Q&A RANDOM #11

Question Number 1 of 40
Parents of a 7 year-old child call the clinic nurse because their
daughter was sent home from school because of a rash. The child had
been seen the day before by the health care provider and diagnosed
with Fifth Disease (erythema infectiosum). What is the most
appropriate action by the nurse?
Tell the parents to bring the child to the clinic for further
evaluation
Refer the school officials to printed materials about this
B)
viral illness
Inform the teacher that the child is receiving antibiotics for
C)
the rash
Explain that this rash is not contagious and does not
D)
require isolation
The correct answer is D: Explain that this rash is not contagious and does
not require isolation
Fifth Disease is a viral illness with an uncertain period of communicability
(perhaps 1 week prior to and 1 week after onset). Isolation of the child with
Fifth Disease is not necessary except in cases of hospitalized children who
are immunosuppressed or having aplastic crises. The parents may need
written confirmation of this from the health care provider.
A)

Question Number 2 of 40
What principle of HIV disease should the nurse keep in mind when
planning care for a newborn who was infected in utero?
The disease will incubate longer and progress more slowly
in this infant
B) The infant is very susceptible to infections
Growth and development patterns will proceed at a normal
C)
rate
D) Careful monitoring of renal function is indicated
The correct answer is B: The infant is very susceptible to infections
HIV infected children are susceptible to opportunistic infections due to a
compromised immune system.
A)

Question Number 3 of 40
While teaching a client about their medications, the client asks how
long it will take before the effects of lithium take place. What is the
best response of the nurse?
A)
Immediately
B)
Several days
C)
2 weeks
D)
1 month
The correct answer is C: 2 weeks
Lithium is started immediately to treat bipolar disorder because it is quite
effective in controlling mania. Lithium takes approximately 2 weeks to effect
change in a clients symptoms.
Question Number 4 of 40
The nurse is caring for a 12 year-old with an acute illness. Which of
the following indicates the nurse understands common sibling
reactions to hospitalization?
A) Younger siblings adapt very well
B) Visitation is helpful for both
C) The siblings may enjoy privacy
D) Those cared for at home cope better
The correct answer is B: Visitation is helpful for both
Contact with the ill child helps siblings understand the reasons for
hospitalization and maintains the relationship.
Question Number 5 of 40
Following a cocaine high, the user commonly experiences an extremely
unpleasant feeling called
A)
Craving
B)
Crashing
C)
Outward bound
D)
Nodding out
The correct answer is B: Crashing
Following cocaine use, the intense pleasure is replaced by an equally
unpleasant feeling referred to as crashing.

Question Number 6 of 40

One reason that domestic violence remains extensively undetected is

A) Few battered victims seek medical care
B) There is typically a series of minor, vague complaints
C) Expenses due to police and court costs are prohibitive
Very little knowledge is currently known about batterers
D)
and battering relationships
The correct answer is B: There is typically a series of minor, vague
complaints
Signs of abuse may not be clearly manifested and a series a minor
complaints such as headache, abdominal pain, insomnia, back pain, and
dizziness may be covert indications of abuse undetected. Complaints may be
vague.
Question Number 7 of 40
When making a home visit to a client with chronic pyelonephritis,
which nursing action has the highest priority?
A) Follow-up on lab values before the visit
B) Observe client findings for the effectiveness of antibiotics
C) Ask for a log of urinary output
D) As for the log of the oral intake
The correct answer is C: Ask for a log of urinary output
The nurse must monitor the urine output as a priority because it is the best
indictor of renal function. The other options would be done after an
evaluation of the urine output.
Question Number 8 of 40
When a client is having a general tonic clonic seizure, the nurse should
A) Hold the client's arms at their side
B) Place the client on their side
C) Insert a padded tongue blade in client's mouth
D) Elevate the head of the bed
The correct answer is B: Place the client on their side
The correct answer is B. This position keeps the airway patent and prevents
aspiration.
Question Number 9 of 40
The nurse is teaching a client with dysrhythmia about the electrical
pathway of an impulse as it travels through the heart. Which of these
demonstrates the normal pathway?
A) AV node, SA node, Bundle of His, Purkinje fibers
B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node

D) SA node, AV node, Bundle of His, Purkinje fibers

The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers
The pathway of a normal electrical impulse through the heart is: SA node,
AV node, Bundle of His, Purkinje fibers.
Question Number 10 of 40
Clients with mitral stenosis would likely manifest findings associated
with congestion in the
A)
B)
C)
D)

Pulmonary circulation
Descending aorta
Superior vena cava
Bundle of His

The correct answer is A: Pulmonary circulation

Congestion occurs in the pulmonary circulation due to the inefficient
emptying of the left ventricle and the lack of a competent valve to prevent
back flow into the pulmonary vein.
Question Number 11 of 40
In assessing the healing of a client's wound during a home visit, which
of the following is the best indicator of good healing?
A)
White patches
B)
Green drainage
C)
Reddened tissue
D)
Eschar development
The correct answer is C: Reddened tissue
As the wound granulates, redness indicates healing.
Question Number 12 of 40
The nursing intervention that best describes treatment to deal with
the behaviors of clients with personality disorders include
Pointing out inconsistencies in speech patterns to correct
thought disorders
B) Accepting client and the client's behavior unconditionally
C) Encouraging dependency in order to develop ego controls
D) Consistent limit-setting enforced 24 hours per day
The correct answer is D: Consistent limit-setting enforced 24 hours per day
Treatment approaches that include restructuring the personality, assisting
the person with developmental level and setting limits for maladaptive
behavior such as acting out.
A)

Question Number 13 of 40

A client has received her first dose of fluphenazine (Prolixin) 2 hours

ago. She suddenly experiences torticollis and involuntary spastic
muscle movement. In addition to administering the ordered
anticholinergic drug, what other measure should the nurse implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication
The correct answer is A: Have respiratory support equipment available
Persons receiving neuroleptic medication experiencing torticollis and
involuntary muscle movement are demonstrating side effects that could lead
to respiratory failure.
Question Number 14 of 40
The nurse asks a client with a history of alcoholism about the clients
drinking behavior. The client states "I didnt hurt anyone. I just like to
have a good time, and drinking helps me to relax." The client is using
which defense mechanism?
A)
Denial
B)
Projection
C)
Intellectualization
D)
Rationalization
The correct answer is D: Rationalization
Rationalization is justifying illogical or unreasonable ideas, actions, or
feelings by developing acceptable explanations that satisfies the teller as
well as the listener.
Question Number 15 of 40
The nurse is teaching a smoking cessation class and notices there are
2 pregnant women in the group. Which information is a priority for
these women?
A) Low tar cigarettes are less harmful during pregnancy
There is a relationship between smoking and low birth
B)
weight
C) The placenta serves as a barrier to nicotine
D) Moderate smoking is effective in weight control
The correct answer is B: There is a relationship between smoking and low
birth weight
Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or
placenta previa, decreasing the growth potential of the fetus.
Question Number 16 of 40

The nurse is caring for a client with end stage renal disease. What
action should the nurse take to assess for patency in a fistula used for
hemodialysis?
A) Observe for edema proximal to the site
B) Irrigate with 5 mls of 0.9% Normal Saline
C) Palpate for a thrill over the fistula
D) Check color and warmth in the extremity
The correct answer is C: Palpate for a thrill over the fistula
To assess for patency in a fistula or graft, the nurse auscultates for a bruit
and palpates for a thrill. Other options are not related to evaluation for
patency.
Question Number 17 of 40
Which therapeutic communication skill is most likely to encourage a
depressed client to vent feelings?
A)
Direct confrontation
B)
Reality orientation
C)
Projective identification
D)
Active listening
The correct answer is D: Active listening
Use of therapeutic communication skills such as silence and active listening
encourages verbalization of feelings.
Question Number 18 of 40
The nurse walks into a client's room and finds the client lying still and
silent on the floor. The nurse should first
A) Assess the client's airway
B) Call for help
C) Establish that the client is unresponsive
D) See if anyone saw the client fall
The correct answer is C: Establish that the client is unresponsive
The first step in CPR is to establish unresponsiveness. Second is to call for
help. Third is opening the airway.
Question Number 19 of 40
What is the best way for the nurse to accomplish a health history on a
14 year-old client?
A) Have the mother present to verify information
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent

D) Focus the discussion of risk factors in the peer group

The correct answer is B: Allow an opportunity for the teen to express
feelings
Adolescents need to express their feelings. Generally, they talk freely when
given an opportunity and some privacy to do so.
Question Number 20 of 40
A new nurse on the unit notes that the nurse manager seems to be
highly respected by the nursing staff. The new nurse is surprised when
one of the nurses states: "The manager makes all decisions and rarely
asks for our input." The best description of the nurse manager's
management style is
A)
Participative or democratic
B)
Ultraliberal or communicative
C)
Autocratic or authoritarian
D)
Laissez faire or permissive
The correct answer is C: Autocratic or authoritarian
Autocratic leadership style is suggested in this situation. It is appropriate for
groups with little education and experience and who need strong direction,
while participative or democratic style is usually more successful on nursing
units.