Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. These include lying flat either on the back or stomach after a meal, or lying on the right side. The left side-lying position with the head of the bed elevated is most likely to give relief to the client.
A nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances that will increase the lower esophageal sphincter (LES) pressure. The nurse tells the client to include which item in the diet?
1. Fatty foods
2. Nonfat milk
3. Tea
4. Coffee
Answer: 2
Rationale: Foods that increase the LES pressure will decrease reflux, and lessen the symptoms of GERD. The food item that will increase the LES pressure is nonfat milk. The other items listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods and alcohol.
A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which of the following items as part of the client’s care plan?

1. Checking for return of a gag reflex
2. Giving warm gargles for a sore throat
3. Monitoring the temperature
4. Monitoring for complaints of heartburn
Answer: 1
Rationale: The nurse places highest priority on managing the client’s airway. This includes assessing for return of the gag reflex. The client’s vital signs are also monitored and a sudden sharp increase in temperature could indicate perforation of the gastrointestinal tract. This would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; the client’s airway still takes priority however.
A nurse has taught a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs additional information if the client makes which statement?
1. “I know I must sign a consent form.”
2. “I’m glad I don’t have to lie still for this procedure.”
3. “I’m glad some medication will be given IV to relax me.”
4. “I hope the throat spray keeps me from gagging.”
Answer: 2
Rationale: The client needs to lie still for ERCP, which takes about an hour to perform. The client also needs to sign a consent form. IV sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.
A client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?

1. Remove all metal and jewelry before the test.
2. Eat a regular supper and breakfast.
3. Continue to take all oral medications as scheduled.
4. Monitor own bowel movement pattern for constipation.
Answer: 1
Rationale: A barium swallow is an x-ray that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test, so it won’t interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on the physician’s instructions. Most oral medications are also withheld before the test, depending on the physician’s instructions. It is important after the procedure to monitor for constipation following the procedure, which can occur as a result of the presence of barium in the GI tract.
A nurse is teaching the client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which of the following positions for the procedure?

1. Left Sims’ position
2. Right Sims’ position
3. Knee-chest position
4. Lithotomy position
Answer: 1
Rationale: The client is placed in the left Sims’ position for the procedure. This position takes the best advantage of the client’s anatomy for ease in introducing the colonoscope. The other options are incorrect.
A nurse has given postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that the client did not fully understand the directions if the client states that:

1. Intake should be light at first, then progress to regular intake.
2. It is normal to feel gassy or bloated after the procedure.
3. The abdominal muscles may be tender from stretching during the procedure.
4. It is all right to drive once the client has been home for an hour or so.
Answer: 4
Rationale: The client should not drive for several hours after this test because the client would have received sedative medications during the procedure. The client should resume intake slowly, and progress as tolerated. The client may experience gas or abdominal tenderness for a short while after the procedure, and this is normal.
A nurse instructs the ileostomy client to do which of the following as part of essential care of the stoma?

1. Cleanse the peristomal skin meticulously.
2. Eat high-fiber foods, such as nuts.
3. Massage the area below the stoma every morning and every evening.
4. Limit fluid intake to prevent diarrhea.
Answer: 1
Rationale: The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Fluid intake should be maintained by at least six to eight glasses of water per day to prevent dehydration.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse would teach the client to avoid which of the following, which is contraindicated with hiatal hernia?

1. Eating small, frequent, bland meals
2. Lying recumbent following meals
3. Raising the head of the bed on 6-inch blocks
4. Taking histamine receptor antagonist medication, as prescribed
Answer: 2
Rationale: Hiatal hernia is due to a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; by histamine antagonists and antacids; and by elevation of the thorax following meals and during sleep.
A nurse is monitoring for stoma prolapse in a client with a colostomy. The nurse would observe which of the following appearances in the stoma if prolapse occurred?

1. Sunken and hidden
2. Dark and bluish in color
3. Narrowed and flattened
4. Protruding and swollen
Answer: 4
Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.
A client with a new colostomy is concerned about odor from stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?

1. Yogurt
2. Broccoli
3. Cucumbers
4. Eggs
Answer: 1
Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor, but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods.
A nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client did not fully understand the instructions if the client states that he or she eats which of the following foods to make the stool less watery?

1. Pasta
2. Boiled rice
3. Bran
4. Low-fat cheese
Answer: 3
Rationale: Foods that help to thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber, and thus will increase the output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid by nature. Addition or elimination of various foods can help thicken or loosen this liquid drainage.
A nurse is assigned to care for a client following a left pneumonectomy. The nurse would avoid positioning the client:

1. On the side
2. In a semi-Fowler’s
3. In a low-Fowler’s
4. With the head of the bed elevated 40 degrees
Answer: 1
Rationale: Complete lateral positioning should be avoided following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, extreme turning may cause mediastinal shift and compression of the remaining lung.
A female client is scheduled to have a chest x-ray. Which question is most importance to ask the client during data collection?

1. “Is there any possibility that you could be pregnant?”
2. “Are you wearing any metal chains or jewelry?”
3. “Can you hold your breath easily?”
4. “Are you able to hold your arms above your head?”
Answer: 1
Rationale: The most important question to ask is about the client’s pregnancy status, because pregnant women should not be exposed to radiation. Clients are also asked to remove any chains or metal objects that could interfere with obtaining an adequate film. A chest x-ray is most often done at full inspiration, which gives optimal lung expansion. If a lateral view of the chest is ordered, the client is asked to raise the arms above the head. Most films are taken in the posterior-anterior (PA) view.
A nurse is caring for a client following pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by noting the presence of:

1. Hematoma in the left groin
2. Discomfort in the left groin
3. Respiratory distress
4. Hypothermia
Answer: 3
Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Discomfort is expected. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction.
A nurse is teaching the client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to:

1. Inhale through the nose.
2. Inhale quickly.
3. Take two inhalations during one breath.
4. Hold the breath after inhalation.
Answer: 4
Rationale: Instructions for using a metered-dose inhaler include shake the canister, hold it right-side up, inhale slowly and evenly through the mouth, deliver one spray per breath, and hold the breath after inhalation.
A nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?

1. Blood-streaked sputum
2. Cough
3. Wheezing
4. Pleuritic pain
Answer: 2
Rationale: Cough is the most frequent early symptom of lung cancer, which begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Wheezing and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature.
A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

1. Lowering the head of the bed to a flat position
2. Applying manual pressure over the site
3. Monitoring the client’s airway
4. Calling the physician immediately
Answer: 1
Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site, and calls the physician immediately.
A nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse determines that the client understands the information if the client verbalizes to report which early sign of exacerbation?

1. Fever
2. Weight loss
3. Fatigue
4. Shortness of breath
Answer: 4
Rationale: Dry cough and dyspnea are typical signs and symptoms of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms include weakness and fatigue, malaise, fever, and weight loss.
A nurse working on a respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would identify which of the following clients as being at the least risk for developing infection with tuberculosis?

1. A woman newly immigrated from Korea
2. An uninsured man who is homeless
3. An older woman admitted from a long-term care facility
4. A man who is an inspector for the United States Postal Service
Answer: 4
Rationale: People at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania; medically underserved populations (ethnic minorities, homeless); those with human immunodeficiency virus or other immunosuppressive disorders; residents in group settings (long-term care, correctional facilities); and health care workers.
A nurse is reading the results of a Mantoux skin test on a client with no documented health problems. The site has no induration and a 1 mm area of ecchymosis. The nurse interprets that the result is:

1. Positive
2. Negative
3. Uncertain
4. Borderline
Answer: 2
Rationale: A positive Mantoux reading has an induration measuring 15 mm or more in diameter in low-risk individuals. A small area of ecchymosis is insignificant and is probably related to injection technique.
A nurse reads a client’s Mantoux skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse’s response is based on the understanding that the client has:

1. No evidence of tuberculosis
2. Systemic tuberculosis
3. Pulmonary tuberculosis
4. Exposure to tuberculosis
Answer: 4
Rationale: A client who tests positive on a Mantoux skin test has either been exposed to tuberculosis or has inactive (dormant) tuberculosis. The client must then tested by chest x-ray and sputum culture to confirm the diagnosis.
A nurse is caring for a client who had a Mantoux skin test implantation 48 hours ago on admission to the nursing unit and reads the result of the skin test as positive. Which action by the nurse is the priority?

1. Report the findings.
2. Call the radiology department for a chest x-ray.
3. Document the finding in the client’s record.
4. Call the employee health service department.
Answer: 1
Rationale: The nurse who interprets a Mantoux test as positive notifies the physician immediately. The physician would order a chest x-ray to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be done to confirm the diagnosis of active TB. The client is placed on TB precautions prophylactically until a final diagnosis is made. The findings are documented in the client’s record but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.
A nurse is caring for a client with tuberculosis who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which of the following as the best strategy to assist the client in coping with the disease?

1. Encourage the client to visit with the pastoral care department chaplain.
2. Ask family members if they wish a psychiatric consult.
3. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.
4. Allow the client to deal with the disease in an individual fashion.
Answer: 3
Rationale: A primary role of the nurse in working with the client with tuberculosis is to teach the client about medication therapy. The anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids) and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy, which will eradicate it. This gives the client a measure of power over the situation and outcome.
A nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further reinforcement of information if the client makes which of the following statements?

1. “It’s very important to wash my hands after I touch my mask, tissues, or body fluids.”
2. “I should cough into tissues and throw them away carefully.”
3. “It’s important to cover my mouth if I laugh, sneeze, or cough.”
4. “I should use disposable plates, forks, and knives.”
Answer: 4
Rationale: Because tuberculosis is transmitted by droplets, it cannot be carried on clothing, eating utensils, or other possessions. It is important to perform proper hand washing after contact with body substances, tissues, or face masks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing, and dispose of tissues the carefully.
A nurse is caring for the client diagnosed with tuberculosis (TB). Which of the following findings, if made by the nurse, would be inconsistent with the usual clinical presentation of tuberculosis?

1. Nonproductive or productive cough
2. Anorexia and weight loss
3. Chills and night sweats
4. High-grade fever
Answer: 4
Rationale: The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweating (which may occur at night), and a low-grade fever.
A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting the family and others. The nurse determines that the client would get the most reassurance from the knowledge that:

1. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy.
2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy.
3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy.
4. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
Answer: 4
Rationale: Family members or others who have been in close contact with a client diagnosed with TB are placed on prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug resistant TB.
A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse plans to tell the client that this is:

1. A short-lived problem, which should be gone within 1 week of medication therapy
2. An unexpected finding with TB, but it should resolve within about 1 month
3. Expected, and the client should very gradually increase activity as tolerated
4. Expected, and will last for at least a year
Answer: 3
Rationale: The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses, and that the client should gradually increase activity as energy levels permit.
A nurse is teaching a client with tuberculosis (TB) about dietary elements that should be increased in the diet. The nurse suggests that the client increase the intake of:

1. Meats and citrus fruits
2. Grains and broccoli
3. Eggs and spinach
4. Potatoes and fish
Answer: 1
Rationale: The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats, from which 10% to 30% of available iron is absorbed. Less than 10% of iron is absorbed from eggs and less than 5% is absorbed from grains and vegetables.
A nurse has reinforced discharge teaching with a client who was diagnosed with tuberculosis (TB) and has been on medication for 1½ weeks. The nurse determines that the client has understood the information if the client makes which statement?

1. “I need to continue medication therapy for 2 months.”
2. “I should not be contagious after 2 to 3 weeks of medication therapy.”
3. “I can’t shop at the mall for the next 6 months.”
4. “I can return to work if a sputum culture comes back negative.”
Answer: 2
Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client is generally considered to be not contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds, until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative.
A client with tuberculosis asks a nurse about precautions to take after discharge from the hospital to prevent infection of others. The nurse develops a response to the client’s question based on the understanding that:

1. The client should maintain enteric precautions only.
2. The disease is transmitted by droplet nuclei.
3. Clothing and sheets should be bleached after each use.
4. Deep pile carpet should be removed from the home.
Answer: 2
Rationale: Tuberculosis is spread by droplet nuclei or the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand washing technique. It is unnecessary to remove carpeting from the home.
A nurse is preparing to give a bed bath to the immobilized client with tuberculosis (TB). The nurse should plan to wear which of the following items when performing this care?

1. Particulate respirator, gown, and gloves
2. Particulate respirator and protective eye wear
3. Surgical mask and gloves
4. Surgical mask, gown, and protective eye wear
Answer: 1
Rationale: The nurse who is in contact with a client with TB should wear an individually fitted particulate respirator. The nurse would also wear gloves as per standard precautions. The nurse wears a gown whenever there is a possibility that the clothing could become contaminated, such as when giving a bed bath.
A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when:

1. Three sputum cultures are negative.
2. Five sputum cultures are negative.
3. A sputum culture and a chest x-ray are negative.
4. A sputum culture and a Mantoux test are negative.
Answer: 1
Rationale: The client must have sputum cultures tested every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. The Mantoux test will not revert to negative once it is positive. The chest x-ray may or may not be negative.
1. A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure?

1. Intake and output
2. Peripheral pulse rates
3. Height and weight
4. Allergy to iodine or shellfish
Answer: 4
Rationale: This procedure requires a signed consent, because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious, and must be assessed before the procedure. Although options 1, 2, and 3 may be a component of data collection, they are not the most critical items.
2. A client is scheduled for a dipyridamole (Persantine) thallium scan. The nurse would check to make sure that the client has not had which of the following before the procedure?

1. Milk products
2. Caffeine
3. Excess sugar
4. Fatty meal
Answer: 2
Rationale: This test is an alternative to the exercise stress test. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline. Aminophylline is the antagonist to dipyridamole.
A client with no history of cardiovascular disease presents to the ambulatory clinic with flu-like symptoms. While at the clinic, the client suddenly develops chest pain. Which question would best help the nurse to discriminate pain caused by a noncardiac problem?

1. “Have you ever had this pain before?”
2. “Can you describe the pain to me?”
3. “Does the pain get worse when you breathe in?”
4. “Can you rate the pain on a scale of 1 to 10, with 10 being the worst?”
Answer: 3
Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?

1. Strict bed rest for 24 hours
2. Bathroom privileges and self-care activities
3. Unsupervised hallway ambulation with distances less than 200 feet
4. Ad lib activities, because the client is monitored
Answer: 2
Rationale: Upon transfer from CCU, the client is allowed self care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).
A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction admitted 2 days ago. The nurse would plan to do which of the following next?

1. Review the intake and output records for the last 2 days.
2. Change the time of diuretic administration from morning to evening.
3. Request a sodium restriction of 1 g/day from the physician.
4. Order daily weights starting on the following morning.
Answer: 1
Rationale: Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.
A nurse is collecting data from a client with a primary diagnosis of heart failure. Which following disorder reported by the client is not associated with exacerbating the heart failure?

1. Recent upper respiratory infection
2. Nutritional anemia
3. Peptic ulcer disease
4. Atrial fibrillation
Answer: 3
Rationale: Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
A nurse is collecting data from a client with heart failure who is being sent directly to the hospital from the physician’s office. The nurse reviews the physician’s orders and expects to note an order for which medication?

1. Diltiazem (Cardizem)
2. Digoxin (Lanoxin)
3. Propranolol (Inderal)
4. Metoprolol (Lopressor)
Answer: 2
Rationale: Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. It is the medication of choice used to treat heart failure. Diltiazem (calcium channel blocker), propranolol, and metoprolol (beta-adrenergic blockers) have a negative inotropic effect, and would worsen the failing heart.
A nurse checks the sternotomy incision of a client on the third postoperative day after cardiac surgery. The incision shows some slight “puffiness” along the edges, is nonreddened, with no apparent drainage. The client’s temperature is 99 F (37.2 C) orally. The white blood cell (WBC) count is 7500/mm3. The nurse interprets that the incision line:

1. Is slightly edematous but shows no active signs of infection
2. Shows no sign of infection although the WBC count is elevated
3. Shows early signs of infection although the temperature is near normal
4. Shows early signs of infection supported by an elevated WBC count
Answer: 1
Rationale: Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, and induration. An elevated temperature and elevated WBC count after 3 to 4 days usually indicate infection. A WBC count of 7500/mm3 is within the normal range.
A postcardiac surgery client has a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of IV fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen (BUN) level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. The nurse interprets that the client is at risk for:

1. Hypovolemia
2. Urinary tract infection
3. Glomerulonephritis
4. Acute renal failure
Answer: 4
Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion, and could possibly need peritoneal dialysis or hemodialysis.
A nurse is preparing to ambulate the client on the third postoperative day following cardiac surgery. The nurse plans to do which of the following to enable the client to best tolerate the ambulation?

1. Encourage the client to cough and deep breathe.
2. Premedicate the client with an analgesic.
3. Provide the client with a walker.
4. Remove the telemetry equipment.
Answer: 2
Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption due to pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.
A client is wearing a continuous cardiac monitor, which begins to alarms. The nurse sees no electrocardiographic complexes on the screen. The nurse would first:

1. Check the client status and lead placement
2. Press the recorder button on the ECG console
3. Call the physician
4. Call a code blue
Answer: 1
Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Assessment of the client and equipment is the first action by the nurse.
A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the:

1. Vagus nerve to slow the heart rate
2. Vagus nerve to increase the heart rate
3. Diaphragmatic nerve to slow the heart rate
4. Diaphragmatic nerve to increase the heart rate
Answer: 1
Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.
A nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia followed by ventricular fibrillation (VF). The client immediately loses consciousness. The nurse would immediately:

1. Call for help and initiate cardiopulmonary resuscitation (CPR).
2. Start oxygen by cannula at 10 L/minute and lower the head of the bed.
3. Go to the nurse’s station quickly and call a code.
4. Run to get a defibrillator from an adjacent nursing unit.
Answer: 1
Rationale: When VF occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options 2, 3, and 4 are incorrect.
A nurse is monitoring a client following cardioversion. Which of the following observations would be of highest priority to the nurse?

1. Oxygen flow rate
2. Status of airway
3. Blood pressure
4. Level of consciousness
Answer: 2
Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
An automatic external defibrillator is available to treat the client who goes into cardiac arrest and is receiving cardiopulmonary resuscitation (CPR). With this device, the nurse checks the cardiac rhythm by:

1. Applying standard electrocardiographic monitoring leads to the client and observing the rhythm
2. Holding the defibrillator paddles firmly against the chest
3. Applying the adhesive patch electrodes to the skin and moving away from the client
4. Connecting standard electrocardiographic electrodes to a transtelephonic monitoring device
Answer: 3
Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client’s chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Standard electrocardiographic monitoring leads do not play an active role once resuscitation is underway (options 1 and 4). Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation.
The nurse is caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse takes care not to dislodge the pacing catheter by:

1. Limiting movement and abduction of the right arm
2. Limiting movement and abduction of the left arm
3. Assisting the client to get out of bed and ambulate with a walker
4. Having the physical therapist do active range of motion to the right arm
Answer: 1
Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client’s activities.
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and is visibly anxious. The nurse immediately checks the client for other signs and symptoms of:

1. Myocardial infarction
2. Pneumonia
3. Pulmonary embolism
4. Pulmonary edema
Answer: 3
Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. A nurse listens to breath sounds, expecting to hear bilateral:

1. Rhonchi
2. Diminished breath sounds
3. Crackles
4. Wheezes
Answer: 3
Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.
A nurse caring for a client in one room is told by another nurse that a second client has developed severe pulmonary edema. On entering the second client's room, the nurse would expect the client to be:

1. Slightly anxious
2. Mildly anxious
3. Moderately anxious
4. Extremely anxious
Answer: 4
Rationale: Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering.
A nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition?

1. Dyspnea
2. Crackles on lung auscultation
3. Hacking cough
4. Dependent edema
Answer: 4
Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.
A client is admitted to the hospital with an arterial ischemic leg ulcer. The nurse assesses the ulcer, expecting to note that it:

1. Has a pink-colored base
2. Is superficial, with uneven edges
3. Has little granulation tissue
4. Has brown pigmentation surrounding it
Answer: 3
Rationale: Arterial leg ulcers tend to be deep and pale, with uneven edges and little granulation tissue. The client usually has rest pain, and the ulcer site is painful. Options 1, 2, and 4 are incorrect.
A nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:

1. Normal, caused by increased blood flow through the leg
2. Slightly deteriorating, and should be monitored for another hour
3. Moderately impaired, and the surgeon should be called
4. Adequate from an arterial approach, but venous complications are arising
Answer: 1
Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity cause by increased blood flow. Options 2, 3, and 4 are incorrect.
A client newly diagnosed with chronic renal failure has recently begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse monitors the client during dialysis for:

1. Hypertension, tachycardia, and fever
2. Hypotension, bradycardia, and hypothermia
3. Restlessness, irritability, and generalized weakness
4. Headache, deteriorating level of consciousness, and twitching
Answer: 4
Rationale: Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching and possible seizure activity. It is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and is prevented by dialyzing for shorter times or at reduced blood flow rates.
A client with chronic renal failure has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse interprets that this data is compatible with:

1. Phosphate overdose
2. Aluminum intoxication
3. Advancing uremia
4. Folic acid deficiency
Answer: 2
Rationale: Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.
A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which manifestation of this disorder?

1. Warmth, redness, and pain in the left hand
2. Pallor, diminished pulse, and pain in the left hand
3. Edema and purplish discoloration of the left arm
4. Aching pain, pallor, and edema of the left arm
Answer: 2
Rationale: Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia. Warmth, redness, and pain would more likely characterize a problem with infection. Options 3 and 4 are not characteristics of steal syndrome.
A nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client’s record, would the nurse identify as a risk factor for this pyelonephritis?

1. Hypoglycemia
2. Coronary artery disease
3. Diabetes mellitus
4. Orthostatic hypotension
Answer: 3
Rationale: Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.
A nurse is reviewing the client’s record and notes that the physician has documented that the client has a renal disorder. On review of the laboratory results, the nurse would most likely expect to note which of the following?

1. Elevated blood urea nitrogen (BUN) level
2. Decreased hemoglobin V
3. Decreased red blood cell (RBC) count
4.Decreased white blood cell (WBC)count
Answer: 1
Rationale: BUN testing is a frequently used laboratory test to determine renal function. The BUN level starts to rise when the glomerular filtration rate falls below 40% to 60%. A decreased hemoglobin and RBC count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease.
Which of the following would the nurse include in the plan of care for a client following a renal scan?

1. Place the client on radiation precautions for 18 hours.
2. Save all urine in a radiation-safe container for 18 hours.
3.Limit contact with the client for 20 minutes per hour.
4. No special precautions required, except to wear gloves if coming in contact with the client’s urine.
Answer: 4
Rationale: There are no specific precautions following a renal scan. The nurse wears gloves to maintain standard precautions. Options 1, 2, and 3 are unnecessary measures.
A client is scheduled for intravenous pyelography (IVP). Before the test, the priority nursing action would be to:

1. Administer an oral preparation of radiopaque dye.
2. Restrict fluids.
3. Determine a history of allergies.
4. Administer a sedative.
Answer: 3
Rationale: The iodine-based dye used during the IVP can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Assessing for allergies is the priority.
Following a renal biopsy, the client complains of pain at the biopsy site, which radiates to the front of the abdomen. The nurse interprets this complaint and further monitors the client for:

1. Bleeding
2. Infection
3. Renal colic
4. Normal, expected pain
Answer: 1
Rationale: If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria would also indicate bleeding. Signs of infection would not appear immediately following a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic.
A nurse is monitoring an 88-year-old woman suspected of having a urinary tract infection (UTI) for signs of the infection. Which of the following would alert the nurse to the possibility of the presence of a UTI?

1. Fever
2. Frequency
3. Confusion
4. Urgency
Answer: 3
Rationale: In an older client, the only symptom of a UTI may be something a vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client and fever can be associated with a variety of conditions.
A nurse is performing an admission assessment on a client with a diagnosis of bladder cancer. Which of the following would the nurse most likely expect to note on data collection of this client?

1. Hematuria
2. Burning
3. Urgency
4. Frequency
Answer: 1
Rationale: Gross, painless hematuria is most frequently the first manifestation of bladder cancer. As the disease progresses the client may experience dysuria, frequency, and urgency.
A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. The nurse monitors the client for signs of transurethral resection syndrome. Which of the following data would indicate the onset of this syndrome?

1. Bradycardia and confusion
2. Tachycardia and diarrhea
3. Decreased urinary output and bladder spasms
4. Increased urinary output and anemia
Answer: 1
Rationale: TUR syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.
A nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test knowing that which of the following identifies the accurate procedure for this visual acuity test?

1. Both eyes are tested together, followed by the testing of the right and then the left eye.
2. The right eye is tested, followed by the left eye, and then both eyes are tested.
3. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart.
4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.
Answer: 2
Rationale: Visual acuity is tested in one eye at a time, and then in both eyes together, with the client comfortably seated. Begin with the right eye while the left eye is covered and then test the left eye with the right eye covered, followed by testing both eyes together. Visual acuity is measured with or without corrective lenses, with the client standing at a distance of 20 feet from the chart.
A client’s vision is tested with a Snellen chart. The results of the test is documented as 20/60. The nurse interprets this as:

1. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.
2. The client is legally blind.
3. The client’s vision is normal.
4. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.
Answer: 4
Rationale: Vision that is 20/20 is normal—that is, the client can read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.
A clinic notes that following several eye examinations the physician has documented a diagnosis of legal blindness in the client’s chart. Which of the following would the nurse expect to note documented as the result of the Snellen chart test?

1. 20/20 vision
2. 20/40 vision
3. 20/60 vision
4. 20/200 vision
Answer: 4
Rationale: Legal blindness is defined as the best visual acuity with corrective lenses in the better eye as 20/200 or less, or if visual acuity is less than 20 degrees of the visual field in the better eye. Options 1, 2, and 3 are incorrect descriptions.
A nurse is preparing the client for eye testing and the examiner is planning to test the eyes using the confrontational method. The nurse tells the client that this test is performed to:

1. Examine visual fields or peripheral vision
2. Check for glaucoma
3. Check for color blindness
4. Examine pupil constriction
Answer: 1
Rationale: The confrontational method of eye testing is used to examine visual fields or peripheral vision. Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is used to test pupillary response to light.
Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test results as documented in the client’s chart and understands that normal intraocular pressure is:

1. 2 to 7 mm Hg
2. 10 to 21 mm Hg
3. 22 to 30 mm Hg
4. 31 to 35 mm Hg
Answer: 2
Rationale: Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range.
A nurse is monitoring a client with a blunt head injury sustained from a motor vehicle accident. Which of the following would indicate a basal skull fracture as a result of the injury?

1. Purulent drainage from the auditory canal
2. Bloody or clear drainage from the auditory canal
3. Epistaxis
4. Periorbital edema
Answer: 2
Rationale: Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal leak following trauma and suggests a basal skull fracture. This warrants immediate attention. Option 1 is indicative of an infectious process. Options 3 and 4 are not specifically associated with a basal skull fracture.
A nurse is reviewing the record of a client with mastoiditis. The nurse would expect to note which of the following documented regarding the results of the otoscopic examination?

1. A pink tympanic membrane
2. A pearl-colored tympanic membrane
3. A red, dull, thick and immobile tympanic membrane
4. A transparent and clear tympanic membrane
Answer: 3
Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. Options 1, 2, and 4 are not findings that would be noted in this examination in the client with mastoiditis.
A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which of the following is the most common client complaint associated with a disorder involving the inner ear?

1. Hearing loss
2. Pruritus
3. Tinnitus
4. Burning in the ear
Answer: 3
Rationale: Tinnitus is the most common complaint of clients with otologic disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client’s thinking process and attention span. Hearing loss may or may not occur. Options 2 and 4 are not specifically associated with inner ear problems.
A nurse is assigned to care for a client with a diagnosis of Ménière’s disease. The nurse plans care knowing that this condition is a disorder of the:

1. External ear canal
2. Tympanic membrane
3. Middle ear
4. Inner ear
Answer: 4
Rationale: Ménière’s disease is a disorder of the labyrinth of the inner ear. This disorder does not affect the external ear, tympanic membrane, or the middle ear.
A nurse is caring for a client who will be undergoing surgical treatment for Ménière’s disease. The nurse plans care understanding that surgical treatment for this disorder is performed to:

1. Provide relief from accumulation of inner ear fluid in the endolymphatic sac.
2. Repair the tympanic membrane.
3. Replace the stapes footplate.
4. Provide relief from accumulation of fluid in the middle ear.
Answer: 1
Rationale: Surgical treatment for Ménière’s disease involves relief from accumulation of inner ear fluid in the endolymphatic sac. Procedures may be directed toward relief of pressure by the bony structures surrounding the sac or toward opening the sac and diverting the flow of endolymph by a shunt to the mastoid bone or to the subarachnoid space. Options 2, 3, and 4 are procedures that are unrelated to Ménière’s disease.
A nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse would expect to note documentation of which early symptom of this disorder?

1. Ringing in the ears
2. Blurred vision
3. Headache
4. Vertigo
Answer: 1
Rationale: Otosclerosis involves the formation of spongy bone in the capsule of the labyrinth of the ear, often causing the auditory ossicles to become fixed and less able to pass on vibrations when sound enters the ear. An early symptom is ringing in the ears, but the most noticeable symptom is progressive hearing loss. Options 2, 3, and 4 are not associated with this condition.
A nurse is positioning the client with increased intracranial pressure (ICP). Which position would the nurse avoid?

1. Head turned to the side
2. Head midline
3. Neck in neutral position
4. Head of bed elevated 30 to 45 degrees
Answer: 1
Rationale: The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities?

1. Exhaling during repositioning
2. Isometric exercises
3. Blowing the nose
4. Coughing vigorously
Answer: 1
Rationale: Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
A family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition, and wondering if the client will ever recover. The nurse intervenes, based on the understanding that:

1. The family needs immediate crisis intervention.
2. The family could benefit from a conference with the physician.
3. It is possible the client can hear the family.
4. The client might have wanted a visit from the hospital chaplain.
Answer: 3
Rationale: Some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact, and act accordingly. Research has also demonstrated that positive outcomes are associated with coma stimulation—that is, speaking to and touching the client.
A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach may not be beneficial in controlling the client's ICP from an environmental viewpoint?

1. Maintaining a calm atmosphere
2. Reducing environmental noise
3. Clustering nursing activities to be done all at once
4. Allowing the client uninterrupted time for sleep
Answer: 3
Rationale: Nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include maintaining a calm, quiet environment and avoiding emotional stress and interruption of sleep.
A client has clear fluid leaking from the nose following a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid:

1. Clumps together on the dressing and has a pH of 7
2. Separates into concentric rings and tests positive for glucose
3. Is grossly bloody in appearance and has a pH of 6
4. Is clear in appearance and tests negative for glucose
Answer: 2
Rationale: Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose. Options 1, 3, and 4 are not characteristics of ICP.
A nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan placement of objects:

1. Within the client's reach, on the right side
2. Within the client's reach, on the left side
3. Just out of the client's reach, on the right side
4. Just out of the client's reach, on the left side
Answer: 2
Rationale: Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. Other helpful activities with hemiparesis include range-of-motion exercises to the affected side and muscle strengthening exercises to the unaffected side.
A client with a cerebrovascular accident (CVA) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?

1. Giving the client thin liquids
2. Thickening liquids to the consistency of oatmeal
3. Placing food on the unaffected side of the mouth
4. Allowing plenty of time for chewing and swallowing
Answer: 1
Rationale: Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed, and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
A nurse has instructed the family of a cerebrovascular accident (CVA) client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will:

1. Place objects in the client's impaired field of vision
2. Approach the client from the impaired field of vision.
3. Remind the client to turn the head to scan the lost visual field
4. Discourage the client from wearing own eyeglasses
Answer: 3
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
A nurse is trying to communicate with a cerebrovascular accident (CVA) client with aphasia. Which action by the nurse would be least helpful to the client?

1. Speaking to the client at a slower rate
2. Completing the sentences that the client cannot finish
3. Looking directly at the client during attempts at speech
4. Allowing plenty of time for the client to respond
Answer: 2
Rationale: Clients with aphasia after CVA often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members give all the responses for the client.
A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute and the blood pressure (BP) is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing:

1. Spinal shock
2. Malignant hypertension
3. Pulmonary embolism
4. Autonomic dysreflexia
Answer: 4
Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.
A nurse provides cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further instructions if the client states that:

1. A stockinette will be placed over the leg area to be casted
2. The cast edges may be trimmed with a cast knife.
3. The cast will give off heat as it dries
4. The client may bear weight on the cast in 30 minutes
Answer: 4
Rationale: The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.
A nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion would the nurse include in the teaching plan?

1. Lift the left arm up over the head.
2. Lift the right arm up over the head.
3. Make a fist with the hand of the casted arm.
4. Use a sling on the left arm.
Answer: 1
Rationale: Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value.
A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. The nurse replies that the client will be able to bear weight on the cast:

1. Within 20 to 30 minutes of application
2. In approximately 8 hours
3. In 24 hours
4. In 48 hours
Answer: 1
Rationale: A fiberglass cast is made of water-activated polyurethane materials, which are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.
A nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse tells the client to advance the:

1. Left leg and right crutch, then right leg and left crutch
2. Crutches and then both legs simultaneously
3. Crutches and the right leg, then advance the left leg
4. Crutches and the left leg, then advance the right leg
Answer: 4
Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1 describes a two-point gait. Option 2 describes a swing-to gait. Option 3 describes the three-point gait used for a right leg problem.
A nurse has given the client instructions regarding crutch safety. The nurse determines that the client needs reinforcement of the instructions if the client states:

1. The need to have spare crutches and tips available
2. That crutch tips will not slip, even when wet
3. Not to use someone else’s crutches
4. That crutch tips should be inspected periodically for wear
Answer: 2
Rationale: Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.
A client has slight weakness in the right leg. Based on this data, the nurse determines that the client would benefit most from the use of a:

1. Walker
2. Wooden crutch
3. Lofstrand crutch
4. Straight-leg cane
Answer: 4
Rationale: A straight-leg cane is useful for the client with slight weakness in one leg. A walker is beneficial to the client with greater or bilateral weakness or who is at risk for falls. Wooden crutches are often used by clients with a leg cast. Lofstrand crutches aid clients who need crutches, but have limited arm strength.
A client who has experienced a cerebrovascular accident (CVA) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is not quite sufficient any longer. The nurse determines that the client could benefit from the somewhat greater support and stability provided by a:

1. Quad cane
2. Wooden crutch
3. Lofstrand crutch
4. Wheelchair
Answer: 1
Rationale: A quad cane may be used by the client requiring greater support and stability than is provided by a straight-leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair are indicated for a client such as described in the question.
A client with right-sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

1. Left hand, and placing the cane in front of the left foot
2. Right hand, and placing the cane in front of the right foot
3. Left hand, and 6 inches lateral to the left foot
4. Right hand, and 6 inches lateral to the right foot
Answer: 3
Rationale: The client is taught to hold the cane on the opposite side of the weakness. This is done because, with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.
A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the greatest reassurance by telling the client that:

1. Canes prevent falls, not cause them.
2. The cane has a flared tip with concentric rings to provide stability.
3. The physical therapist will determine if the cane is inadequate.
4. The cane would help to break a fall, even if the client does slip.
Answer: 2
Rationale: A cane should have a slightly flared tip, with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. Options 1, 3, and 4 are not incorrect.
A client has requested and undergone testing for human immunodeficiency virus (HIV). The client now asks what will be done next, because the results of two enzyme-linked immunosorbent assay (ELISA) tests have been positive. The nurse’s response is based on the understanding that:

1. The client will probably have a bone marrow biopsy done.
2. A Western blot test will be done to confirm these findings.
3. A CD4+ cell count will be obtained to measure T-helper lymphocytes.
4. The client will be definitively diagnosed as HIV-positive at this point.
Answer: 2
Rationale: If the results of two ELISA tests are positive, the Western blot test is done to confirm the findings. If the result of the Western blot test is positive, then the client is considered to be positive for HIV and infected with the HIV virus.
A nurse is caring for the client with acquired immunodeficiency syndrome (AIDS). The nurse detects early infection with Pneumocystis jiroveci (formerly called Pneumocystis carinii) by monitoring the client for which clinical manifestation?

1. Dyspnea on exertion
2. Dyspnea at rest
3. Fever
4. Cough
Answer: 4
Rationale: The client with Pneumocystis jiroveci (formerly P. carinii) infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. The nurse notes during data collection that the client has enlarged lymph nodes. The nurse interprets that:

1. The client has disseminated histoplasmosis infection.
2. This is a side effect of the medications given to treat AIDS.
3. This indicates that the histoplasmosis is resolving.
4. The client probably has yet another infection that is developing.
Answer: 1
Rationale: Histoplasmosis usually starts as a respiratory infection in the client with AIDS. It then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. Options 2, 3, and 4 are incorrect.
A nurse is caring for the client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention would be least helpful in managing this symptom?

1. Keep a change of bed linens nearby in case they are needed.
2. Administer an antipyretic after the client spikes the fever.
3. Make sure that the pillow has a plastic cover.
4. Keep liquids at the bedside.
Answer: 2
Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer the client an antipyretic of choice before going to sleep. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink.
A client with acquired immunodeficiency syndrome (AIDS) has raised, dark purplish-colored lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi’s sarcoma?

1. Enzyme-linked immunosorbent assay (ELISA)
2. Western blot test
3. Skin biopsy
4. Lung biopsy
Answer: 3
Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi’s sarcoma. Lung biopsy would confirm Pneumocystis jiroveci (formerly P. carinii) infection. The ELISA and Western blot tests are used to diagnose HIV status.
The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client’s sexual-reproductive status. The client states, “I don't want to discuss this; it's private and personal.” Which statement by the nurse indicates a therapeutic response?

1. “I hate being asked these sorts of questions too.”
2. “I am a nurse and as such I'll have you know that all information is kept confidential.”
3. “I know that some of these questions are difficult for you, but as a nurse, I must legally respect your confidentiality.”
4. “This is difficult for you to speak about, but I am trying to perform a complete data collection and I need this information.”
Answer: 3
Rationale: Option 3 is the only option that identifies a therapeutic response. In option 1, the nurse’s feelings are the focus. This response clearly ignores the fact that the issue is about the client and the client's discomfort, not about the nurse. In option 2, the nurse becomes pompous and a little angry and supercilious, which is not therapeutic. In option 4, the nurse begins correctly with an empathic stance but then becomes demanding.
A nurse is caring for a client who says, “I don't want you to touch me. I'll take care of myself!” The nurse makes which therapeutic response to the client?

1. “I will respect your feelings. I'll just leave this cup for you to collect your urine in. After breakfast, I will take more blood from you.”
2. “If you didn't want our care, why did you come here?”
3. “Why are you being so difficult? I only want to help you.”
4. “Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request.”
Answer: 4
Rationale: The therapeutic response is the one that reflects the client's feelings and offers the client control of care. In option 1, the nurse uses avoidance and gives information. Option 2 is an aggressive and nontherapeutic communication technique. Option 3 is social and nontherapeutic, because it labels the client's behavior and is likely to provoke anger from the client.
A nurse collects data on a client with a diagnosis of bipolar affective disorder–mania. The finding that requires the nurse’s immediate intervention is:

1. The client’s outlandish behaviors and inappropriate dress
2. The client’s grandiose delusions of being a royal descendant of King Arthur
3. The client’s nonstop physical activity and poor nutritional intake
4. The client’s constant, incessant talking that includes sexual innuendoes and teasing the staff
Answer: 3
Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. It is a period when the mood is predominantly elevated, expansive, or irritable. Option 3 identifies a physiological need requiring immediate intervention.
A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. The appropriate nursing action is to:

1. Quietly approach the client, escort her to her room, and assist her in getting dressed.
2. Approach the client in the hallway and insist that she go to her room.
3. Confront the client on the inappropriateness of her behaviors and offer her a time-out.
4. Ask the other clients to ignore her behavior; eventually she will return to her room.
Answer: 1
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. A quiet, firm approach while distracting the client (walking her to her room and assisting her to get dressed) achieves the goal of having her being dressed appropriately and preserving her psychosocial integrity. Option 4 is inappropriate. “Insisting” that the client go to her room may meet with a great deal of resistance. Confronting the client and offering her a consequence of “time-out” may be meaningless to her.
A nurse reviews the activity schedule for the day and determines that the best activity that the manic client could participate in is:

1. A brown bag lunch and a book review
2. Ping-Pong
3. A paint by number activity
4. A deep breathing and progressive relaxation group
Answer: 2
Rationale: A person who is experiencing mania is overactive, full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow him or her to utilize excess energy, but not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities may lead to increased frustration and anxiety for the client. Ping-Pong is an activity that will help to expend the increased energy this client is experiencing.
A client who is delusional says to the nurse, “The federal guards were sent to kill me.” The nurse should make which appropriate response to the client?

1. “The guards are not out to kill you.”
2. “I don’t believe this is true.”
3. “I don’t know anything about the guards. Do you feel afraid that people are trying to hurt you?”
4. “What makes you think the guards were sent to hurt you?”
Answer: 3
Rationale: Disagreeing with delusions may make the client more defensive and the client may cling to the delusions even more. It is most therapeutic for the nurse to empathize with the client’s experience. Options 1 and 2 are statements that disagree with the client. Option 4 encourages discussion regarding the delusion.
A woman comes into the emergency room in a severe state of anxiety following a car accident. The most important nursing intervention is to:

1. Remain with the client
2. Put the client in a quiet room
3. Teach the client deep breathing
4. Encourage the client to talk about her feelings and concerns
Answer: 1
Rationale: If a client is left alone with severe anxiety, he or she may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep breathing until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
A male client with delirium becomes agitated and confused in his room at night. The best initial intervention by the nurse is to:

1. Use a night-light and turn off the television.
2. Keep the television and a soft light on during the night.
3. Move the client next to the nurse’s station.
4. Play soft music during the night and maintain a well-lit room.
Answer: 1
Rationale: It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses’ station is not the initial intervention.
A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

1. "I talked to the voices you're hearing and they won't hurt you now."
2. "I can hear the voice and she wants you to come to dinner."
3. "Sometimes people hear things or voices others can't hear."
4. "I know you feel ‘they are out to get you’ but it's not true."
Answer: 3
Rationale: It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.
A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are most likely caused by:

1. Inadequate dietary intake and dehydration
2. Lack of exercise and poor diet
3. Poor dietary choices
4. Psychomotor retardation and side effects of medication
Answer: 4
Rationale: Constipation can be related to inadequate food intake, lack of exercise, and poor diet. In this situation, urinary retention is most likely due to medications. Option 4 is the only option that addresses both constipation and urinary retention.
A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client’s mother begins to cry and states, “My son’s brain will be destroyed. How can the doctor do this to him?” The nurse makes which therapeutic response?

1. “It sounds as though you need to speak to the psychiatrist.”
2. “Your son has decided to have this treatment. You should be supportive of him.”
3. “Perhaps you’d like to see the ECT room and speak to the staff.”
4. “It sounds as though you have some concerns about the ECT procedure. Why don’t we sit down together and discuss any concerns you may have.”
Answer: 4
Rationale: The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.
A nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia occurs, the nurse would most likely observe:

1. Abnormal movements and involuntary movements of the mouth, tongue, and face
2. Abnormal breathing through the nostrils
3. Severe headache, flushing, tremor, and ataxia
4. Severe hypertension, migraine headache, and ‘marbles in the mouth’ syndrome
Answer: 1
Rationale: Tardive dyskinesia is a severe reaction associated with the long-term use of antipsychotic medication. The clinical manifestations are abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue, and face. In its more severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued.
A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse?

1. "You understand that people fear for their children but you're feeling unfairly treated?"
2. "When children are hurt as you hurt them, people want you isolated."
3. "You seem angry but you have committed serious crimes against several children, so your neighbors are frightened."
4. "You're lucky it doesn't escalate into something pretty scary after your crime."
Answer: 1
Rationale: Focusing and verbalizing the implied is the therapeutic response because it assists the client to clarify thinking and re-examine what the client is really saying. Option 1 is the only option that reflects the use of this therapeutic communication technique. Option 2 is insensitive and anxiety-provoking. Option 3 does not facilitate the client’s expression of feelings. Option 4 gives advice and also does not facilitate the client's expression of feelings.
A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

1. "My medications won’t make me anxious."
2. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."
3. “I’ll go to support group and talk so that I won't hurt anyone."
4. “I won't get anxious or hear things if I get enough sleep and eat well."
Answer: 2
Rationale: There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm (self) or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 2 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.
A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse monitors for which of the following?

1. Hypertension, disorientation, hallucinations
2. Hypotension, ataxia, vomiting
3. Stupor, agitation, muscular rigidity
4. Hypotension, coarse hand tremor, agitation
Answer: 1
Rationale: The symptoms associated with alcohol withdrawal typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and delusions.
The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, “I should get out of this bad situation.” The most helpful response by the nurse would be:

1. “I agree with you. You should get out of this situation.”
2. “What do you find difficult about this situation?”
3. “Why don’t you tell your husband about this?”
4. “This is not the best time to make that decision.”
Answer: 2
Rationale: The most helpful response is the one that encourages the client to problem-solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client nor should the nurse request that the client provide explanations.
A nurse is caring for a client who is suspected of being dependent on drugs. Which question
would be most appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

1. "Why did you get started on these drugs?"
2. "How long did you think you could take these drugs without someone finding out?"
3. "How much do you use and what effect does it have on you?"
4. The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room
Answer: 3
Rationale: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option 2 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.
A client who has been drinking alcohol on a regular basis admits to having “a problem” and is asking for assistance with the problem. The nurse would encourage the client to attend which of the following community groups?

1. Al-Anon
2. Alcoholics Anonymous
3. Families Anonymous
4. Fresh Start
Answer: 2
Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 3 is for parents of children who abuse substances. Option 4 is for nicotine addicts.
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client’s room. Which client would be an appropriate choice as this client’s roommate?

1. A client with pneumonia
2. A client receiving diagnostic tests
3. A client who could benefit from the client’s assistance at mealtime
4. A client who thrives on managing others
Answer: 2
Rationale: The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of their own hunger.
A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client would best indicate to the nurse that the client has well assimilated therapy session topics and coping response styles, and has processed information effectively for self-use?

1. “I know I’m ready to be discharged; I feel like I can say ‘no’ and leave a group of friends if they are drinking. No problem.”
2. “This group has really helped a lot. I know it will be different when I go home. But I’m sure that my family and friends will all help me like the people in this group have. They’ll all help me; I know they will. They won’t let me go back to my old ways.”
3. “I’m looking forward to leaving here; I know that I will miss all of you. So, I’m happy and I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong and that everyone isn’t going to be as helpful as you people.”
4 . “I’ll keep all my appointments and go to all my AA groups. I’ll do everything I’m supposed to. Nothing will go wrong that way.”
Answer: 3
Rationale: In option 3, the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in the statement. Option 1 indicates client denial. In option 2, the client is relying heavily on others. In option 4, the client is concrete and procedure-oriented; again, the client denies that “nothing will go wrong that way” if the client follows all the directions.
A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will develop within how much time after cessation or reduction of alcohol intake?

1. Within a few hours
2. In 7 days
3. In 14 days
4. In 21 days
Answer: 1
Rationale: Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.
A nurse determines that the wife of an alcoholic client is benefiting from attending an Al- Anon group when the nurse hears the wife say:

1. “My attendance at the meetings has helped me to see that I provoke my husband's violence."
2. “I no longer feel that I deserve the beatings my husband inflicts on me."
3. "I can tolerate my husband's destructive behaviors now that I know they are common in alcoholics."
4. "I enjoy attending the meetings because they get me out of the house and away from my husband."
Answer: 2
Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option 2 is the healthiest response, because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option 1). Option 3 indicates that the wife remains codependent. Option 4 indicates that the group is being seen as an escape, not a place to work on issues.
A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as:

1. Normal
2. Indicative of the client’s ambivalence
3. Evidence of the client’s altered and distorted body image
4. Regression
Answer: 3
Rationale: Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client’s coping pattern relates to the basic issue of distorted body image. The nurse should address this need in the support group.
A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want any more treatment. I have things that I have to do right away.” The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After discussing the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to:

1. Restrain the client until the physician can be reached.
2. Call security to block all exit areas.
3. Tell the client that they cannot return to this hospital again if they leave now.
4. Call the nursing supervisor.
Answer: 4
Rationale: A nurse can be charged with false imprisonment if a client is made to wrongfully believe that they cannot leave the hospital. Most health care facilities have documents that the client is asked to sign, which relate to the client’s responsibilities when they leave against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving but, if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.
A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?

1. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis.
2. A crisis state indicates that the individual is suffering from an emotional illness.
3. A crisis state indicates that the individual is suffering from a mental illness.
4. A client’s response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.
Answer: 4
Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person, because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness
A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

1. “What is causing you to become agitated?”
2. “You need to stop that behavior now!”
3. “You will need to be restrained if you do not change your behavior.”
4. “You will need to be placed in seclusion!”
Answer: 1
Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and will assist the nurse in planning appropriate interventions for the client. Option 2 is demanding behavior, which could cause increased agitation in the client. Options 3 and 4 are threats to the client and are inappropriate.
During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, “My family would be better off without me.” The nurse should make which therapeutic response to the client?

1. “Everyone feels this way when they are depressed.”
2. “Have you talked to your family about this?”
3. “You sound very upset. Are you thinking of hurting yourself?”
4. “You will feel better once your medication begins to work.”
Answer: 3
Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Options 1, 2, and 4 are not therapeutic responses.
A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

1. "That seems rather unlikely to me."
2. "You must be feeling all alone at this point."
3. "I don't believe that, and neither do you."
4. "Right! Why not just ‘pack it in’?"
Answer: 2
Rationale: The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option 1, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option 3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions. In option 4, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response.
A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care?

1. Keeping the door to the client’s room open when with the client
2. Assigning the client to a room at the end of the hall to avoid disturbing the other clients
3. Facing the client when providing care
4. Ensuring that a security officer is within the immediate area
Answer: 2
Rationale: The client should be placed in a room near the nurses’ station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client’s room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case of a suspicion of the possibility of violence.
Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

1. The client becomes angry while speaking on the telephone and slams the receiver down on the hook.
2. The client runs out of the therapy group swearing at the group leader, and runs to her room.
3. The client gets angry with her roommate when the roommate borrows her clothes without asking.
4. The client gives away a prized CD and a cherished autographed picture of the performer.
Answer: 4
Rationale: A depressed, suicidal client often gives away that which is of value as a way of saying “goodbye” and wanting to be remembered. Options 1, 2, and 3 identify acting-out behaviors.