A child is being assessed for conduct disorder.

Which of the following

if manifested by the child is not in line with conduct disorder?

Select one:
a. property destruction and serious violation of school rules
b. None of the above
c. A history of theft and gross dishonesty
d. Aggression and bullying against the child’s playmate and teachers
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A student nurse discusses the pathophysiology of ADHD. She is
correct if she relates the client’s “impulsivity” with which of the
following?

Select one:
a. Norepinephrine
b. dopamine
c. Serotonin
d. GABA
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Patient Gringo Biloba is a 7 year-old patient taking a daily
maintenance dose of Methylphenidate for ADHD. Which of the
 following drug adverse effects should the nurse emphasize for the
mother to monitor?

Select one:
a. Failure to thrive and delay of psychomotor development
b. Loss of symptoms
c. Decreased attention when eating
d. Retardation of growth
During postprandial monitoring, Patient Klime who is a 39 year old
with bulimia nervosa tells the nurse, “You can sit with me, but you’re
just wasting your time. After you sat with me yesterday, I was still
able to purge. Today, my goal is to do it twice.” Which options
indicates Nurse Ryan’s best response?

Select one:
a. “Don’t worry. I won’t allow you to purge today.”
b. “I know it’s important for you to feel in control, but I’ll monitor you for
90 minutes after you eat.”
c. “I trust you not to purge.”
d. “How are you purging and when do you do it?”
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A patient diagnosed with amnestic disorder is being taken care at a
psych facility. Which nursing diagnoses is a priority at this time?

Select one:
a. Panic Attack
b. Risk for trauma
c. Anxiety
d. Chronic Confusion
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Nurse Vladimir Pluteen plans to include the parents in therapy
sessions along with the client who is suffering from Anorexia
Nervosa. Which fact should nurse Vladimir remember to be typical of
parents of clients with anorexia nervosa?

Select one:
a. They alternate between loving and rejecting their children.
b. They usually have a history of substance abuse.
c. They maintain emotional distance from their children.
d. They tend to overprotect their children.
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The nurse is caring for a client diagnosed with dementia who has
needs related to nutrition. Which appropriate goal should the nurse
plan for with this client?

Select one:
a. Client will be free from hallucinations
b. Client will correctly identify objects in his or her room by the time of
discharge
c. Client will feed self with cueing within 24 hours
d. Client will be oriented to place by the time of discharge
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Nurse Dorita is caring for a patient with cognitive impairment. Which
of the following will he use when communicating with her client?

Select one:
a. Pictures or gestures instead of words.
b. Stimulating words and phrases to capture the client’s attention.
c. Short words and simple sentences.
d. Complete explanations with multiple details.
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A nurse plans for a child with ADHD. Which of the following should
not be in the nurse’s plan?

Select one:
a. Give positive reinforcements
b. encourage sleep at least 12 hours a day
c. Accept the child or individual as what he is
d. Implement scheduled routine every day
All of the following are hallmarks of a child with ADHD except:

Select one:
a. Hyperactivity
b. Inattention
c. Impulsivity
d. Lack of care and attention from family and parents
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The inability to maintain the physiologic requirements in sexual
intercourse is:

Select one:
a. Orgasm Disorder.
b. Sexual Desire Disorder.
c. Sexual Pain Disorder.
d. Sexual Arousal Disorder.
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A client is admitted to the psychiatric unit with a diagnosis of
anorexia nervosa. Although she is 5′ 8″ (1.7 m) tall and weighs only
103 lb (46.7 kg), she talks incessantly about how fat she is. Which
measure should the nurse take first when caring for this client?

Select one:
a. Discuss cultural stereotypes regarding thinness and attractiveness.
b. Teach the client about nutrition, calories, and a balanced diet.
c. Explore the reasons why the client doesn’t eat.
d. Establish a trusting relationship with the client.
 A depressive client verbalizes that when she engages in sexual
intercourse with her husband, she has difficulty or absence of
orgasm. This condition is known as:

Select one:
a. dyspareunia
b. Female arousal disorder
c. Anorgasmia
d. Anhedonia
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A patient with Down Syndrome who was admitted for epilepsy is now
being discharged with Dilantin for his home meds. Which of the
following drug adverse effects should the nurse plans to educate the
mother about?

Select one:
a. Take the medication with orange juice
b. Do not take the medication with grape juice
c. Monitor Apical pulses before administration
d. Watch out for bleeding and inflamed gums
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All of the following are symptoms of Alzheimer’s disease except:
 Select one:
a. None of the above
b. Poor judgement and reasoning, confabulation of stories,
hallucinations, delusions and illusions
c. Wandering, getting lost, insomnia, irritation
d. Memory Loss, confusion, Repeating questions
During a counseling session, a couple had expressed concern about
the factors that cause Autism. Which statements by the nurse
indicate further education?

Select one:
a. “Boys are about four times more likely to develop autism spectrum
disorder than girls are”
b. “Babies born before 26 weeks of gestation may have a greater risk of
autism spectrum disorder.”
c. There may be a connection between children born to teen age parents
and autism spectrum disorder, but more research is necessary to
establish this link.
d. “Families who have one child with autism spectrum disorder have an
increased risk of having another child with the disorder.”
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A child with kleptomania is now being interviewed at the school
clinic. Which of the following indicates to the nurse about the
disorder?

Select one:
a. none of the above
b. Feeling terrible guilt, remorse, self-loathing, shame or fear of arrest
after the theft
c. Absence of track record with theft and robbery
d. the child has no history of hurting other people and animals
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The nurse asks a client to roll up his sleeves so she can take his blood
pressure. The client replies “If you want I can go naked for you.” The
most therapeutic response by the nurse is:

Select one:
a. “I will report you to the guard if you don’t control yourself.”
b. “You’re attractive, but I’m not interested.”
c. “You wouldn’t be the first that I will see naked.”
d. “I only need access to your arm. Putting up your sleeve is fine.”
An adult patient who was rushed to the hospital is now being studied
for amnestic disorder. Which of the following descriptions suits
receptive aphasia?

Select one:
a. the patient smiles and follows instructions but is not able to say any
comprehensible word
b. Patient is having difficulty writing or copying letters, words, and
sentences
c. Patient’s ability to elicit motor communication is impaired
d. Having difficulty understanding spoken utterances
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A patient asks the nurse about the ways on how to possibly prevent
Alzheimer’s disease. The nurse is correct if she educates the patient
to:

Select one:
a. Avoid crossword puzzles and mind games as these may cause brain
strain
b. Avoid getting active too much as this can impair the brain process
c. Avoid purines and salty diet as these may cause neuronal
crystallization
d. Follow DASH diet
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A 5 year old boy is being assessed in the clinic for his regular check
up as a patient under autistic spectrum. The child does not talk to the
nurse at all and does not throw any eye contact with the people
around. Knowing that autistic children have poor to absent social
engagement, the nurse knows that special children can be victims of
child abuse at home. Which of the following is not a manifestation of
child abuse?

Select one:
a. The child shows rhinorrhea
b. Battle’s sign seen with he child
c. Presence of Racoon’s eyes
d. Mother reports that the child usually bangs his head on the wall
Clear my choice
When being interviewed at a psyche facility, a female patient admits
to having recurrent, intense sexual urges, behaviors, or sexually
arousing fantasies, involving acts in which the psychological or
physical suffering (including humiliation) of her partner is sexually
exciting. The nurse who overhears this knows that the patient’s
description suits which of the following paraphilia?

Select one:
a. Sadism
b. Necrophilia
c. Sado-Masochism
d. Masochism
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A patient with conduct disorder is currently being investigated for
possible involvement with illegal drug trade. Which of the following
most possibly makes him involved?

Select one:
a. A prescription by the doctor of a monthly stock for methylphenidate
(Daytrana) patch
b. one of his parents is in a rehabilitation center
c. association with a school gang
d. Getting punched by school bullies
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A child is being assessed for cognitive development. Which of the
following indicates to the nurse that the patient is a gifted child?

Select one:
a. IQ of 145
b. IQ exam finds the child profound
c. Child exhibits extraordinary interest in music
d. an IQ of above average
Which of the following statements about ADHD in children is false?

Select one:
a. Black parents tend to be less sure of potential causes of and
treatments for ADHD than white parents, and they are less likely to
connect ADHD to their child’s school experiences.
b. The Multimodal Treatment Study of Children with ADHD suggests that
pharmacological treatment of ADHD is as effective as behavioral
therapy alone.
c. The chances of successful treatment are adversely affected if the
parent responsible for implementing the treatment has untreated
ADHD.
d. Because of its frequent genetic etiology, ADHD in a child is likely
foreshadowed by ADHD in other family members.
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 Nurse Gio is conducting a home visit for a patient with ADHD. Which
of the following food items would he recommend best for the
patient?

Select one:
a. Lucky Me pancit canton, marie biscuits and a banana fruit
b. Chicken liver adobo, igado and pinakbet with pineapple juice
c. Wendy’s Spaghetti, a slice of tuna and chopped broccoli
d. Jolibee Chicken Joy, Shakey’s Pizza and Malunggay Biscuits
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The hallmark manifestation of delirium is which of the following?

Select one:
a. Agitation and restlessness
b. presence of delusions, hallucinations and illusions
c. Cheyne-stokes respiration
d. Loss of consciousness and irritation
The school nurse assesses Brook, a child newly diagnosed with
attention deficit hyperactivity disorder (ADHD). Which of the
following symptoms is not a characteristic of the disorder? Select all
that apply.

Select one:
a. Excessive fatigue and somatic complaints because of hyperactivity
b. Talking constantly, even when inappropriate
c. Constant fidgeting and squirming
d. Difficulty paying attention to details
e. Easily distracted
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A patient with bulimia nervosa is seen with persistent binging and
induced vomiting. Which of the following assessment findings is a
priority for the nurse associated in the patient’s condition?

Select one:
a. initiate aspiration precautions without fail
b. corrosion and inflammations of the patient’s gums
c. serum potassium of 2.05
d. fractured teeth
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The nurse is developing a plan of care for an older client with
dementia. The nurse develops which realistic outcome for the client?

Select one:
a. The client will be admitted to a nursing home to have the needs of
activities of daily living met.
b. The client will function at the highest level of independence possible.
c. The nursing staff will attend to all of the client's activities of daily living
needs during the hospital stay.
d. The client will complete all activities of daily living independently
within a 1- to 1½-hour time frame.
A client with anorexia nervosa tells the nurse, “When I look in the
mirror, I hate what I see. I look so fat and ugly.” Which strategy
should the nurse use to deal with the client’s distorted perceptions
and feelings?

Select one:
a. Avoid discussing unrealistic cultural standards regarding weight.
b. Focus discussions on food and weight.
c. Provide objective data and feedback regarding the client’s weight and
attractiveness.
d. Avoid discussing the client’s perceptions and feelings.
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Which of the following does not indicate a condition called
frotteurism?

Select one:
a. Rubbing a genital to a 9 year old while at a train
b. preoccupation with intense sexual urges or fantasies, involving
touching or rubbing against a consenting person and the individual
has acted on these sexual urges with a consenting person
c. Non of the above
d. Touching sexual organ to a sleeping individual in a classroom
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Nurse Claire is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is?

Select one:
a. Encourage to avoid foods
b. Identify anxiety causing situations
c. Eat only three meals a day
d. Avoid shopping plenty of groceries
In a client with ADHD, disturbance of which of the following is
responsible for the patient’s lack of attention?

Select one:
a. Serotonin
b. Norepinephrine
c. Parents’lack of time spent with the patient because they have to work
far from home.
d. Dopamine
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The nurse is caring for a female client who was recently admitted to
the hospital with a diagnosis of anorexia nervosa. When the nurse
enters the room, the client is engaged in rigorous push-ups. Which
nursing action would be therapeutic?

Select one:
a. Allow the client to complete the exercise program.
b. Interrupt the client and weigh the client immediately.
c. Interrupt the client and offer to take the client for a walk.
d. Tell the client that she is not allowed to exercise rigorously.
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A 15-year-old boy was hospitalized in a psychiatric unit because he
initiates frequent fights with peers. Which implementation is most
appropriate?

Select one:
a. Anticipate and neutralize potentially explosive situations.
b. Isolate the adolescent from contact with peers.
c. Talk to the adolescent each time fighting occurs.
d. Ignore minor infractions of rules against fighting.
A client is admitted to a mental health unit with a diagnosis of
anorexia nervosa. When planning care for this client, which primary
intervention should health promotion focus on?

Select one:
a. Emphasizing social interaction with clients who are withdrawn
b. Helping the client identify and examine dysfunctional thoughts and
beliefs
c. Providing a supportive environment
d. Examining intrapsychic conflicts and past issues
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Which condition is described as involuntary constriction of the outer
third of the vagina, which prevents penile insertion and intercourse?

Select one:
a. Vaginismus
b. vaginitis
c. vaginosis
d. vaginal trauma
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The nurse is assessing a 17-year-old female who is admitted to the
eating disorders unit with a history of weight fluctuation, abdominal
pain, teeth erosion, receding gums, and bad breath. She states that
her health has been a problem but there are no other concerns in her
life. Which of the following assessments will be the least useful as the
nurse develops the care plan?

Select one:
a. Ability to socialize with peers.
b. Whether she has a sexual relationship with a boyfriend.
c. Information regarding recent mood changes.
d. Family functioning using a genogram.
Nurse Brenny care for Patient MEily, a client with anorexia nervosa.
Which goal takes the highest priority?

Select one:
a. The client will identify self-perceptions about body size as unrealistic.
b. The client will verbalize the possible physiological consequences of
self-starvation.
c. The client will make a contract with the nurse that sets a target weight.
d. The client will establish adequate daily nutritional intake.
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Nurse Tiffany reinforces the behavioral contract for a child having
difficulty controlling aggressive behaviors on the psychiatric unit.
Which of the following is the best rationale for this method of
treatment?

Select one:
a. It will avoid having the nurse be responsible for setting the rules.
b. It will maintain the nurse’s role in controlling the child’s behavior.
c. It will prevent the child from manipulating the nurse.
d. It will assist the child to develop more adaptive coping methods.
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Which behavioral assessment in a child is most consistent with a
diagnosis of conduct disorder?

Select one:
a. Physical aggression toward others.
b. Refusal to separate from caretaker.
c. Gross impairment in communication.
d. Arguing with adults.
A patient asks the nurse how dementia defers from delirium. The
nurse is correct if she says that the difference between the 2 is which
of the following?

Select one:
a. Delirium is a temporary state that begins suddenly. Dementia is
chronic (long-term) confusion that usually begins gradually and
worsens over time.
b. Delirium mostly affects a person’s memory. Dementia affects attention
and senses.
c. Dementia is a symptom of delirium
d. None of the above
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The nurse is performing an assessment on a client with a diagnosis of
anorexia nervosa to the nursing unit. The nurse reviews the client's
medical record before performing the assessment and expects to
note which finding in the record?

Select one:
a. Elevated potassium levels
b. Low blood urea nitrogen
c. Weight loss of 4% of original weight over a short period
d. That the client is knowledgeable about the caloric value of food
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Which is not a characteristic of a sexual behavior disorder?

Select one:
a. Frequent Masturbation
b. Sexual arousal from observing unsuspecting people either naked or
engaged in sexual activity.
c. Sexual arousal from being humiliated, beaten, bound, or otherwise
made to suffer.
d. Lack of sexual pleasure
Which of the following is not a priority for a patient diagnosed with
sexual disorder?

Select one:
a. Identify factors affecting client’s sexuality
b. Provide a structured environment
c. Ensure patient’s safety
d. Determine stressors
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A nurse prepares a nursing care plan for a patient diagnosed with
sexual disorder. Which of the following diagnoses does not suit the
disorder?

Select one:
a. Sexual Dysfunction
b. Ineffective sexuality pattern
c. High esteem
d. Disturbed personal identity
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Tony, expresses concern to nurse Labia about changes of behavior
which he noted in his elderly aunt. Which would cause the nurse to
suspect a cognitive impairment disorder?

Select one:
a. Increased complaints of physical ailments.
b. Fearfulness of being alone at night.
c. Decreased interest in activities that she once enjoyed.
d. Problems with preparing a meal or balancing her checkbook.
The patient was rushed to the ER due to memory loss. Upon taking
the history, the patient’s brother says that they observed the patient’s
memory loss “occurring with confusion or agitation and it comes and
goes repeatedly over the course of several hours.” The nurse should
know that which type of amnestic disorder is being described by the
client’s brother?

Select one:
a. Transient global amnesia
b. Retrograde amnesia
c. Infantile Amnesia
d. Anterograde amnesia
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The nurse assigned to care for a client with anorexia nervosa notes
that the client has a distorted body image. The nurse determines that
which would be an appropriate goal for this client?

Select one:
a. Client verbalizes body size accurately and states a beginning
acceptance of a more mature-appearing body.
b. Client verbalizes knowledge of maintenance diet and expected
average weight.
c. Client practices problem-solving approaches to deal with issues, such
as roles, sexuality, and social interactions with others.
d. Client practices beginning assertive behavioral skills.
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For a child that has been diagnosed with conduct disorder, the nurse
must formulate her therapeutic plans based on the understanding
that which is considered the universal language of the child?

Select one:
a. play
b. tantrums
c. crying
d. cooing
 Methylphenidate (Ritalin) is prescribed to an 8-year-old child for the
treatment of attention deficit hyperactivity disorder (ADHD). The
nurse will most likely monitor which of the following during the
medication therapy?

Select one:
a. Intake and output.
b. Temperature and breath sound.
c. Height and weight.
d. A. Deep tendon reflex.
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A patient was admitted after he was found to have been manifesting
sudden changes in thinking and loss of the ability to focus attention.
The patient is currently observed for delirium. Which of the following
is a proper intervention for the nurse?

Select one:
a. Do not give food and water as the patient is at very high risk for
aspiration at this time
b. provide reassurances even if the patient is manifesting psychosis
c. avoid talking to the patient during active delirium. This will trigger
agitation and irritability
d. Prevent the patient from falling asleep as sleeping will aggravate the
disorder
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The nurse admits a client to the hospital with a suspected diagnosis
of bulimia nervosa. While performing the admission assessment, the
nurse asks questions and expects to elicit which data about bulimia?

Select one:
a. Binge eats, then purges
b. Is accepting of body size
c. Overeats in response to losing control of diet
d. Overeats for the enjoyment of eating food
The nurse taking care of a patient with ADHD needs to understand
that ADHD may come along with many forms of disorders like the all
of the following except:

Select one:
a. Tourette syndrome
b. Conduct disorder
c. Simple form of Pediatric Schizophrenia
d. Bipolar Disorder
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A toddler with mental retardation is now being assessed in the clinic.
When assessing the patient’s ears, the nurse intends to do which of
the following techniques for ear inspection?

Select one:
a. Pulls back the ear auricles and insert laryngoscope
b. All of the above options are applicable for a mentally retarded child
c. Pulls back the ear lobes and down
d. Pulls back the ear lobes and then up
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Mark Ian is a student nurse who is caring for a 75-year-old client who
has progressive dementia and is now very confused. Mark Ian’s
communication tools should include:

Select one:
a. flat facial expression.
b. written directions for bathing.
c. speaking very loudly.
d. gentle touch while guiding ADLs (activities of daily living).
A 35 year old woman with amnestic disorder was found to have been
suddenly shouting, agitated and restless. Which of the following
should the nurse expect to give?

Select one:
a. SSRI
b. Amlodipine tablet
c. Benzodiazepine
d. Neuroleptic
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Nurse Brenda Maige is creating a discharge plan for a patient with
ADHD. Which of the following if instructed to the child’s care giver
will be best for the child?

Select one:
a. Wait until the child asks for food before giving him his favorite soup
and fish dish.
b. Do not force the child to eat meals at a structured time and Give hand
held food
c. Assert proper behavior during meal time to increase the child’s focus
in eating.
d. Initiate a structured meal plan and time
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For a child with Trisomy 21, the nurse expects to find the following
manifestations except:

Select one:
a. Presence of Brushfield’s spots and simian crease
b. Presence of pectum excavatum
c. High set ears, Sunset eyes and Monggolian slant
d. Mental Retardation at an IQ result of at least educable level
An elderly man is admitted to the hospital. He was alert and oriented
during the admission interview. However, his family states that he
becomes disruptive and disoriented around dinnertime. One night he
was shouting furiously and didn’t know where he was. He was
sedated and the next morning he was fine. At dinnertime the
 disruptive behavior returned. The client is diagnosed as having
sundown syndrome. The client’s son asks the nurse what causes
sundown syndrome. The nurse’s best response is that it is attributed
to

Select one:
a. inadequate cerebral flow.
b. an underlying depression.
c. changes in the sensory environment.
d. fluctuating levels of oxygen exchange.
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Patient Nonito is being monitored for delirium. The nurse is aware
that which hallmark manifestation indicates presence of delirium?

Select one:
a. Signs of psychosis
b. ptosis and drooling
c. Tachycardia, Tachypnea and irritation
d. Syndenham’s chorea
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 Nurse Ganda is planning for patient Vizzie, a 10-year-old child. Which
outcome criteria would be appropriate for a child diagnosed with
oppositional defiant disorder?

Select one:
a. Accept responsibility for own behaviors.
b. Set firm and consistent limits with the client.
c. Be able to verbalize own needs and assert rights.
d. Allow the child to establish his own limits and boundaries.
The nurse is caring for an adolescent female who reports
amenorrhea, weight loss, and depression. Which additional
assessment finding would suggest that the woman has an eating
disorder?

Select one:
a. Oily skin
b. Wearing tight-fitting clothing
c. Excessive and ritualized exercise
d. Increased blood pressure
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Nurse Gwyneth is conducting a visit on a patient diagnosed with
autism. She is correct if she states that which of the following is not
an expected behavioral pattern from an autistic client?

Select one:
a. Has specific food preferences, such as eating only a few foods, or
refusing foods with a certain texture
b. Performs activities that could cause self-harm, such as biting or head-
banging
c. Is fascinated by details of an object, such as the spinning wheels of a
toy car, but doesn't understand the overall purpose or function of the
object
d. engages in imitative or make-believe play
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Which of the following activities involves a patient diagnosed with
exhibitionism?

Select one:
a. exposure of one’s genitals to an unsuspecting stranger
b. A porn actor who engages in porn industry
c. display of genitals to a group of 6 individuals who subscribed for a
private sexual live show.
d. all of the above
A patient diagnosed with Oppositional Defiant Disorder will most
likely to present as:

Select one:
a. with Temper tantrums
b. One who often deliberately seduces others.
c. A person with personality cluster C
d. one who often argues with authority figures or, for children and
adolescents, with adults.
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The nurse may encounter clients with concerns on sexuality. The
most basic factor in the intervention with clients in the area of
sexuality is:

Select one:
a. Ability to communicate effectively.
b. Knowledge about sexuality.
c. Experience in dealing with clients with sexual problems.
d. Comfort with one’s sexuality.
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A client with anorexia nervosa describes herself as “a whale.”
However, the nurse’s assessment reveals that the client is 5′ 8″ (1.7 m)
tall and weighs only 90 lb (40.8 kg). Considering the client’s
unrealistic body image, which intervention should be included in the
plan of care?

Select one:
a. Telling the client of the nurse’s concern for her health and desire to
help her make decisions to keep her healthy
b. Asking the client to compare her figure with magazine photographs of
women her age
c. Assigning the client to group therapy in which participants provide
realistic feedback about her weight
d. Confronting the client about her actual appearance during one-on-
one sessions, scheduled during each shift
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Nurse Nickita Minaj is caring for a one year old boy diagnosed with
autism. In planning care for the child, Nurse Nickita Minaj should
know that which play suits her patient best?

Select one:
a. Parallel Play
b. Solitary Play
c. Role Play
d. Romantic Play
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A patient diagnosed with conduct disorder, kleptomania and
pyromania is admitted to a psych hospital. Which of the following
should the nurse anticipate to be a part of the patient’s medication
chart?

Select one:
a. Tranquilizers
b. Barbiturates
c. Stimulants
d. Antidepressants
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Nurse Gloria questions the parents of a child with oppositional
defiant disorder about the roles of each parent in setting rules of
behavior. The purpose for this type of questioning is to assess which
element of the family system?

Select one:
a. Quality of communication.
b. Knowledge of growth and development.
c. Anxiety levels.
d. Generational boundaries.
A child is being assessed for mental retardation. Which
developmental finding would the nurse expect note for a 10-month
old patient?

Select one:
a. Child seeks for lost toy as a sign of increased permanence
b. Collects pokemon stickers and cards as priced collectibles
c. The child rides on the soft broom to role play as a horse back rider,
indicating the child’s symbolic representation
d. The concept of animism is alive
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A mother is now being educated by the nurse about signs when her
child will be ready for toilet training. Which of the following
statements by the nurse indicates a need for further teaching?

Select one:
a. “it is the best time to initiate toilet training for the child when he tells
his mother so or when the child exhibits interest in doing it”
b. “When your child can squat, stand and walk alone, he is ready for
toilet training”
c. “one of the signs for the child’s readiness for toilet training is when the
child is able to communicate his toilet needs”
d. “Start the child for toilet training when he is able to maintain dryness
for 2 hours, at least”
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Nurse Daya, a school nurse, is meeting with the school and health
treatment team about a child who has been receiving
methylphenidate (Ritalin) two (2) months. The meeting is to evaluate
the results of the child’s medication use. Which behavior change
noted by the teacher will help determine the medication’s
effectiveness.

Select one:
a. Decreased signs of anxiety
b. Increased depressed mood
c. Increased ability to concentrate on tasks
d. Decrease repetitive behaviors
An older adult client at the retirement center spits her food out and
throws it on the floor. She yells, "This turkey is dry and cold! I can't
stand the food here!" How should the nurse respond to the client?

Select one:
a. "One of the things that was agreed upon was that anyone who did not
use appropriate behavior would be asked to leave the dining room.
Please leave now."
b. "Let me get you another serving that is more to your liking. Would
you like to see the chef and select your own serving?"
c. "I think you had better return to your apartment now. I'll make
arrangements for a new meal to be served to you there."
d. "Now look what you've done! You're ruining this meal for the whole
community. Aren't you ashamed of yourself?"
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A patient with Conduct disorder is admitted to a juvenile psych ward.
Which is a priority nursing diagnosis?

Select one:
a. Risk for other directed injury
b. pyromania
c. Defiance from the hospital policies and rules
d. Risk for suicide
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A patient being evaluated for sexual disorder complains that she is
having current or persistent pain during sexual intercourse. The nurse
knows that this condition may called as:

Select one:
a. Anhedonia
b. Vaginismus
c. Vaginitis
d. Dyspareunia
For a client with amnestic disorder, which of the following is the most
important intervention?

Select one:
a. Encourage expression of feelings
b. Encourage independence
c. Encourage group participation
d. Reminisce events with the client
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Nurse Anna is caring for a patient under active delirium. She can
minimize agitation in a disturbed client by?

Select one:
a. Increasing stimulation
b. increasing appropriate sensory perception
c. ensuring constant client and staff contact
d. limiting unnecessary interaction
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 80-year-old Mr. Stevens is accompanied to the clinic by his son, who
tells the nurse that the client’s constant confusion, incontinence, and
tendency to wander are intolerable. The client was diagnosed with
chronic cognitive impairment disorder. Which nursing diagnosis is
most appropriate for the client’s son?

Select one:
a. Risk for other-directed violence.
b. Disturbed sleep pattern.
c. Caregiver role strain.
d. Social isolation.
Which of the following social markers does not indicate that a person
may be suffering from sexual disorder?

Select one:
a. Ejaculation occurs with minimal sexual stimulation or before, on, or
shortly after penetration and before the individual wishes it.
b. Discrepancy between partners’ levels of desire for sexual activity.
c. Presence of subjective sense of sexual excitement during sexual
activity.
d. Inability to produce adequate lubrication for sexual activity.
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Patient Cora was admitted for cognative disorder. The nurse should
know that the phenomenon of increased confusion in the early
evening hours is called:

Select one:
a. Sundowning.
b. Aphasia.
c. Confabulation
d. Agnosia.
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Which is the best indicator of success in the long term management
of the client with Gender and Personality Disorder?

Select one:
a. His symptoms are replaced by indifference to his feelings.
b. He participates in diversionary activities.
c. He learns to verbalize his feelings and concerns.
d. He states that his behavior is irrational.
Nurse Aileen is taking care of a patient with amnestic disorder. Which
is a priority intervention for the patient?

Select one:
a. Supportive care
b. establish trust
c. Identifying underlying cause
d. ensure safety
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 A nurse may encounter children with mental disorders. Her
knowledge of these various disorders is vital. When planning school
interventions for a child with a diagnosis of attention deficit
hyperactivity disorder, a guide to remember is to:

Select one:
a. Provide as much structure as possible for the child.
b. Remove the child from the classroom when disruptive behavior
occurs.
c. Ignore the child’s overactivity.
d. Encourage the child to engage in any play activity to dissipate energy.
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Patient Robbie William is a toddler who is currently admitted for
bacterial pneumonia. Which of the following if elicited by the child
should the nurse view as an expected normal social developmental
manifestation?

Select one:
a. Child can sit up with support
b. negativistic trait as the child’s way to search for independence
c. Laugh aloud using bubbling sounds
d. child can button his shirts on and off
Which of the following describes a 12-year-old patient with under
the autistic spectrum?

Select one:
a. responds to his or her name or appears to hear you at all times
b. Has problems with coordination or has odd movement patterns, such
as clumsiness or walking on toes, and has odd, stiff or exaggerated
body language
c. Genius and intelligent at recognizing nonverbal cues, such as
interpreting other people's facial expressions, body postures or tone
of voice
d. Likes cuddling and holding, but seems to prefer playing alone,
retreating into his or her own world
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Nurse Patricia is aware that the major health complication associated
with intractable anorexia nervosa would be?

Select one:
a. Decreased metabolism causing cold intolerance
b. Cardiac dysrhythmias resulting to cardiac arrest
c. Glucose intolerance resulting in protracted hypoglycemia
d. Endocrine imbalance causing cold amenorrhea
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When manifested by a client, which of the following manifestations
indicate that the patient may be having Cri-Du-Chat Syndrome?

Select one:
a. Wide Set Eyes
b. Signs of Down’s Syndrome
c. Severe Mental Retardation: Profound Idiot
d. All or any of the above
Nurse Bryan is currently assigned to Patient Reynelita who is a 35
year old with bulimia nervosa. He notes a problem of improper
nutrition in the chart. Nurse Bryan determines that which would be
appropriate to assess based on this problem?

Select one:
a. Previous and current coping skills
b. Client's eating patterns, food preferences, and concerns about eating
c. Client's sense of lack of control about the treatment plan
d. Client's feelings about self and body weight
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A child is being managed at the hospital following a falling injury.
Upon assessments, the following would indicate to the nurse that the
patient may be having Patau Syndrome except?

Select one:
a. Able to answer yes and no questions despite presence of cleft lip
b. History of seizures and apnea
c. Low set ears and deafness
d. Small penis, and small undescended testes
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A patient has been diagnosed with Intermittent Explosive Disorder.
The nurse is right knowing that which of the following describes the
disorder?

Select one:
a. A disorder that involves repeated, unforeseen episodes of impulsive,
destructive, violent behavior or angry verbal outbursts in which the
person react grossly out of proportion to the situation.
b. A mental condition in which a person has a long-term pattern of
manipulating, abusing, or violating the rights of others without any
guilt.
c. A childhood mental health disorder that includes frequent and
persistent pattern of anger, irritability, arguing, defiance or
vindictiveness toward a person and other authority figures.
d. A disorder that is characterized by an impulse to set fires.
A 2-year-old patient is being evaluated with his mother at a pediatric
ward. Which of the following observations if stated by the mother
would prompt the nurse to conduct a deeper evaluation for autistic
spectrum disorder?

Select one:
a. “My baby is brilliant. She can utter 2 word phrases”
b. “My child uses gesture — such as point or wave — by 14 months”
c. “My baby has already babbled or cooed by 12 months”
d. “My child doesn't play "make-believe" or pretend by 18 months”
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Which of the following is correct about the cause of Alzheimer’s
disease?

Select one:
a. It is caused by a viral infection
b. It is caused by declining brain mass
c. It is caused by damaged communication between neurons brought
about by tangles and plaques formation
d. It is a normal physiologic changes for an elderly
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A patient who has mental retardation and cleft lip and cleft palate
was rushed to a pediatric clinic. The patient is restful and calm with
normal breathing mechanisms, pulse rates. The mother verbalizes her
concern that the child may not be having enough nutrition because
he is difficult to be fed. Which of the following is the nurse’s priority
diagnosis to consider at this time?

Select one:
a. Imbalanced Nutrition, less than body requirements
b. Risk for Aspiration
c. Impaired airway clearance
d. Severe Malnutrition secondary to Kwashiorkor
Martin Sanchez is a nine (9)-year-old child admitted to a psychiatric
treatment unit accompanied by Mr. and Mrs. Sanchez. To establish
trust and position of neutrality, which action would the nurse take?

Select one:
a. Interview Martin with his parents together, observing their interaction.
b. Encourage Mr. and Mrs. Sanchez to leave while Martin is being
interviewed.
c. Review the clinical record prior to interviewing Mr. and Mrs. Sanchez.
d. Provide diversion for Martin, and interview Mr. and Mrs. Sanchez
alone.
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Which of the following statements is true for gender identity
disorder?

Select one:
a. It is the desire to live or involve in reactions of the opposite sex.
b. It is a pleasure derived from being humiliated and made to suffer.
c. It is a pleasure of shocking the victim with exposure of the genitalia.
d. It is a sexual pleasure derived from inanimate objects.
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When a husband takes out his work frustrations and anger by
abusing his wife at home, the nurse would identify this crisis as which
type?

Select one:
a. anticipated life transition
b. psychiatric emergency crisis
c. developmental crisis
d. dispositional crisis
Nurse Aileen is assessing a patient with amnestic disorder. Which of the following does
not indicate the disorder?

Select one:
a. disorientation
b. hallucination
c. confabulation
d. amnesia

A 25 year-old presents to the ER with unexplained paralysis from the hips downward.
The patient explains that a few days ago her feet were feeling weird and she had trouble
walking and now she is unable to move her lower extremities. The patient reports
suffering an illness about 2 weeks ago, but has no other health history. The physician
suspects Guillain-Barré Syndrome and orders some diagnostic tests. Which finding
below during your assessment requires immediate nursing action?

Select one:
a. The patient has absent reflexes in the lower extremities.
b. The patient reports a headache.
c. The patient has a weak cough.

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A 50-year-old man complains of recurring headaches. He describes these as sharp,

stabbing, and located around his left eye. He also reports that his left eye seems to swell
and get teary when these headaches occur. Based on this history, you suspect that he
has:

Select one:
a. MIgraine headache
b. Medication overdose headache
c. Cluster headache
d. Tension headache

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A 68-year-old patient is diagnosed with moderate dementia after multiple strokes.

During assessment of the patient, the nurse would expect to find:

Select one:
a. Excessive nighttime sleepiness.
b. Fluctuating ability to perform simple tasks.
c. Loss of recent and long-term memory.
d. Difficulty eating and swallowing.

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A 72-year-old female patient is brought to the clinic by the patient's spouse, who
reports that she is unable to solve common problems around the house. To obtain
information about the patient's current mental status, which question should the nurse
ask the patient?

Select one:
a. "What did you eat for breakfast?"
b. "Are you sad?"
c. "How is your self-image?"

d. "Where were you were born?"

A 75-year-old patient asked the nurse the significance of a head to toe assessment. Best
response would be?
Select one:
a. Oh nothing, it is just something that we do.
b. Maybe you can tell me how you got here.
c. I will need to determine the etiology of any pathologic symptoms you might have.
d. It is a way for us to know how we are going to take care of you later

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A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which
nursing intervention initially should receive the lowest priority?

Select one:
a. Teaching residual limb care
b. Maintaining the compression dressing
c. Using therapeutic interviewing techniques
d. Monitoring hemoglobin levels

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A client had a craniotomy for excision of a brain tumor. After surgery, the nurse
monitors the client for increased intracranial pressure. Which clinical finding supports an
increase in intracranial pressure?
Select one:
a. Lowered level of consciousness
b. Thready, weak pulse
c. Regular, shallow breathing
d. Narrowing pulse pressure

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A client is in skin traction while awaiting surgery for repair of a fractured femur. The
client reports leg discomfort and asks the nurse to release the traction. Which is the
nurse’s best initial response?
Select one:
a. “I can’t because the weights are needed to keep the bone aligned.”
b. “I have to follow the health care provider’s directions, and releasing weights is not
ordered.
c. “I will remove half of the weights and notify your health care provider.”

d. “I’ll get your prescribed pain medication to help relieve your discomfort.”
A client with a history of seizures is admitted with a partial occlusion of the left common
carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When
planning care for this client, what should the nurse do first?

Select one:
a. Obtain a history of seizure type and incidence.
b. Observe the client for increased restlessness and agitation
c. Place an airway and restraints at the bedside.
d. Ask the client to remove any dentures and eyeglasses.

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A client with myasthenia gravis asks the nurse why the disease has occurred. What
pathology underlies the nurse’s reply?

Select one:
a. A genetic defect in the production of acetylcholine
b. An inefficient use of the neurotransmitter acetylcholine
c. An inhibition of the enzyme AChE, leaving the endplates folded
d. A decreased number of functioning acetylcholine receptor sites

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A client with myasthenia gravis continues to become weaker despite treatment with
neostigmine (Prostigmin). What reason should the nurse identify for the health care
provider’s prescription for edrophonium (Enlon)?
Select one:
a. Promote a synergistic effect
b. Rule out cholinergic crisis
c. Overcome neostigmine resistance
d. Confirm the diagnosis of myasthenia

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A client with myasthenia gravis experiences dysphagia. What is the priority risk
associated with dysphagia that must be considered when planning nursing care?
Select one:
a. Aspiration
b. Impaired communication
c. Nutritional imbalance
d. Dehydratio
A client with myasthenia gravis has been receiving neostigmine (Prostigmin) and asks
about its action. What information about its action should the nurse consider when
formulating a response?

Select one:
a. Replaces deficient neurotransmitters
b. Blocks the action of cholinesterase
c. Accelerates transmission along neural sheaths
d. Stimulates the cerebral cortex

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A client with the diagnosis of Parkinson disease asks the nurse, “Why do I drool so
much?” Which is the nurse’s best response?

Select one:
a. “We don’t know why this happens.”
b. “You have a loss of involuntary movements.”
c. “There is a paralysis of the throat muscles.”
d. “Muscle rigidity prevents normal swallowing.”

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A diagnosis of "possible Alzheimer's" means that:

Select one:
a. Doctors don't really know what the problem is.
b. The doctor believes there is a 50 to 60 percent chance that the patient has the
disease.
c. The patient probably has age-related dementia.
d. The patient probably has Alzheimer's disease but there may also be another disorder
causing dementia as well.

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A nurse enters the room of a client with myasthenia gravis and identifies that the client
is experiencing increased dysphagia. What should the nurse do first?

Select one:
a. Call the health care provider
b. Raise the head of the bed.
c. Perform tracheal suctioning.

d. Administer oxygen.
A nurse is assessing a client whose mouth is drawn over to the left. The nurse should
consider damage to which cranial nerve to be the most likely explanation for this clinical
finding?

Select one:
a. Left facial nerve
b. Right facial nerve
c. Left abducens nerve
d. Right trigeminal nerve

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A nurse is caring for a client who had a total hip replacement. What is the priority
assessment when monitoring the client for hemorrhage?

Select one:
a. Measuring the circumference of the thigh
b. Examining the bedding under the client
c. Observing for ecchymosis at the operative site
d. Checking vital signs every four hours

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A nurse is caring for a client with the diagnosis of GuillainBarré syndrome. The nurse
identifies that the client is having difficulty expectorating respiratory secretions. What
should be the nurse’s first intervention?
Select one:
a. Place the client in the orthopneic position
b. Administer oxygen via nasal cannula
c. Auscultate for breath sounds.
d. Suction the client’s oropharynx.

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A nurse is monitoring a client who is having a computed tomography (CT) scan of the
brain with contrast. Which response indicates that the client is having an untoward
reaction to the contrast medium?
Select one:
a. Shortness of breath
b. Pelvic warmth
c. Salty taste in the mouth

d. Feeling flushed
A nurse should expect a client with a spinal cord injury to have some spasticity of the
lower extremities. What should the nurse include in the plan of care for this client to
prevent the development of lower extremity contractures?
Select one:
a. Deep massage
b. Active exercise
c. Use of a tilt board
d. Proper positioning

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A patient has been diagnosed with osteosarcoma of the humerus. He shows an

understanding of his treatment options when he states:

Select one:
a. “This tumor is related to the melanoma I had 3 years ago.”
b. “The chemotherapy before surgery will shrink the tumor.”
c. “I accept that I have to lose my arm with surgery.”
d. “I’m glad they can take out the cancer with such a small scar.”

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A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the
patient's adult children that:

Select one:
a. The presence of brain atrophy detected by magnetic resonance imaging (MRI) will
confirm the diagnosis of AD.
b. New drugs have been shown to reverse AD dramatically in some patients.
c. The most important risk factor for AD is a family history of the disorder.
d. A diagnosis of AD is made only after other causes of dementia are ruled out.

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A patient is suspected of having a brain tumor. The signs and symptoms include
memory deficits, visual disturbances, weakness of right upper and lower extremities, and
personality changes. The nurse recognizes that the tumor is most likely located in the:
Select one:
a. Temporal lobe
b. Occipital lobe
c. Parietal lobe

d. Frontal lobe
 patient with a comminuted fracture of the tibia is to have an open reduction with
internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated in which
of the following instances?
Select one:
a. A temporary cast would be too unstable to provide normal mobility.
b. Adequate alignment cannot be obtained by other nonsurgical methods.
c. The patient cannot tolerate the surgery of a closed reduction.
d. The patient is unable to tolerate prolonged immobilization.

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A recently hospitalized client with multiple sclerosis is concerned about generalized

weakness and fluctuating physical status. What is the priority nursing intervention for
this client?
Select one:
a. Space activities throughout the day.
b. Encourage bed rest.
c. Teach the limitations imposed by the disease.
d. Have one of the client’s relatives stay at the bedside

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Abnormal swishing sounds heard over organs, glands and arteries and results from an
abnormality in an artery resulting from narrow or partially occluded artery such as those
in atherosclerosis.
Select one:
a. Crackles
b. Thrill
c. Wheezes
d. Bruits

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After a client is treated for a spinal cord injury, the health care provider informs the
family that the client is a paraplegic. The family asks the nurse what this means. What
explanation should the nurse provide?
Select one:
a. Both lower and upper extremities are paralyzed.
b. One side of the body is paralyzed.
c. Lower extremities are paralyzed.

d. Upper extremities are paralyzed.

Biographical Data is also called
Select one:
a. Identifying data
b. Source information
c. None of the above
d. Census Data

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Data regarding mobility, strength, coordination, and activity tolerance are important for
nurses as part of neurologic assessment for what specific reason?
Select one:
a. These are the first functions to be affected by neurologic diseases.
b. Aspects of movement are the most important function of the nervous system
c. Patients are less able to identify other neurologic impairments.
d. Many neurologic diseases affect one or more of these areas.

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During a health fair, the nurse takes an adult’s blood pressure and it is 200/120 mm Hg.
The nurse should base the next nursing intervention on the understanding that:

Select one:
a. The elevated blood pressure reflects the “white coat syndrome.”
b. Information should be obtained regarding prescribed medications
c. Walking around the fair probably raised the adult's blood pressure.
d. There is an increased risk for having a brain attack.

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During interview, since we are not actually touching the patient, handwashing:
Select one:
a. Is Necessary
b. As long as it is required
c. Can be ignored

d. Is Not necessary

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based
on this finding, the nurse may omit testing for:

Select one:
a. Heel to shin movements
b. Patellar reflexes
c. Position sense
d. Temperature perception

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During nursing report you learn that the patient you will be caring for has Guillain-Barré
Syndrome. As the nurse you know that this disease tends to present with:
Select one:
a. Signs and symptoms that are unilateral and descending that start in the lower
extremities.
b. Signs and symptoms that are symmetrical and ascending that start in the upper
extremities.
c. Signs and symptoms that are asymmetrical and ascending that start in the upper
extremities.
d. Signs and symptoms that are symmetrical and ascending that start in the lower
extremities.

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During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the
patient is short of breath. The patient’s respiratory distress is caused by:

Select one:
a. Immobility resulting from ascending paralysis.
b. Elevated protein levels in the CSF.
c. Degeneration of motor neurons in the brainstem and spinal cord.
d. Paralysis ascending to the nerves that stimulate the thoracic area

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During the postoperative period, the nurse instructs the patient with an above-the-knee
amputation that the residual limb should not be routinely elevated because this position
promotes:
Select one:
a. Hip flexion contractures.
b. Increased risk of wound dehiscence
c. Clot formation at the incision site.

d. Skin irritation and breakdown.

Each of the three components of the Glasgow Coma Scale have a number of steps.
Which of these are the correct combinations?

Select one:
a. Eyes 5 Verbal 4 Motor 6
b. Eyes 4 Verbal 5 Motor 6
c. Eyes 4 Verbal 5 Motor 5
d. None of the Above

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How does Guillain-Barre spread?

Select one:
a. Both
b. Ascending
c. Descending
d. Either way

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In each component of the Glasgow Coma Scale the ‘Best Response’ is:

Select one:
a. A normal response
b. Spontaneous
c. Zero
d. No response

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In head to toe assessment, after performing neurologic examination, which should be

assessed next?

Select one:
a. Skin, hair, head and neck including eyes, ear, nose and mouth
b. Perineal area, legs and feet
c. Chest, back, arm, abdomen

d. Eyes and ears alone

Monitoring for signs of a fat embolus is of particular importance when caring for a client
with which problem?
Select one:
a. Osteogenesis imperfecta
b. Femoral fracture
c. Degenerative disc disease
d. Systemic lupus erythematosus

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Nursing care of a client with a fractured hip should include the assessment of pedal
pulses. The nurse should assess for which important characteristics of the pedal pulses?
Select one:
a. Local temperature and visible pulsations
b. Contractility and rate
c. Color of skin and rhythm
d. Amplitude and symmetry

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People in the early stages of Alzheimer's can't learn new information.

Select one:
a. True
b. False

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PERRLA refers to 

Select one:
a. Motor function
b. Order of assessment
c. Level of consciousness

d. Pupillary response
Scientists believe that _______ develop in the brain of an Alzheimer's patient, and may be
a cause of the disease.

Select one:
a. Tumors
b. Cholesterols
c. Plaques and tangles
d. Ruptured blood vessels

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Soon after admission to the hospital with a head injury, a client’s temperature increases
to 102.2° F (39° C). The nurse considers that the client has sustained injury to what
structure?
Select one:
a. Globus pallidus
b. Thalamus
c. Hypothalamus
d. Temporal lobe

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The client has just had a total knee replacement for severe osteoarthritis. Which of the
following assessment findings should suspect possible nerve damage?

Select one:
a. Bleeding
b. Numbness
c. Pinkness
d. Dislocation

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The collection of the data regarding clients’ health in chronological order.

Select one:
a. Physical Exam
b. Biographical Data
c. Health Data

d. Health History
The difference between a "head to toe" assessment and a "focused assessment":
Select one:
a. Head to toe is done on every shift while focused is done when the person is admitted.
b. Both RN's and LPN's should do head to toe assessments as well as focused
assessments.
c. Head to toe is completed when the patient is admitted; focused concentrates on a
particular part of a body.
d. Head to toe is systemic while focused concentrates on regional parts.

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The nurse assists the health care provider to perform a lumbar puncture. When pressure
is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is
expected to increase. Which sign should the nurse expect the health care provider to
document?

Select one:
a. Romberg
b. Homan
c. Chvostek
d. Queckenstedt

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The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client
problem "impaired physical mobility." Which long-term goal should be written for this
problem?
Select one:
a. The client will turn every two (2) hours while awake.
b. The client will have no skin irritation.
c. The client will have no muscle atrophy.
d. The client will perform range-of-motion exercises.
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The nurse is administering a mental status examination to a 48-year-old patient who has
hypertension. The nurse suspects depression when the patient responds to the nurse's
questions with:

Select one:
a. "I don't know."
b. "Who are those people over there?"
c. "Is that right?"

d. "Wait, let me think about that."

The school nurse is attending to a student athlete who reports muscle pain after a
practice session. What should the nurse identify as a cause of this pain when providing
instruction to the student?

Select one:
a. Hydrochloric acid
b. Acetoacetic acid
c. Lactic acid
d. Butyric acid

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To reduce a hip fracture, the client is placed in traction before surgery for an open
reduction and internal fixation. Because the client keeps slipping down in bed, increased
countertraction is ordered. How does the nurse increase the countertraction?

Select one:
a. Add more weight to the traction.
b. Use a slight Trendelenburg position
c. Elevate the head of the bed.
d. Tie a chest restraint around the client

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True or False: Guillain-Barré Syndrome occurs when the body's immune system attacks
the myelin sheath on the nerves in the central nervous system.

Select one:
a. True
b. False

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Use of alcohol, cigarette, caffeine or supplements are important in heath history and
should be included in:

Select one:
a. Personal and Social
b. Fun and Pleasure
c. Illegal activity

d. Rest and recreation

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Vital signs are reliable even when there is neurologic deficit.

Select one:
a. True
b. Not all the time
c. False
d. Sometimes

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What are the primary presenting symptoms that distinguish Vascular Dementia from
Alzheimer's disease and/or other dementias?

Select one:
a. Tremors
b. Memory impairment
c. Gait alterations
d. Impaired judgment

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What are the three components of the Glasgow Coma Scale?

Select one:
a. Eyes, Motor, Memory
b. None of the above
c. Eyes, Verbal, Motor

d. Eyes, Motor, Pain

When assessing a patient, you should:
Select one:
a. Look, Feel, Rate, Stimulate
b. None of the above
c. Check, Observe, Stimulate, Rate
d. Observe, Move, Feel, Rate

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When auscultating for lung sounds, which part of the stethoscope is designed to
transmit the higher pitch of abnormal sounds.

Select one:
a. Ear piece
b. Bell
c. Tubes
d. Diaphragm

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When communicating with patients who have dementia, which of the following
responses is most effective?

Select one:
a. Repeat questions and comments frequently
b. Have the patients begin tasks on their own to promote independence
c. Utilize visual cues such as pointing or touching items
d. Speak louder to the patient who has delayed response time

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When completing a neurological assessment, the nurse determines that a client has a
positive Romberg test. Which finding supports the nurse’s conclusion?

Select one:
a. Fanning of toes when the sole of the foot is firmly stroked
b. Dilation of pupils when focusing on an object in the distance
c. Inability to stand with feet together when eyes are closed

d. Movement of eyes toward the opposite side when head is turned

When conducting Physical assessment, which should be prioritized?

Select one:
a. Offer a glass of water
b. Give a patient a jacket
c. Offer a chair
d. Ask the patient to empty bladder

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When entering a room in a medical unit, the nurse identifies that a client is having a
seizure. What should the nurse do in addition to protecting the client from self-injury?

Select one:
a. Begin oxygen by mask at 8 L/min
b. Turn the client on the left side.
c. Insert an oral airway.
d. Monitor the seizure activity.

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When monitoring a client for compartment syndrome, which question should be

included in the assessment?
Select one:
a. “Is there a red line going down your arm?”
b. “Has the pain increased in your arm?”
c. “Has the swelling increased near your shoulder?”
d. “Does it hurt when you flex the muscle of your arm?”

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Which assessment intervention should the nurse implement specifically for the diagnosis
of Guillain-Barré syndrome?
Select one:
a. Assess deep tendon reflexes.
b. Check for Babinski's reflex.
c. Take the client's vital signs.

d. Complete a Glasgow Coma Scale.

Which client is most at risk for developing Alzheimer's Disease?
Select one:
a. A 60-year-old male who is also a physician.
b. A 50-year-old, Caucasian female.
c. A 40-year-old mom of 3.
d. A 70-year-old African-American Female.

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Which complaint would be expected when reviewing the health history of a client with
rheumatoid arthritis?
Select one:
a. Joint stiffness for 1–2 hours on arising.
b. Rash over the nose and cheeks.
c. Intolerance of vegetable protein.
d. Reddened edematous joints.

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Which intervention will the nurse include in the plan of care for a patient with moderate
dementia who had an appendectomy 2 days ago?
Select one:
a. Remind the patient frequently about being in the hospital.
b. Place suction at the bedside to decrease the risk for aspiration.
c. Provide complete personal hygiene care for the patient.
d. Reposition the patient frequently to avoid skin breakdown.

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Which intervention would appropriately be included in the care plan of a client

experiencing an acute episode of rheumatoid arthritis?
Select one:
a. Assist the client to weight bear on affected joints for at least 15 minutes three times a
day.
b. Guide the client in active exercises for the affected joints twice a day.
c. Apply ice packs to affected joints.

d. Maintain affected joints in a hyperextended position

Which of the following is a good treatment option for Guillain-Barre syndrome?

Select one:
a. Kidney transplant
b. Plasmapheresis
c. Cryotherapy
d. Antifungal
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Which of the following is not included in the neurologic assessment?

Select one:
a. Level of consciousness
b. Range of motion
c. None of the above
d. Motor function

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Which of the following is the most important risk factor for developing late-onset
Alzheimer's disease?

Select one:
a. Head injuries
b. Advanced age
c. A family history of the disease
d. Drinking from aluminum cans or cooking in aluminum pots

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Which priority client problem should be included in the care plan for the client
diagnosed with Guillain-Barré syndrome?

Select one:
a. High risk for injury.
b. Altered nutrition.
c. Fear and anxiety.

d. Ineffective breathing pattern.

Which statement by the client supports the diagnosis of Guillain-Barré syndrome?

Select one:
a. "I think one of the people I work with had this."
b. "I had a really bad cold just a few weeks ago."
c. "I just returned from a short trip to Japan."
d. "I have been taking some herbs for more than a year."

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Which topic would be included in the teaching plan for a client with gout?
Select one:
a. Need to include foods high in purine in the daily diet
b. Benefits of decreasing intake of dairy products
c. Importance of restricting use of alcohol
d. Necessity of limiting fluid intake

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You are teaching a patient with osteopenia. What is important to include in the teaching
plan?
Select one:
a. Stop smoking.
b. Lose weight.
c. Eat a high-protein diet
d. Start swimming for exercise.

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You're assessing a patient's health history for risk factors associated with developing
Guillain-Barré Syndrome. What is the risk factor that is present with this condition?
Select one:
a. Hyperthermia.
b. Recent upper respiratory infection.
c. Patient's age: 3 years old.

d. Negative stool culture

Nurse Vladimir Puteen plans to include the parents in therapy sessions along with the client who
suffering from Anorexia Nervosa. Which fact should nurse Vladimir remember to be typical of parents of
clients with anorexia t ervosa

a. They alternate between loving and rejecting their children

Ob They maintain emotional distance from their children

c. They usually have a history of substance abuse.

d. They tend to overprotect their children

A child is being managed at the hospital following a falling injury. Upon assessments, the following
would indicate to the nurse that the patient may be having Patau Syndrome except?

O a History of seizures and apnea

O b. Able to answer yes and no questions despite presence of cleft lip

Oc Small penis, and small undescended testes

Od Low set ears and deafness

During a visit, Patient Robaba tells Nurse Rico Yan he's not taking prescribed doses of haloperidol
anymore because she's tired of bothering with it. He exclaims he doesn't need it. Which is Nurse Ric
Yan's Best response

a. Consult with the physician about changing the medication to haloperidol decanoate (Haldol

Decanoate) injections.

b. Have the client's family begin commitment procedures so that her medication regimen can
be supervised more closely

OcExplain the negative effects of skipping the medication

d. Refer the client to a partial hospitalization program so that she can participate regularly in

group therapy sessions

Mark lan is a student nurse who is caring for a 25-year old client who has progressive dementia and is
now very confused Mark lan's communication tools should include

a speaking very loudly.

Ob gentle touch while guiding ADLS (activities of daily living)

Ⓒc written directions for bathing

Od flat facial expression.

A 4-year-old boy is brought to the office due to unusual behavior and concerns about intellectual
development His parents state that "be doesn't speak a lot and doesn't seem to listen. They describe
him as a slow learner who uses only single words and frequently mumbles. The patient is able to
recognize a circle and the colors yellow and red, but he struggles to recognize other shapes and colors.
He scribbles but does not draw lines. The patient crawled at 7 months and walked by 13 months. When
he briefly attended preschool, he refused to speak at all and preferred to play with toy cars by himself
He was asked to leave the school due to daily temper tantrums in which be became hyperactive and
banged his head with his hands when the teacher tried to redirect him. The patient was born at term
from an uncomplicated pregnancy and delivery, and his physical growth has been normal Weight and
height are at the 50th percentile During the examination, the pat ent refuses to speak with the physician
and sits in the corner lining up toy cars. When his mother attempts to divert his attention from playing
he has a temper tantrum and begins to hit his head A brief physical examination is normal. Which of the
following is the most likely explanation for this child's behavior?

a. Selective mutism

O b. Lesch-Nyhan syndrome

O c. Developmental language disorder

O d. Fragile X syndrome

O e. Global developmental delay O f. Autism spectrum disorder

O g. Stereotypic movement disorder

Methylphenidate (Ritalin) is prescribed to an 8-year-old child for the treatment of attention deficit
hyperactivity disorder (ADHD). The nurse will most likely monitor which of the following during the
medication therapy?

O a. Height and weight

O b. Temperature and breath sound.

O Intake and output.

Od A Deep tendon reflex

Nurse Ganda is planning for patient Vizzie, a 10-year-old child. Which outcome criteria would be
appropriate for a child diagnosed with oppositional defiant disorder?

a. Allow the child to establish his own limits and boundaries

b. Accept responsibility for own behaviors.

c.Set firm and consistent limits with the client.

d. Be able to verbalize own needs and assert rights

A 27-year-cid woman is brought to the emergency department by her husband after she failitedat home
the patient is an avid runner and follows a strict diet and exercise regimen She has been on a special
juice fast and is training for a marathon with her husband She also describes feeling out of control when
she hat periods in which she craves sweet foods and eats everything insight She frets depressed and
guilty afterward and tries to make up for at by fasting and running an additionatimes the next day. The
patient breaks down in tears as she describes fears that her husband will leave her because of her
"disgusting body Review of systems is unremarkable except for mental tegularity Temperature in 37C
(58 6 F blood pressure is 962 mmHg pulue is 96/min and spirations am 14/m 20 kg/m2. Physical
examination is unremarkable. Which of the following is the most likely diagnosis in this paint

Oa. Obsessive-compulsive personality disorder

Ob. Avoidant/restrictive food intake disorder

Oc Binge-eating disorder

Od Anorexia nervosa

Oe Body dysmorphic disorder

1. Bulimia nervosa

A nurse may encounter children with mental disorders Her knowledge of these various disorders is vital.
When planning school interventions for a child with a diagnosis of attention deficit hyperactivity
disorder, a guide to remember is to

Select one:

O a. Remove the child from the classroom when disruptive behavior occurs.

Ob. Encourage the child to engage in any play activity to dissipate energy

O c Ignore the child's overactivity.

d. Provide as much structure as possible for the child

A 22-year old woman is brought to the emergency department by friends after passing out at a party
They report that alcohol and marijuana were available at the party but are not sure what the patient
was using The friends have seen her use cocaine and mantuana in the past bottles of prescription
alprazolam and hydrocodone are found in her handbag. The patient has no known history of medical
problems and there is no evidence of trauma. On examination, she is stuporous Temperature is 36.1 C
(97 F) blood pressure 15 100/60 mm Hg, pulse is 54/min, and respirations are 6/min. The pupils are 3
mm and reactive Heart and lung examination is normal and bowel sounds are present. On neurologic
examination, the patient responds to painful stimuli and has decreased reflexes bilaterally
Administration of naloxone has no effect Which of the following substances is the most likely cause of
these findings?

O a Alcohol and cocaine

Ob. Alcohol and marijuana

Oc Alcohol and opiates

Od Benzodiazepinesonly
A 58-year old woman comes to the emergency department after developing a headache following a
gourmet meal that included heavy sauces and wine On arrival the patient is aroious and tremulous
Medical history includes recurrent major depression with psychotic features, generalized anxiety
disorder, and osteoarthritis Medications include phenetzine and risperidone, which she takes as
prescribed Her depression has been m remission for the past 5 years. She does not use Illicit druge
Which of the following is the most likely finding on physical examination?

O Muscle rigidity

Ob Hypotension

OcMyoclonus

Od Hyperthermia

Hypertension

OLHyperreflexia

A 10-month-old boy is brought to the office by his mother for a checkup. She is concerned that for the
past several months he has cried and had screaming fits whenever another adult attempts to hold him.
She plans to return to work next month and is worried about leaving him with the babysitter. The family
recently moved to a new home so that she will be closer to her office. The patient pulls to a stand, and
says "Ma" The mother tries to feed him a range of food but he often refuses to eat certain vegetables
During the interview, the infant sits quietly on his mother's lap but cries when being weighed by the
nurse. During the examination, the patient turns his head away from the physician, cries, and does not
respond to his name. Physical examination is normal and the infant is at the 55th percentile for growth.
Which of the following is the most appropriate response to the mother's concerns?

Oait is likely that your son has stranger anxiety, which is normal at this age

Ob Attachment anxiety is normal at this age but he should be monitored for reactive attachment

disorder

Oe. Your son's attachment anxiety is likely an adjustment reaction to your recent move and should
resolve with time. O

d. It is possible that your son is developing separation anxiety disorder.

Oe. This behavior suggests that your son has insecure attachment and needs extra time to separate from
you

Of. Not responding to one's name may be an early sign of autism and we should monitor your son
closely
A 12-year-old boy is accused of setting his neighbor's house on fire. His parents say. "We can't believe he
would do anything like this: he has always been hyperactive but is basically a good kid The past year he
has been a little more irritable and argumentative with us, but that's just typical of preteens. The
parents add that he has been obsessed with becoming a firefighter since a young age and spends hours
on the internet watching videos about fires and firefighting. The boy's grades are average, and his
teachers describe him as a loner who has difficulty making friends at school. Two years ago, he was
caught setting a fire in his backyard. The boy has also been linked to several suspicious fires in the
neighborhood although no criminal charges have been brought against him. Based on this information,
which of the following is the most likely diagnosis?

O a Obsessive-compulsive disorder

b. Pyromania

Oe Oppositional defiant disorder

Od Normal developmental experimentation

A patient was admitted after he was found to have been manifesting sudden changes in thinking and
loss of the ability to focus attention. The patient is currently observed for delirium. Which of the
following is a proper intervention for the nurse

O a. Do not give food and water as the patient is at very high risk for aspiration at this time

Ob provide reassurances even if the patient is manifesting psychosis

Oc avoid talking to the patient during active delirium. Thiswill trigger agitation and irritability

O d. Prevent the patient from falling asleep as sleeping will aggravate the disorder

A 36-year-cid man comes to the office for a routine annual examination accompanied by his wife The
patient has no new medical problems and physical examination is unremarkable. At the end of the visit
the wife asks to speak with the physician privately and expresses concerns about her husband's
behavior. She reports that over the past few years, he has become increasingly irritable less interested s
his work and obsessed with schemes to make huge sums of money this behavior has increased even
more since his mother's death 2 months ago. She says, "My husband stays up all night to gamble online
and then misses work the next day He was recently placed on probation at his job as an insurance agent
for poor performance When she confronts him about his behavior, he becomes angrier and more
imitable. Although the patient has lost a considerable amount of money. he is convinced that he has the
ability to win it all back and more if he could just borrow enough from friends and play my cards right
The patient denies that he has any problems and says. Tve just been a little down since my mother died
and insists that gambling is the only thing that makes him feel really good Which of the following is the
best explanation for the patients behavior

O a. Bipolar disorder

O b. Obsessive-compulsive disorder

Ⓒc Cyclothymic disorder

Od. Adjustment disorder with disturbance of emotions and conduct

Oe Obsessive-compulsive personality disorder

F. Gambling disorder

A 5 year old boy is being assessed in the clinic for his regular check up as a patient under autistic
spectrum. The child does not talk to the nurse at all and does not throw any eye contact with the people
around. Knowing that autistic children have poor to absent social engagement, the nurse knows that
special children can be victims of child abuse at home. Which of the following is not a manifestation of
child abuse?

O a Mother reports that the child usually bangs his head on the wall

Ob. The child shows rhinorthea

Oc Presence of Racoon's eyes

Od Battle's sign seen with he child

Patient Corazon has been prescribed flucvetine (Prozac) 20 mg to be taken at bedtime Shee claims that
"Prozac is not even helping her to sleep Nurse Carla can educate her that

OaThat the client is on the wrong medication

b. That the client should take Prozac in the morning

c. That the clients symptoms of depression seem to be getting worse

Od. That dose is too high

Patient Gwagwa has been admitted for observation from the clinic of Dr. Ferrer for potassium
replacement infusion The patient has a history of psychosis on home meds and verbalized feelings of
palpitations and weakness. Which of the following will the nurse prioritize to investigate about?

O a Diet and nutritional status

Ob Time of the last and the next Quetiapine dose

Oc. Ability of the patient to decide for himself

Od. Presence of needle marks in the patient's arms

Nurse Aileen is assessing a patient with amnestic disorder Which of the following does not indicate the
disorder?

Da hallucination

Ob disorientation

Ocamnesia

O d. confabulation

Which of the following describes a 12-year-old patient with under the autistic spectrum

Oa Has problems with coordination or has odd movement patterns, such as clumsiness or walking on
toes and has odd stiff or exaggerated body language

Ob Genius and intelligent at recognizing nonverbal cues, such as interpreting other people's facial
expressions, body postures or tone of voice

Oc Likes cuddling and holding but seems to prefer playing alone, retreating into his or her own

world

O d. responds to his or her name or appears to hear you at all times

A 6-year-old girl is brought to the clinic for evaluation of 'strange behavior. Her parents have noticed
that she seems to have conversations with herself when no one else is there, especially when she is
alone in her room. In addition, when the girl dropped a plate at dinner, she said that "Mudsie did it and
that Mudsie was a friend who went to school with her. She states. "Mudsie is my invisible friend who is a
bit clumsy, but I am teaching her to go slowly so that she gets better The patient has no chronic medical
conditions and has reached all her developmental milestones on time. Her maternal aunt was recently
diagnosed with bipolar disorder. The patient has friends at school and gets along well with her 2 older
siblings She plays basketball although she worries that she is not a good player because she drops the
ball often. On mental status examination, the patient is friendly, cooperative, and responds
appropriately to questions She says that she can see and hear Mudsie but reports no other auditory or
visual hallucinations. At one point in the interview she looks over her shoulder and says. "Shhh, Mudsie,
not now. Her parents are concerned that her behavior is abnormal and will interfere with her ability to
make real friends. Which of the following is the most appropriate response?

a Your daughter will likely no longer need her imaginary friend once she feels more confident playing
basketball

b. Your daughter may be experiencing early signs of psychosis she requires further evaluation.

c Having imaginary friends is often associated with mood disorders starting cognitivebehavioral therapy
should be considered

d Having imaginary friends is normal however, their presence can adversely affect the development of
real friendships

e Having imaginary friends is normal at this age and may help with social relationships

Mario is admitted to the emergency room with drug-included araiety related to over ingestion of
prescribed antipsychotic medication. The most important piece of information the nurse in charge
should obtain initially is the:

O a Length of time on the medication

Ob Reason for the suicide attempt

O c Name of the ingested medication &amp: the amount ingested

O d. Name of the nearest relative & their phone number

A 46-year-old hospitalized man is evaluated for confusion. He was admitted 3 days ago after a motor
vehicle collaion in which he was a passenger He sustained fractures of the right tibia and fibula which
were surgically reduced and fixed. The patient had a small subdural hematoma without midine shift,
which was managed nonoperatively. He has been receiving intravenous morphine for pain control. This
moming the patient was agitated and disruptive and was talking to persons who were not there. He no
significant medical history and takes no regular medications Temperature 37.5 C (995), blood pressure is
170/100 mm Fig pulse is 120/min and regular and respirations are 22/min. Pulse oximetry shows 96% on
room air The patient appears diaphoretic and tremulous and is trying to pull out the intravenous lines.
He is not cooperative for funduscopic examination, but pupils are equal and reactive bilaterally Breath
sounds are normal and no heart murmurs are heard The abdomen is soft and nontender The surgical
incision shows no surrounding erythema The patient moves all extremities without limitations. Which of
the following is the most likely cause of this patient's acute confusion?

a. Delirium tremens

O b. Fat embolism syndrome

Ⓒc. Neuroleptic malignant syndrome

O d. Opiate intoxication

O e. Pulmonary embolism

Of Malignant hyperthermia.

qg. Elevated intracranial pressure

Which of the following signals incidence of delirium tremens for a patient suffering from alcohol

withdrawal?

O a Delusion of grandeur

O Psychosis

cRapid, cheyn stokes respirations

O d. Panic attack

A student nurse discusses the pathophysiology of ADHD She is correct if she relates the client's

"impulsivity with which of the following?

Oa GABA

O b. dopamine

Oc.Norepinephrine
Od. Serotonin

1. Client Zarina, who is taking tranylcypromine sulfate (Parnate), is requesting information about foods
that she would be allowed to eat while under the medication. Which item is safe to consume while
taking such medication?

Select one:

a Sunmaid raisins and prunes

O b. Nestle Yogurt

O c. Smoked galunggong

Od. Orange fruit from Aling Carmina's stall

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia
nervosa. Which assessment findings should the nurse does not expect to note?

a Loss of tooth enamel

Ob Dental decay

c. Electrolyte imbalance

Od. Maist, oily skin

When being interviewed at a psyche facility, a female patient admits to having recurrent, intense sesual
urges behaviors, or sexually arousing fantasies, involving acts in which the psychological or physical
suffering (including humiliation) of her partner is sexually exciting The nurse who overhears this knows
that the patient's description suits which of the following paraphilia?

O & Necrophilia

Ob. Sadism

cMasochism
Od Sado-Masochism

A dient has been prescribed diazepam (Valium). Which assessment finding indicates an adverse effect of
the medication?

O a Slurred Speech

Ob Hypercapnic Hypoxemia

OcFatigue

Od Drowsiness

A mother brings her 13-year-old daughter to the office due to changes in her behavior. The mother
reports that her daughter seems obsessed with her appearance and has refused to leave the house
without wearing a hat for the past several months erviewed alone, the patient says "I have this ugly bald
spot and it is so embarrassing I pull my hair when I get anxious. I try to stop myself but sometimes I
don't even realize I'm doing it The patient has no problems with sleep and her appetite is good She does
well in school and has many friends. Family history is significant for obsessive compulsive disorder.
Temperature is 367 C (98 F), blood pressure is 110/80 mm Hg, pulse 88/min, and respirations are
14/min. She weighs 75 kg (165 3 lb) and is 167.5 cm (5 ft 6 in) tall The patient's hair is long with
numerous broken strands over the majority of the scalp and a small alopecic patch with a few strands of
various lengths on the occiput. The remainder of her physical examination is normal. Which of the
following is the most likely diagnosis in this patient?

Ⓒa. Body dysmorphic disorder

Ob. Trichotillomania

Oc. Generalized anxiety disorder

O d. Obsessive-compulsive disorder

O e. Alopecia areata

A woman brings her 17-year-old son to the office for evaluation of his behavior, saying "He har been
getting into trouble for years and does poorly in school I can't deal with him anymore The boy says that
he cannot pay attention in class because the teachers are so boring' He refuses to do any homework and
has received mostly 75-79% throughout high school. The mother says. "He never listens to me and has
always been so impulsive Last week he was found stealing P2000 from a neighbor's house. The patient
explaine looked through the window and saw the money on the kitchen table I thought I should take it
because they never paid me for mowing their lawn last year He has been suspended from school several
times for fighting truancy, and taking back to teachers The boy often argues with and lies to his parents
and her stolen small amounts of money from them as well. The patient uses alcohol and marijuana
when I get the opportunity He has tried cocaine but felt it made him soo hyper" Which of the following
is the most likely explanation for the patient's behavior

Antisocial personality doorder

A 26-year-old man is brought to the emergency department after an attempted suicide by medication
overdose. He has had 2 seizures in the past hour. Temperature is 38.8 C (102 F), blood pressure is 90/60
mm Hg, pulse is 110/min, and respirations are 22/min. The patient is not oriented to time, place, and
person. Pupils are dilated and respond poorly to light the skin is flushed and dry Abdominal examination
shows reduced bowel sounds: ECG shows prolonged ORS complexes (0.19 sec) Toxicology studies are
pending Which of the following is the best predictor of complications due to overdose of the suspected
drug?

Select one

Oa. Serum drug levels

O b. QRS duration

OcBowel sounds

O d. Pupillary size

Oe Urine drug levels

A 22-year-cid man comes to the office for a paychiatric evaluation at his mothes insistefice. She is
worried that her son has no dose friends, does not date and shows no interest in activities popular with
young adults. His mother describes normal developmental milestones but says "1 thought he would
outgrow his shyness, but he seems more isolated than ever The patient attends a local university where
he studies engineering and performs well academicaly After class he returns home and enjoys playing
computer games or reading comic books When interviewed alone the patient makes limited eye contact
He gives brief reponses and appears somewhat anious and uncomfortable at times but his affect is
predominantly nat in response to questioning about reasons for avoiding social activities, he replies, Tm
just not comfortable around people I don't like it when people try to get too personal and would rather
keep to mysell! This patient's behavior is most consistent with which of the following!

a Avoidant personality disorder

Ob Schizoid personality disorder

Parano1d personalitydsorder

d. Autism spectrum disorder O e Antisocial personality disorder

O f. Schizotypal personalitydisorder

O g. Social anxietydisorder

A patient was rushed to ER due to hypoventilation and loss of consciousness. Which of the following
indicates that the patient is suffering from benzodiazepine toxicity?

a. Ataxia

O b. Irritability

O c. Seizure

Od. Diarrhea

The nurse asks a cient to roll up his sleeves so she can take his blood pressure. The client replies you
want i can go naked for you. The most therapeutic response by the nurse is

0 & You would be the first that I will see naked

Db1only need access to your arm Putting up your sleeve is fine"

Oc"You're attractive, but I'm not interested.

Od will report you to the guard if you don't control yoursell

In a client with ADHD, disturbance of which of the following is responsible for the patient's lack of
attention?

O Serotonin

O b. Parents lack of time spent with the patient because they have to work far from home.

O cDopamine

d. Norepinephrine

Nurse Dorita is caring for a patient with cognitive impairment. Which of the following will he use when
communicating with her client?

A. Short words and simple sentences

b. Complete explanations with multiple details

c Stimulating words and phrases to capture the client's attention

d Pictures or gestures instead of words.

All of the following are hallmarks of a child with ADHD except

O a Hyperactivity

Ob Impulsivity

C.Inattention

Od Lack of care and attention from family and parents

A 15-year-cid girl is brought to the office by her mother, who is concerned about her moodiness and
behavior. She was recently suspended from school for talking back to the principal The girl says that she
initially g in trouble of not following "some stupid classroom rule. When the panent was sent to the
principal's office, she lost her temper and impulsively cursed at him. She blames her consistency poor
grades on "boring teachers and being unfaidly penalized for handing in assignments late. The mother
says "I think she's just a rebellious and moody teenager but it's difficult when she doesn't leten to me I
worry when she stays out past her curfew Her room is a total mess, and she gets extremely annoyed
when I ask her to do the smallest household chore There is a history of bipolar disorder in the patients
maternal aunt and depression in her sister Mental statue examination is notable for irritable affect and
moderately loud speech Which of the following is the most likely diagnosis!

Oa Antisocial personality disorder

b Oppositional defiant disorder

Oc Cyclothymic disorder

A 16-year-old boy comes to the office with a lengthy history of frequent episodes in which he swears
uncontrollably at others according to his mother. The episodes are accompanied by blinking grunting
and grimacing The patient has tried habit reversal therapy with limited benefit and has been treated
with guanfacine for the past year His mother is concerned that, despite the medication, these episodes
have progressively worsened, and she fears that he is bullied at school. The symptoms have affected his
ability to take tests and socialize with others leading to increased isolation and worsening academic
performance She asks if there is another medication that could help control his symptoms. Which of the
following describes the patient's demeanor?

a. Conduct Disorder

O b. ASD

O COCO

Od Tourette Syndrome

E.Antisocial Personality disorder

f Boarderline Personality Disorder

g Oppositional defiant disorder

A child is being assessed for mental retardation. Which developmental finding would the nurse expect
note for a 10-month old patient?

O a The child rides on the soft broom to role play as a horse back rider, indicating the child's symbolic
representation

b. Child seeks for lost toy as a sign of increased permanence

Oc Collects pokemon stickers and cards as priced collectibles

Od. The concept of animism is alive

Patient Nonito is being monitored for delirium. The nurse is aware that which hallmark manifestation
indicates presence of delirium?

a Tachycardia Tachypnea and irritation

b. ptosis and drooling

C Signs of psychosis

Od. Syndenham's chorea

A patient who has mental retardation and cleft Ig and cleft palate was rushed to a pediatric clinic

The patient is restful and calm with normal breathing mechanisms, pulse rates. The mother

verbalizes her concern that the child may not be having enough nutrition because he is difficult to be led
Which of the following is the numa's priority diagnosis to consider at this time?

O a imbalanced Nutrition less than body requirements

b. Severe Malnutrition secondary to Kwashiorkor

DcRisk for Aspiration

Od Impared airway clearance

A patient with bulimia nervosa is seen with persistent binging and induced vomiting. Which of the
following assessment findings is a priority for the nurse associated in the patient's condition?

a. serum potassium of 2.05

Ob corrosion and inflammations of the patient's gums

O fractured teeth

Od initiate aspiration precautions without fail

A patient diagnosed with Oppositional Defant Disorder will most likely to present as

a A person with personality chater

b.one whis often argues with authority figures or, for children and adolescents with adults

One who often deliberately seduce the

d. with Temper tantrums

A 2-year old patient is being evaluated with his mother at a pediatric ward. Which of the following
observations if stated by the mother would prompt the nurse to conduct a deeper evaluation for autistic
spectrum disorder?

Da My child uses gesture-such as point or wave-by 14 month

b My baby has already babbled or cooed by 12 months

O'My child doesn't play make believe or pretend by 18 months

Od My baby is brilliant She car utter 2 word phrases

A 27-year old woman comes to the office for a pre employment physical examination. The patient has
no medical conditions but is concerned about weight gain, iregular menses, abdominal boating and
constipation She exercises for an hour on most days but mentions that her energy has been lower than
she would like. She takes no medications. The patient drinks 1 or 2 glaces of wine several times a week
when socialing with friends She weighs 5 kg (1433 and is 162.5 cm (5 4 in) tall Temperature is 17C (6)
blood pressure is 100/70mm Hg, pube is 36/min and respirations are 10mm, Physical examination shows
dry skin enlarged parotid glands abrasions on her right hand and mild generalized abdominal tenderness
to palpation. The remainder of the examination is remarkable Which of the following abnormalities is
most likely in this patient

a Metabolik acidosis

B. Hypercortisolemia

C.Low hemoglobin and hematoot

D. Hyperchloremia

e Hypokalemia

F.Elevated TSH level

A 7-year-old boy is brought to the office by his parents for an annual checkup He is in 2nd grade does
well academically and has no medical problems His mother worries that he has no friends and prefers to
play computer games by himself or spend time repeatedly organizing his extensive baseball card
collection On further questioning she says that the boy moved to a new school this year because he was
being bullied The mother says. He is different from the other kids and struggles to join in their games
and conversations" She also mentions that be eats only 3 specific foods and has unusual food rituals.
"He likes his glass to be led to a certain level and doesn't want different foods touching each other on
the plate The father disagrees and says, "He's just a picky eater like was as a kid Other kids can be means
its just part of growing up I take time for him to t used to this new school and make friends.
Developmental milestones are within normal range get u There is no known psychiatric history On
examination, the boy makes poor eye contact and answers the physician's questions in a polite but
formal manner. Physical examination and growth curves an normal The father asks the physician to
reassure his wife that octhing is wrong. Which of the following is the most appropriate course of action

A. inform the parents of an autism spectrum diagnosis and recommend immediate intervention

Ob Monitor his behavior over the course of the next year as he adapts to his new school OcExplain that
his behavior is characteristic of high-functioning autism, but no intervention is

necessary if he is otherwise doing well

Od. Reassure the parents that there is no concern as the boy does well in school and his growth curves
are normal

Oe Explain the spectrum of developmental disorders and recommend further evaluation

Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client
diagnosed with bulimia is

Select one

O a Encourage to avoid foods

Ob Avoid shopping plenty of groceries OcEat only three meals a day

Od identify anxiety causing situations

A dient is admitted to a mental health unit with a diagnosis of anorexia nervosa When planning care for
this client, which primary intervention should health promotion focus on?

O a Emphasizing social interaction with clients who are withdrawn O b. Examining intrapsychic conflicts
and past issues

c. Helping the client identify and examine dysfunctional thoughts and beliefs

Od. Providing a supportive environment

A 74-year old woman comes to the office accompanied by her husband for a routine checkup The
patient has a history of hypertension and hypercholesterolemia. She has no other medical problems or
physical limitations At today's visit, her blood pressure is elevated and her husband says that she often
forgets to take her blood pressure pills The patient says "Its herd to remember to take them every day
Her husband believes that her speech has changed as she occasionally struggles find approp10te words
and sometimes cannot recall people s names Two days ago, she drove to a nearby grocery store and was
unable to find her way back She naps during the day, has difficulty faling asleep at night, and always
wakes up early m the morning. Hier appetite is good Physical examination is within normal limits. On
mental status examination, the pabent is calm and cooperative She says her mood is good. Which of the
following is the most specific indicator of dementia (major neurocognitive disorder) as opposed to
normal aging in this patient

O a Patient's awareness of forgetfulness

Ob Forgetting to take her medication without reminders sundowning

Od Getting lost in familiar terffory

De Sleep disturbance

OfWord finding difficulty

An 18-month-old boy is brought to the office by his mother for a checkup The patient was born at full
term without complications Growth has been consistently along the 80th percentile for height and
weight The mother reports. He is healthy and seems happy just playing by himself, but I am concerned
about him not talking" She says that he makes some sounds that are unintelligible, has a 1-word
vocabulary of no," and does not yet say "mama" "dada", or "bye-bye" The patient is able to walk and is
starting to run. He can scribble and with help can use a spoon to feed himself. On examination, he does
not make eye contact, respond to his name, or follow the doctor's gaze when toys are pointed out to
him. Hearing testing is normal. Which of the following is the most likely explanation for the patient's
behavior?

f. Autism spectrum disorder

For a client with amnestic disorder, which of the following is the most importare indeenton

Da Incourage expression of feelings

Ob Encourage independence
C.Reminisce events with the client

Od. Encourage group participation

Nurse Gwyneth is conducting a visit on a patient diagnosed with autism. She is correct if the states that
which of the following is not an expected behavioral pattern from an autistic client!

a engages in imitative or make-believe play

Db. Hes specific food preferences, such as caring only a few foods, or refusing food with a certain
texture L

Oc Performes activities that could car self-hur, such as biting on head-banging

Od is fascinated by details of an object such as the spinning wheels of a toy car, ber doesn't understand
the overall purpose or function of the object

which of the fillowing sites involves a patent diagnosed with exhibit

Acapes of nees genital tan especting munger Ob Aport actor who mgages in porn industry

& call of the above

e display of gas to a group of his subsbelive

A 22-year-cid man is brought to the emergency department by his girlfriend after sustaining a hand
injury. The couple was waiting in line for a table at a crowded bar when the hostess inadvertently seated
another couple that was behind them in line. The man suddenly became enraged started pacing back
and forth shouted at the hostess that she was stupid and incompetent and threw a nearby chair against
the wall causing damage to the wall and in using his own hand. The patient sa college student and works
part-time as an events-coordinator. He is remorseful about his behavioe but his girlfriend adds. He can
be moody, frequently gets defensive and loses his temper with the slightest provocation. They have had
several heated arguments during which he has thrown and broken objects The patient has no medical
history. Physical examination is unremarkable except for swelling and lacerations of the hand. Which of
the following is the most likely diagnosis in this patient?

O a Borderline personality disorder

Ob. Narcissistic personality disorder

Oc Antisocial personality disorder

d. Substance intoxication

O e. Disruptive mood dysregulation disorder

f. Intermittent explosive disorder

The nurse is developing a plan of care for an older client with dementia. The nurse develops which
realistic outcome for the client?

O a The dient will function at the highest level of independence possible

Ob The nursing staff will attend to all of the client's activities of daily living needs during the hospital stay

Oc The dient will complete all activities of daily living independently within a 1: to 1%-hour time

frame

Od The client will be admitted to a nursing home to have the needs of activities of daily living

met

Which of the following activities involves a patient diagnosed with thibitionism

Select one:

Ⓒa exposure.ofones genitals to an unsuspering stranger

Ob A porn actor who engages in pore industry

call of the above

Os display of genitals to a group of 6 individuals who subscribed for a private sexual live show

The norte is developing a plan of care for an older client with deeneetia. The nurse develops which
realistic outcome for the dient?

select one

Ⓒa. The client will function at the highest level of independence possible

b. The nursing staff will attend to all of the clients activities of daily living needs during the

hospital stay O The dient will complete all activities of daily lig independently within a 1-to 1-hour time
frame

Od the diens wil be admitted to a nursing home to have the needs of activities of daily living

The nurse is performing an assessment on a client with a diagnosis of anorexia nervosa to the

nursing unit. The nurse reviews the client's medical record before performing the assessment and
expects to note which finding in the record?

a. Elevated potassium levels

b Weight loss of 4% of original weight over a short period

c. Low blood urea nitrogen

Cd. That the client is knowledgeable about the caloric value of food

Nurse Brenda Mage is creating a discharge plan for a patient with ADHD. Which of the following if
instructed to the child's care giver will be best for the child!

a. Do not force the child to eat meals at a structured time and Give hand held food
b. Assert proper behavior during meal time to increase the child's focus in eating.

c.Wait until the child asks for food before giving him his favorite soup and fish dish

d. Initiate a structured meal plan and time

A young mother brings her 5-year-old daughter to the office due to problems at school. The patient
started kindergarten 2 months ago and appeared to be doing fine. Last werk, the teacher called to say
that the child has persistently refused to answer questions or speak to others in class since ther anival.
The teacher did not report it earlier as she thought the child was undergoing an adjustment period
During playtime she prefers to play by herself in class she remains quiet while the other children sing
songs or recite the alphabet The mother finds this very surprising as the patient is talkative at home and
plays with her siblings and neighborhood friends. In addition, the patient did not report any issues with
school to her mother, saying it was fine." She is a little shat social gatherings but interacts with other
kids and adults when she gets to know them. The child is able to te ber shoelaces, jump rope, and dress
and feed herselt She can copy a triangle and is able to count to 10. Physical examination shows no
abnormalities. Which of the following is the most likely diagnosis in this patient?

Oa Stranger anxiety

Ob. Adjustment disorder

O Selective mutism

d. Separation anxiety disorder

e Social (pragmatic) communication disorder

f. Normal shyness

A 44-year-cid man is brought to the emergency department after being found talking to himself in a
park. When authorities asked him to leave, he became agitated and combative, saying he was "destined
to lead and has to wait in the park for the sign The patient admits to not sleeping for the past week. His
thoughts jump from topic to topic and he appears distractible, disorganized, and unable to care for
himself. The patient is admitted to the hospital and started on daily haloperidol and valproate. Over the
next week, he becomes significantly calmer. Although he continues to believe that he will lead a spiritual
revolution. he is sleeping 6 hours a night and is better able to focus Ten days after admission, he fails to
come out of his room for breakfast. Nursing staff members find him lying in bed, confused, sweating,
and stiff. Vital signs are temperature 39.2 C (102.6 F), blood pressure 164/98 mm Hg, pulse 122/min, and
respirations 28/min. As a precaution, all medications are stopped if the patient fails to improve with
supportive measures, which of the following medications would be most appropriate to administer at
this time?

a. Propranolol

b Benztropine

c Cyproheptadine

d. Bromocriptine

Oe. Succinylcholine

A 4-year-old boy is brought to the office for a routine visit. He is growing well and talking in short
sentences. The patient can hop and copy a square He has started to play board games with his brothers
and sister but occasionally hits his siblings when he loses a game His parents are concerned that he
cannot yet tie his shoelaces and ask if it is normal for him to occasionally fondle his genitals in public or
try to touch his brother's genitals while bathing The mother says. "He has shown me dolls kissing each
other's private parts a few times and has asked where babies come from. I haven't even had that talk
with his 6-year-old brother, Is that a normal question for a 4-year old to ask? The parents are also
concemed that the patient still sucks his thumb when anxious and occasionally wets his bed at night He
will be starting preschool soon. Which of the following Jehavior is concerning in this patient?

a Nocturnal enuresis

b Thumb sucking

c Touching the genitals of a sibling while bathing

d. Inability to the shoelaces

e. Simulating oral sex using dolls

f Becoming physically aggressive when losing a game

G. Fonding one's own genital in public

A mother brings her 4-year-old adopted daughter to the office due to concerns about her adjustment to
preschool The patient was taken away from her birth mother, who was abusing cocaine and alcohol, at
the age of 2 and moved to an orphanage The girl was adopted by her current family 6 months ago
Prenatal history is unknown. The adoptive mother reports that the patient doesn't interact with
classmates and prefers to play by herself. At home, the girl hardly speaks with the family and stays in her
room, where the mother has seen her hoarding toys and food under the bed. The patient is able to dress
herself, copy a triangle, write the letters of her name, and walk down the stairs without aid. Her mother
says. "Sometimes she doesn't pay attention or listen to me. At other times she will start to cry for no
reason. She doesn't like being hugged or picked up; nothing I do seems to comfort her." On
examination, the patient is sitting quietly playing with various toys in the doctor's office. She makes
some eye contact. Speech is normal but answers are brief with little facial expression Vital signs and
physical examination are normal. Which of the following is the most likely diagnosis in this patient?

Select one:

O a. Reactive attachment disorder

O b. Disinhibited social engagement disorder

Oc. Post-traumatic stress disorder

d. Adjustment disorder

.O e. Attention-deficit hyperactivity disorder, inattentive type

Of Autism spectrum disorder

Og. Global developmental delay

A42-year old man is brought to the emergency department by police officers after he was found
wandering aimlessly at an airport. The man is alert and answers questions appropriately, however, he
appears to be confused about his identity and does not recognize the name on his driver's license in his
wallet. Extensive inquiry fails to reveal any helpful information as the patient is perplexed and does not
remember where he lives, how he got to the airport, his family members of his profession. His cognitive
function is otherwise intact. A search of his personal belongings reveals an airline ticket from Cebu. An
emergency contact on the patient's phone leads to his wife in Cebu, who reports that her husband "just
disappeared after he found out that his father had passed away.

O a Transient global amnesia

Ob. Brief psychotic disorder

Cc Depersonalization/derealization disorder Od. Post-traumatic stress disorder

Oe. Acute stress disorder

t. Dissociative identity disorder

g Dissociative amnesia

A patient with Down Syndrome who was admitted for epilepsy is now being discharged with Dilantin for
his home meds. Which of the following drug adverse effects should the nurse plans to educate the
mother about?

a. Do not take the medication with grape juice

O b. Watch out for bleeding and inflamed gums

c. Monitor Apical pulses before administration

O d. Take the medication with orange juice

Nurse Bryan is currently assigned to Patient Reynelita who is a 35 year old with bulimia nervosa. He
notes a problem of improper nutrition in the chart. Nurse Bryan determines that which would be
appropriate to assess based on this problem?

a. Previous and current coping skills

b. Client's feelings about self and body weight

O c. Client's eating patterns, food preferences, and concerns about eating

Od. Client's sense of lack of control about the treatment plan

An elderly man is admitted to the hospital. He was alert and oriented during the admission interview.
However, his family states that he becomes disruptive and disoriented around dinnertime. One night he
was shouting furiously and didn't know where he was. He was sedated and the next morning he was fine
At dinnertime the disruptive behavior returned. The client is diagnosed as having sundown syndrome.
The client's son asks the nurse what causes sundown syndrome. The nurse's best response is that it is
attributed to

O a. fluctuating levels of oxygen exchange

. O b. changes in the sensory environment.

Oc. an underlying depression

Od. inadequate cerebral flow.

For a child with Trisomy 21, the nurse expects to find the following manifestations except

O a. Mental Retardation at an IQ result of at least educable level

"O b. Presence of pectum excavatum

O High set ears, Sunset eyes and Monggolian slant

Od. Presence of Brushfield's spots and simian crease

During a counseling session, a couple had expressed concern about the factors that cause Autism. Which
statements by the nurse indicate further education?

O a. "Babies born before 26 weeks of gestation may have a greater risk of autism spectrum disorder.

O b. Families who have one child with autism spectrum disorder have an increased risk of having
another child with the disorder.

Oc"Boys are about four times more likely to develop autism spectrum disorder than girls are

Od. There may be a connection between children born to teen age parents and autism spectrum
disorder, but more research is necessary to establish this link

Martin Sanchez is a nine (9)-year-old child admitted to a psychiatric treatment unit accompanied by Mr.
and Mrs. Sanchez. To establish trust and position of neutrality, which action would the nurse take.

Ca. Review the clinical record prior to interviewing Mr. and Mrs. Sanchez. Encourage Mr. and Mrs.
Sanchez to leave while Martin is being interviewed

. c. Interview Martin with his parents together, observing their interaction.

d. Provide diversion for Martin, and interview Mr. and Mrs. Sanchez alone.

A child is being assessed for cognitive development. Which of the following indicates to the nurse that
the patient is a gifted child?
Oa 10 exam finds the child profound

b. an of above average

Oc Child exhibits extraordinary interest in music

d 10 of 145

Patient Marina is admited for alcoholism. After the family meeting, the client's husband asks the nurse
about ways on how to help the family deal with the effects of alcoholism. Nurse Cheryll should suggest
that the family can join which organization?

a. Alcoholics Anonymous

O b. Make Today Count

c. Al-Anon

O d. Emotions Anonymous

Which of the following specifically describes a patient with Tourette syndrome?

O a. Pyromania

O b. Defiance from laws and rules

c. Uncontrollable urge for theft

O d. Coprolalia

O e. Cognitive impairment

Of. Conduct disorder

A 35 year old woman with amnestic disorder was found to have been suddenly shouting, agitated and
restless. Which of the following should the nurse expect to give?

Da. Amlodipine tablet

Ob. Neuroleptic

Oc Benzodiazepine
Od SSRI

A 32-year cld man comes to the office for evaluation of attention-deficit hyperactivity disorder (ADHD)
Although never treated. he had behavioral problems starting in kindergarten frequently getting into
trouble both at school and at home for not listening, talking out of tum, i inability to sit still. Many of
these difficulties persisted throughout high school and college. The patient continues to struggle with
distractibility forgetfulness disorganization, and impulsivity. He is concerned that ADHD is affecting his
relationships and work performance and mentions that he has been passed over for promotion several
limes. The patient has a history of alcohol and cocaine use disorder from age 18-24 and a family history
of alcohol and opioid abuse in his father and paternal uncle. The patient does not use alcohol or any
illicit drugs. He hopes that medication can help but is concerned about taking anything addictive. Which
of the following is the most appropriate next step in management of this patient?

a Clonidine

O b. Cognitive-behavioral therapy

Oc Modafinil

d Desipramine

e. Dextroamphetamine

O f. Methylphenidate

O g. Atomoxetine

An 11-year old boy is brought to the office by his mother due to concerns about his anxiety and
adjustment to school. Six months ago, he started a new school that requires him to change classrooms
for different subjects This has been stressful for him and has not become easier over time. He often gets
in trouble because he forgets to raise his hand and blurts out answers. The patient reads at grade level
and does well in math but he has particular difficulty in classes that require oral participation or group
projects. His mother says he has always been shy He has no friends at school and can annoy others by
taking incessantly about his interest in space exploration The patient's behavior outside school causes
problems as wel. When morning traffic required departing from routine by taking a different route to
school, he became agitated and refused to go When interviewed the patient locks away from the
physician and interrupts him to recite the names of planets Physical examination is remarkable for a
repetitive opening and closing motion of his hands, which becomes more intense when he is asked
about school, but is otherwise normal. Which of the following is the most likely explanation for the
patient's behavior?
a. Adjustment disorder

b. Attention-deficit hyperactivity disorder

Oc Social anxiety disorder

Od Obsessive-compulsive disorder

e. Tourette syndrome

Autism spectrum disorder

Og. Schizoid personality disorder

A patient is being evaluated for Serotonin Syndrome. Which is not a manifestation?

O a. Bradyreflexia

O b. Hyperthermia

O c. Mydriasis

Od. Myoclonus tremor

A9-year-old boy is brought to the office by his parents for evaluation of behavior problems His mother
says that he never listens gets distracted wasily, and is hyperactive all the time. He is unable to sit still at
the dinner table constantly terupts her when she is speaking on the phone, and makes excuses for
forgetting his homework and chores. The father says his wife is overeacting as the boy has always been
very active. He adds was the same way as a kid I grow out of e There have been no changes in the
patient's appetite or sleep He has friends at school and likes to play sure he'll sports and video games
Physical examination is remarkable for a scar on his right leg and multiple scabs on his right knee which
he reports are due to falling off his bike and skateboard. The remainder of the physical examinat on is
normal The child's mother asks if there is any medication that can help him "calm down Which of the
following is the most appropriate next step in management of this patient?

Select one
& Reassure parents that behavorie age-appropriate

Obinitate a trial of methylphenidate

When manifested by a dient, which of the following manifestations indicate that the patient may be
having Cr-Du-Chat Syndrome?

Select one All or any of the above

Cb. Wide Sety

Severe Mental Retardation Profound idiot

Od Signs of Downs Syndrome

A 17-year old client whose boyfriend has recently broke up with her is brought into the ER after taking a
handful of lorazepam (ativan). Which nursing intervention would take priority in this situation

O a. Decrease fluids and place the chent on isolation

O b. Discuss the client's feelings about breaking up with her boyfriend

OC Monitor vital signs and note any signs of CNS depression

Od. Allow the client time to rest since lorazepam is sedating

Head Nurse Aiza is conducting an education about depression. Which of the following statements about
depressionindicates that she need further teaching about depression!

dA major depressive disorder reflects a level of depression that persists ove 2-week period.

A 32-year-cid man is brought to the emergency department due to confusion. He was hospitalized 2
weeks ago for an episode of bizane behavior in which he was found running naked down a highway
while prodaiming he could walk on water. The patient was diagnosed with bipolar disorder and treated
with inthiure and an antipsychotic medication. The patient's history is significant for an episode of
depression in his 20s as well as asthma treated with albuterol as needed. in the emergency department,
temperature 398 C (101.6 F). blood pressure is 160/100 mm Hg pulse is 116/min, and respirations are
22/min. He a not oriented to time place, or person Mucous membraries are dry Profuse diaphoresis is
present The lungs are clear to auscultation Abdominal neck and extremity muscles are rigid Muscle tone
is increased Deep tendon reflexes are 2+ Laboratory studies show a lithium level of 0.9 mEq/L serum
creatine kinase of 50.000 EUIL and a total white blood cell count of 23 000/mm Which of the following is
the most appropriate next step in management of this patient?

Start Benztropine

Ob Dacontinue lithium

Start Cyproheptadine

d. Start Diphenhydramine Start Propranolol

Start Antibiotics

A patient diagnosed with conduct disorder, kleptomania and pyromania admitted to a psych hospital.
Which of the following should the nurse anticipate to be a part of the patient's medication chart?

Da Stimulants

b. Barbiturates

Oc Antidepressants

Od Tranquilizers

The hallmark manifestation of delirium is which of the following?

O a presence of delusions, hallucinations and illusions

O b. Agitation and restlessness

O c. Cheyne-stokes respiration

O d. Loss of consciouless and irritation

An 11-year-old boy is brought to the office by his mother for a routine examination. She is womed that
her son will be laughed at of bullied because of some unusual behaviors. The boy has a 4-year history of
episodes in which he clears his throat grimaces and blinks his eyes He has also recently started shrugging
his left shoulder, which his mother fears in very noticeable to others. His medical history is otherwise
unremarkable. The boy is having difficulty in math but is warning passing grades in other subjects He has
a few friends at school but prefers to play the piano and clarinet by himself after school. The mother
notes that his shoulder movements stop when he plays a musical instrument. Physical examination is
unremarkable with the exception of sporadic left sided shoulder shrugs. Which of the following most like
describes the manifestations in this boy?

a Major depressive disorder

Db. Antisonal personality disorder

OcObsessive-compulsive disorder

d. Secure disorder

O Conduct disorder

O Tourette syndrome

Og Autism spectrum disorder

Oh Oppositional defiant disorder

A toddler with mental retardation is now being assessed in the clinic. When assessing the patient's ears
the nurse intend to do which of the following techniques for ear inspection

& Pulls back the ear auncies and incert laryngoscope

Db. All of the above options are applicable for a mentally retarded child

Pulls back the ear lobes and then up

d. Pulls back the ear lobes and down

A 4-year old boy is brought to the office for a routine visit. He has no medical problems and started
preschool 3 weeks ago. The mother is concerned about his adjustment to school as he wants to stay
home like his baby sister, frequently takes a long time to get dressed and becomes upset when dropped
off at school. On the first clay of school she was embarrassed when her son stamped his feet, yelled
"Take me home and wrapped his arms around her legs, physically preventing her from leaving the
classroom. The teacher reports that the boy settles clown a few minutes after the mother leaves. He is
shy but plays with the other children and participates in all class activities. The boy's sleep and appetite
are normal although he refuses to eat anything with peas in at His growth and developmental
milestones are within normal range. Which of the following is the most likely explanation for the boy's
behavior?

Od. Separation anxiety disorder

Oe Parent-child relational problem

Of. Adjustment disorder

Og. Oppositional defiant disorder

3. Patent Jethro has been admitted to the emergency unit with a diagnosis of Alcohol Intoxication Labs
have confirmed.Which of the following should the nurse prioritize to monitor?

Oa Hypertensive episodes

Ob Hypoglycemia

Vomiting episodes

Od. Amonia level

A 15-year-old girl is brought to the clinic by her mother, who became concerned after hearing her
daughter vomit in the bathroom on 2 separate occasions last week. The giet is preparing for a debate
competition and says that the occasionally vomits from nervousness as an event approaches. She
describes intense pressure to perform well in school and gain acceptance to a prestigious college Her
mother adds that the patient is very self conscious and frequently her appearance the patient takes no
medications and has no drug allergies. Her last menstrual penod was 5 weeks ago worries about S
Temperature 362 C (972 F blood pressure is 106168 mm Hg pulses 62/min, and respirations are 16/min
EMI for age is at the 4th percentile. The patient appears slightly anxious and wears baggy clothes to hide
my huge stomach Physical examination shows pharyngeal erythema bilateral parutid gland enlargement
normal heart and lungs scaphoid abdomen with normal bowel sounds and abrasions on the knuckles.
Which of the following is the most likely diagnosis

Oa Anorexia nervosa
b. Body dysmorphic disorder

Oc. Generalized anxiety disorder

dBulimia nervosa

De Performance anxoety

A patient being evaluated for secual disorder complains that she is having current or persistent pain
during sexual

intercourse. The nuese knows that this condition may called as

Ca Anhedonia

Ob Vaginitis

c. Vaginismus

Od Dyspareunia

Nurse Gio is conducting a home visit for a patient with ADHD Which of the following food items would
he recommendbest for the patient?

a Jolibee Joy, Shakey's Pizza and Malunggay BiscuiChickents

Ob. Lucky Me pancit canton marie biscuits and a banana fruit

c. Chicken liver adobo, igado and pinakbet with pineapple juice

d. Wendy's Spaghetti a slice of tuna and chopped broccol

Patient Robbie William is a toddler who is currently admitted for bacterial pneumonia. Which of the
following if elicited by the child should the nurse view as an expected normal social developmental
manifestation?

Oa negativistic trait as the child's way to search for independence

b. child can button his shirts on and off

C.hild can sit up with support

Od. Laugh aloud using bubbling sounds

The nurse taking care of a patient with ADHD needs to understand that ADHD may come along with
many forms of disorders the the all of the following except

Select one

Conduct disorder

Gb Tourette syndrome

Simple form of Pediatric Schizophrenia

Bipolar Disorder

A cient with anorexia nervosa is a member of a predischarge support group. The dient verbalizes that
she would like to buy some new clothes but her finances are limited Group members have bebught
some used clothes to the client to replace the client's old clothes. The client believes that the new
clothes are much too tight and has reduced her calorie intake to 800 calories daily, How should the
nurse evaluate this behavior?

Ca Evidence of the client's disturbed body image

b. Indicative of the cent's ambivalence about hospital discharge

Normal behavior

Od Regression as the client is moving toward the community

Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa
would be?

O a Decreased metabolism causing cold intolerance

Ob. Endocrine imbalance causing cold amenorrhea

Oc. Glucose intolerance resulting in protracted hypoglycemia

Od. Cardiac dyarhythmias resulting to cardiac arrest

Which condition is described as involuntary constriction of the outer third of the vagina which prevents
penile insertion and intercourse?

a vaginal trauma

Ob vaginosis

e vaginitis

Od Vaginumus

The nurse may encounter clients with concems on sexuality. The most basic factor in the intervention
with clients in the area of sexuality is.

O a Knowledge about sexuality.

Ob. Comfort with one's sexuality

c. Ability to communicate effectively.

Od Experience in dealing with clients with sexual problems.

A child is being assessed for conduct disorder. Which of the following if mandested by the child is not in
line with conduct disorder?

a. None of the above

O b. property destruction and serious violation of school rules

Oc. Aggression and bullying against the child's playmate and teachers

O d. A history of theft and gross dishonesty

Binibining Bursa, was diagnosed with anorexia nervosa and is in a state of starvation. Which room ma
patient Bursa's room would be the best choice?

O a. A client who could benefit from the client's assistance at mealtime

O b. A client with pneumonia

OC. A client undergoing diagnostic tests

 You are caring for a group of clients who are adversely affected with phobias Which form of group
therapy will you most tely employ to treat these certs?

OaCognitive behavioral psychotherapy

Db Cognitive psychotherapy

C.Behavioral psychotherapy

d. Psychcanalysis

A 68-year-old client suffers from rheumatoid arthritis in the joints of her arms, legs, and hands. The
doctor has prescribed oral corticosteroid treatment for the client's condition. Which information should
the nurse include about how this medication works to treat arthritis?

Select one:

a. Corticosteroids stimulate opioid receptors to increase pain control

b. Corticosteroids counteract many neurotransmitters secreted by the brain

c. Corticosteroids prevent the body from releasing the stress hormone cortisol

O d. Corticosteroids decrease prostaglandin levels that affect inflammation

A 85 year old patient has an accidental fall while going to the bathroom without assistance. It appears
the patient has sustained a bone fracture to the left leg. The leg's shape is deformed and the patient is
unable to move it. The patient is alert and oriented but in pain. What will you do FIRST after confirming
the patient is safe and stable?
Select one

a. Apply an ice pack covered with a towel to the site.

O b. Immobilize the fracture with a splint.

c. Administer pain medication.

d. Elevate the extremity above heart

A client has just returned from surgery after having his left leg amputated below the knee. Physician's
orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing
assistant has placed a pillow under the client's amputated limb. The nursing action is to:

Select one:

a. Leave the pillow as his stump is elevated

O b. Remove the pillow and elevate the foot of the bed

c. Leave the pillow and elevate the foot of the bed

d. Check with the physician and clarify the orders

A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has
been applied. To prevent pressure points from occurring around the top of the splint, the most
important intervention is to:

Select one:

a. Protect the skin with lotion

b. Keep the client pulled up in bed

O c. Pad the top of the splint with washcloths

d. Provide a footplate in the bed

A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is
suspected. Which of these assessments best support this diagnosis.

Select one:

a. The client reports pain in the affected leg

b. A large hematoma is visible in the affected extremity

O c. The affected extremity is shortened, adducted, and extremely rotated

d. The affected extremity is edematous

A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect
early manifestations of compartmentbsyndrome, which of these assessmentsnshould the nurse make?

Select one:

a. Observe the color of the fingers

b. Palpate the radial pulse under the cast

c. Check the cast for odor anddrainage

O d. Evaluate the response to analgesics

A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response by the
nurse is correct?

Select one:

O a. Vitamin D improves the absorption of calcium

b. Vitamin D helps preventconstipation from increased calciumintake

c. Vitamin D reduces excretion of calcium in the kidneys

d. Vitamin D minimizes the risk of kidney stones

A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the
last two years. The most important assessment question for the nurse to ask related to the client's drug
therapy is whether she has

Select one:

a. Headache

O b. Tarry stool

c. Blurred vision

d. Decreased appetite
A nurse is caring for a client who has suffered a fracture to the humerus after falling on their
outstretched arm. The ends of the bone were driven into each other during the fall. This type of fracture
is best described as which of the following?

Select one:

a. Greenstick fracture

b. Comminuted fracture

c. Oblique fracture

O d. Impacted fracture

A patient complains of a slight tingling in the toes of the affected leg 2 hours after the application of
Buck's traction with a foam boot with Velcro straps.Which nursing intervention will prevent potential
complications related to the patient complaint?

Select one:

a. Apply warm blankets to the feetand reassess.

O b. Check the fit of the traction device near the knee.

c. Medicate the patient for pain with an opioid analgesic.

d. Reassure the patient that this is a common complaint.

A patient sustained a fracture to the femur. The patient has suddenly become confused, restless, and
has a respiratory rate of 30 breaths per minute. Based on the location of fracture and the presenting
symptoms, this patient may be experiencing what type of complication?
Select one:

a. Compartment Syndrome

b. Osteomyelitis

O c. Fat embolism

d. Hypovolemia

A patient with a fracture of the right ankle has a nursing diagnosis of Impaired Physical Mobility. As
charge nurse you observe a new graduate RN perform all of these interventions. For which action should
you intervene?

Select one:

O a. EncOurages the patient to go from lying to standing position

b. Administers pain medication prior to beginning exercises

c. Explains to the patient and family the purpose of the exercise program

d. Reminds the patient about correct usage of crutches

A patient with a fractured fibula is receiving skeletal traction and has

skeletal pins in place. You instruct the nursing assistant to immediately report which of the following?

Select one:
a. The patient wants to changeposition in bed.

b. There is a small amount of clear fluid on the pin sites.

O c. The traction weights are resting on the floor.

d. The patient is complaining of pain and muscle spasm.

A patient with fractures of the femur and pelvis is restless and has a heart rate of 112 and a respiratory
rate of 28.What actions should the nurse take?

Select one:

O a. Notify the healthcare provider and check vital signs.

b. Restrict physical activity and elevate the head of the bed.

c. Reposition the patient and administer pain medication.

d. Listen to the lung sounds and give muscle relaxant.

After change-of-shift report, which patient should the nurse assess first?

Select one:

a. A 42-year-old patient with carpal tunnel syndrome complaining of pain

O b. A 64-year-old patient with osteoporosis who is waiting for discharge

c. A 28-year-old patient with fracture complaining that the cast is tight

d. A 56-year-old patient with left leg amputation complaining of phantom pain

After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by
the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

Select one:

a. History of Epstein-Barr virus infection

b. Female gender

O c. Adults between the ages 60 to 75 years

d. Positive testing for human leukocyte antigen (HLA) DR4 allele

An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery
where a nail plate was inserted for internal fixation. The client has been instructed that she should not
flex her hip. The best explanation of why this movement would be harmful is:

Select one:

a. It will be very painful for the client

b. The soft tissue around the site will be damaged

O c. Displacement can occur with flexion

d. It will pull the hip out of alignment

During discharge preparations, a patient with osteoporosis makes all of these statements. Which
statement indicates to you that the patient needs additional teaching?

Select one:

O a. "I take my ibuprofen every morning as soon as I get up."

b. "My daughter removed all of the throw rugs in my home."

c. "My husband helps me every afternoon with range-of-motion exercises."

d. "I rest in my recliner chair every day for at least an hour."

Following an amputation, the advantage to the client for an immediate prosthesis fitting is:

Select one:

a. Ability to ambulate sooner

O b. Less change of phantom limb sensation

c. Dressing changes are notnecessary

d. Better fit of the prosthesis

In order for Buck's traction applied to the right leg to be effective, the client should be placed in which
position?

Select one:

O a. Supine

b. Prone

c. Sim's

d. Lithotomy

Neurovascular assessment includes component as below, except:

Select one:

a. Check for pulse

b. Check for sensation

c. Check for capillary refill

O d. Bleeding

The client immobilized skeletal leg traction complains of being bored and restless. Based on these
complaints, the nurse formulates which of the following nursing diagnoses for this client?

Select one
O a. Divertional activity deficiency

b. Powerlessness

c. Self care deficit

d. Impaired physical mobility

The client who had an open femoral fracture was discharged to her home, where she developed, fever,
night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets
these finding as indicating which of the following?

Select one:

a. Pulmonary emboli

b. Osteomyelitis

O c. Fat emboli

d. Urinary tract infection

The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In
which of the following exercises would the nurse instruct the client to best prepare him for using
crutches?

Select one:
a. Abdominal exercises

b. Isometric shoulder exercises

c. Quadriceps setting exerCise

O d. Triceps stretching exercises

The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted.
When teaching the client about using the crutches, the nurse instructs the client to support her weight
primarily on which of the following body areas?

Select one:

a. Axillae

b. Elbows

c. Upper arms

O d. Hand

The 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:

Select one:

a. Left hand and placing the cane in front of the left foo

b. Right hand and placing the cane in front of the right foot
O c. Left hand and 6 inches lateral to the left foot

d. Right hand and 6 inches lateral to the left foot

The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The
nurse evaluates that the client states to:

Select one

a. Wear a clean nylon stump sock daily

b. Toughen the skin of the sturmp by rubbing it with alcohol

c. Prevent cracking of the skin of the stump by applying lotion

O d. Using a mirror to inspect all areas of the stump each day

The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following
signs and symptoms indicative of infection?

Select one:

a. Coolness and pallor of the extremity

b. Presence of a "hot spot" on the cast

c. Diminished distal pulse

O d. Dependent edema
The nurse is assigned to care of a patient in traction, the nurse creates a plan of care for the patient and
should include what nursing intervention in her care?

Select one:

a. Ensure the knots are at the pulleys

O b. Check the weights to ensure that they are off of the floor

c. Ensure that the head of the bed are raise 45 to 90 degrees.

d. Monitor the weights to ensure that they are resting on firm surface.

The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse
expect to note in the client?

Select one:

O a. Uric acid level of 8 mg/dl

b. Calcium level of 9 mg/dl

c. Phosphorus level of 3 mg/di

d. Uric acid level of 5 mg/dl

The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb
was wrapped with an elastic compression bandage which has come off. The nurse immediately:

Select one:

a. Calls the physIcian

O b. Rewrap the stump with an elastic compression bandage

c. Applies ice to the site

d. Applies a dry sterile dressing and elevates it on a pillow

The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The
client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

Select one:

a. Left leg and right crutch then right leg and left crutch

b. Crutches and then both legs simultaneously

c. Crutches and the right leg then advance the left leg

O d. Crutches and the left leg then advance the right leg
The nurse is caring for the client who is going to have an arthogram using a

contrast medium. Which of the following assessments by the nurse are of highest priority?

Select one:

O a. Allergy to iodine or shelfish

b. Ability of the client to remain still during the procedure

c. Whether the client has any remaining questions about the procedure

d. Whether the client wishes to void before the procedure

The nurse is preparing a patient for discharge after application of a plaster cast.What information does
the nurse include in the patient teaching?

Select one:

O a. Report any changes in sensation or mobility.

b. Use a cool blow dryer to dry a wet cast.

c. Use only soft objects to scratch inside the cast.

d. Trim the cast if the skin becomes irritated.

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a
fractured right hip.
The nurse uses a:

Select one:

a. Pillow to keep the right leg abducted during turning

b. Pillow to keep the right legg adducted during turning

c. Trochanter roll to prevent external rotation while turn

Od. Trochanter roll to prevent abduction while turning

The nurse prepares to place the patient in skin traction.Which is the nurse's main concern before
applying the skin traction?

Select one:

a. Obtain informed consent from patient.

O b. Verify that the patient assessment is complete.

c. Prepare a sterile field for pin insertion.

d. Assemble the overhead frame and pulleys.

The patient suffered a fractured femur. Which of the following would you tell the nursing assistant to
report immediately?
Select one:

a. The patient complains of pain.

O b. The patient appears confused.

c. The patient's blood pressure is

130/80.

d. The patient voided using the bedpan.

When admitting a client with a fractured extremity, the nurse would focus the assessment on which of
the following?

Select one:

a. The area proximal to the fracture

b. The actual fracture site

O c. The area distal to the fracture

d. The opposite extremity for baseline comparison

When antibiotics are not producing the desired outcome for a client wIth osteomyelitis, the nurse
interprets this as suggesting the occurrence of which of the following as most likely?

Select one:
a. Formation of scar tissue interfering with absorption

b. Development of pus leading to ischemia

O c. Production of bacterial growth by avascular tissue

d. Antibiotics not being instilled directly into the bone

When completing the history and physical examination of a client diagnosed with osteoarthritis, which
of the following would the nurse assess?

Select one:

a. Anemia

b. Osteoporosis

c.Weight loss

O d. Local joint pain

When the client is lying supine, the nurse will prevent external rotation of the lowe extremity by using a:

Select one:

a. Trochanter roll by the knee

b. Sandbag to the lateral calf

Oc. Trochanter roll to the thigh

d. Footboard

Which assessment finding found while assessing a patient with a fracture who has traction requires
immediate intervention?

Select one:

O a. The weights are freely hanging on the floor.

b. Pin sites are free from drainage.

c. Patient uses the overhead trapeze bar to move around in the bed.

d. Patient's extremities have a capillary refill of less than 2 seconds.

Which of the following actions would be a priority for a client who has been in the postanesthesia care
unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot
on the ace bondagge above the amputation site?

Select one:

a. Elevate the stump

b. Reinforcing the dressing

c. Calling the surgeon

O d. Drawing a mark around the site

Which of the following would be inappropriate to include when preparing a client for magnetic
resonance imaging (MRI) to evaluate a rupture disc?

Select one

a. Informing the client that the procedure is painlesss

b. Taking a thorough history of past surgeries

O c. Checking for previous complaints of claustropphobia

d. Starting an intravenous line at keep-open rate

Which of the following would lead the nurse to suspect that a client with a fracture of the right femur
may be developing a fat embolus?

Select one:

O a. Acute respiratory distress syndrome

b. Migraine like headaches

c. Numbness in the right leg

d. Muscle spasms in the right thigh

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to
notify the physician immediately?

Select one:

a. "It is really itchy inside my cast!"

O b. "My pain is so severe that it hurts to stretch or elevate my arm."

c. "I can feel my fingers and move them."

d. "Ive been using ice packs to reduce swelling""

Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the
room. Which action by the significant other requires you to re-educate the patient and family about cast
care?

Select one:

O a. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying.

b. Positioning the cast at heart level with pillows.

c. Checking the color and temperature of the right foot.

d. Using a hair dryer on the cool setting to help with drying.

Which test is performed to definitively diagnose osteoporosis?

Select one:
a. Vitamin D blood levels

b. Calcium blood levels

O c. Dual energy x-ray absorptiometry

d. Exercise stress test

A 68-year-old client suffers from rheumatoid arthritis in the joints of her arms, legs, and hands. The
doctor has prescribed oral corticosteroid treatment for the client's condition. Which information should
the nurse include about how this medication works to treat arthritis?

Select one:

a. Corticosteroids stimulate opioid receptors to increase pain control

b. Corticosteroids counteract many neurotransmitters secreted by the brain

c. Corticosteroids prevent the body from releasing the stress hormone cortisol

O d. Corticosteroids decrease prostaglandin levels that affect inflammation

A 85 year old patient has an accidental fall while going to the bathroom without assistance. It appears
the patient has sustained a bone fracture to the left leg. The leg's shape is deformed and the patient is
unable to move it. The patient is alert and oriented but in pain. What will you do FIRST after confirming
the patient is safe and stable?

Select one

a. Apply an ice pack covered with a towel to the site.

O b. Immobilize the fracture with a splint.

c. Administer pain medication.

d. Elevate the extremity above heart

A client has just returned from surgery after having his left leg amputated below the knee. Physician's
orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing
assistant has placed a pillow under the client's amputated limb. The nursing action is to:

Select one:

a. Leave the pillow as his stump is elevated

O b. Remove the pillow and elevate the foot of the bed

c. Leave the pillow and elevate the foot of the bed

d. Check with the physician and clarify the orders

A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has
been applied. To prevent pressure points from occurring around the top of the splint, the most
important intervention is to:

Select one:
a. Protect the skin with lotion

b. Keep the client pulled up in bed

O c. Pad the top of the splint with washcloths

d. Provide a footplate in the bed

A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is
suspected. Which of these assessments best support this diagnosis.

Select one:

a. The client reports pain in the affected leg

b. A large hematoma is visible in the affected extremity

O c. The affected extremity is shortened, adducted, and extremely rotated

d. The affected extremity is edematous

A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect
early manifestations of compartmentbsyndrome, which of these assessmentsnshould the nurse make?

Select one:

a. Observe the color of the fingers

b. Palpate the radial pulse under the cast

c. Check the cast for odor anddrainage

O d. Evaluate the response to analgesics

A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response by the
nurse is correct?

Select one:

O a. Vitamin D improves the absorption of calcium

b. Vitamin D helps preventconstipation from increased calciumintake

c. Vitamin D reduces excretion of calcium in the kidneys

d. Vitamin D minimizes the risk of kidney stones

A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the
last two years. The most important assessment question for the nurse to ask related to the client's drug
therapy is whether she has

Select one:

a. Headache

O b. Tarry stool

c. Blurred vision
d. Decreased appetite

A nurse is caring for a client who has suffered a fracture to the humerus after falling on their
outstretched arm. The ends of the bone were driven into each other during the fall. This type of fracture
is best described as which of the following?

Select one:

a. Greenstick fracture

b. Comminuted fracture

c. Oblique fracture

O d. Impacted fracture

A patient complains of a slight tingling in the toes of the affected leg 2 hours after the application of
Buck's traction with a foam boot with Velcro straps.Which nursing intervention will prevent potential
complications related to the patient complaint?

Select one:

a. Apply warm blankets to the feetand reassess.

O b. Check the fit of the traction device near the knee.

c. Medicate the patient for pain with an opioid analgesic.

d. Reassure the patient that this is a common complaint.

A patient sustained a fracture to the femur. The patient has suddenly become confused, restless, and
has a respiratory rate of 30 breaths per minute. Based on the location of fracture and the presenting
symptoms, this patient may be experiencing what type of complication?

Select one:

a. Compartment Syndrome

b. Osteomyelitis

O c. Fat embolism

d. Hypovolemia

A patient with a fracture of the right ankle has a nursing diagnosis of Impaired Physical Mobility. As
charge nurse you observe a new graduate RN perform all of these interventions. For which action should
you intervene?

Select one:

O a. EncOurages the patient to go from lying to standing position

b. Administers pain medication prior to beginning exercises

c. Explains to the patient and family the purpose of the exercise program

d. Reminds the patient about correct usage of crutches

A patient with a fractured fibula is receiving skeletal traction and has

skeletal pins in place. You instruct the nursing assistant to immediately report which of the following?

Select one:

a. The patient wants to changeposition in bed.

b. There is a small amount of clear fluid on the pin sites.

O c. The traction weights are resting on

the floor.

d. The patient is complaining of pain

and muscle spasm.

A patient with fractures of the femur and pelvis is restless and has a heart rate of 112 and a respiratory
rate of 28.What actions should the nurse take?

Select one:

O a. Notify the healthcare provider and check vital signs.

b. Restrict physical activity and elevate the head of the bed.

c. Reposition the patient and administer pain medication.

d. Listen to the lung sounds and give muscle relaxant.

After change-of-shift report, which patient should the nurse assess first?
Select one:

a. A 42-year-old patient with carpal tunnel syndrome complaining of pain

O b. A 64-year-old patient with osteoporosis who is waiting for discharge

c. A 28-year-old patient with fracture complaining that the cast is tight

d. A 56-year-old patient with left leg amputation complaining of phantom pain

After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by
the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

Select one:

a. History of Epstein-Barr virus infection

b. Female gender

O c. Adults between the ages 60 to 75 years

d. Positive testing for human leukocyte antigen (HLA) DR4 allele

An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery
where a nail plate was inserted for internal fixation. The client has been instructed that she should not
flex her hip. The best explanation of why this movement would be harmful is:
Select one:

a. It will be very painful for the client

b. The soft tissue around the site will be damaged

O c. Displacement can occur with flexion

d. It will pull the hip out of alignment

During discharge preparations, a patient with osteoporosis makes all of these statements. Which
statement indicates to you that the patient needs additional teaching?

Select one:

O a. "I take my ibuprofen every morning as soon as I get up."

b. "My daughter removed all of the throw rugs in my home."

c. "My husband helps me every afternoon with range-of-motion exercises."

d. "I rest in my recliner chair every day for at least an hour."

Following an amputation, the advantage to the client for an immediate prosthesis fitting is:
Select one:

a. Ability to ambulate sooner

O b. Less change of phantom limb sensation

c. Dressing changes are notnecessary

d. Better fit of the prosthesis

In order for Buck's traction applied to the right leg to be effective, the client should be placed in which
position?

Select one:

O a. Supine

b. Prone

c. Sim's

d. Lithotomy

Neurovascular assessment includes component as below, except:

Select one:

a. Check for pulse

b. Check for sensation

c. Check for capillary refill

O d. Bleeding

The client immobilized skeletal leg traction complains of being bored and restless. Based on these
complaints, the nurse formulates which of the following nursing diagnoses for this client?

Select one

O a. Divertional activity deficiency

b. Powerlessness

c. Self care deficit

d. Impaired physical mobility

The client who had an open femoral fracture was discharged to her home, where she developed, fever,
night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets
these finding as indicating which of the following?

Select one:

a. Pulmonary emboli

b. Osteomyelitis

O c. Fat emboli
d. Urinary tract infection

The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In
which of the following exercises would the nurse instruct the client to best prepare him for using
crutches?

Select one:

a. Abdominal exercises

b. Isometric shoulder exercises

c. Quadriceps setting exerCise

O d. Triceps stretching exercises

The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted.
When teaching the client about using the crutches, the nurse instructs the client to support her weight
primarily on which of the following body areas?

Select one:

a. Axillae

b. Elbows

c. Upper arms
O d. Hand

The 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:

Select one:

a. Left hand and placing the cane in front of the left foo

b. Right hand and placing the cane in front of the right foot

O c. Left hand and 6 inches lateral to the left foot

d. Right hand and 6 inches lateral to the left foot

The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The
nurse evaluates that the client states to:

Select one

a. Wear a clean nylon stump sock daily

b. Toughen the skin of the sturmp by rubbing it with alcohol

c. Prevent cracking of the skin of the stump by applying lotion

O d. Using a mirror to inspect all areas of the stump each day

The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following
signs and symptoms indicative of infection?

Select one:

a. Coolness and pallor of the extremity

b. Presence of a "hot spot" on the cast

c. Diminished distal pulse

O d. Dependent edema

The nurse is assigned to care of a patient in traction, the nurse creates a plan of care for the patient and
should include what nursing intervention in her care?

Select one:

a. Ensure the knots are at the pulleys

O b. Check the weights to ensure that they are off of the floor

c. Ensure that the head of the bed are raise 45 to 90 degrees.

d. Monitor the weights to ensure that they are resting on firm surface.

The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse
expect to note in the client?
Select one:

O a. Uric acid level of 8 mg/dl

b. Calcium level of 9 mg/dl

c. Phosphorus level of 3 mg/di

d. Uric acid level of 5 mg/dl

The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb
was wrapped with an elastic compression bandage which has come off. The nurse immediately:

Select one:

a. Calls the physIcian

O b. Rewrap the stump with an elastic compression bandage

c. Applies ice to the site

d. Applies a dry sterile dressing and elevates it on a pillow

The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The
client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

Select one:
a. Left leg and right crutch then right leg and left crutch

b. Crutches and then both legs simultaneously

c. Crutches and the right leg then advance the left leg

O d. Crutches and the left leg then advance the right leg

The nurse is caring for the client who is going to have an arthogram using a

contrast medium. Which of the following assessments by the nurse are of highest priority?

Select one:

O a. Allergy to iodine or shelfish

b. Ability of the client to remain still during the procedure

c. Whether the client has any remaining questions about the procedure

d. Whether the client wishes to void before the procedure

The nurse is preparing a patient for discharge after application of a plaster cast.What information does
the nurse include in the patient teaching?

Select one:

O a. Report any changes in sensation or mobility.

b. Use a cool blow dryer to dry a wet cast.

c. Use only soft objects to scratch inside the cast.

d. Trim the cast if the skin becomes irritated.

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a
fractured right hip.

The nurse uses a:

Select one:

a. Pillow to keep the right leg abducted during turning

b. Pillow to keep the right legg adducted during turning

c. Trochanter roll to prevent external rotation while turn

Od. Trochanter roll to prevent abduction while turning

The nurse prepares to place the patient in skin traction.Which is the nurse's main concern before
applying the skin traction?

Select one:

a. Obtain informed consent from patient.

O b. Verify that the patient assessment is complete.

c. Prepare a sterile field for pin insertion.

d. Assemble the overhead frame and pulleys.

The patient suffered a fractured femur. Which of the following would you tell the nursing assistant to
report immediately?

Select one:

a. The patient complains of pain.

O b. The patient appears confused.

c. The patient's blood pressure is

130/80.

d. The patient voided using the bedpan.

When admitting a client with a fractured extremity, the nurse would focus the assessment on which of
the following?

Select one:

a. The area proximal to the fracture

b. The actual fracture site

O c. The area distal to the fracture

d. The opposite extremity for baseline comparison

When antibiotics are not producing the desired outcome for a client wIth osteomyelitis, the nurse
interprets this as suggesting the occurrence of which of the following as most likely?

Select one:

a. Formation of scar tissue interfering with absorption

b. Development of pus leading to ischemia

O c. Production of bacterial growth by avascular tissue

d. Antibiotics not being instilled directly into the bone

When completing the history and physical examination of a client diagnosed with osteoarthritis, which
of the following would the nurse assess?

Select one:

a. Anemia

b. Osteoporosis

c.Weight loss

O d. Local joint pain

When the client is lying supine, the nurse will prevent external rotation of the lowe extremity by using a:

Select one:

a. Trochanter roll by the knee

b. Sandbag to the lateral calf

Oc. Trochanter roll to the thigh

d. Footboard

Which assessment finding found while assessing a patient with a fracture who has traction requires
immediate intervention?

Select one:

O a. The weights are freely hanging on the floor.

b. Pin sites are free from drainage.

c. Patient uses the overhead trapeze bar to move around in the bed.

d. Patient's extremities have a capillary refill of less than 2 seconds.

Which of the following actions would be a priority for a client who has been in the postanesthesia care
unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot
on the ace bondagge above the amputation site?

Select one:

a. Elevate the stump

b. Reinforcing the dressing

c. Calling the surgeon

O d. Drawing a mark around the site

Which of the following would be inappropriate to include when preparing a client for magnetic
resonance imaging (MRI) to evaluate a rupture disc?

Select one

a. Informing the client that the

procedure is painlesss

b. Taking a thorough history of past surgeries

O c. Checking for previous complaints of claustropphobia

d. Starting an intravenous line at

keep-open rate
Which of the following would lead the nurse to suspect that a client with a fracture of the right femur
may be developing a fat embolus?

Select one:

O a. Acute respiratory distress syndrome

b. Migraine like headaches

c. Numbness in the right leg

d. Muscle spasms in the right thigh

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to
notify the physician immediately?

Select one:

a. "It is really itchy inside my cast!"

O b. "My pain is so severe that it hurts to stretch or elevate my arm."

c. "I can feel my fingers and move them."

d. "Ive been using ice packs to reduce swelling""

Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the
room. Which action by the significant other requires you to re-educate the patient and family about cast
care?
Select one:

O a. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying.

b. Positioning the cast at heart level with pillows.

c. Checking the color and temperature of the right foot.

d. Using a hair dryer on the cool setting to help with drying.

Which test is performed to definitively diagnose osteoporosis?

Select one:

a. Vitamin D blood levels

b. Calcium blood levels

O c. Dual energy x-ray absorptiometry

d. Exercise stress test