Quiz #2: 75 Questions

1. A 28-year-old male has been found wandering around in a confusing pattern. The
male is sweaty and pale. Which of the following tests is most likely to be
performed first?
A. Blood sugar check

B. CT scan

C. Blood cultures

D. Arterial blood gases

Correct Answer: A. Blood sugar check

With a history of diabetes, the first response should be to check blood sugar levels.
 Option B: Performing a CT scan at this stage of assessment is unnecessary. A
computerized tomography (CT) scan combines a series of X-ray images taken
from different angles around the body and uses computer processing to create
cross-sectional images (slices) of the bones, blood vessels, and soft tissues inside
the body. CT scan images provide more detailed information than plain X-rays
do.
 Option C: A blood culture test helps the doctor figure out if the client has a kind
of infection that is in the bloodstream and can affect the entire body. Doctors call
this a systemic infection. The test checks a sample of the blood for bacteria or
yeast that might be causing the infection.
 Option D: An arterial blood gas (ABG) test measures oxygen and carbon dioxide
levels in the blood. It also measures the body’s acid-base (pH) level, which is
usually in balance when healthy.

2. A mother is inquiring about her child’s ability to potty train. Which of the following
factors is the most important aspect of toilet training?

A. The age of the child

B. The child's ability to understand instruction

C. The overall mental and physical abilities of the child

D. Frequent attempts with positive reinforcement

Correct Answer: C. The overall mental and physical abilities of the child.
Age is not the greatest factor in potty training. The overall mental and physical abilities
of the child are the most important factor.
 Option A: Readiness for toilet training varies with every age of the child.
 Option B: A child who can follow simple instructions may start toilet training.
However, it is not considered the most important factor.
 Option D: Positive reinforcement is a great tool for toilet training, yet, it may not
be the most important one.
3. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her
child drank for 20 minutes. Which of the following is the most important instruction the
nurse can give the parent?

A. This too shall pass

B. Take the child immediately to the ER

C. Contact the Poison Control Center quickly

D. Give the child syrup of ipecac

Correct Answer: C. Contact the Poison Control Center quickly.

The poison control center will have an exact plan of action for this child.
 Option A: Ingestion of a chemical is an emergency and should not be delayed.
 Option B: Taking the client to the ER may be correct, however, they will still have
to contact the Poison Control Center.
 Option D: It should not be given to someone who swallowed chemicals that
cause burns on contact or medicines that can cause seizures very quickly. It can
be dangerous to people with some types of medical problems. When such
poisoning victims got Ipecac anyway, they developed serious complications or
even died.

4. A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the

following target areas is the most appropriate?
A. Gluteus maximus

B. Gluteus minimus

C. Vastus lateralis

D. Vastus medialis

Correct Answer: C. Vastus lateralis

Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which
is the junction of the upper and middle thirds of this muscle.
 Option A: Intramuscular injections given at the dorsogluteal and ventrogluteal
sites are intended for the gluteus maximus and gluteus medius muscles,
respectively. However, little research has confirmed the reliability of these sites
for the presence and thickness of the target and other muscles, and
subcutaneous fat.
 Option B: Never give an IM injection in the gluteal muscles to avoid the risk of
sciatica nerve damage.
 Option D: The vastus medialis muscle is a part of the quadriceps muscle group,
located on the front of the thigh.
5. A nurse has just started her rounds delivering medication. A new patient on her
rounds is a 4-year-old boy who is non-verbal. This child does not have any identification
on. What should the nurse do?

A. Contact the provider

B. Ask the child to write their name on paper

C. Ask a coworker about the identification of the child

D. Ask the father who is in the room the child’s name

Correct Answer: D. Ask the father who is in the room the child’s name.
In this case, you can determine the name of the child by the father’s statement. You
should not withhold the medication from the child after identification.
 Option A: Contacting the provider is unnecessary and may take time. A pediatric
patient must have folks with them inside the room, so asking the child’s folks
would be the most appropriate intervention.
 Option B: The child may have not yet developed his writing abilities. Some
children are able to write their names at age 4, but some typically developing
children still aren’t ready until well into age.
 Option C: Asking a coworker would be inappropriate and against the patient’s
confidentiality.

6. A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism.

A nurse checking the patient’s lab results would expect which of the following changes
in laboratory findings?
A. Elevated serum calcium

B. Low serum parathyroid hormone (PTH)

C. Elevated serum vitamin D

D. Low urine calcium

Correct Answer: A. Elevated serum calcium

The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism,
the serum calcium level will be elevated. The chronic excessive resorption of calcium
from bone caused by excessive parathyroid hormone can result in osteopenia.
 Option B: Parathyroid hormone levels may be high or normal but not low. The
main effects of parathyroid hormone are to increase the concentration of plasma
calcium by increasing the release of calcium and phosphate from bone matrix,
increasing calcium reabsorption by the kidney, and increasing renal production of
1,25-dihydroxyvitamin D-3 (calcitriol), which increases intestinal absorption of
calcium.
 Option C: The body will lower the level of vitamin D in an attempt to lower
calcium. Vitamin D levels should be measured in the evaluation of primary
hyperparathyroidism. Vitamin D deficiency (a 25-hydroxyvitamin D level of less
than 20 ng per milliliter) can cause secondary hyperparathyroidism, and repletion
of vitamin D deficiency can help to reduce parathyroid hormone levels.
 Option D: Urine calcium may be elevated, with calcium spilling over from
elevated serum levels. This may cause renal stones. In addition, the chronically
 increased excretion of calcium in the urine can predispose to the formation of
renal stones.

7. A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of
the following diet modifications is not recommended?
A. A diet high in grains

B. A diet with adequate caloric intake

C. A high protein diet

D. A restricted sodium diet

Correct Answer: D. A restricted sodium diet

A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid
loss. Patients should eat an unrestricted diet. Those with primary adrenal insufficiency
(Addison disease) should have ample access to salt because of the salt-wasting that
occurs if their condition is untreated. Infants with primary adrenal insufficiency often
need 2-4 g of sodium chloride per day.
 Option A: A well-balanced diet is the best way to keep the body healthy and to
regulate sugar levels. Doctors recommend balancing protein, healthy fats, and
high-quality, nutrient-dense carbohydrates.
 Option B: High-calorie comfort food reduces symptoms of neuroglycopenia in
Addison patients, suggesting that Addison’s disease is associated with a deficit in
cerebral energy supply that can partly be alleviated by intake of palatable food.
 Option C: Healthy fats and high-quality proteins slow the blood sugar
rollercoaster and promote stable blood sugar levels throughout the day.

8. A patient with a history of diabetes mellitus is on the second postoperative day

following cholecystectomy. She has complained of nausea and isn’t able to eat solid
foods. The nurse enters the room to find the patient confused and shaky. Which of the
following is the most likely explanation for the patient’s symptoms?
A. Anesthesia reaction

B. Hyperglycemia

C. Hypoglycemia
D. Diabetic ketoacidosis

Correct Answer: C. Hypoglycemia

A postoperative diabetic patient who is unable to eat is likely to be suffering from
hypoglycemia. Confusion and shakiness are common symptoms. Reduction in cerebral
glucose availability (ie, neuroglycopenia) can manifest as confusion, difficulty with
concentration, irritability, hallucinations, focal impairments (eg, hemiplegia), and,
eventually, coma and death.
 Option A: An anesthesia reaction would not occur on the second postoperative
day. The adrenergic symptoms often precede the neuroglycopenic symptoms
and, thus, provide an early warning system for the patient. Studies have shown
that the primary stimulus for the release of catecholamines is the absolute level
of plasma glucose; the rate of decrease of glucose is less important.
  Option B: Neuropathy affects up to 50% of patients with type 1 DM, but
symptomatic neuropathy is typically a late development, developing after many
years of chronic prolonged hyperglycemia. Peripheral neuropathy presents as
numbness and tingling in both hands and feet, in a glove-and-stocking pattern; it
is bilateral, symmetric, and ascending.
 Option D: Symptoms of hyperglycemia associated with diabetic ketoacidosis may
include thirst, polyuria, polydipsia, and nocturia.

9. A nurse assigned to the emergency department evaluates a patient who underwent

fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal
pain, fever, and chills. Which of the following conditions poses the most immediate
concern?

A. Bowel perforation

B. Viral Gastroenteritis
C. Colon cancer

D. Diverticulitis

Correct Answer: A. Bowel perforation

Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important
signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate
advancing peritonitis. One of the most serious complications of colonoscopy is
endoscopic perforation of the colon, which has been reported as between 0.03% and
0.7%. Although colonoscopic perforation (CP) occurs rarely, it can be associated with
high mortality and morbidity rates.
 Option B: Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea,
anorexia, weight loss, and dehydration. Isolated cases can occur, but viral
gastroenteritis more commonly occurs in outbreaks within close communities
such as daycare centers, nursing facilities, and cruise ships. Many different viruses
can lead to symptomatology, though in routine clinical practice the true causative
virus is generally not identified.
 Option C: If the patient is age 50 or older and at average risk of colon cancer —
he has no colon cancer risk factors other than age — the doctor may recommend
a colonoscopy every 10 years or sometimes sooner to screen for colon cancer.
Colonoscopy is one option for colon cancer screening.
 Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious
than perforation and peritonitis.

10. A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the
following laboratory tests assesses coagulation? Select all that apply.

A. Partial thromboplastin time

B. Prothrombin time

C. Platelet count
D. Hemoglobin
Correct Answer: A, B, & C
Prothrombin time, partial thromboplastin time, and platelet count are all included in
coagulation studies.
 Option A: The partial thromboplastin time (PTT; also known as activated partial
thromboplastin time (aPTT)) is a screening test that helps evaluate a person’s
ability to appropriately form blood clots. It measures the number of seconds it
takes for a clot to form in a sample of blood after substances (reagents) are
added.
 Option B: Prothrombin time (PT) is a blood test that measures how long it takes
blood to clot. A prothrombin time test can be used to check for bleeding
problems. PT is also used to check whether medicine to prevent blood clots is
working.
 Option C: Platelets, also called thrombocytes, are tiny fragments of cells that are
essential for normal blood clotting. They are formed from very large cells called
megakaryocytes in the bone marrow and are released into the blood to circulate.
The platelet count is a test that determines the number of platelets in a sample of
blood.
 Option D: The hemoglobin level, though important information prior to an
invasive procedure such as liver biopsy, does not assess coagulation.

11. A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the
following is the most likely route of transmission?

A. Sexual contact with an infected partner

B. Contaminated food

C. Blood transfusion

D. Illegal drug use

Correct Answer: B. Contaminated food

Hepatitis A is the only type that is transmitted by the fecal-oral route through
contaminated food. HAV is a single-stranded, positive-sense, linear RNA enterovirus of
the Picornaviridae family. In humans, viral replication depends on hepatocyte uptake
and synthesis, and assembly occurs exclusively in the liver cells. Virus acquisition results
almost exclusively from ingestion (eg, fecal-oral transmission)
 Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is
commonly transmitted via body fluids such as blood, semen, and vaginal
secretions. [1] Consequently, sexual contact, accidental needle sticks or sharing of
needles, blood transfusions, and organ transplantation are routes for HBV
infection.
 Option C: Before widespread screening of the blood supply in 1992, hepatitis C
was also spread through blood transfusions and organ transplants. Now, the risk
of transmission to recipients of blood or blood products is extremely low.
 Option D: Today, most people become infected with hepatitis B, C, or D by
sharing needles, syringes, or any other equipment used to prepare and inject
drugs.
12. A leukemia patient has a relative who wants to donate blood for transfusion. Which
of the following donor medical conditions would prevent this?
A. A history of hepatitis C five years previously

B. Cholecystitis requiring cholecystectomy one year previously

C. Asymptomatic diverticulosis

D. Crohn's disease in remission

Correct Answer: A. A history of hepatitis C five years previously

Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing
inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion
due to the high risk of infection in the recipient.
 Option B: Cholecystitis is the inflammation of the gallbladder. This condition
does not transmit through bodily fluids.
 Option C: Diverticulosis is when pockets called diverticula form in the wall of the
digestive tract. The inner layer of the intestine pushes through weak spots in the
outer lining. This pressure makes them bulge out, making little pouches.
 Option D: Crohn’s disease is an inflammatory bowel disease. It causes
inflammation of the digestive tract. This disease does not transmit through the
blood.

13. A physician has diagnosed acute gastritis in a clinic patient. Which of the following
medications would be contraindicated for this patient?

A. Naproxen sodium (Naprosyn)

B. Calcium carbonate

C. Clarithromycin (Biaxin)

D. Furosemide (Lasix)

Correct Answer: A. Naproxen sodium (Naprosyn)

Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation
of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis.
Naproxen is used to relieve pain from various conditions such as headache, muscle
aches, tendonitis, dental pain, and menstrual cramps. It also reduces pain, swelling, and
joint stiffness caused by arthritis, bursitis, and gout attacks.
 Option B: Calcium carbonate is used as an antacid for the relief of indigestion
and is not contraindicated. Calcium carbonate is a dietary supplement used when
the amount of calcium taken in the diet is not enough. Calcium is needed by the
body for healthy bones, muscles, nervous system, and heart. Calcium carbonate
also is used as an antacid to relieve heartburn, acid indigestion, and upset
stomach. It is available with or without a prescription.
 Option C: Clarithromycin is an antibacterial often used for the treatment of
Helicobacter pylori in gastritis. Clarithromycin is used to treat certain bacterial
infections, such as pneumonia (a lung infection), bronchitis (infection of the tubes
leading to the lungs), and infections of the ears, sinuses, skin, and throat. It also is
used to treat and prevent disseminated Mycobacterium avium complex (MAC)
infection [a type of lung infection that often affects people with human
immunodeficiency virus (HIV)]. It is used in combination with other medications
 to eliminate H. pylori, a bacterium that causes ulcers. Clarithromycin is in a class
of medications called macrolide antibiotics. It works by stopping the growth of
bacteria.
 Option D: Furosemide is a loop diuretic and is NOT contraindicated in a patient
with gastritis. Furosemide is used alone or in combination with other medications
to treat high blood pressure. Furosemide is used to treat edema (fluid retention;
excess fluid held in body tissues) caused by various medical problems, including
heart, kidney, and liver disease. Furosemide is in a class of medications called
diuretics (‘water pills’). It works by causing the kidneys to get rid of unneeded
water and salt from the body into the urine.

14. The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of
the following information is important to communicate?
A. The patient must maintain a low-calorie diet.

B. The patient must maintain a high protein/low carbohydrate diet.

C. The patient should limit sweets and sugary drinks.

D. The patient should limit fatty foods.

Correct Answer: D. The patient should limit fatty foods.

Cholecystitis, inflammation of the gallbladder, is most commonly caused by the
presence of gallstones, which may block bile (necessary for fat absorption) from
entering the intestines. Patients should decrease dietary fat by limiting foods like fatty
meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.
 Option A: The patient may maintain a moderate to a high-calorie diet, as a very
low-calorie diet may increase the risk for gallstones that predisposes to
cholecystitis.
 Option B: Both animal fat and animal protein may contribute to the formation of
gallstones. Vitamin C, which is abundant in plants and absent from meat affects
the rate-limiting step in the catabolism of cholesterol to bile acids and is inversely
related to the risk of gallstones and cholecystitis. Individuals consuming the most
refined carbohydrates have a 60% greater risk for developing gallstones,
compared with those who consumed the least.
 Option C: Replacing sugary drinks with drinks high in fiber would reduce the risk
of gallbladder stones by 15%.

15. A patient admitted to the hospital with myocardial infarction develops severe
pulmonary edema. Which of the following symptoms should the nurse expect the
patient to exhibit?

A. Slow, deep respirations

B. Stridor

C. Bradycardia

D. Air hunger
Correct Answer: D. Air hunger
Patients with pulmonary edema experience air hunger, anxiety, and agitation. Symptoms
may also include coughing up blood or bloody froth; difficulty breathing when lying
down (orthopnea); feeling of “air hunger” or “drowning” (this feeling is called
“paroxysmal nocturnal dyspnea” if it causes you to wake up 1 to 2 hours after falling
asleep and struggle to catch your breath).
 Option A: Physical findings in patients with pulmonary edema are notable for
tachypnea and tachycardia. Patients may be sitting upright, they may
demonstrate air hunger, and they may become agitated and confused. Patients
usually appear anxious and diaphoretic.
 Option B: Auscultation of the lungs usually reveals fine, crepitant rales, but
rhonchi or wheezes may also be present. Rales are usually heard at the bases first;
as the condition worsens, they progress to the apices.
 Option C: Cardiovascular findings are usually notable for S3, accentuation of the
pulmonic component of S2, and jugular venous distention. Auscultation of
murmurs can help in the diagnosis of acute valvular disorders manifesting with
pulmonary edema.

16. A nurse caring for several patients in the cardiac unit is told that one is scheduled for
implantation of an automatic internal cardioverter-defibrillator. Which of the following
patients is most likely to have this procedure?
A. A patient admitted for myocardial infarction without cardiac muscle damage.

B. A postoperative coronary bypass patient, recovering on schedule.

C. A patient with a history of ventricular tachycardia and syncopal episodes.

D. A patient with a history of atrial tachycardia and fatigue.

Correct Answer: C. A patient with a history of ventricular tachycardia and syncopal

episodes.
An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to
terminate episodes of ventricular tachycardia and ventricular fibrillation. This is
necessary for a patient with significant ventricular symptoms, such as tachycardia
resulting in syncope.
 Option A: A patient with myocardial infarction that resolved with no permanent
cardiac damage would not be a candidate.
 Option B: A patient recovering well from coronary bypass would not need the
device.
 Option D: Atrial tachycardia is less serious and is treated conservatively with
medication and cardioversion as a last resort.

17. A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected
lung cancer. Which of the following is a contraindication to the study for this patient?
A. The patient is allergic to shellfish.

B. The patient has a pacemaker.

C. The patient suffers from claustrophobia.

D. The patient takes antipsychotic medication.

Correct Answer: B. The patient has a pacemaker
The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and
may be deactivated by them. Patients with cardiac implantable electronic devices or
CIED are at risk for inappropriate device therapy, device heating/movement, and
arrhythmia during MRI. These patients must be scheduled in a CIED blocked slot or
scheduled with electrophysiology nurse or technician support. But nowadays MRI
conditional cardiac implantable electronic devices are widely available.
 Option A: Shellfish/iodine allergy is not a contraindication because the contrast
used in MRI scanning is not iodine-based. MRI contrast agents are gadolinium
chelates with different stability, viscosity, and osmolality. Gadolinium is a
relatively very safe contrast; however, it rarely might cause allergic reactions in
patients.
 Options C: Open MRI scanners and anti-anxiety medications are available for
patients with claustrophobia. Claustrophobic patients might refuse to complete
the MRI scan and need sedation. These patients need to be well informed about
the MRI scan procedure. The recommendation is that a physician has a discussion
with them about the details in advance. Using Larger and opener MRI systems
might be helpful in claustrophobic patients.
 Option D: Psychiatric medication is not a contraindication to MRI scanning. MRI
helps in high-resolution investigations of soft tissues without the use of ionizing
radiation. This safe modality currently becomes the imaging technique of choice
for diagnosing musculoskeletal, neurologic, and cardiovascular disease. However,
there are restrictions and contraindications caused by MRI magnetic fields,
machine structure, and gadolinium contrast agents.

18. A nurse calls a physician with the concern that a patient has developed a pulmonary
embolism. Which of the following symptoms has the nurse most likely observed?

A. The patient is somnolent with decreased response to the family.

B. The patient suddenly complains of chest pain and shortness of breath.

C. The patient has developed a wet cough and the nurse hears crackles on
auscultation of the lungs.

D. The patient has a fever, chills, and loss of appetite.

Correct Answer: B. The patient suddenly complains of chest pain and shortness of
breath.
Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and
severe anxiety. The physician should be notified immediately. Clinical signs and
symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of
having pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest
pain or the presence of risk factors for pulmonary embolism—must undergo diagnostic
tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is
confirmed.
 Option A: The patient may present atypical symptoms based on risk factors, such
as delirium or a decreasing level of consciousness.
 Option B: The diagnosis of pulmonary embolism should be sought actively in
patients with respiratory symptoms UNEXPLAINED by an alternative diagnosis;
symptoms may include productive cough and wheezing.
  Option D: A patient with fever, chills, and loss of appetite may be developing
pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of patients;
however, a temperature higher than 39.5°C (103.1º) F is not from a pulmonary
embolism.

19. A patient comes to the emergency department with abdominal pain. Work-up
reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the
following actions should the nurse expect?
A. The patient will be admitted to the medicine unit for observation and medication.

B. The patient will be admitted to the day surgery unit for sclerotherapy.

C. The patient will be admitted to the surgical unit and resection will be scheduled.

D. The patient will be discharged home to follow-up with his cardiologist in 24

hours.

Correct Answer: C. The patient will be admitted to the surgical unit and resection
will be scheduled.
A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and
should be resected as soon as possible. No other appropriate treatment options
currently exist.
 Option A: Admitting the patient for observation will be a delay and may result in
the rupture of the aneurysm. Immediate surgery is the only recommended
management.
 Option B: Sclerotherapy, in which a solution is injected into a vein, causing it to
collapse, scar, and fade, remains the primary treatment for the small-vessel
varicose disease of the lower extremities.
 Option D: The patient should not be discharged because the abdominal
aneurysm may rupture at any time and place the patient’s life at risk.

20. A patient with leukemia is receiving chemotherapy that is known to depress bone
marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter.
Which of the following actions related specifically to the platelet count should be
included in the nursing care plan?
A. Monitor for fever every 4 hours.

B. Require visitors to wear respiratory masks and protective clothing.

C. Consider transfusion of packed red blood cells.

D. Check for signs of bleeding, including examination of urine and stool for blood.

Correct Answer: D. Check for signs of bleeding, including examination of urine and
stool for blood.
A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt
the initiation of bleeding precautions, including monitoring urine and stool for evidence
of bleeding.
 Option A: According to three retrospective case reviews of childhood leukemia
(in which 75% to 100% of the cases were acute lymphoblastic leukemia), common
 presenting signs and symptoms include fever (17% to 77%), lethargy (12% to
39%), and bleeding (10% to 45%).
 Option B: Requiring protective clothing is indicated to prevent infection if white
blood cells are decreased. Protective garments consisting of gloves,
chemotherapy gowns, eye protection e.g.; goggles, N95 respirator, and shoe
covers will be worn according to the task being performed with a
Chemotherapy/Biotherapy agent or excreta of a patient who has received a
Chemotherapy/Biotherapy agent within the last 48 hours.
 Option C: Transfusion of red cells is indicated for severe anemia. Blood
transfusions represent one of the most important forms of supportive care for
patients with leukemia. Cancer is the major cause of transfusion. One-third of
transfused patients have a malignant disease, with acute leukemia being the
malignancy in a large part of them.

21. A nurse in the emergency department is observing a 4-year-old child for signs of
increased intracranial pressure after a fall from a bicycle, resulting in head trauma.
Which of the following signs or symptoms would be cause for concern?

A. Bulging anterior fontanel

B. Repeated vomiting

C. Signs of sleepiness at 10 PM
D. Inability to read short words from a distance of 18 inches

Correct Answer: B. Repeated vomiting

Increased pressure caused by bleeding or swelling within the skull can damage delicate
brain tissue and may become life-threatening. Repeated vomiting can be an early sign
of pressure as the vomiting center within the medulla is stimulated.
 Option A: The anterior fontanel is closed in a 4-year-old child. The average
closure time of the anterior fontanelle ranges from 13 to 24 months. Infants of
African descent statically have larger fontanelles that range from 1.4 to 4.7 cm,
and in terms of sex, the fontanelles of male infants will closer sooner compared
to female infants.
 Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old. Young
toddlers have a sleep schedule supplemented by two naps a day. Toddler sleep
problems are compounded by separation anxiety and a fear of missing out, which
translates to stalling techniques and stubbornness at bedtime.
 Option D: The average 4-year-old child cannot read yet, so this too is normal. At
4, many children just aren’t ready to sit still and focus on a book for long. Others
may learn the mechanics of reading but aren’t cognitively ready to comprehend
the words.

22. A nonimmunized child appears at the clinic with a visible rash. Which of the
following observations indicates the child may have rubeola (measles)?
A. Small blue-white spots are visible on the oral mucosa.

B. The rash begins on the trunk and spreads outward.

C. There is low-grade fever.

D. The lesions have a "teardrop-on-a-rose-petal" appearance.

Correct Answer: A. Small blue-white spots are visible on the oral mucosa.
Koplik’s spots are small blue-white spots visible on the oral mucosa and are
characteristic of measles infection. Near the end of the prodrome, Koplik spots (ie,
bluish-gray specks or “grains of sand” on a red base) appear on the buccal mucosa
opposite the second molars. The Koplik spots generally are first seen 1-2 days before
the appearance of the rash and last until 2 days after the rash appears. This enanthem
begins to slough as the rash appears. Although this is the pathognomonic enanthem of
measles, its absence does not exclude the diagnosis.
 Option B: The body rash typically begins on the face and travels downward.
Blanching, erythematous macules and papules begin on the face at the hairline,
on the sides of the neck, and behind the ears (see the images below). Within 48
hours, they coalesce into patches and plaques that spread cephalocaudally to the
trunk and extremities, including the palms and soles, while beginning to regress
cephalocaudally, starting from the head and neck. Lesion density is greatest
above the shoulders, where macular lesions may coalesce. The eruption may also
be petechial or ecchymotic in nature.
 Option C: High fever (may spike to more than 104°F) is often present. The first
sign of measles is usually a high fever (often >104o F [40o C]) that typically lasts
4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the
classic triad of conjunctivitis (see the image below), cough, and coryza (the “3
Cs”).
 Option D: “Teardrop on a rose petal” refers to the lesions found in varicella
(chickenpox). The characteristic chickenpox vesicle, surrounded by an
erythematous halo, is described as a dewdrop on a rose petal

23. A child is seen in the emergency department for scarlet fever. Which of the following
descriptions of scarlet fever is not correct?
A. Scarlet fever is caused by infection with group A Streptococcus bacteria.

B. "Strawberry tongue" is a characteristic sign.

C. Petechiae occur on the soft palate.

D. The pharynx is red and swollen.

Correct Answer: C. Petechiae occur on the soft palate.

Petechiae on the soft palate is characteristic of rubella infection.
 Option A: Bacteria called group A Streptococcus or group A strep cause scarlet
fever. The bacteria sometimes make a poison (toxin), which causes a rash- the
“scarlet” of scarlet fever. As the name “scarlet fever” implies, an erythematous
eruption is associated with a febrile illness. The circulating toxin, produced by
GABHS and often referred to as erythemogenic or erythrogenic toxin, causes the
pathognomonic rash as a consequence of local production of inflammatory
mediators and alteration of the cutaneous cytokine milieu. This results in a sparse
inflammatory response and dilatation of blood vessels, leading to the
characteristic scarlet color of the rash.
 Option B: The tongue may have a “strawberry”-like (red and bumpy) appearance,
which is a characteristic sign of scarlet fever. On day 1 or 2, the tongue is heavily
coated with a white membrane through which edematous red papillae protrude
(classic appearance of white strawberry tongue). By day 4 or 5, the white
 membrane sloughs off, revealing a shiny red tongue with prominent papillae (red
strawberry tongue). Red, edematous, exudative tonsils are typically observed if
the infection originates in this area.
 Option D: The throat and tonsils may be very red and sore with scarlet fever, and
swallowing may be painful. The mucous membranes usually are bright red and
scattered petechiae and small red papular lesions on the soft palate are often
present.

24. A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an
allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is
prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the
following best describes the prescribed drug dose?

A. It is the correct dose

B. The dose is too low

C. The dose is too high

D. The dose should be increased or decreased, depending on the symptoms

Correct Answer: B. The dose is too low

This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X
30 = 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day,
the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage
should not be titrated based on symptoms without consulting a physician.
 Option A: Diphenhydramine is used to relieve red, irritated, itchy, watery eyes;
sneezing; and runny nose caused by hay fever, allergies, or the common cold.
Diphenhydramine is also used to relieve coughs caused by minor throat or airway
irritation.
 Option C: Diphenhydramine comes as a tablet, a rapidly disintegrating
(dissolving) tablet, a capsule, a liquid-filled capsule, a dissolving strip, powder,
and a liquid to take by mouth. When diphenhydramine is used for the relief of
allergies, cold, and cough symptoms, it is usually taken every 4 to 6 hours.
 Option D: Before you give a diphenhydramine product to a child, check the
package label to find out how much medication the child should receive. Give the
dose that matches the child’s age on the chart. Ask the child’s doctor if you don’t
know how much medication to give the child.

25. The mother of a 2-month-old infant brings the child to the clinic for a well-baby
check. She is concerned because she feels only one testis in the scrotal sac. Which of the
following statements about the undescended testis is the most accurate?

A. Normally, the testes are descended by birth.

B. The infant will likely require surgical intervention.

C. The infant probably has only one testis.

D. Normally, the testes descend by one year of age.

Correct Answer: D. Normally, the testes descend by one year of age.
Normally, the testes descend by one year of age. In young infants, it is common for the
testes to retract into the inguinal canal when the environment is cold or the cremasteric
reflex is stimulated. The exam should be done in a warm room with warm hands. It is
most likely that both testes are present and will descend by a year. If not, a full
assessment will determine the appropriate treatment.
 Option A: The testes usually descend by one year of age. Most of the time, a
boy’s testicles descend by the time he is 9 months old. Undescended testicles are
common in infants who are born early. The problem occurs less in full-term
infants.
 Option B: Surgical intervention is unnecessary; the testes descend by one year of
age. The testicles will descend normally at puberty and surgery is not needed.
Testicles that do not naturally descend into the scrotum are considered
abnormal. An undescended testicle is more likely to develop cancer, even if it is
brought into the scrotum with surgery. Cancer is also more likely in the other
testicle.
 Option C: In young infants, it is common for the testes to retract into the inguinal
canal when the environment is cold or the cremasteric reflex is stimulated.

26. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which
of the following statements most accurately describes this stage?
A. The tumor is less than 3 cm. in size and requires no chemotherapy.

B. The tumor did not extend beyond the kidney and was completely resected.

C. The tumor extended beyond the kidney but was completely resected.

D. The tumor has spread into the abdominal cavity and cannot be resected.

Correct Answer: C. The tumor extended beyond the kidney but was completely
resected.
The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is
limited to the kidney and completely resected; stage II, the tumor extends beyond the
kidney but is completely resected; stage III, the residual non-hematogenous tumor is
confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread
beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
 Option A: The mass is solid at presentation and usually >10 cm.
 Option B: This option describes stage 1, wherein the tumor is limited to the
kidney and completely resected.
 Option D: In stage IV, hematogenous metastasis has occurred with spread
beyond the abdomen.

27. A teen patient is admitted to the hospital by his physician who suspects a diagnosis
of acute glomerulonephritis. Which of the following findings is consistent with this
diagnosis? Select all that apply.
A. Urine specific gravity of 1.040

B. Urine output of 350 ml in 24 hours

C. Brown ("tea-colored") urine

D. Generalized edema
Correct Answer: A, B, & C
Acute glomerulonephritis is characterized by high urine specific gravity related to
oliguria as well as dark “tea-colored” urine caused by large amounts of red blood cells.
Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and RBC casts
are present.
 Option B: Functional changes include proteinuria, hematuria, reduction in GFR
(ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The
decreased GFR and avid distal nephron salt and water retention result in the
expansion of intravascular volume, edema, and, frequently, systemic
hypertension.
 Option C: This is a universal finding, even if it is microscopic. Gross hematuria is
reported in 30% of pediatric patients, often manifesting as smoky-, coffee-, or
cola-colored urine.
 Option D: There is periorbital edema, but generalized edema is seen in nephrotic
syndrome, not acute glomerulonephritis. Most often, the patient is a boy, aged 2-
14 years, who suddenly develop puffiness of the eyelids and facial edema in the
setting of a post-streptococcal infection.

28. Which of the following conditions most commonly causes acute glomerulonephritis?

A. A congenital condition leading to renal dysfunction.

B. Prior infection with group A Streptococcus within the past 10-14 days.

C. Viral infection of the glomeruli.

D. Nephrotic syndrome.

Correct Answer: B. Prior infection with group A Streptococcus within the past 10-
14 days.
Acute glomerulonephritis is most commonly caused by the immune response to a prior
upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine, and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
 Option A: No congenital condition predisposes to glomerulonephritis.
Noninfectious causes of acute GN may be divided into primary renal diseases,
systemic diseases, and miscellaneous conditions or agents.
 Option C: Viruses may cause acute glomerulonephritis but rarely.
Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B virus
(HBV), rubella, rickettsiae (as in scrub typhus), parvovirus B19, and mumps virus
are accepted as viral causes only if it can be documented that a recent group A
beta-hemolytic streptococcal infection did not occur. Acute GN has been
documented as a rare complication of hepatitis A.
 Option D: Nephrotic syndrome does not cause acute glomerulonephritis. PSGN
usually develops 1-3 weeks after acute infection with specific nephritogenic
strains of group A beta-hemolytic streptococcus. The incidence of GN is
approximately 5-10% in persons with pharyngitis and 25% in those with skin
infections.
29. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age.
The scrotum is smaller than it was at birth, but the fluid is still visible on illumination.
Which of the following actions is the physician likely to recommend?

A. Massaging the groin area twice a day until the fluid is gone.

B. Referral to a surgeon for repair.

C. No treatment is necessary; the fluid is reabsorbing normally.

D. Keeping the infant in a flat, supine position until the fluid is gone.

Correct Answer: C. No treatment is necessary; the fluid is reabsorbing normally.

A hydrocele is a collection of fluid in the scrotum that results from a patent tunica
vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In
most cases, the fluid reabsorbs within the first few months of life and no treatment is
necessary.
 Option A: A hydrocele can develop before birth. Normally, the testicles descend
from the developing baby’s abdominal cavity into the scrotum. A sac
accompanies each testicle, allowing fluid to surround the testicles. Usually, each
sac closes and the fluid is absorbed. Sometimes, the fluid remains after the sac
closes (noncommunicating hydrocele). The fluid is usually absorbed gradually
within the first year of life. But occasionally, the sac remains open
(communicating hydrocele). The sac can change size or if the scrotal sac is
compressed, fluid can flow back into the abdomen. Communicating hydroceles
are often associated with inguinal hernia.
 Option B: A hydrocele that doesn’t disappear on its own might need to be
surgically removed, typically as an outpatient procedure. The surgery to remove a
hydrocele (hydrocelectomy) can be done under general or regional anesthesia.
An incision is made in the scrotum or lower abdomen to remove the hydrocele. If
a hydrocele is found during surgery to repair an inguinal hernia, the surgeon
might remove the hydrocele even if it’s causing no discomfort.
 Option D: A baby’s hydrocele typically disappears on its own. But if the baby’s
hydrocele doesn’t disappear after a year or if it enlarges, ask the child’s doctor to
examine the hydrocele again.

30. A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of
any kind. Which of the following is the most likely explanation for these symptoms?

A. Inadequate tissue perfusion leading to nerve damage.

B. Fluid overload leading to compression of nerve tissue.

C. Sensation distortion due to psychiatric disturbance.

D. Inflammation of the skin on the hands and feet.

Correct Answer: A. Inadequate tissue perfusion leading to nerve damage.

Patients with peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced
by the effects of gravity.
 Option B: Fluid overload is not characteristic of PVD. Assess the heart for
murmurs or other abnormalities. Investigate all peripheral vessels, including
carotid, abdominal, and femoral, for pulse quality and bruit. Note that the
dorsalis pedis artery is absent in 5-8% of normal subjects, but the posterior tibial
artery usually is present. Both pulses are absent in only about 0.5% of patients.
Exercise may cause the obliteration of these pulses.
 Option C: There is nothing to indicate a psychiatric disturbance in the patient.
 Option D: Skin changes in PVD are secondary to decreased tissue perfusion
rather than primary inflammation. The skin may have an atrophic, shiny
appearance and may demonstrate trophic changes, including alopecia; dry, scaly,
or erythematous skin; chronic pigmentation changes; and brittle nails.

31. A patient in the cardiac unit is concerned about the risk factors associated with
atherosclerosis. Which of the following are hereditary risk factors for developing
atherosclerosis?

A. Family history of heart disease

B. Overweight

C. Smoking
D. Age

Correct Answer: A. Family history of heart disease.

A family history of heart disease is an inherited risk factor that is not subject to a lifestyle
change. Having a first-degree relative with heart disease has been shown to significantly
increase risk.
 Option B: Overweight is a risk factor that is subject to lifestyle change and can
reduce risk significantly. The terms “overweight” and “obesity” refer to body
weight that’s greater than what is considered healthy for a certain height.
 Option C: Smoking can damage and tighten blood vessels, raise cholesterol
levels, and raise blood pressure. Smoking also doesn’t allow enough oxygen to
reach the body’s tissues.
 Option D: Advancing age increases the risk of atherosclerosis but is not a
hereditary factor. As one gets older, the risk for atherosclerosis increases. Genetic
or lifestyle factors cause plaque to build up in the arteries as one ages. By the
time one is middle-aged or older, enough plaque has built up to cause signs or
symptoms. In men, the risk increases after age 45. In women, the risk increases
after age 55.
32. Claudication is a well-known effect of peripheral vascular disease. Which of the
following facts about claudication is correct? Select all that apply:

A. It results when oxygen demand is greater than oxygen supply.

B. It is characterized by pain that often occurs during rest.

C. It is a result of tissue hypoxia.

D. It is characterized by cramping and weakness.

E. It always affects the upper extremities.

Correct Answer: A, C, & D.
Claudication describes the pain experienced by a patient with a peripheral vascular
disease when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue
becomes hypoxic, causing cramping, weakness, and discomfort.
 Option A: Claudication refers to muscle pain due to lack of oxygen that’s
triggered by activity and relieved by rest.
 Option B: This most often occurs during activity when demand increases in
muscle tissue.
 Option C: The condition is also called intermittent claudication because the pain
usually isn’t constant. It begins during exercise and ends with rest. As claudication
worsens, however, the pain may occur during rest.
 Option D: Claudication is pain caused by too little blood flow to muscles during
exercise. Most often this pain occurs in the legs after walking at a certain pace
and for a certain amount of time — depending on the severity of the condition.
Option E: Pain in the shoulders, biceps, and forearms may occur, but less often.

33. A nurse is providing discharge information to a patient with peripheral vascular

disease. Which of the following information should be included in the instructions?
A. Walk barefoot whenever possible.

B. Use a heating pad to keep feet warm.

C. Avoid crossing the legs.

D. Use antibacterial ointment to treat skin lesions at risk of infection.

Correct Answer: C. Avoid crossing the legs.

Patients with peripheral vascular disease should avoid crossing the legs because this can
impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result
of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with
a fibrous intravascular covering. The atherosclerotic process may gradually progress to
complete occlusion of medium-sized and large arteries. The disease typically is
segmental, with significant variation from patient to patient.
 Option A: Walking barefoot is not advised, as foot protection is important to
avoid the trauma that may lead to serious infection.
 Option B: Heating pads can cause injury, which can also increase the risk of
infection.
 Option D: Skin lesions at risk for infection should be examined and treated by a
physician.

34. A patient who has been diagnosed with the vasospastic disorder (Raynaud’s disease)
complains of cold and stiffness in the fingers. Which of the following descriptions is
most likely to fit the patient?
A. An adolescent male

B. An elderly woman
C. A young woman

D. An elderly man
Correct Answer: C. young woman.
Raynaud’s disease is most common in young women and is frequently associated with
rheumatologic disorders, such as lupus and rheumatoid arthritis. Vasospasm of the
arteries reduces blood flow to the fingers and toes. In people who have Raynaud’s, the
disorder usually affects the fingers. In about 40 percent of people who have Raynaud’s,
it affects the toes. Rarely, the disorder affects the nose, ears, nipples, and lips.
 Option A: Primary Raynaud’s usually develops before the age of 30. In primary
Raynaud’s (also called Raynaud’s disease), the cause isn’t known. Primary
Raynaud’s are more common and tend to be less severe than secondary
Raynaud’s.
 Option B: Secondary Raynaud’s usually develops after the age of 30. Secondary
Raynaud’s is caused by an underlying disease, condition, or other factors. This
type of Raynaud’s is often called Raynaud’s phenomenon.
 Option D: Although anyone can develop the condition, Raynaud’s disease often
begins between the ages 15 to 30, but it mostly affects women. If one has
primary or secondary Raynaud’s, cold temperatures or stress can trigger
“Raynaud’s attacks.” During an attack, little or no blood flows to affected body
parts.

35. A 23-year-old patient in the 27th week of pregnancy has been hospitalized on
complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied
by chest pain. Which of the following conditions is the most likely cause of her
symptoms?
A. Myocardial infarction due to a history of atherosclerosis.

B. Pulmonary embolism due to deep vein thrombosis (DVT).

C. Anxiety attacks due to worries about her baby's health.

D. Congestive heart failure due to fluid overload.

Correct Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT).

In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset
shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged
inactivity both increase the risk of clot formation in the deep veins of the legs. These
clots can then break loose and travel to the lungs.
 Option A: Atherosclerosis is the disease primarily responsible for most acute
coronary syndrome (ACS) cases. Approximately 90% of myocardial infarctions
(MIs) result from an acute thrombus that obstructs an atherosclerotic coronary
artery. Plaque rupture and erosion are considered to be the major triggers for
coronary thrombosis. Following plaque erosion or rupture, platelet activation and
aggregation, coagulation pathway activation, and endothelial vasoconstriction
occur, leading to coronary thrombosis and occlusion.
 Option C: There is no reason to suspect an anxiety disorder in this patient.
Though anxiety is a possible cause of her symptoms, the seriousness of
pulmonary embolism demands that it be considered first.
 Option D: According to 2017 American Heart Association (AHA) data, heart
failure affects an estimated 6.5 million Americans aged 20 years and older. [31]
With improved survival of patients with acute myocardial infarction and with a
population that continues to age, heart failure will continue to increase in
prominence as a major health problem in the United States.
36. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which
of the following is a significant complication associated with thrombolytic therapy?
A. Air embolus.

B. Cerebral hemorrhage.

C. Expansion of the clot.

D. Resolution of the clot.

Correct Answer: B. Cerebral hemorrhage.

Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic
therapy intended to dissolve a suspected clot. The success of the treatment demands
that it be instituted as soon as possible, often before the cause of stroke has been
determined.
 Option A: Air embolism is not a concern. Thrombosis is an important part of the
normal hemostatic response that limits hemorrhage caused by microscopic or
macroscopic vascular injury. Physiologic thrombosis is counterbalanced by
intrinsic antithrombotic properties and fibrinolysis. Under normal conditions, a
thrombus is confined to the immediate area of injury and does not obstruct flow
to critical areas, unless the blood vessel lumen is already diminished, as it is in
atherosclerosis.
 Option C: Both hemostasis and thrombosis depend on the coagulation cascade,
vascular wall integrity, and platelet response. Several cellular factors are
responsible for thrombus formation. When a vascular insult occurs, an immediate
local cellular response takes place. Platelets migrate to the area of injury, where
they secrete several cellular factors and mediators. These mediators promote clot
formation.
 Option D: Thrombolytic therapy does not lead to the expansion of the clot, but
to resolution, which is the intended effect.

37. An infant is brought to the clinic by his mother, who has noticed that he holds his
head in an unusual position and always faces to one side. Which of the following is
the most likely explanation?
A. Torticollis, with shortening of the sternocleidomastoid muscle.
B. Craniosynostosis, with premature closure of the cranial sutures.

C. Plagiocephaly, with flattening of one side of the head.

D. Hydrocephalus, with increased head size.

Correct Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle.

In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion
of the neck and causing the chin to point to the opposing side.
 Option B: In craniosynostosis one of the cranial sutures, often the sagittal, closes
prematurely, causing the head to grow in an abnormal shape.
 Option C: Plagiocephaly refers to the flattening of one side of the head, caused
by the infant being placed supine in the same position over time.
 Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the
brain resulting in large head size.
38. An adolescent brings a physician’s note to school stating that he is not to participate
in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following
statements about the disease is correct?

A. The condition was caused by the student's competitive swimming schedule.

B. The student will most likely require surgical intervention.

C. The student experiences pain in the inferior aspect of the knee.

D. The student is trying to avoid participation in physical education.

Correct Answer: C. The student experiences pain in the inferior aspect of the knee.
Osgood-Schlatter disease occurs in adolescents in the rapid growth phase when the
infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain
and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly
caused by activities that require repeated use of the quadriceps, including track and
soccer.
 Option A: Swimming is not a likely cause. OSD is a traction phenomenon
resulting from repetitive quadriceps contraction through the patellar tendon at its
insertion upon the skeletally immature tibial tubercle. This occurs in
preadolescence during a time when the tibial tubercle is susceptible to strain. The
pain associated will be localized to the tibial tubercle and occasionally the
patellar tendon itself.
 Option B: The condition is usually self-limited, responding to ice, rest, and
analgesics. OSD is a self-limiting condition. In a study by Krause et al, 90% of
patients treated with conservative care were relieved of all of their symptoms
approximately 1 year after the onset of symptoms. [3] After skeletal maturity,
patients may continue to have problems kneeling. This typically is due to
tenderness over an unfused tibial tubercle ossicle or a bursa that may require
resection.
 Option D: Continued participation will worsen the condition and the symptoms.
The onset of OSD is usually gradual, with patients commonly complaining of pain
in the tibial tubercle and/or patellar tendon region after repetitive activities.
Typically, running or jumping activities that significantly stress the patellar tendon
insertion upon the tibial tubercle aggravate the patient’s symptoms.

39. The clinic nurse asks a 13-year-old female to bend forward at the waist with arms
hanging freely. Which of the following assessments is the nurse most likely conducting?

A. Spinal flexibility
B. Leg length disparity

C. Hypostatic blood pressure

D. Scoliosis

Correct Answer: D. Scoliosis.

A check for scoliosis, a lateral deviation of the spine, is an important part of the routine
adolescent exam. It is assessed by having the teen bend at the waist with arms dangling,
while observing for lateral curvature and uneven rib level. Scoliosis is more common in
female adolescents.
  Options A: The ability to move the spine through its full range of motion, both
forward and backward, is called spinal flexibility. However, it is not included in
routine adolescent exams.
 Options B: Leg length discrepancy or disparity is a condition in which the paired
lower extremity limbs have a noticeably unequal length.
 Option C: Hypostatic or orthostatic blood pressure is a form of low blood
pressure that happens when one is sitting or stands up suddenly.

40. A clinic nurse interviews a parent who is suspected of abusing her child. Which of the
following characteristics is the nurse least likely to find in an abusing parent?
A. Low self-esteem

B. Unemployment
C. Self-blame for the injury to the child

D. Single status

Correct Answer: C. Self-blame for the injury to the child.

The profile of a parent at risk of abusive behavior includes a tendency to blame the child
or others for the injury sustained. Abusers typically blame others, especially their
partners, for the mistakes in their lives. This is related to hypersensitivity, but they are
not necessarily alike. This occurs because most abusive people don’t hold themselves as
being accountable for the actions they commit. Instead, they’ll try to shift the blame to
the person that they have abused and somehow say they “deserved it” or that they were
forced into a corner.
 Option A: Basically, domestic violence offenders always feel the need to be in
control of their victims. The less in control an offender feels, the more they want
to hurt others.
 Option B: One study suggests that unemployment can cause an increase in child
neglect because parents have more limited access to the resources required to
provide for a child’s basic needs, such as clothing, food, and medical care.
 Option D: A “favorite” of abusers is to isolate their partners from family or
friends. This type of isolation is often very common and often represents the first
step in an abusive relationship. The abusive partner will attempt to set up an “us
versus them” attitude and will begin isolating family members. This can work
through the abuser’s use of jealousy, controlling behavior, or veiled concern.

41. A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who
has just been diagnosed with juvenile idiopathic arthritis. Which of the following
statements about the disease is most accurate?

A. The child has a poor chance of recovery without joint deformity.

B. Most children progress to adult rheumatoid arthritis.

C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

D. Physical activity should be minimized.

Correct Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in
treatment.
Nonsteroidal anti-inflammatory drugs are an important first-line treatment for juvenile
idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4
weeks for the therapeutic anti-inflammatory effects to be realized.
 Options A: Advances in treatment over the last 20 years—especially the
introduction of early use of intra-articular steroids, methotrexate, and biologic
medications—have dramatically improved the prognosis for children with
arthritis. Almost all children with JIA lead productive lives. However, many
patients, particularly those with a polyarticular disease, may have problems with
the active disease throughout adulthood, with sustained remission attained in a
minority of patients.
 Option B: Children with the systemic-onset disease tend to either respond
completely to medical therapy or develop a severe polyarticular course that tends
to be refractory to medical treatment, with disease persisting into adulthood.
 Option D: Physical activity is an integral part of therapy. Encourage patients to be
as active as possible. Bed rest is not a part of the treatment. In fact, the more
active the patient, the better the long-term prognosis. Children may experience
increased pain during routine physical activities. As a result, these children must
be allowed to self-limit their activities, particularly during physical education
classes. A consistent physical therapy program, with attention to stretching
exercises, pain modalities, joint protection, and home exercises, can help ensure
that patients are as active as possible.

42. A child is admitted to the hospital several days after stepping on a sharp object that
punctured her athletic shoe and entered the flesh of her foot. The physician is
concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the
following actions is done immediately before the antibiotic is started?
A. The admission orders are written.

B. A blood culture is drawn.

C. A complete blood count with differential is drawn.

D. The parents arrive.

Correct Answer: B. A blood culture is drawn.

Antibiotics must be started after the blood culture is drawn, as they may interfere with
the identification of the causative organism.
 Option A: Making sure that the physician’s orders for antibiotics are written,
instead of admitting orders, should be done.
 Option C: The blood count will reveal the presence of infection but does not help
identify an organism or guide antibiotic treatment.
 Option D: Parental presence is important for the adjustment of the child but not
for the administration of medication.
43. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse
in the emergency department documents swelling of the lower affected leg. Which of
the following does the nurse suspect is the cause of the child’s symptoms?

A. Possible fracture of the tibia.

B. Bruising of the gastrocnemius muscle.

C. Possible fracture of the radius.

D. No anatomic injury, the child wants his mother to carry him.

Correct Answer: A. Possible fracture of the tibia.

The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture.
 Option B: Toddlers will often continue to walk on a muscle that is bruised or
strained.
 Option C: The radius is found in the lower arm and is not relevant to this
question.
 Option D: Toddlers rarely feign injury to be carried, and swelling indicates a
physical injury.

44. A toddler has recently been diagnosed with cerebral palsy. Which of the following
information should the nurse provide to the parents? Select all that apply.

A. Regular developmental screening is important to avoid secondary developmental

delays.

B. Cerebral palsy is caused by injury to the upper motor neurons and results in
motor dysfunction, as well as possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no
additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health
care issues.

E. Therapies and surgical interventions can cure cerebral palsy.

Correct Answer: A, B, and D.

Delayed developmental milestones are characteristic of cerebral palsy, so regular
screening and intervention is essential. Because of injury to upper motor neurons,
children may have ocular and speech difficulties. Parent support groups help families to
share and cope. Physical therapy and other interventions can minimize the extent of the
delay in developmental milestones.
 Option A: During a developmental screening, a short test is given to see if the
child has specific developmental delays, such as motor or movement delays. If
the results of the screening test are cause for concern, then the doctor will make
referrals for developmental and medical evaluations.
 Option B: Cerebral palsy (CP) is a group of disorders that affect a person’s ability
to move and maintain balance and posture. CP is the most common motor
disability in childhood. Cerebral means having to do with the brain. Palsy means
weakness or problems with using the muscles. CP is caused by abnormal brain
development or damage to the developing brain that affects a person’s ability to
control his or her muscles.
  Option C: Delayed developmental milestones definitely need interventions and
constant follow ups. Developmental monitoring (also called surveillance) means
tracking a child’s growth and development over time. If any concerns about the
child’s development are raised during monitoring, then a developmental
screening test should be given as soon as possible.
 Option D: Both early intervention and school-aged services are available through
a special education law—the Individuals with Disabilities Education Act (IDEA).
Part C of IDEA deals with early intervention services (birth through 36 months of
age), while Part B applies to services for school-aged children (3 through 21 years
of age). Even if the child has not been diagnosed with CP, he or she may be
eligible for IDEA services.
 Option E: Cerebral palsy has no cure, but treatment can improve the lives of
those who have the condition. After a CP diagnosis is made, a team of health
professionals works with the child and family to develop a plan to help the child
reach his or her full potential. Common treatments include medicines; surgery;
braces; and physical, occupational, and speech therapy. No single treatment is
the best one for all children with CP. Before deciding on a treatment plan, it is
important to talk with the child’s doctor to understand all the risks and benefits.

45. A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The
parents are receiving genetic counseling prior to planning another pregnancy. Which of
the following statements includes the most accurate information?

A. Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of

being carriers and sons a 50% chance of developing the disease.

B. Duchenne's is an X-linked recessive disorder, so both daughters and sons have a

50% chance of developing the disease.
C. Each child has a 1 in 4 (25%) chance of developing the disorder.

D. Sons only have a 1 in 4 (25%) chance of developing the disorder.

Correct Answer: A. Duchenne’s is an X-linked recessive disorder, so daughters have

a 50% chance of being carriers and sons a 50% chance of developing the disease.
The recessive Duchenne gene is located on one of the two X chromosomes of a female
carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a
50% chance of a son being affected. Daughters are not affected, but 50% are carriers
because they inherit one copy of the defective gene from the mother. The other X
chromosome comes from the father, who cannot be a carrier.
 Option B: DMD carriers are females who have a normal dystrophin gene on one
X chromosome and an abnormal dystrophin gene on the other X chromosome.
Most carriers of DMD do not themselves have signs and symptoms of the
disease, but a minority do.
 Option C: Advances in molecular biology techniques illuminate the genetic basis
underlying all MD: defects in the genetic code for dystrophin, a 427-kd skeletal
muscle protein (Dp427). These defects result in the various manifestations
commonly associated with MD, such as weakness and pseudohypertrophy.
 Option D: Minor variations notwithstanding, all types of MD have in common
progressive muscle weakness that tends to occur in a proximal-to-distal direction,
though there are some rare distal myopathies that cause predominantly distal
weakness. The decreasing muscle strength in those who are affected may
 compromise the patient’s ambulation potential and, eventually, cardiopulmonary
function.

46. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA).

The nurse knows that a PTCA is the
A. Surgical repair of a diseased coronary artery.

B. Placement of an automatic internal cardiac defibrillator.

C. Procedure that compresses plaque against the wall of the diseased coronary
artery to improve blood flow.
D. Non-invasive radiographic examination of the heart.

Correct Answer: C. Procedure that compresses plaque against the wall of the
diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is
performed during a cardiac catheterization. Aorta coronary bypass graft is the surgical
procedure to repair a diseased coronary artery.
 Option A: Coronary artery bypass grafting is the surgical repair of a diseased
coronary artery.
 Option B: Angioplasty does not involve the placement of an internal cardiac
defibrillator. An internal cardiac defibrillator is needed if the client has ventricular
tachycardia or ventricular fibrillation because they detect and stop abnormal
heartbeats or arrhythmias.
 Option D: PTCA is not a radiographic examination of the heart.

47. A newborn has been diagnosed with hypothyroidism. In discussing the condition and
treatment with the family, the nurse should emphasize:

A. They can expect the child will be mentally retarded.

B. Administration of thyroid hormone will prevent problems.

C. This rare problem is always hereditary.

D. Physical growth/development will be delayed.

Correct Answer: B. Administration of thyroid hormone will prevent problems.

Early identification and continued treatment with hormone replacement correct this
condition.
 Option A: Mental retardation can be prevented with early detection and
treatment. Neurologic sequelae, characterized by spasticity, tremor, and
hyperactive deep tendon reflexes, are found frequently in severe cretinism, but
not in mild cretinism or acquired hypothyroidism. The severity of neurologic
sequelae parallels mental retardation. Early therapy apparently prevents, in part,
these sequelae.
 Option C: Congenital hypothyroidism is caused by iodine deficiency and is
occasionally exacerbated by naturally occurring goitrogens. In the majority of
patients, CH is caused by abnormal development of the thyroid gland (thyroid
dysgenesis) which is a sporadic disorder and accounts for 85% of cases, and the
remaining 15% of cases are caused by dyshormonogenesis. The clinical features
 of congenital hypothyroidism are so subtle that many newborn infants remain
undiagnosed at birth and delayed diagnosis leads to the most severe outcome of
CH, mental retardation, emphasizing the importance of neonatal screening.
 Option D: The growth and development of an infant with congenital
hypothyroidism can be normal if it is detected and treated early. In overt
hypothyroidism, the severe impairment of linear growth leads to dwarfism, which
is characterized by limbs that are disproportionately short compared with the
48. A priority goal of involuntary hospitalization of the severely mentally ill client is

A. Re-orientation to reality

B. Elimination of symptoms

C. Protection from harm to self or others

D. Return to independent functioning

Correct Answer: C. Protection from self-harm and harm to others.

Involuntary hospitalization may be required for persons considered dangerous to self or
others or for individuals who are considered gravely disabled.
 Option A: Mentally ill clients should be kept safe first before reorienting them
back to reality. In keeping with emergent mental health public policy and nursing
professional ethics, the articulated aims of deinstitutionalization included
returning individuals to home communities to restore freedom and autonomy
and reducing or eliminating nursing practices grounded in punishment that was
being societally reconceptualized as harmful.
 Option B: Gradual elimination of the symptoms is not the primary goal in the
hospitalization of a mentally ill client. There are two important concepts of
psychological treatment. First, although it is called “psychological” treatment, the
ultimate effect of these treatments is to bring some changes in the very delicate
change in the structure and function of neurons by changing the way a person
habitually thinks and behaves. They also promote the healing of the brain by
reducing the stress experienced by the patients in daily life. In psychological
treatment, all treatment effects come from the effort to take new behavior and
adopt new ways of thinking.
 Option D: The client should be kept safe from himself and others first before he
can return to independent functioning. The measurement of functional capacity
in mental illness is an important recent development. Determination of functional
capacity may serve as a surrogate marker for real-world functioning, thereby
aiding clinicians in making important treatment determinations.

49. A 19-year-old client is paralyzed in a car accident. Which statement used by the
client would indicate to the nurse that the client was using the mechanism of
“suppression”?

A. “I don’t remember anything about what happened to me.”

B. “I’d rather not talk about it right now.”

C. “It’s the other entire guy’s fault! He was going too fast.”

D. “My mother is heartbroken about this.”

Correct Answer: A. “I don’t remember anything about what happened to me.”
Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A
deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-
esteem.
 Option B: Denial is a defense mechanism proposed by Anna Freud which
involves a refusal to accept reality, thus blocking external events from awareness.
If a situation is just too much to handle, the person may respond by refusing to
perceive it or by denying that it exists.
 Option C: This statement refers to projection, which is when an individual
attributes her negative self-concept onto others.
 Option D: This statement refers to the identification, which is when the client
identifies herself with an image that she sees is ideal to our ego.

50. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation
indicates that the membranes were ruptured for 36 hours prior to delivery. What are the
priority nursing diagnoses at this time?
Altered tissue perfusion

Risk for fluid volume deficit

High risk for hemorrhage

Risk for infection

Correct Answer: D. Risk for infection

Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection
to both mother and the newborn. Rupture of membranes results from a variety of
factors that ultimately lead to accelerated membrane weakening. This is caused by an
increase in local cytokines, an imbalance in the interaction between matrix
metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased
collagenase and protease activity, and other factors that can cause increased
intrauterine pressure.
 Option A: There should be little or no alteration in perfusion after premature
rupture of the membranes. Decreased tissue perfusion can be temporary, with
few or minimal consequences to the health of the patient, or it can be more acute
or protracted, with potentially destructive effects on the patient. When
diminished tissue perfusion becomes chronic, it can result in tissue or organ
damage or death.
 Option B: There may be a risk for deficient fluid volume, but it is not a priority.
Fluid volume deficit (FVD) or hypovolemia is a state or condition where the fluid
output exceeds the fluid intake. It occurs when the body loses both water and
electrolytes from the ECF in similar proportions. Common sources of fluid loss are
the gastrointestinal tract, polyuria, and increased perspiration.
 Option C: Hemorrhage is not a great risk in premature rupture of membranes.
One of the complications of PROM is intraventricular hemorrhage. This is because
blood vessels in the brain of premature infants are not fully developed, and are
therefore weaker than that of term babies. Research shows that intraventricular
hemorrhages (IVH) or brain bleeds are significantly reduced by steroid treatment,
without an increase in either maternal or neonatal infection.
51. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying,
the nurse should:
A. Expose the cast to air and turn the child frequently.

B. Use a heat lamp to reduce the drying time.

C. Handle the cast with the abductor bar.

D. Turn the child as little as possible.

Correct Answer: A. Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with the surface exposed to the air. Casts and
splints hold the bones in place while they heal. They also reduce pain, swelling, and
muscle spasm.
 Option B: Heat lamps may cause burns in the skin inside the cast. Inspect the
skin around the cast. If the skin becomes red or raw around the cast, contact a
doctor.
 Option C: Do not handle the cast until it is dry because it might still break. It
takes about one hour for fiberglass, and two to three days for plaster to become
hard enough to walk on. Some physicians will give a “cast shoe” to wear over a
walking cast. The cast shoe will help protect the bottom of the cast.
 Option D: Turning the child would ensure equal drying of the cast at all sides.
Keep the cast dry. If the cast becomes wet, it can hurt the child’s skin. Do not try
to dry cast with something warm (i.e., a blow dryer) this may cause burns.

52. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the
client for this test, the nurse would:
A. Instruct the client to maintain a regular diet the day prior to the examination.

B. Restrict the client’s fluid intake 4 hours prior to the examination.

C. Administer a laxative to the client the evening before the examination.

D. Inform the client that only 1 x-ray of his abdomen is necessary.

Correct Answer: C. Administer a laxative to the client the evening before the
examination
Bowel prep is important because it will allow greater visualization of the bladder and
ureters. Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast
material to evaluate the kidneys, ureters, and bladder and help diagnose blood in the
urine or pain in the side or lower back. An IVP may provide enough information to allow
the doctor to treat with medication and avoid surgery.
 Option A: Eating and drinking the night before the exam should be avoided.
 Option B: Restriction of fluids on the night before the exam should be
emphasized.
 Option D: An intravenous pyelogram is an x-ray of the kidneys, ureters, and
urinary bladder that uses iodinated contrast material injected into veins.
53. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child,
the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s
response is based on an understanding that:

A. AGN is a streptococcal infection that involves the kidney tubules.

B. The disease is easily transmissible in schools and camps.

C. The illness is usually associated with chronic respiratory infections.

D. It is not “caught” but is a response to a previous B-hemolytic strep infection.

Correct Answer: D. It is not “caught” but is a response to a previous B-hemolytic

strep infection.
AGN is generally accepted as an immune-complex disease in relation to an antecedent
streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal
disease.
 Option A: Acute glomerulonephritis comprises a specific set of renal diseases in
which an immunologic mechanism triggers inflammation and proliferation of
glomerular tissue that can result in damage to the basement membrane,
mesangium, or capillary endothelium.
 Option B: The disease is most commonly caused by Streptococcus species.
Glomerulonephritis may develop a week or two after recovery from a strep throat
infection or, rarely, a skin infection (impetigo). To fight the infection, the body
produces extra antibodies that can eventually settle in the glomeruli, causing
inflammation.
 Option C: Acute glomerulonephritis is usually associated with staphylococcal
infection. Infections with other types of bacteria, such as staphylococcus and
pneumococcus, viral infections, such as chickenpox, and parasitic infections, such
as malaria, can also result in acute glomerulonephritis. Acute glomerulonephritis
that results from any of these infections is called postinfectious
glomerulonephritis.

54. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea,
occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with
5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35
ml/hr. Which finding should be reported to the healthcare provider immediately?
A. 3 episodes of vomiting in 1 hour.

B. Periodic crying and irritability.

C. Vigorous sucking on a pacifier.

D. No measurable voiding in 4 hours.

Correct Answer: D. No measurable voiding in 4 hours.

The concern is possible hyperkalemia, which could occur with continued potassium
administration and a decrease in urinary output since potassium is excreted via the
kidneys. Successful management of acute hyperkalemia involves protecting the heart
from arrhythmias with the administration of calcium, shifting potassium (K+) into the
cells, and enhancing the elimination of K+ from the body.
 Option A: Episodes of vomiting should be reported, but it is not the priority and
is currently being managed with intravenous infusions. Once clinically significant
 dehydration is present, effective and safe strategies for rehydration are required.
Additionally, following rehydration there may be a risk of recurrence of
dehydration and appropriate fluid management may reduce the likelihood of that
event.
 Option B: Crying and irritability is a normal reaction of an infant who is unwell.
 Option C: Vigorous sucking is a good sign in an infant who has episodes of
vomiting.

55. While caring for the client during the first hour after delivery, the nurse determines
that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first
action?
A. Check vital signs.

B. Massage the fundus.

C. Offer a bedpan.
D. Check for perineal lacerations.

Correct Answer: B. Massage the fundus

The nurse’s first action should be to massage the fundus until it is firm as uterine atony
is the primary cause of bleeding in the first hour after delivery. Approximately 3% to 5%
of obstetric patients will experience postpartum hemorrhage. Annually, these
preventable events are the cause of one-fourth of maternal deaths worldwide and 12%
of maternal deaths in the United States.
 Option A: Vital signs should be checked after vaginal delivery, but in this
situation, the nurse should prioritize prevention of bleeding. 20% of postpartum
hemorrhage occurs in women with no risk factors, so physicians must be
prepared to manage this condition at every delivery
 Option C: The client’s fundus should be massaged first to prevent uterine atony
and hemorrhage. Uterine atony is the most common cause of postpartum
hemorrhage. Brisk blood flow after delivery of the placenta unresponsive to
transabdominal massage should prompt immediate action including bimanual
compression of the uterus and use of uterotonic medications. Massage is
performed by placing one hand in the vagina and pushing against the body of
the uterus while the other hand compresses the fundus from above through the
abdominal wall
 Option D: Perineal lacerations may be present but it is not a primary concern
during uterine atony. Lacerations and hematomas due to birth trauma can cause
significant blood loss that can be lessened by hemostasis and timely repair.
Episiotomy increases the risk of blood loss and anal sphincter tears; this
procedure should be avoided unless urgent delivery is necessary and the
perineum is thought to be a limiting factor.
56. The nurse is assessing an infant with developmental dysplasia of the hip. Which
finding would the nurse anticipate?
A. Unequal leg length

B. Limited adduction

C. Diminished femoral pulses

D. Symmetrical gluteal folds

Correct Answer: A. Unequal leg length

Shortening of a leg is a sign of developmental dysplasia of the hip. The hip is a “ball-
and-socket” joint. In a normal hip, the ball at the upper end of the thigh bone (femur)
fits firmly into the socket, which is part of the large pelvis bone. In babies and children
with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not
formed normally. The ball is loose in the socket and may be easy to dislocate.
 Option B: Limited adduction is not a sign of developmental dysplasia. In all cases
of DDH, the socket (acetabulum) is shallow, meaning that the ball of the
thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that
help to hold the joint in place are stretched. The degree of hip looseness, or
instability, varies among children with DDH.
 Option C: Femoral pulses in a client with developmental dysplasia of the hip are
normal.
 Option D: Asymmetric gluteal folds with uneven gluteal creases are associated
with developmental hip dysplasia.

57. To prevent a Valsalva maneuver in a client recovering from an acute myocardial

infarction, the nurse would:

A. Assist the client to use the bedside commode.

B. Administer stool softeners every day as ordered.

C. Administer antidysrhythmics prn as ordered.

D. Maintain the client on strict bed rest.

Correct Answer: B. Administer stool softeners every day as ordered.

Administering stool softeners every day will prevent straining on defecation which
causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary
to prevent straining. If straining on defecation produced the Valsalva maneuver and
rhythm disturbances resulted then antidysrhythmics would be appropriate.
 Option A: A bedside commode for a client with acute MI should be provided, but
it does not prevent Valsalva maneuver alone.
 Option C: Antidysrhythmics do not prevent Valsalva maneuver. Antidysrhythmic
agents, which are also known as antiarrhythmic agents, are a broad category of
medications that help ameliorate the spectrum of cardiac arrhythmias to maintain
normal rhythm and conduction in the heart.
 Option D: A client with acute MI can be given bathroom privileges with
assistance.
58. On admission to the psychiatric unit, the client is trembling and appears fearful. The
nurse’s initial response should be to:
A. Give the client orientation materials and review the unit rules and regulations.

B. Introduce him/her and accompany the client to the client’s room.

C. Take the client to the day room and introduce her to the other clients.

D. Ask the nursing assistant to get the client’s vital signs and complete the
admission search.

Correct Answer: B. Introduce him/herself and accompany the client to the client’s
room.
Anxiety is triggered by change that threatens the individual’s sense of security. In
response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move
the client to a calmer, more secure/safe setting.
 Option A: The client is still confused and fearful. Orientation should be
postponed until he is calm. They can deliver effective, safe care by assessing risk
and building a rapport with the patient during the admission process; utilizing
crisis prevention strategies, including appropriate medication administration,
environmental, psychobiological, counseling, and health teaching interventions;
and employing conflict resolution techniques.
 Option C: The client should be taken to a calm environment with less stimuli so
he could feel safe and become calmer.
 Option D: Taking the client’s vital signs while he is still fearful would further
aggravate his feelings of insecurity and fear. Utilizing the nursing process, the
nurse can provide effective therapeutic interventions to promote safety for both
the patient and the nurse.

59. During the admission assessment on a client with chronic bilateral glaucoma, which
statement by the client would the nurse anticipate since it is associated with this
problem?

A. “I have constant blurred vision.”

B. “I can’t see on my left side.”

C. “I have to turn my head to see my room.”

D. “I have specks floating in my eyes.”

Correct Answer: C. “I have to turn my head to see my room.”

Intraocular pressure becomes elevated which slowly produces a progressive loss of the
peripheral visual field in the affected eye along with rainbow halos around lights.
Intraocular pressure becomes elevated from the microscopic obstruction of the
trabecular meshwork. If left untreated or undetected blindness results in the affected
eye.
 Option A: Central vision is one of the most common signs of glaucoma. The fluid
inside the eye, called aqueous humor, usually flows out of the eye through a
mesh-like channel. If this channel gets blocked, the liquid builds up. Sometimes,
experts don’t know what causes this blockage. But it can be inherited, meaning
it’s passed from parents to children.
  Option B: The peripheral field of vision is most often lost in a client with
glaucoma. The increased pressure in the eye, called intraocular pressure, can
damage the optic nerve, which sends images to the brain. If the damage worsens,
glaucoma can cause permanent vision loss or even total blindness within a few
years.
 Option D: Patchy blind spots in the peripheral or central vision of both eyes is a
symptom of open-angle glaucoma. It is caused by the drainage channels in the
eye becoming gradually clogged over time.

60. A client with asthma has low pitched wheezes present in the final half of exhalation.
One hour later the client has high pitched wheezes extending throughout exhalation.
This change in assessment indicates to the nurse that the client:

A. Has increased airway obstruction.

B. Has improved airway obstruction.

C. Needs to be suctioned.

D. Exhibits hyperventilation.

Correct Answer: A. Has increased airway obstruction.

The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction
has increased or worsened. With no evidence of secretions no support exists to indicate
the need for suctioning.
 Option B: Improvement in airway obstruction should decrease the presence of
wheezes. Wheezing most often is caused by an obstruction (blockage) or
narrowing of the small bronchial tubes in the chest. It can also be caused by an
obstruction in the larger airways or vocal cords. The tone of the wheeze can vary
depending on which part of the respiratory system is blocked or narrowed.
 Option C: There is no indication for suctioning. Suctioning is used to obtain
mucus and other fluids (secretions) and cells from the windpipe (trachea) and
large airways (bronchi) and is typically used in people who are on mechanical
ventilation or have problems with nerves or muscles that make coughing less
effective for bringing up secretions.
 Option D: Hyperventilation does not produce high pitched wheezes that extend
throughout exhalation. The lowered carbon dioxide levels in the blood can cause
squeezing of the airways, which then results in wheezing. Hyperventilation
syndrome may cause the following chest symptoms like chest pains or
tenderness, shortness of breath, and wheezing.

61. Which behavioral characteristic describes the domestic abuser?

A. Alcoholic

B. Overconfident

C. High tolerance for frustrations

D. Low self-esteem
Correct Answer: D. Low self-esteem
Batterers are usually physically or psychologically abused as children or have had
experiences of parental violence. Batterers are also manipulative, have low self-esteem,
and have a great need to exercise control or power-over partners.
 Option A: Being an alcoholic predisposes an individual to be a domestic abuser.
To be perfectly clear, alcohol and alcoholism are never a sole trigger for, or cause
of, domestic abuse. Rather, they are compounding factors that could eventually
trigger intimate partner abuse in a violent individual.
 Option B: Most domestic abusers have low self-confidence or self-esteem.
Basically, domestic violence offenders always feel the need to be in control of
their victims. The less in control an offender feels, the more they want to hurt
others.
 Option C: Domestic abusers often vent out their frustrations on their partners or
children. Domestic abuse, often referred to as domestic violence or intimate
partner violence (IPV), is a pattern of behavior or behaviors used by one partner
to maintain power and control over another partner that they are in a
relationship with. Anyone, regardless of race, gender, sexual orientation, religion,
or age, can be a victim or perpetrator of domestic abuse. Abuse can be physical,
sexual, emotional, mental, social, and financial.

62. The nurse is caring for a client with a long leg cast. During discharge teaching about
appropriate exercises for the affected extremity, the nurse should recommend:

A. Isometric

B. Range of motion

C. Aerobic

D. Isotonic

Correct Answer: A. Isometric

The nurse should instruct the client on isometric exercises for the muscles of the casted
extremity, i.e., instruct the client to alternately contract and relax muscles without
moving the affected part.
 Option B: Active range of motion exercises should accompany isometric
exercises for every joint that is not immobilized at regular and frequent intervals.
 Option C: Aerobic exercise is any type of cardiovascular conditioning and is
inappropriate for a client who has a leg cast.
 Option D: Isotonic exercise is one method of muscular exercise and it is not
recommended for a client who has leg cast.

63. A client is in her third month of her first pregnancy. During the interview, she tells
the nurse that she has several sex partners and is unsure of the identity of the baby’s
father. Which of the following nursing interventions is a priority?
A. Counsel the woman to consent to HIV screening.

B. Perform tests for sexually transmitted diseases.

C. Discuss her high risk for cervical cancer.

D. Refer the client to a family planning clinic.

Correct Answer: A. Counsel the woman to consent to HIV screening
The client’s behavior places her at high risk for HIV. Testing is the first step. If the
woman is HIV positive, the earlier treatment begins, the better the outcome.
 Option B: Before performing the tests, the client should be informed first and
she must give her consent. Separate written consent for HIV testing is not
recommended. General informed consent for medical care that notifies the
patient that an HIV test will be performed unless the patient declines (opt-out
screening) should be considered sufficient to encompass informed consent for
HIV testing.
 Option C: Discussion about the risks can come after determining if the client is
HIV positive or not. Increased HIV vulnerability is often associated with legal and
social factors, which increases exposure to risk situations and creates barriers to
accessing effective, quality and affordable HIV prevention, testing and treatment
services.
 Option D: Family planning could come after the HIV screening has results. For
women with HIV who want to become pregnant, use of antiretroviral prophylaxis
during pregnancy can reduce mother-to-child transmission of HIV. Afterwards,
family planning services that promote healthy timing and spacing of pregnancies
are important to reduce the risk of adverse pregnancy outcomes such as low
birth weight, preterm birth, and infant mortality.

64. A 16-month-old child has just been admitted to the hospital. As the nurse assigned
to this child enters the hospital room for the first time, the toddler runs to the mother,
clings to her, and begins to cry. What would be the initial action by the nurse?

A. Arrange to change client care assignments.

B. Explain that this behavior is expected.

C. Discuss the appropriate use of “time-out”.

D. Explain that the child needs extra attention.

Correct Answer: B. Explain that this behavior is expected.

During normal development, fear of strangers becomes prominent beginning around
age 6-8 months. Such behaviors include clinging to parents, crying, and turning away
from the stranger. These fears/behaviors extend into the toddler period and may persist
into preschool.
 Option A: Changing client assignments is unnecessary. The nurse may wait for
the child to calm down.
 Option C: Time outs are usually not appropriate for a toddler, especially if she is
in a new environment.
 Option D: The behavior shown by the toddler is normal and she does not need
any additional attention.
65. While planning care for a 2-year-old hospitalized child, which situation would the
nurse expect to most likely affect the behavior?
A. Strange bed and surroundings.

B. Separation from parents.

C. Presence of other toddlers.

D. Unfamiliar toys and games.

Correct Answer: B. Separation from parents

Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest
stress imposed on a toddler by hospitalization. If separation is avoided, young children
have a tremendous capacity to withstand other stress.
 Option A: Most children, even school-aged children, are fearful of a strange bed
and new surroundings.
 Option C: The presence of other toddlers might help the client calm down and
adjust with the environment.
 Option D: Unfamiliar toys and games would least likely affect the toddler’s
behavior.

66. While explaining an illness to a 10-year-old, what should the nurse keep in mind
about the cognitive development at this age?

A. They are able to make simple associations of ideas.

B. They are able to think logically in organizing facts.

C. Interpretation of events originates from their own perspective.

D. Conclusions are based on previous experiences.

Correct Answer: B. They are able to think logically in organizing facts.

The child in the concrete operational stage, according to Piaget, is capable of mature
thought when allowed to manipulate and organize objects.
 Option A: Option A describes the preoperational stage. During this stage, young
children can think about things symbolically. The preoperational stage is the
second stage in Piaget’s theory of cognitive development. This stage begins
around age 2, as children start to talk, and lasts until approximately age 7. 1
During this stage, children begin to engage in symbolic play and learn to
manipulate symbols.
 Option C: In the formal operational stage, people develop the ability to think
about abstract concepts, and logically test hypotheses.
 Option D: Option D describes the formal operational stage. The formal
operational stage begins at approximately age twelve and lasts into adulthood.
As adolescents enter this stage, they gain the ability to think in an abstract
manner by manipulating ideas in their head, without any dependence on
concrete manipulation.
67. The nurse has just admitted a client with severe depression. From which focus
should the nurse identify a priority nursing diagnosis?
A. Nutrition

B. Elimination

C. Activity

D. Safety

Correct Answer: D. Safety

Safety is a priority of care for the depressed client. Precautions to prevent suicide must
be a part of the plan. Depression can be effectively treated in primary care settings
using an evidence-based collaborative approach in which primary care providers are
systematically supported by mental health providers in caring for a caseload of patients.
 Option A: The client’s nutritional plan can be discussed after his safety has been
ensured. Researchers found that a healthy diet (the Mediterranean diet as an
example) was associated with a significantly lower risk of developing depressive
symptoms.
 Option B: Elimination should also be part of the nursing care plan, but this is not
the priority. Any psychosocial disturbances can impact on nervous system
neuroplasticity and this, in turn, will adversely affect downstream systems
including the GIT.
 Option C: Activities for a depressed client should be structured and introduced
gradually. Teach visualization as a tool to “bring them back down to their bodies”
and out of the constant cycle of negative thoughts. Clients learn methods such as
the “tree meditation,” in which they imagine themselves as a tree that is growing
from the ground and sprouting branches.

68. Which playroom activities should the nurse organize for a small group of 7-year-old
hospitalized children?
A. Sports and games with rules

B. Finger paints and water play.

C. “Dress-up” clothes and props.

D. Chess and television programs

Correct Answer: A. Sports and games with rules

The purpose of play for the 7-year-old is cooperation. Rules are very important. Logical
reasoning and social skills are developed through play.
 Option B: Finger paints and water play are appropriate play for toddlers. Most
toddlers do parallel play. When a child plays alongside or near others but does
not play with them this stage is referred to as parallel play.
 Option C: Dress-up and props are recommended for preschool. When a child
plays together with others and has interest in both the activity and other children
involved in playing they are participating in cooperative play.
 Option D: Chess is recommended for school-age to adolescent stage. During the
school-age years, you’ll see a change in your child. He or she will move from
playing alone to having multiple friends and social groups.
69. A client is discharged following hospitalization for congestive heart failure. The nurse
teaching the family suggests they encourage the client to rest frequently in which of the
following positions?

A. High Fowler’s

B. Supine

C. Left lateral

D. Low Fowler’s

Correct Answer: A. High Fowler’s

Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac
workload and facilitates breathing.
 Option B: Lying flat or in a supine position would be difficult for the client and
may induce increased cardiac workload.
 Option C: Left lateral position may increase the client’s cardiac workload.
 Option D: Low Fowler’s may not be sufficient enough to support the client’s
cardiac workload.

70. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is:

A. Urinary output of 30 ml per hour

B. No complaints of thirst

C. Increased hematocrit

D. Good skin turgor around burn

Correct Answer: A. Urinary output of 30 ml per hour

For a child of this age, this is adequate output, yet does not suggest overload.
Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift
which contributes to hypovolemia and cellular edema. Heat injury also initiates the
release of inflammatory and vasoactive mediators. These mediators are responsible for
local vasoconstriction, systemic vasodilation, and increased transcapillary permeability.
Increase in transcapillary permeability results in a rapid transfer of water, inorganic
solutes, and plasma proteins between the intravascular and interstitial spaces.
 Option B: Relying on the client’s thirst would not create accurate results. The
steady intravascular fluid loss due to these sequences of events requires
sustained replacement of intravascular volume in order to prevent end-organ
hypoperfusion and ischemia.
 Option C: An increase in hematocrit suggests vascular space fluid losses.
Reduced cardiac output is a hallmark in this early post-injury phase. The
reduction in cardiac output is the combined result of decreased plasma volume,
increased afterload and decreased cardiac contractility, induced by circulating
mediators.
 Option D: A good skin turgor is not an accurate indicator of adequate fluid
replacement. The goal of fluid management in major burn injuries is to maintain
the tissue perfusion in the early phase of burn shock, in which hypovolemia finally
occurs due to steady fluid extravasation from the intravascular compartment.
71. What is the priority nursing diagnosis for a patient experiencing a migraine
headache?
A. Acute pain related to biologic and chemical factors

B. Anxiety related to change in or threat to health status

C. Hopelessness related to deteriorating physiological condition

D. Risk for Side effects related to medical therapy

Correct Answer: A. Acute pain related to biologic and chemical factors

The priority for interdisciplinary care for the patient experiencing a migraine headache is
pain management.
 Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension
headaches are common for people that struggle with severe anxiety or anxiety
disorders. Tension headaches can be described as a heavy head, migraine, head
pressure, or feeling like there is a tight band wrapped around their head. These
headaches are due to a tightening of the neck and scalp muscles.
 Option C: Hopelessness should be addressed as part of the nursing care plan,
but it does not require urgency. Hopelessness can result when someone is going
through difficult times or unpleasant experiences. A person may feel
overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to
multiple stresses and losses. He or she might think that challenges are
unconquerable or that there are no solutions to the problems and may not be
able to mobilize the energy needed to act on his or her own behalf.
 Option D: The risk for side effects is accurate, but it is not as urgent as the issue
of pain, which is often incapacitating. Focus: Prioritization

72. You are creating a teaching plan for a patient with newly diagnosed migraine
headaches. Which key items should be included in the teaching plan? Select all that
apply.
A. Avoid foods that contain tyramine, such as alcohol and aged cheese.

B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.

C. Abortive therapy is aimed at eliminating the pain during the aura.

D. A potential side effect of medications is rebound headache.

E. Complementary therapies such as relaxation may be helpful.

F. Continue taking estrogen as prescribed by your physician.

Correct Answer: A, B, C, D, & E.

The client should be counseled on the food and drugs that are allowed. He should also
be educated about the side effects of the medications given. Methods of distraction
from pain should also be included in the teaching plan.
 Option A: One explanation is that it causes nerve cells in the brain to release the
chemical norepinephrine. Having higher levels of tyramine in the system — along
with an unusual level of brain chemicals — can cause changes in the brain that
lead to headaches.
  Option B: Oral contraceptives and vasodilators, such as nitroglycerin, can
aggravate migraines. Dilation of cerebral arteries causes the commonly reported
side effect of migraine-type headache.
 Option C: Abortive therapy should be used as early as possible in the course of a
migraine. Combination analgesics containing aspirin, caffeine, and
acetaminophen are an effective first-line abortive treatment for migraines.
Ibuprofen at standard doses is effective for acute migraine treatment.
 Option D: Medication overuse headaches or rebound headaches are caused by
regular, long-term use of medication to treat headaches, such as migraines. Pain
relievers offer relief for occasional headaches. But if one takes them more than a
couple of days a week, they may trigger medication overuse headaches.
 Option E: Complementary therapies are add-on therapies meant to be used
along with traditional treatment, according to the National Center for
Complementary and Integrative Health (NCCIH). Massage, spinal manipulation,
and acupuncture are examples of complementary therapies that may be
beneficial for people with migraines.
 Option F: Medications such as estrogen supplements may actually trigger a
migraine headache attack. Fluctuations in estrogen, such as before or during
menstrual periods, pregnancy, and menopause, seem to trigger headaches in
many women.

73. The patient with migraine headaches has a seizure. After the seizure, which action
can you delegate to the nursing assistant?
A. Document the seizure

B. Perform neurologic checks

C. Take the patient’s vital signs

D. Restrain the patient for protection

Correct Answer: C. Take the patient’s vital signs.

Taking vital signs is within the education and scope of practice for a nursing assistant.
 Option A: Documentation is one of the nursing responsibilities.
 Option B: The nurse should perform neurologic checks.
 Option D: Patients with seizures should not be restrained; however, the nurse
may guide the patient’s movements as necessary. Focus: Delegation/supervision

74. You are preparing to admit a patient with a seizure disorder. Which of the following
actions can you delegate to LPN/LVN?
A. Complete admission assessment

B. Set up oxygen and suction equipment

C. Place a padded tongue blade at the bedside

D. Pad the side rails before the patient arrives

Correct Answer: B. Set up oxygen and suction equipment
The LPN/LVN can set up the equipment for oxygen and suction.
 Option A: The RN should perform the complete initial assessment.
 Option C: Tongue blades should not be at the bedside and should never be
inserted into the patient’s mouth after a seizure begins.
 Option D: Padded side rails are controversial in terms of whether they actually
provide safety and may embarrass the patient and family.

75. A nursing student is teaching a patient and family about epilepsy prior to the
patient’s discharge. For which statement should you intervene?
A. “You should avoid consumption of all forms of alcohol.”

B. “Wear your medical alert bracelet at all times.”

C. “Protect your loved one’s airway during a seizure.”

D. “It’s OK to take over-the-counter medications.”

Correct Answer: D. “It’s OK to take over-the-counter medications.”

A patient with a seizure disorder should not take over-the-counter medications without
consulting with the physician first.
 Option A: Alcohol is not allowed for patients with seizures because it increases
the risk of another episode.
 Option B: A medical alert bracelet bears the message that the wearer has an
important medical condition that might require immediate attention.
 Option C: One of the priorities during a seizure is to prevent obstruction of the
airway by turning the client into a side-lying position to allow drainage to flow.