Professional Documents
Culture Documents
Docx
Docx
Docx
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure Correct
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on
the morning of the test." Correct
D. "I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for
the test can be constipating."
2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's answering
service and is told that the physician is off for the night and will be available in the morning. The
nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician Correct
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available
4.
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial
infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's
carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by
the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client Correct
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
5.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the
client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should:
A. Administer the antihypertensive with a small sip of water Correct
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the ECT
6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's
office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed.
Which response by the nurse is therapeutic?
7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse
notes that the fluid is yellow and has a strong odor. Which of the following actions should be the
nurse’s priority?
8 A nurse has assisted a physician in inserting a central venous access device into a client with a
diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the
catheter, the nurse immediately plans to:
9 A rape victim being treated in the emergency department says to the nurse, "I’m really worried that
I’ve got HIV now." What is the appropriate response by the nurse?
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and
650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours,
diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley
catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening
shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-
hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total
intake during the 24-hour period? Type your answer in the space provided.
Answer: ________mL
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client
for the management of anxiety. The nurse prepares the medication as prescribed and administers
the medication over a period of:
A. 3 minutes Correct
B. 10 seconds
C. 15 seconds
D. 30 minutes
13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus
infection, asks the client about medications that he is taking. The client tells the nurse that he is
taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines
that the client most likely has a history of:
A. Depression Correct
B. Diabetes mellitus
C. Hyperthyroidism
D. Coronary artery disease
14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client to contact the
physician immediately if she experiences:
A. Dry mouth
B. Restlessness
C. Feelings of depression
D. Neck stiffness or soreness Correct
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the
treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the
nurse to contact the prescribing physician before administering the medication?
16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted
to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-
term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?
A. Fever
B. Diarrhea
C. Hypertension
D. Tongue protrusion Correct
17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which
of the following diagnoses, if noted on the client's record, would indicate a need to contact the
physician who is scheduled to perform the ECT?
A. Recent stroke Correct
B. Hypothyroidism
C. History of glaucoma
D. Peripheral vascular disease
18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the
surgery. The client later asks the nurse to explain again how the prostate is going to be removed.
The nurse tells the client that the prostate will be removed through:
19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer.
Which of the following recommendations does the nurse include on the poster? Select all that
apply.
20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of
the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation,
which finding would the nurse expect to note on assessment of the client’s breast?
A.
B. Correct
C.
D.
21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a
member of the school soccer team and expresses concern about her child's participation in sports.
The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose
control, tells the mother:
22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life
says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter
what I do if I’m never going to get better!" On the basis of the client's statement, the nurse
determines that the client is experiencing which problem?
A. Anxiety
B. Powerlessness Correct
C. Ineffective coping
D. Disturbed body image
23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to
talk and shows little interest in participating in hygiene care. Which statement by the nurse would be
therapeutic?
24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client
for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse,
assisting the physician with the procedure, expect to note?
25 An emergency department nurse is told that a client with carbon monoxide poisoning resulting
from a suicide attempt is being brought to the hospital by emergency medical services. Which
intervention will the nurse carry out as a priority upon arrival of the client?
26 A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work
and worried about how he will care financially for his wife and three small children. On the basis of
the client's concern, which problem does the nurse identify?
A. Anxiety Correct
B. Powerlessness
C. Disruption of thought processes
D. Inability to maintain health
27 A nurse, performing an assessment of a client who has been admitted to the hospital with
suspected silicosis, is gathering both subjective and objective data. Which question by the nurse
would elicit data specific to the cause of this disorder?
Answer: _____mL
Incorrect
Correct Responses: "1, .625, 0.625"
29 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and
reports that his urine has become darker since he started taking the medication. The nurse should
tell the client:
30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines
that the client is gaining a therapeutic effect from the medication after noting:
A. Bradycardia
B. Increased heart rate
C. Decreased blood pressure
D. Improved swallowing function Correct
31 A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the
treatment of Parkinson's disease. Which finding from the history and physical examination would
cause the nurse to determine that the client may be experiencing an adverse effect of the
medication?
A. Insomnia
B. Rigidity and akinesia
C. Bilateral lung wheezes Correct
D. Orthostatic hypotension
32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information
regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include
in the pamphlet?Select all that apply.
A. Smoking Correct
B. A high-calcium diet
C. High alcohol intake Correct
D. White or Asian ethnicity Correct
E. Participation in physical activities that promote flexibility and muscle strength
A. Corn
B. Cocoa
C. Peaches
D. Sardines Correct
34 A nurse is providing information to a client with acute gout about home care. Which of the
following measures does the nurse tell the client to take? Select all that apply.
35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid
arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that
apply.
A. Fatigue Correct
B. Anemia
C. Weight loss
D. Low-grade fever Correct
E. Joint deformities
36 A nurse is reviewing the medical record of a client with a suspected systemic lupus
erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the
client’s medical record? Select all that apply.
A. Fever Correct
B. Vasculitis Correct
C. Weight gain
D. Increased energy
E. Abdominal pain Correct
A. Beer Correct
B. Apples
C. Yogurt Correct
D. Baked haddock
E. Pickled herring Correct
F. Roasted fresh potatoes
38 The blood serum level of imipramine is determined in a client who is being treated for depression
with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this
result, the nurse should:
39 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for
the treatment of bipolar disorder. Which of these statements by the client indicate a need for further
instruction? Select all that apply.
40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large
volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On
the basis of these findings, the nurse should:
41 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In
explaining the treatment to the client, the nurse tells the client that this technique involves:
42 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The
client says to the nurse, "I’m really thirsty — may I have something to drink?" Before giving the client
a drink, the nurse should:
43 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern
does the nurse recognize as the priority?
A. Inability to cope
B. Decreased nutrition
C. Decreased fluid volume Correct
D. Inability to tolerate activity
44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse
explains to the client that amniocentesis is often performed during the third trimester to determine:
45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of
these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.
A. Bananas
B. Potatoes
C. Spinach Correct
D. Legumes Correct
E. Whole grains Correct
F. Milk products
46 A nurse caring for a client with preeclampsia prepares for the administration of an intravenous
infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available
at the client's bedside?
A. Vitamin K
B. Protamine sulfate
C. Potassium chloride
D. Calcium gluconate Correct
48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the
client that:
49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of
the following information elicited during the assessment indicate that the condition has not yet
resolved? Type the option number that is the correct answer.
A. Spontaneous bruising Correct
B. Decrease in uterine size
C. Urine output of 30 mL/hr
D. Brownish vaginal discharge
51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse
monitoring the client notes uterine hypertonicity and immediately:
52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor
tracing (see figure). Which of the following actions should the nurse take as a result of this
observation?
A. Repositioning the mother
B. Documenting the finding Correct
C. Notifying the nurse-midwife
D. Taking the mother's vital signs
53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which
adverse effect of cisplatin will the nurse assess the client?
A. Nausea
B. Bloody urine
C. Hearing loss Correct
D. Electrocardiographic changes
54 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing
vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of
the client?
A. A discoid uterus
B. Sudden sharp vaginal pain
C. Shortening of the umbilical cord
D. A sudden gush of dark blood from the introitus Correct
57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy
for the treatment of cancer. Which statement by the client indicates a need for further instruction?
58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic
dehydration. What findings does the nurse expect to note during the admission assessment? Select
all that apply.
A. Skin tenting Correct
B. Flat neck veins Correct
C. Weak peripheral pulses Correct
D. Moist oral mucous membranes
E. A heart rate of 88 beats/min
F. A respiratory rate of 18 breaths/min
59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid
restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have
between 7 a.m. and 3 p.m.?Type your answer in the space provided.
Answer ____mL
A. Salt substitutes
B. Herbs and spices Correct
C. Salt with cooking only
D. Processed foods as desired
61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary
disease (COPD). Which of the following menu selections by the client tells the nurse that the client
understands the instructions?
A. Coffee
B. Broccoli
C. Cheeseburger Correct
D. Chocolate milk
62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the
relief of choreiform movements. Of which common side effect does the nurse warn the client?
A. Headache
B. Drowsiness Correct
C. Photophobia
D. Urinary frequency
63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous
reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client?
A. Diarrhea
B. Vomiting
C. Epistaxis Correct
D. Epigastric pain
64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses
how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to
permit assessment of whether the infant is receiving an adequate amount of milk?
A. Count the number of times that the infant swallows during a feeding
B. Weigh the infant every day and check for a daily weight gain of 2 oz
C. Count wet diapers to be sure that the infant is having at least six to 10 each day Correct
D. Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the
infant
65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic
(TLSO) brace, and the nurse provides information to the mother about the brace. Which statement
by the mother indicates a need for further information?
66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take
the medication with:
A. Milk
B. Water
C. Any meal
D. Tomato juice Correct
67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse
provides information to the client about dietary and insulin needs and tells the client that during the
first trimester, insulin needs generally:
A. Increase
B. Decrease Correct
C. Remain unchanged
D. Double from what they normally are
68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb
on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left
a persistent depression. On the basis of this finding, the nurse concludes that:
69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+
(i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling
of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate
intervention does the nurse prepare the client?
A. Hysterectomy
B. Insertion of an indwelling catheter
C. Administration of oxytocin (Pitocin)
D. Replacement of the uterus through the vagina into a normal position Correct
71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours
ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of
this finding, the nurse would:
72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at
the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action
should be:
73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks'
gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the
nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a
reassuring pattern, and that both the client and her husband are anxious about the condition of the
fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the
priority at this time?
A. Anxiety Correct
B. Premature grief
C. Fluid volume loss
D. Fluid volume overload
74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis
who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would
indicate to the nurse that DIC has developed in the client?
A. Tachycardia Correct
B. Cool, clammy skin
C. Decreased respiratory rate
D. Diminished peripheral pulses Correct
E. Urine output of less than 30 mL/hr
76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial
nursing measures to be implemented in the event of the development of shock. After contacting the
physician, which of the following does the nurse specify as the first action in the event of shock?
77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about
normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells
the client to report to the physician?
80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the
first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse
determines that the estimated date of delivery (EDD) is:
A. June 2, 2013
B. July 2, 2013 Correct
C. October 2, 2013
D. September 18, 2013
81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does
the nurse instruct the client to limit consumption of while taking this medication?
A. Steak Correct
B. Spinach
C. Chicken
D. Oranges
82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing
chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect
of the chemotherapy?
83 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse?
A. Nulliparity
B. Early menarche
C. Multiple sexual partners Correct
D. Hormone-replacement therapy
84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does
the nurse interpret this finding?
85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to
resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
A. At any time after the surgery
B. When menstruation resumes
C. When pelvic sensation and response to stimuli return
D. In about 6 weeks, when the vaginal vault is satisfactorily healed Correct
86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the
treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery
is:
87- A nurse is caring for a client with community-acquired pneumonia who is being treated with
levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the
medication, does the nurse monitor the client?
A. Fever Correct
B. Dizziness
C. Flatulence
D. Drowsiness
88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide
(Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client
to report to the physician?
A. Nausea
B. Dark urine Correct
C. Urinary frequency
D. Decreased appetite
89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of
tube, does the nurse implement?
A. Frequent suctioning
B. Maintaining cuff pressure Correct
C. Maintaining mechanical ventilation settings
D. Alternating the use of a cuffed tube with a cuffless tube on a daily basis
90 - A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse
place the client before inserting the tube?
A.
B.
C.
D. Correct
91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions
does the nurse implement? Select all that apply.
A. Keeping the room slightly darkened Correct
B. Placing the client in a room with a quiet roommate
C. Encouraging isometric exercises if bed rest is prescribed
D. Monitoring the client for changes in alertness or mental status Correct
E. Restricting visits to close family members and significant others and keeping visits short Correct
92 -A nurse, providing information to a client who has just been found to have diabetes mellitus,
gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on
being asked to list the symptoms, tells the nurse that the client understands the information? Select
all that apply.
A. Hunger Correct
B. Weakness Correct
C. Blurred vision Correct
D. Increased thirst
E. Increased urine output
93- A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches.
The nurse reviews the physician's instructions, understanding that the gait was selected after
assessment of the client's:
94- A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral
tube feedings that will be continued after he is discharged home. When the nurse tells the client that
he will be taught how to administer the feedings, the client states, "I don't think I’ll be able to do
these feedings by myself." Which response by the nurse is appropriate?
95- A client is brought to the emergency department after sustaining smoke inhalation. Humidified
oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are
measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis
of the ABG result, the nurse prepares to:
96- A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of
severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper
alignment is being maintained. Which of the following actions should the nurse take next?
A. Providing pin care
B. Medicating the client
C. Notifying the physician Correct
D. Removing some weight from the traction
97 -A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago.
The client tells the nurse that the skin is being irritated by the edges of the cast. What is the
appropriate action on the part of the nurse
98 -A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a
mass in my pancreas and that it’s probably cancer. Does this mean I'm going to die?" The nurse
interprets the client's initial reaction as:
A. Fear Correct
B. Denial
C. Acceptance
D. Preoccupation with self
99 -A nurse notes documentation in the client’s medical record indicating that the client has a stage
II pressure ulcer. On the basis of this information, which of the following findings does the nurse
expect to note?
A.
B. Correct
C.
D.
100- A nurse is providing instruction in how to perform Kegel exercises to a client with stress
incontinence. The nurse tells the client to:
A. Always perform the exercises while lying down
B. Expect an improvement in the control of urine in about 1 week
C. Tighten the pelvic muscles for as long as 5 minutes, three or four times a day
D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Correct
101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following
occurrences does the nurse tell the client to report to the physician if she experiences them while
taking the medication?
A. Cough
B. Fatigue and lethargy
C. Dizziness and fatigue
D. Numbness and tingling of the fingers or toes Correct
102 -A client with post–traumatic stress disorder tells the nurse that he has stopped taking his
prescribed medication because he didn't like how the medication was making him feel. Which of the
following initial responses by the nurse is appropriate?
103- A nurse provides information to a client with peripheral vascular disease about ways to limit the
disease’s progression. Which of the following measures does the nurse tell the client to take? Select
all that apply.
104 -A client with depression is anorexic. Which measure does the nurse take to assist the client in
meeting nutritional needs?
105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse
provides information about the medication and tells the client:
106 A client with depression is being encouraged to attend art therapy as part of the treatment plan.
The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is
therapeutic?
107 A hospitalized female client with mania enters the unit community room and says to a client who
is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the
appropriate response by the nurse?
108- A nurse working the evening shift is helping clients get ready for sleep. A female client with
mania is hyperactive and pacing the hallway. The appropriate nursing action is to:
109 -Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides
information to the client about the medication. Which statement by the client indicates to the nurse
that the client understands the information?
A. "I need to limit my intake of fluids while I’m taking this medication."
B. "I need to stop the medication and call my doctor if I have severe diarrhea." Correct
C. "I can expect skin redness and a rash when I take this medication."
D. "I may get a burning feeling in my throat, but it’s normal and will go away."
110 -A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which
of the following behaviors is a characteristic of the disorder?
A. Neediness
B. Perfectionism
C. Preoccupation with details
D. Hypersensitivity to negative evaluation Correct
111 -A female client admitted to the mental health unit tells the nurse that she cannot leave the
house without checking to be sure that she has shut off the coffee maker and unplugged her curling
iron. The client states that she even leaves the house, gets into her car, and then has to go back into
the house to check these appliances again and that these behaviors are interfering with her work
and social commitments. With which of the following anxiety disorders does the nurse associate this
client's symptoms?
A. Agoraphobia
B. Avoidant personality disorder
C. Obsessive-compulsive disorder Correct
D. Dependent personality disorder
112 -A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of
paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan
of care?
113 -A client on the mental health unit says to the nurse, "Everything is contaminated." The client
scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that
compulsive behavior:
114 -A male client arrives at the emergency department and reports to the nurse, "I woke up this
morning and couldn't move my arms." He also tells the nurse that he works in a factory and
witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine.
What is the priority response by the nurse?
116 -A client arrives in the emergency department and tells the nurse that she is experiencing
tingling in both hands and is unable to move her fingers. The client states that she has been unable
to work because of the problem. During the psychosocial assessment, the client reports that 2 days
earlier her husband told her that he wanted a separation and that she would have to support herself
financially. The nurse concludes that this client is exhibiting signs compatible with:
A. Severe anxiety
B. Conversion disorder Correct
C. Posttraumatic stress disorder (PTSD)
D. Obsessive-compulsive disorder
117 -A client experiencing delusions says to the nurse, "I am the only one who can save the world
from all of the terrorists." What is the appropriate response by the nurse?
A. "Tell me your plan for saving the world."
B. "Why do you think that you can accomplish this by yourself?"
C. "I don't think anyone can save the world from the terrorists by himself." Correct
D. "You must be powerful. Do you really believe that you can do this by yourself?"
118- A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with
cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What
does the nurse instruct the client to do during chemotherapy? Select all that apply.
119- A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall
out?" The nurse responds by telling the client that:
121- A nurse provides home care instructions to a client who has undergone fluorescein
angiography. The nurse determines that the client needs further instruction if the client states that he
must:
122 -An emergency department nurse is assessing a client with acute closed-angle glaucoma.
Which of the following characteristics of the disorder does the nurse expect the client to exhibit?
Select all that apply.
A. Nausea Correct
B. Eye pain Correct
C. Vomiting Correct
D. Headache Correct
E. Diminished central vision
F. Increased light perception
123 - A nurse is measuring intraocular pressure by means of tonometry in a client who has just been
found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this
client?
A. 8 mm Hg
B. 14 mm Hg
C. 20 mm Hg
D. 28 mm Hg Correct
124- An emergency department nurse assessing a client with Bell's palsy collects subjective and
objective data. Which of the following findings does the nurse expect to note?
A. A symmetrical smile
B. Tightening of all facial muscles
C. Ability to wrinkle the forehead on request
D. Complaints of inability to close the eye on the affected side Correct
125 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing
vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most
appropriate?
126 A school nurse observing a child with Down syndrome is participating in a physical education
class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see
the child and conducts an assessment, during which the child complains of neck pain and loss of
bladder control. What is the appropriate action by the nurse in this situation?
127 -A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease.
What does the nurse ask the client during assessment for adverse effects of the medication?
128 -A nurse is providing instruction about insulin therapy and its administration to an adolescent
client who has just been found to have diabetes mellitus. Which statement by the client indicates a
need for further instruction?
130- A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need
your help!" What is the appropriate way for the nurse to document this occurrence in the client's
record?
131 A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will
be admitted from the emergency department. Which item does the nurse give priority to placing at
the client's bedside?
A. Bedside commode
B. Suctioning equipment
C. Electrocardiography machine
D. Oxygen cannula and flowmeter Correct
132 -Cascara sagrada has been prescribed for a client with diminished colonic motor response as a
means of promoting defecation. The nurse provides information to the client about the medication
and tells the client to: