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Question 1

A client's history reveals that her mother used the drug diethylstilbestrol (DES). The client asks the
nurse what affect does this drug have on me. The nurse's best response is:

"You will have a difficult time becoming pregnant."

"You are at risk of not carrying a baby to term."

"Your child is at risk of having Down syndrome."

"Your daughter will be affected."

Correct. The answer is


"You are at risk of not carrying a baby to term."

Explanation:
The correct answer is "You are at risk of not carrying a baby to term." There is a higher incidence of uterine
malformations and hormonal difficulty with daughters of mothers who took the drug diethylstilbestrol (DES).
Therefore there is a higher incidence of miscarriage.

Question 2

The nurse will be handling blood and body fluids when working in hospitals and other health care
facilities. It is necessary to follow standard precautions. Which of the following is NOT a true
statement regarding standard precautions?

These precautions apply to blood, all body fluids, secretions, excretions, and mucous
membranes.
Nurses should practice these precautions with clients' presumed infectious.

These precautions promote handwashing and the use of gloves, when appropriate.

Clean spills of blood with bleach and water (diluted 1:10) or agency-approved
disinfectant.

Incorrect. The answer is


Nurses should practice these precautions with clients' presumed infectious.

Explanation:
The Correct answer is:
Nurses should practice these precautions with clients' presumed infectious.

Standard precautions should be practiced with all clients regardless of the diagnosis or presumed infectiousness.
Other precautions include discarding sharp instruments and needles in a puncture-resistant container, do not re-
cap needles, use needleless devices whenever possible to reduce the risk of needlesticks. The other answers (a, c,
and d) are all true statements concerning standard precautions.

Question 3

The parents of a chronically ill child may exhibit which of the following behaviors that indicates
feelings of guilt about the child's illness?

Anger.

Sadness.

Shock.

Overindulgence
Incorrect. The answer is
Overindulgence

Explanation:
Correct answer:
Overindulgence

Parents who feel guilty about a child's illness may overindulge the child. Anger, sadness, and shock are common in
parents of chronically ill children but do not necessarily indicate feelings of guilt.

Question 4

The nurse understands that for the parathyroid hormone to exert appropriately, what must be
present?

Decreased phosphate level.

Adequate vitamin D level.

Functioning thyroid gland.

Increased calcium level.

Incorrect. The answer is


Adequate vitamin D level.

Explanation:
Correct answer:
Adequate vitamin D level

Adequate vitamin D must be present for parathyroid hormone to exert its effect - that is to help regulate calcium
metabolism. Vitamin D promotes calcium absorption from the intestines.

Question 5

Which of the following central venous catheters is designed for short-term use and is most
commonly used?

Tunneled catheter.

Multilumen catheter.

Peripherally inserted central catheter (PICC).

Implanted port.

Incorrect. The answer is


Multilumen catheter.

Explanation:
Correct answer:
Multilumen catheter

Patients such as those undergoing chemotherapy for cancer utilize the tunneled catheter because it is designed
for longer-term use. A PICC is used for inpatient occasions that are expected to continue for several weeks.
Implanted ports are for long-term use and are implanted beneath the subcutaneous tissue.

Question 6

A 66-year-old female is admitted for a myocardial infarction (MI). The nurse observes that the client
has a low blood pressure, a weak pulse and her urine output has decreased. Which of the following
indicates the most likely complication of (MI) for the client?
cardiogenic shock

pericardial effusion

arrhythmia

diaphoresis

Correct. The answer is


cardiogenic shock

Explanation:
The correct answer is cardiogenic shock. Cardiogenic shock is a complication of myocardial infarction. Signs of
cardiogenic shock are low blood pressure, weak pulse, a decrease in urine output.

Question 7

What treatment is the most appropriate in reducing cancer-related pain?

Give aspirin as needed.

Have the client perform mild exercise to increase


strength.
Use heat or cold as needed.

Use biofeedback techniques.

Incorrect. The answer is


Use heat or cold as needed.

Explanation:
Correct answer:
Use heat or cold as needed

Use heat or cold as needed. This will assist in reducing inflammation.

Question 8

Nurse Smith is in the hallway talking to another nurse loudly about the diagnosis of her patient, Mr.
Miller. Nurse Smith is speaking loudly because she wants the patient’s wife, Mrs. Miller to hear her.
Nurse Smith has committed which of the following?

Assault and battery.

False imprisonment.

Slander.

Libel.

Incorrect. The answer is


Slander.

Explanation:
Correct answer:
Slander

Nurse Smith intentionally reveals information about Mr. Miller so that Mrs. Miller hears it. This information hurts the
patient’s reputation.
Question 9

Which blood type would the nurse identify as the rarest in the United States?

A.

B.

AB.

O.

Correct. The answer is


AB.

Explanation:
Correct answer:
AB

Group AB individuals comprise only about 4% of the population, and therefore are the rarest blood type. Type O
is the most common, approximately 45% of the population, followed by Type A at 41% and type B at 10%.

Question 10

During which stage of development should the nurse encourage immunizations?

Toddler

Infancy

Early childhood

Middle childhood

Correct. The answer is


Infancy

Explanation:
The correct answer is:
Infancy

Infancy is the age from birth to a year. During this age range it is important for parents to ensure that routine
immunizations are given and up to date.

Question 11

Which of the following is an example of an external disaster?

Radiological accident.

Flood.

Major bus accident.

Chemical spill in the hospital’s laboratory.

Correct. The answer is


Major bus accident.

Explanation:
Correct answer:
Major bus accident

Choice A is an example of a man-made disaster. Choice B is a natural disaster and Choice D, an internal disaster.

Question 12

Which of the following is the third provision of the Code of Ethics for Nurses?

"The nurse in all professional relationships, practices with compassion and respect for
the inherent dignity, worth, and uniqueness of every individual, unrestricted by
considerations of social or economic status, personal attributes, or the nature of health
problems."
“The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the
patient.”

“The nurse is responsible and accountable for individual nursing practice and
determines the appropriate delegation of tasks consistent with the nurse’s obligation to
provide optimum patient care.”
“The nurse’s primary commitment is to the patient, whether an individual, family,
group, or community.”

Incorrect. The answer is


“The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

Explanation:
Correct answer:
"The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient"

Choice A is provision number one of the code of ethics for nurses. Choice C is provision number four and Choice D,
provision number two.

Question 13

The nurse is developing a teaching plan for a client with asthma. Which teaching point has the
HIGHEST priority?

Avoid contact with fur-bearing animals.

Take prescribed medications as scheduled.

Change filters on heating and air conditioning units frequently.

Avoid goose down pillows.

Correct. The answer is


Take prescribed medications as scheduled.

Explanation:
Correct answer
Take prescribed medications as scheduled

Although all measures are appropriate for clients with asthma, taking prescribed medications on time is the most
important measure in preventing asthma attacks.

Question 14

A couple has a child that has been diagnosed with Turner's syndrome. The nurse teaches the couple
about this chromosomal abnormality. Which of the following statements would indicate that the
teaching has been successful?

"We will have to adjust to the catlike cry."

"She will have to have her cleft palate repaired."


"She will not be able to wear open-toed sandals."

"She will need to be placed in a facility due to mental retardation."

Correct. The answer is


"She will not be able to wear open-toed sandals."

Explanation:
The correct answer is:
"She will not be able to wear open-toed sandals."

Children with Turner's syndrome have no toenails. Cat cry syndrome involves children crying like a cat. Cleft
palate is not a characteristic of Turner's syndrome. Children with Turner's syndrome do not experience mental
retardation.

Question 15

A client is hospitalized for pelvic inflammatory disease. Which of the following nursing interventions
would have priority?

Encourage oral fluids.

Administer cefotan IV.

Enforce bedrest.

Remove IUD if present.

Incorrect. The answer is


Administer cefotan IV.

Explanation:
The correct answer is administer cefotan IV. Administration of medications to treat the disease is a priority. Bedrest
and encouraging oral fluids are not a priority. Removal of IUD is not a nursing intervention.

Question 16

Which action will assist in relieving intercranial pressure in patients with a head injury?

Turning the patient on his side.

Raising the head of the bed 25 degrees.

Moving the patient’s bed by the window to take advantage of Vitamin D absorption.

Increasing the intake of oxygen.

Correct. The answer is


Raising the head of the bed 25 degrees.

Explanation:
Correct answer:
Raising the head of the bed 25 degrees

A 15-30 degree angle increase of the head of the bed will help promote drainage of the injury. Choices A, C, and D
are not relevant in this situation.

Question 17

Which of the following is an abnormal finding of the lip during an oral assessment?
Leukoplakia.

Lesions that are painful in the corner of the mouth.

Gingivitis.

Acetone breath.

Incorrect. The answer is


Lesions that are painful in the corner of the mouth.

Explanation:
Correct answer:
Lesions that are painful in the corner of the mouth

Cheilosis, which is painful lesions that are found at the corners of the mouth, is an abnormal finding that can be
identified during an oral assessment. Cheilosis is caused by a deficiency in riboflavin and niacin. Leukoplakia is an
incorrect answer choice as this is an abnormal finding of tongue or inside the cheeks. Gingivitis is an abnormal
finding of the gums. Acetone breath is not associated with the lips. However, it is an abnormal finding that occurs in
the oral cavity.

Question 18

The nurse assesses a client with primary insomnia. Which of the following should the nurse identify as
the cause of insomnia?

Muscle pain.

Stress.

Anxiety.

Depression.

Incorrect. The answer is


Stress.

Explanation:
Correct answer:
Stress

Primary insomnia results from physical or emotional stress that is not triggered by a physiological effect from a
substance. Also, primary stress does not manifest from a medical condition. Anxiety is not the best choice, as
anxiety is due to a psychiatric disorder which causes insomnia as a secondary condition. Pain is related to
neurological conditions or medical conditions thus causing insomnia as a primary condition. Depression which is
caused by a psychiatric condition, may cause insomnia.

Question 19

A nurse is cleaning a wound of a 33-year-old client. The nurse cleans the wound from the center of
the incision and then outward, followed by lateral motions. Which of the following best identifies this
type of wound cleansing?

Horizontal.

Vertical.

Lateral.
Dorsal.

Incorrect. The answer is


Horizontal.

Explanation:
Correct answer:
Horizontal

Horizontal wound cleansing involves the cleaning of the wound from the center starting at the incision site, then
moving outward and laterally. Other cleansing methods are vertical and drain/stab wound.

Question 20

A client with esophageal cancer is admitted to an acute facility. The incidence of esophageal cancer
is highest in what group?

Black males.

Adults of both sexes ages 20 to 30.

Women older than 60.

White boys and girls younger than age 10.

Incorrect. The answer is


Black males.

Explanation:
Correct answer:
Black males

Black males have the highest incidence of esophageal cancer. This type of cancer affects twice as many men as
women. It is more common in black, Japanese, and Chinese males than in White males. Esophageal cancer is
relatively rare in young adults, women older than age 60, and white children.

Question 21

Which evolutionary theory concerning emotions is FALSE?

Darwin proposed that fear of others helps animals avoid danger.

Darwin proposed that fear and aggression are useful when fighting for mates and necessary
resources.

Evolutionary theory proposes that rational thought is developed before emotions.

All of the above statements are FALSE.

Incorrect. The answer is


Evolutionary theory proposes that rational thought is developed before emotions.

Explanation:
Correct answer:
Evolutionary theory proposes that rational thought is developed before emotions

Darwin did not propose that fear and rational thought was developed before emotions. Darwin proposed that
emotions be freely expressed.

Question 22
A client on the behavioral health unit spends several hours a day organizing and reorganizing his
closet. He repeatedly checks to see if his clothing is arranged in the proper order. What term is
commonly used to describe this behavior?

Obsession.

Compulsion.

Exhibitionism.

Transference.

Incorrect. The answer is


Compulsion.

Explanation:
Correct answer:
Compulsion

Compulsion is present when a client exhibits recurrent, persistent, repetitive actions and behaviors, which he feels
driven to perform. This behavior interferes with the client's activities of daily living and is disruptive to the client's
lifestyle. These compulsions relieve the intense anxiety that occurs when the behavior is not performed. Obsession
is a recurrent, persistent, and intrusive thought. Exhibitionism is the compulsive needs to expose a part of the body,
especially the genitals, to an unsuspecting stranger. Transference is the process of placing feelings and thoughts
onto the therapist, who symbolically represents a significant person in the client's past.

Question 23

The fundamental component of psychiatric nursing is which of the following?

helping individuals who present a potential mental illness

providing therapy to client's diagnosed with a mental illness

understanding the legal structure to guide the care and treatment of mentally ill clients

identifying and working with clients on interpersonal skills to aid with treatment

Incorrect. The answer is


understanding the legal structure to guide the care and treatment of mentally ill clients

Explanation:
The correct answer is understanding the legal structure to guide the care and treatment of mentally ill clients. The
fundamental component of nursing to treat and care for individuals with a mental illness is governed by each state's
mental health code. These codes identify specific procedures that mental health professionals, including nurses,
have to follow, such as adhering to the client Care Partnership and upholding the civil rights of all clients.

Question 24

A client asks her nurse, "Is it okay for me to take a tub bath during the heavy part of my menstrual
cycle?" The correct response by the nurse is:

"Tub baths should be avoided during menstruation."

"You should shower and douche daily instead."

"Either a bath or a shower is fine at that time."

"You should limit bathing and use a feminine deodorant spray during menstruation."

Correct. The answer is


"Either a bath or a shower is fine at that time."

Explanation:
The correct answer is "Either a bath or a shower is fine at that time." Bathing, whether it is a tub bath or shower, is
as important during menses as at any other time. Douching should be avoided during menstruation. Femine
deodorant sprays are not necessary.

Question 25

A client who is 38 weeks gestation is in the clinic and you are performing an assessment on her. You
note that the fetal heart rate (FHR) is 174 beats per minute. Due to this finding, what is the most
appropriate nursing action?

Document the finding.

Check the mother's heart rate.

Tell the client that the fetal heart rate is normal.

Notify the physician.

Correct. The answer is


Notify the physician.

Explanation:
The Correct answer is:
Notify the physician.

Depending on the gestational age, the fetal heart rate ranges from 160 to 170 beats per minute in the first trimester,
120 to 160 beats per minute in the second trimester, and at near term, if the fetal heart rate is less than 120 beats
per minute with the uterus at rest, the fetus could be in distress.

Question 26

Which behavior is most healthful for a client with arterial insufficiency?

Cross legs at the knee for only one hour per day.

Cross legs only at ankles for a maximum of two hrs. per day.

Wear loose fitting socks.

Walk barefoot outside, weather permitting.

Correct. The answer is


Wear loose fitting socks.

Explanation:
Correct answer:
Wear loose fitting socks

Loose fitting socks will promote good circulation. Crossing the legs at any point is detrimental to circulation.

Question 27

The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention
should the nurse implement?

give the medication on an empty stomach

warn the client that he'll experience mouth dryness


schedule the medication before meals

administer the medication for complaints of muscle weakness or difficult swallowing.

Incorrect. The answer is


schedule the medication before meals

Explanation:
The correct answer is schedule the medication before meals. Because neostigmine's onset of action is 45 to 75
minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking
neostigmine with a small amount of food reduces GI adverse effects. Adverse effects of the medication include
increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at
scheduled times to ensure consistent blood levels.

Question 28

Which of the following is an infection control method that is also known as clean technique?

Surgical asepsis.

Medical asepsis.

Sterile asepsis.

Clinical asepsis.

Incorrect. The answer is


Medical asepsis.

Explanation:
Correct answer:
Medical asepsis

Medical asepsis is also called clean technique. Medical asepsis is used to reduce pathogens and the spread of
these pathogens.

Question 29

A nurse is reviewing the medical record of the clients scheduled to be see at the dermatology clinic
where she works. Which of the following does the nurse determine is at the greatest risk for
development of an integumentary disorder?

an older female

a physical education teacher

an outdoor construction worker

an adolescent

Correct. The answer is


an outdoor construction worker

Explanation:
The Correct answer is:
an outdoor construction worker

Prolonged exposure to the sun and exposure to unusual cold can damage the skin. Any client working outdoors
would fit into a high-risk category for the development of an integumentary disorder. Immobility and lack of nutrition
would increase the older person's risk but they would not be considered high risk. The physical education teacher is
at low or no risk of developing a skin problem. While some adolescents are prone to development of acne, not all
are.

Question 30

You are conducting an assessment of a client with the diagnosis of cataract who is scheduled for
surgery for the cataract. The MOST appropriate nursing diagnosis for this client's plan of care would
be what?

self-care deficit

nutrition, imbalanced

sensory perception, disturbed

anxiety

Incorrect. The answer is


sensory perception, disturbed

Explanation:
The Correct answer is:
sensory perception, disturbed

The most appropriate would be sensory perception, disturbed (visual) related to lens extraction and replacement.
The other answers (a, b, and d) may be appropriate, they are not related specifically to cataract surgery.

Question 31

Which client has special risk factors that warrant testing for tuberculosis?

An 18-year-old male with asthma

A 45-year-old female who has been homeless for 18 months

A 65-year-old female who is a recent immigrant from Bosnia

A 46-year-old farmer

Correct. The answer is


A 45-year-old female who has been homeless for 18 months

Explanation:
The correct answer is:
A 45-year-old female who has been homeless for 18 months

Homeless populations, no matter the age, race, or gender, are at an especially high risk for TB. Asthmatic
individuals, European immigrants and farmers generally have no bearing on a person’s risk or lack thereof for TB.

Question 32

A client with Guillain-Barre syndrome has been admitted to the nursing unit. You note that the client
has an ascending paralysis to the level of the waist. The RN has knowledge of the complications of this
disorder, so which of the following items do you bring into the client's room?

Electrocardiographic monitoring electrodes and intubation tray.

Flashlight and incentive spirometer.

Blood pressure cuff and flashlight.


Nebulizer and pulse oximeter.

Incorrect. The answer is


Electrocardiographic monitoring electrodes and intubation tray.

Explanation:
The Correct answer is:
electrocardiographic monitoring electrodes and intubation tray

Due to the risk for respiratory failure because of ascending paralysis, the client with Guillain-Barre syndrome should
have an intubation tray available. Since another complication of this condition is cardiac dysrhthmias, the use of
electrocardiographic monitoring equipment will be necessary. There is an increased risk for deep vein thrombosis
and pulmonary embolism, therefore the nurse should assess for this routinely.

Question 33

Which of the following is the most important aspect of nursing care in the postpartum period?

supporting the mother's ability to successfully feed and care for her infant

involving the family in the teaching

providing group discussions on baby care

monitoring the normal progression of lochia

Incorrect. The answer is


supporting the mother's ability to successfully feed and care for her infant

Explanation:
The correct answer is supporting the mother's ability to successfully feed and care for the her infant. Most of the
nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the
parenting role. Although family involvement in teaching, group discussions on baby care, and lochia monitoring are
important aspects of care, the mother's ability to feed and care for her infant takes priority.

Question 34

Which of the following is most accurate of postpartum psychosis?

Symptoms start about 4 weeks after birth.

Symptoms typically do not include delusions or mania.

Suicide and/or infanticide can be common.

There is no history of psychiatric issues with this disorder.

Incorrect. The answer is


There is no history of psychiatric issues with this disorder.

Explanation:
Correct answer:
There is no history of psychiatric issues with this disorder

Postpartum psychosis occurs in less than 1% of the population. Most often it occurs in women with no history of
psychiatric issues. Suicide is rare and infanticide is extremely rare during these episodes.

Question 35

The nurse is performing an assessment on an elderly client with Type 2 diabetes mellitus. The client
has developed an ingrown toenail. Which of the following actions should the nurse take to address the
ingrown toenail?

Contact the physician.

Immediately elevate the foot.

Apply warm, moist soaks.

Take a piece of cotton and place under the nail and clip the nail straight across.

Incorrect. The answer is


Contact the physician.

Explanation:
Correct answer:
Contact the physician

An infection can develop from an ingrown toenail and can be a serious implication for a diabetic client. Therefore,
the nurse should not initiate treatment for the ingrown toenail. Instead, the nurse should contact the physician.

Question 36

You are preparing to administer a high dose of heparin sodium and plan to use an intravenous infusion
pump. When you bring the pump to the bedside, you notice that there is no receptacle available in the
wall socket to insert the plug into. Which of the following is an appropriate action?

Contact the electrical maintenance department for assistance.

Plug in the pump cord in the available plug above the room sink.

Use an extension cord from the nurse's lounge for the pump plug.

Initiate the intravenous line without the use of a pump.

Correct. The answer is


Contact the electrical maintenance department for assistance.

Explanation:
The Correct answer is:
Contact the electrical maintenance department for assistance.

The nurse needs to use hospital resources for assistance. Using the receptacle near the sink presents a hazard. A
regular extension cord should not be used because of fire risk. An intravenous line that contains a high dose of
heparin should be administered by use of a pump.

Question 37

An RN is working on a respiratory unit and is assigned a client with pulmonary embolism as a


diagnosis. Which of the following is NOT an intervention for this client?

Encourage the use of incentive spirometry as prescribed.

Place the client in a high Fowler's position.

Discourage deep breathing to avoid pain.

Administer anticoagulation therapy as prescribed.


Incorrect. The answer is

Discourage deep breathing to avoid pain.

Explanation:
The Correct answer is:
Discourage deep breathing to avoid pain.

Deep breathing and use of the incentive spirometer should be encouraged as prescribed. The other answers (a, b,
and d) are all interventions for the client with pulmonary embolism. Also, oxygen should be administered as
prescribed, maintain bed rest and active and passive range-of-motion exercises, monitor pulse oximetry, monitor
lung sounds, and monitor prothrombin time (PT), international normalized ration (INR), and partial thromboplastin
time (PTT) closely.

Question 38

The nurse understands a complication of Eosphagectomy is which of the following?

Elevated temperature.

Anastomosis leak.

Increased sweating.

Decreased pulse rate.

Correct. The answer is


Anastomosis leak.

Explanation:
Correct answer:
Anastomosis leak

An esophagectomy is the resection of the esophagus that is affected by the cancer. Complications of this procedure
are anastomosis leak, pneumonia, acute respiratory distress syndrome, gastric bleeding, dysrhythmias and sepsis.

Question 39

A client has a tumor on the right side of the face, near the ear. The nurse expects which of the
following procedures to be performed?

Tzanck test.

Scratch test.

Excisional skin biopsy.

Shave biopsy.

Incorrect. The answer is


Excisional skin biopsy.

Explanation:
Correct answer:
Excisional skin biopsy

Tests performed to determine if a nodule on the skin is cancer (malignant) or not cancer (benign) include incisional
or an excisional biopsy. With an excisional skin biopsy, the entire skin lesion is removed and sent for analysis. An
incisional biopsy is where a part of the lesion is removed and sent for analysis. With both procedures an incision is
made into the skin and the incision is closed with sutures. The tzanck test is an incorrect choice as this test helps in
the diagnosis of herpes infections. Further, scratch test is not the best choice since this is an allergy test to
determine types of allergens. A shave skin biopsy is not used to diagnose cancer. Instead, this procedure shaves
off lesions on the top of the skin to determine if infectious lesions from the lesions are inflamed.

Question 40

Which of the following is a brand name for Etidronate?

Armour Thyroid.

Synthroid.

Didronel.

Xanax.

Correct. The answer is


Didronel.

Explanation:
Correct answer:
Didronel

Choice A is a brand name for Thyroid. Choice B is a brand name for Levothyroxine (T4) and choice D, for
Alprazolam.

Question 41

The nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist the
compulsion. Based on this finding, the nurse should assess the client for what?

Feelings of failure.

Depression.

Excessive fear.

Increased anxiety.

Incorrect. The answer is


Increased anxiety.

Explanation:
Correct answer:
Increased anxiety

An obsessive-compulsive client who attempts to resist the compulsion must be evaluated for increased anxiety. A
compulsion is a repetitive, intentional behavior that the client performs in response to a certain obsession; it is
aimed at neutralizing or decreasing anxiety. Resisting the compulsion may increase the client's anxiety. Although a
client with OCD may have feelings of failure, depression, and excessive fear, these are not responses to resisting
the compulsion.

Question 42

A client has fibromyalgia and chronic pain. Which of the following effects may the client experience
with this condition?

Muscle spasms.

Depression.

Hypersensitivity to sunlight.
Peripheral vasospasms.

Incorrect. The answer is


Depression.

Explanation:
Correct answer:
Depression

Clients who have conditions associated with chronic pain, such as fibromyalgia, may experience effects that are a
result of long term battles with pain. Common effects include fatigue, weight gain, poor concentration, divorce, loss
of a job due to chronic pain and depression. Further, fibromyalgia is pain that is felt in the body's joints, muscles
tendons and tissues.

Question 43

Which of the following created rights for the mentally ill patient?

Joint Commission on Accreditation of Healthcare Organizations

American Nurses Association

Mental Health Systems Act

American Hospital Association

Correct. The answer is


Mental Health Systems Act

Explanation:
The correct answer is C. Choice A created policy statements on the rights of the mentally ill. Choice B
created the Code for Nurses. This “code” outlines the nurses’ responsibilities with regard to upholding
clients’ rights. Choice D issued the patients’ bill of rights.

Question 44

A client is suspected of having systemic lupus erythematous (SLE). Knowing this, the nurse monitors
this client for which of the following initial characteristic signs of SLE?

subnormal temperature

elevated red blood cell count

weight gain

rash on the face across the bridge of the nose and on the cheeks

Correct. The answer is


rash on the face across the bridge of the nose and on the cheeks

Explanation:
The Correct answer is:
rash on the face across the bridge of the nose and on the cheeks

A rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of SLE. Other
signs are fever, weight loss, and after time, anemia.

Question 45

During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity
to negative evaluation, fear of criticism, and social ineptitude. The nurse suspects which of the
following personality disorders?
Narcissistic.

Antisocial.

Paranoid.

Avoidant.

Incorrect. The answer is


Avoidant.

Explanation:
Correct answer:
Avoidant

The behaviors describe avoidant behaviors. Antisocial behaviors are against society but are not inhibited. Paranoid
behaviors are those in which a client is suspicious of the actions of others, and narcissistic are self-centered
behaviors.

Question 46

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of
deficient fluid volume?

Cool, clammy skin.

Distended neck veins.

Increased urine osmolarity.

Decreased serum sodium level.

Incorrect. The answer is


Increased urine osmolarity.

Explanation:
Correct answer:
Increased urine osmolarity

In hyperglycemia, urine osmolarity increases as glucose particles move into the urine. The client experiences
glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; distended
neck veins, and a decreased serum sodium level are signs of fluid volume excess the opposite imbalance.

Question 47

The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating
injection sites?

To prevent bruising

To prevent medication leakage from the tissue or muscle

To prevent erratic drug distribution

To prevent the formation of hard nodules

Correct. The answer is


To prevent the formation of hard nodules
Explanation:
The correct answer is:
To prevent the formation of hard nodules

Rotating injection sites promotes adequate drug absorption and prevents the formation of hard nodules caused by
repeated injections into the same site. Nodules may impeded drug absorption with future injections. Rotating sites
does not prevent bruising, medication leakage or erratic drug distribution.

Question 48

Which of the following is a nursing intervention for a nurse who is caring for a child who acquired
immunodeficiency syndrome with a goal of risk for impaired oral mucous membrane?

administer to the client medication for pain

inspect the mouth for blistering

monitor the client for signs of pain

monitor the client for signs of infection

Incorrect. The answer is


inspect the mouth for blistering

Explanation:
The correct answer is inspect the mouth for blistering. For the goal risk for impaired oral mucous membrane, the
nursing intervention may include observing the client's mouth for blisters and lesions, and administering mouth care
with saline solutions. Further, the remaining answer choices are not specific to the goal of risk of impaired oral
mucous membrane. Instead, the remaining answer choices focus on goals dealing with pain related to infections
and deficient knowledge related to the home care of a child with acquired immunodeficiency syndrome.

Question 49

Which outcome indicates effective client teaching to prevent constipation?

the client verbalizes consumption of low-fiber foods

the client maintains a sedentary lifestyle

the client limits water intake to three glasses per day

the client reports engaging in a regular exercise regimen.

Correct. The answer is


the client reports engaging in a regular exercise regimen.

Explanation:
The correct answer is the client reports engaging in a regular exercise regimen. A regular exercise regimen
promotes peristalsis and contributes to regular bowel elimination patterns. A low-fiber diet, a sedentary lifestyle, and
limited water intake would predispose the client to constipation.

Question 50

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

administering an analgesic once per shift, as prescribed, to prevent drug addiction

positioning the client on the side with the knees flexed

encouraging frequent visits from family and friends


administering frequent oral feedings

Correct. The answer is


positioning the client on the side with the knees flexed

Explanation:
The correct answer is positioning the client on the side with the knees flexed. The nurse should place the client with
acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure
on the abdominal muscles. The nurse should administer an analgesic, as needed and prescribed, before pain
becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the
acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are
contraindicated during the acute state to allow the pancreas to rest.

Question 51

A mother complains to the nurse that her 4-year-old son often "lies." What is the nurse's best
response?

"Let the child know that he will be punished for lying."

"Ask him why he is not telling the truth."

"It is probably due to his vivid imagination and creativity."

"Acknowledge him by saying, That is a pretend story."

Incorrect. The answer is


"Acknowledge him by saying, That is a pretend story."

Explanation:
Correct answer:
"Acknowledge him by saying, That is a pretend story"

It is important to acknowledge the child's imagination, while also letting him know in a nice way that what he has
said is not real. Punishment is not appropriate for a 4-year-old child using his imagination, and accusing him of lying
is a negative reinforcement. The child is not truly lying in the adult sense. Imagination and creativity need to be
acknowledged.

Question 52

The nurse is caring for a client who has Bell's Palsy. Which of the following would be an appropriate
nursing care for this client?

Teach the client injury prevention and proper nutrition.

Perform range of motion exercises.

Administer an analgesic for headaches.

Teach the client to identify muscle spasm.

Incorrect. The answer is


Teach the client injury prevention and proper nutrition.

Explanation:
Correct answer:
Teach the client injury prevention and proper nutrition

Much of the care for clients with Bell's Palsy is client self-care. However, nurses do have a role in the care of the
client with Bell's Palsy which includes teaching the client injury prevention, education on proper nutrition, and
assisting the client to develop an understanding of Bell's Palsy.

Question 53

The nurse understands the best location to hear the S1 heart sound is where?

base of the heart

aortic area

apex of the heart

pulmonic area

Correct. The answer is


apex of the heart

Explanation:
The correct answer is the apex of the heart. The first heart sound or S1 is created when the tricuspid and mitral
valves close and ventricular contract starts. The best locations to hear the S1 heart sound during auscultation is the
apex of the heart and tricuspid area of the mitral area. The remaining answer choices are the best locations to hear
the S2 heart sound.

Question 54

Which of the following basic turns for roller bandages requires anchoring the bandage and using two
circular turns to cover distal parts of the body?

Recurrent turns.

Circular turns.

Spiral turns.

Spiral reverse turns.

Incorrect. The answer is


Recurrent turns.

Explanation:
Correct answer:
Recurrent turns

When applying bandages to a client's body parts, there are basic bandaging turns used. These basic turns for roller
bandages are circular, spiral, spiral reverse, recurrent and figure eight. Recurrent bandaging turns are used to
cover body parts that are distal such as the ends of the fingers.

Question 55

What important observation should a nurse look for 12-24 hours after the birth of a child?

Passage of meconium stool

An adjustment in the shape of the newborn’s head

The presence of milia

A change in nail color

Correct. The answer is


Passage of meconium stool

Explanation:
The correct answer is:
Passage of meconium stool

The passing of the meconium stool is an important transition for the newborn. This shows that the baby’s bowels
are working properly.

Question 56

Which of the following is used to treat anxiety?

Kava.

St. John's Wort.

Both A & B.

Saw Palmetto.

Correct. The answer is


Both A & B.

Explanation:
Correct answer:
Both A & B

Saw Palmetto treats urinary symptoms of benign prostatic hypertrophy (BPH). In addition to treating anxiety, Kava
focuses on insomnia and menopausal symptoms. St. John's Wort helps treat depression and sleep disorders.

Question 57

A client has not voided since before surgery, which took place 8 hours ago. When assessing the client,
the nurse will:

Be unable to palpate the bladder.

Feel that the bladder is smooth.

Palpate the bladder above the symphysis pubis.

Palpate the bladder at the umbilicus.

Correct. The answer is


Palpate the bladder above the symphysis pubis.

Explanation:
Correct answer:
Palpate the bladder above the symphysis pubis

Eight hours is a long time not to have voided. The kidneys typically produce 25 to 55 m or urine in 1 hour. After 8
hours of not voiding, the bladder would be full of urine and palpable above the symphysis pubis.

Question 58

A 72 year old female is diagnosed with Alzheimer's disease. The physician prescribes the client
donepezil (Aricept). The nurse should monitor the client for which of the following while taking
donepezil (Aricept)?
urine output

total cholesterol

visual acuity

heart rate

Incorrect. The answer is


heart rate

Explanation:
The correct answer is: heart rate. The nurse's responsibility is to monitor the client's heart rate as bradycardia may
emerge while taking donepezil (Aricept). Also, the nurse should assess the client's cognitive ability while taking this
medication.

Question 59

Dysmorphophobia relates to the fear of what?

A distorted body image

Intercourse even within marriage

The inability to conceive

Excessive weight gain

Correct. The answer is


A distorted body image

Explanation:
The correct answer is A. This illness is a mental disorder, common in those with eating disorders. The person does
not have a proper perception of their body image and may especially see themselves as obese even when they are
extremely thin.

Question 60

A client with scabies asks, "How did I get this"? The nurse's best response is that scabies results from
what?

A venomous spider bite.

A bee sting.

A mosquito bite.

Mites burrowing through the skin.

Incorrect. The answer is


Mites burrowing through the skin.

Explanation:
Correct answer:
Mites burrowing through the skin

Scabies is a parasitic infestation that occurs when mites burrow through the human skin. The mites burrowing
create small red to brown lesions that look like a rash. Skin has an allergic type response to the mite's feces.

Question 61
Which of the following terms is defined as a health care delivery system that focuses on the most
efficient use of personnel and resources to maximize revenue as well as provide high quality
healthcare?

Accountability

Critical path

Variances

Case management

Correct. The answer is


Case management

Explanation:
The correct answer is D. Choice A is defined as a nurse taking responsibility for the consequences of an action.
Choice B is a management system that reduces the length of one’s hospital stay. Choice C refers to the deviations
from the usual critical paths.

Question 62

The nurse is caring for a 70-year-old client. Which of the following should the nurse assess as a
potential cause of falls?

Fear.

Trauma.

Hypertension.

Bright lighting.

Incorrect. The answer is


Fear.

Explanation:
Correct answer:
Fear

Fear is a potential cause for falls among the elderly population. Additional signs and symptoms the nurse can
assess for in order to gauge the risk for falls are unsteady gait, change in medical responsiveness because of
medication, vision difficulties, hypotension, foot diseases and cognitive changes.

Question 63

The nurse recognizes that conversion somatoform disorders are characterized by what?

loss of physical functioning

preoccupation with physical appearance

preoccupation with pain that is not caused by a physical or mental disorder

preoccupation with an illness because of identified physical symptoms

Incorrect. The answer is


loss of physical functioning
Explanation:
The correct answer is loss of physical functioning. Somatoform disorders is a group of disorders where there are
symptoms of a disease. However, there is no evidence of a physical disease or condition that is causing the
symptoms.

With conversion disorder, an individual has psychological factors that are related to a loss of physical functioning.
Further, the preoccupation with physical appearance is not the best answer choice as this is a somatoform disorder
called body dysmorphic disorder. Next, preoccupation with pain that is not caused by a physical or mental disorder
is known as psychogenic pain disorder. Then, preoccupation with an illness because of identified physical
symptoms is a somatoform disorder known as hypochondriasis.

Question 64

A client comes to the outclient department with suspected carpal tunnel syndrome. When assessing
the affected area, the nurse expects to find which abnormality that is typically associated with this
syndrome?

Positive Tinel's sign.

Positive Chvostek's sign.

Negative Phalen's sign.

Negative Trousseau's sign.

Correct. The answer is


Positive Tinel's sign.

Explanation:
Correct answer:
Positive Tinel's sign

The nurse expects a client with carpal tunnel syndrome to exhibit a positive Tinel's sign - tingling or shock like pain
in reaction to light percussion over the median nerve at the wrist. The client may also have a positive Phalen's sign,
characterized by hand tingling with acute wrist flexion. The nurse checks for Chvostek's sign and Trousseau's sign
in a client with suspected hypocalcemia, not carpal tunnel syndrome.

Question 65

What is the short-term goal of nursing care for the patient with acute pancreatitis?

The client denies abdominal pain.

The client is hydrated.

The client expresses a relaxed state of drowsiness.

The client is able to have a bowel movement without medical aid.

Incorrect. The answer is


The client denies abdominal pain.

Explanation:
Correct answer:
The client denies abdominal pain

One of the most severe symptoms of acute pancreatitis is abdominal pain. When the abdominal pain has subsided,
a short-term goal has been met.

Question 66

Which of the following laboratory test results would suggest to the nurse that a client has a
corticotropin-secreting pituitary adenoma?

High corticotropin and low cortisol levels.

Low corticotropin and high cortisol levels.

High corticotropin and high cortisol levels.

Low corticotropin and low cortisol levels.

Correct. The answer is


High corticotropin and high cortisol levels.

Explanation:
Correct answer:
High corticotropin and high cortisol

A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin
level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with
hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the
adrenal glands.

Question 67

Which of the following behavior is assessed with a client diagnosed with pyromania?

recurring impulse to steal

loss of control of aggressive impulses

delusional behavior

setting fires

Correct. The answer is


setting fires

Explanation:
The correct answer is setting fires. Disorder of impulse control deals with the inability to resist temptation to act out
in a way that is harmful to other people. Pyromania is a disorder where an individual is unable to resist setting fires.
A recurring impulse to steal is incorrect as this is kleptomania. The loss of control of aggressive impulses is called
explosive disorder. Delusional behavior is not a characteristic of pyromania.

Question 68

A 55-year-old client has gout. The client has elevated uric acid levels, which may contribute to the
formation of an uric acid stone. Which of the following should the nurse instruct the client to avoid?

Sardines.

Chocolate.

Dried fruits.

Lentils.

Incorrect. The answer is


Sardines.

Explanation:
Correct answer:
Sardines

The client is at risk of developing a uric acid stone due to elevated uric acid levels. With uric acid stones, the client
needs a diet that is low in purines. Therefore, sardines is a purine rich food that should be avoided. Further,
chocolate, dried fruits and lentils are foods high in calcium, which may impact a client that is at risk of developing
calcium stones.

Question 69

In a client who has HIV infection, CD4+ levels are measured to determine what?

The presence of opportunistic infections.

The level of the viral load.

The extent of immune system damage.

The resistance to antigens.

Correct. The answer is


The extent of immune system damage.

Explanation:
Correct answer:
The extent of immune system damage

CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's
immune system. The test indicates the individual's risk of an opportunistic infection but does not identify specific
infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests.

Question 70

The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal
cord lesion. During the MRI scan, which action would pose a threat to the client?

The client lies still.

The client asks questions.

The client hears thumping sounds.

The client wears a watch and wedding band.

Correct. The answer is


The client wears a watch and wedding band.

Explanation:
Correct answer:
The client wears a watch and wedding band

During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull
on them, causing injury to the client and to others if they fly off. The client must lie still during the MRI but can talk to
those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping
sounds, which are caused by the sound waves thumping on the magnetic field.

Question 71

Which signs and symptoms are present with a diagnosis of pericarditis?

Fever, chest discomfort, and elevated erythrocyte sedimentation rate(ESR).


Low urine output, secondary to left ventricular dysfunction.

Lethargy, anorexia, and heart failure.

Pitting edema, chest discomfort, and nonspecific ST-segment elevation.

Incorrect. The answer is


Fever, chest discomfort, and elevated erythrocyte sedimentation rate(ESR).

Explanation:
Correct answer:
Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment
elevation, elevated ESR, and pericardial friction rub. All other symptoms may result from acute renal failure.

Question 72

Which of the following interventions isNOT a part of barrier protection in the transmission-based
precautions that are included in airborne, droplet and contact precautions?

A mask or personal respiratory protection device should be used with airborne diseases.

A private room is necessary for droplet precautions with diseases spread by droplet
transmission.
Masks are necessary for client's who are on contact precautions.

With clients who have contact diseases, use of gloves and gown are needed by the
nurse providing care.

Correct. The answer is


Masks are necessary for client's who are on contact precautions.

Explanation:
The Correct answer is:
Masks are necessary for client's who are on contact precautions.

Masks or personal respiratory precaution devices are necessary for clients who have airborne diseases. Single
rooms are maintained under negative pressure for these clients and the door is kept closed when someone is
entering or exiting the room.

Question 73

Which is NOT a primary risk factor for hypertension?

Obesity.

Stress.

Hormonal contraceptives.

A high intake of sodium or fat.

Incorrect. The answer is


Hormonal contraceptives.

Explanation:
Correct answer:
Hormonal contraceptives
Hormonal contraceptives are a secondary factor. Choices A, B, and D along with family history are all high primary
risk factors for hypertension.

Question 74

Which of the following is a brand name for Dicyclomine HCL?

Bentyl.

Anaspaz.

Imodium.

Antivert.

Correct. The answer is


Bentyl.

Explanation:
Correct answer:
Bentyl

Choice B is a brand name for Hyoscyamine. Choice C is a brand name for Loperamide HCL, and Choice D, for
Meclizine.

Question 75

Which of the following assessment techniques of older patients depends on touch via fingers and
hands to assess the patient?

Palpation

Percussion

Inspection

Auscultation

Correct. The answer is


Palpation

Explanation:
The correct answer is:
Palpation

The percussion technique examines the body parts that are positioned beneath the skin. The size and density of
these parts are also evaluated. This is done by tapping the area and listening to the sound produced as a result.
With the inspection method, nurses rely on sight, smell and sounds to accurately describe the condition of the
patient. When the auscultation technique is used, sounds within the body such as the heart are assessed.

Question 76

A 15-year-old girl is brought by her mother to see a psychiatric nurse practitioner. The client's mother
demands that her daughter be admitted for treatment of "behavioral problems." Her mother states
that the daughter stays out until 4 a.m. and is hanging out with "bad" kids. The nurse will recommend
which of the following?

Outpatient therapy for the mother and daughter

Therapy for the mother


Therapy for the daughter

Involuntary admission for the daughter

Correct. The answer is


Outpatient therapy for the mother and daughter

Explanation:
The correct answer is outpatient therapy for the mother and daughter. The client has the right to treatment in the
least restrictive environment. Outpatient therapy for the client and her mother provides the best treatment
alternative. The client does not meet the criteria for an involuntary admission

Question 77

A client on the psychiatric unit had a hand amputated. During the admission interview, the client was
generally cooperative but said, "I'll answer anything, but do not ask about my hand." Thinking that
the injury may have been self-inflicted, the nurse recognized that the statement represents which
stage in self-injurious behavior?

Attempts to cope

Identification of feelings

Action

Aftermath

Correct. The answer is


Aftermath

Explanation:
The correct answer is aftermath. The client's behavior is from the Aftermath stage, in which feelings of relief,
shame, guilt or a sense of failure occur. The client is probably experiencing a strong sense of shame, guilt or failure
and is avoiding these feelings by refusing to discuss, or perhaps think about, what the client has done (this could
also be suppression). The client is not experiencing identification of feelings (urge to harm), is not engaging in
activities to prevent self-harm (attempts to cope), and is not engaging in self-harm (action).

Question 78

An RN in the postoperative department has just reassessed the condition of a postoperative client who
was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following
parameters most carefully during the next hour?

Temperature of 37.6° C (99.6° F).

Blood pressure of 100/70 mm Hg.

Serous drainage on the surgical dressing.

Urinary output of 20 mL/hr.

Incorrect. The answer is

Urinary output of 20 mL/hr.

Explanation:
The Correct answer is:
urinary output of 20 mL/hr
The urine output of an adult should be maintained at a minimum of 30 mL/hr. A lesser output for 2 consecutive
hours would indicate renal insufficiency and should be reported to the physician. A temperature higher than 37.7° C
(100.0° F) or lower than 36.1° C (97° F) and a falling blood pressure are immediate concerns and should be
reported. Light to moderate serous drainage at a surgical site is expected and should not be reported.

Question 79

A child is seen in the doctor's office with a +3 size tonsil. What is true of this finding?

It is normal

It is indicative of a strep throat infection

It demonstrates crypts

It reveals a lesion

Correct. The answer is


It is indicative of a strep throat infection

Explanation:
The correct answer is it is indicative of a strep throat infection. A child's tonsils that are a size +3 is usually seen in
children who have an infection like strep throat. A tonsil can be graded based on size from a +1 to a + 4, with a size
of +1 or +2 tonsil representing tonsils that are normal.

Question 80

When administering low doses of dopamine (Intropin), the nurse knows that dopamine activates
which receptors?

Alpha.

Beta1.

Dopaminergic.

Beta2.

Correct. The answer is


Dopaminergic.

Explanation:
Correct answer:
Dopaminergic

Dopamine activates dopaminergic receptor sites only at low doses. At normal or high doses, dopamine activates
alpha and beta1 receptor sites. Dopamine does not activate beta2 receptor sites.

Question 81

Which of the following indicates meningitis?

shallow breath sounds

atrophy in the neck muscles

Brudzinski's sign

skin discoloration

Correct. The answer is


Brudzinski's sign

Explanation:
The correct answer is Brudzinski's sign. Brudzinski's sign is the flexion of the hips as the neck is flexed in a supine
position. This flexion is seen in children with meningitis. Also, with Brudzinski's sign, there is pain felt when the neck
is flexed toward the chest.

Question 82

Which of the following is the first step of the grieving process?

Denial.

Depression.

Anger.

Bargaining.

Correct. The answer is


Denial.

Explanation:
Correct answer:
Denial

Depression is the fourth of the five steps of the grieving process. Anger is the second and bargaining, the third step
of the process.

Question 83

Two hours after delivery of a newborn, the client's fundus is boggy and has risen in the abdomen. The
first action the nurse would take is what?

massage the fundus until firm.

express retained clots.

increase the intravenous solution.

call the physician.

Correct. The answer is


massage the fundus until firm.

Explanation:
The correct answer is massage the fundus until firm. Massage of the uterus has to occur before the expression of
retained clots. The physician does not need to be notified until either the uterus does not respond or the bleeding
does not decrease.

Question 85

A patient believes that there is a possibility that she could have been exposed to AIDS. What should
the nurse explain to the client?

AIDS symptoms develop immediately in sexually active individuals.

For an indefinite period of time, the patient could remain asymptomatic.

AIDS symptoms are usually seen before the patient is found to be HIV positive.
Symptoms may develop within 6 to 12 weeks or even up to 6 months after exposure
to the virus.

Correct. The answer is


Symptoms may develop within 6 to 12 weeks or even up to 6 months after exposure to the virus.

Explanation:
Correct answer:
Symptoms may develop within 6 to 12 weeks or even up to 6 months after exposure to the virus

The patient may be HIV positive for years before she is diagnosed with having AIDS. The correct answer is
Choice D.

Question 86

Which of the following should not be taken into consideration when toilet training a child?

The type and consistency of solid foods the child consumes

The overall physical ability of the child

The overall mental ability of the child

An interest shown in toilet training by the child

Correct. The answer is


The type and consistency of solid foods the child consumes

Explanation:
The correct answer is:
The type and consistency of solid foods the child consumes

The type of foods the child eats has nothing to do with potty training. The most important factors in toilet training are
overall ability of the child, both mental and physical, along with an interest shown by the child.

Question 87

The nurse educates second year nursing students that a tort is which of the following?

A civil injustice that is committed against a person or the person's property.

Care provided to a client that meets the acceptable standards of care.

Misconduct that is not the standard level of care given.

A general form of a legal inquest.

Correct. The answer is


A civil injustice that is committed against a person or the person's property.

Explanation:
Correct answer:
A civil injustice that is committed against a person or the person's property

A tort occurs when someone has committed a wrong against someone else or that person's property. As a result,
the wronged individual can sue the person responsible for harming them.

Question 88

Which of the following medications has a possible side effect of eye pain?
Zolpidem Trartrate.

Allopurinol.

Colchicine.

Zalepion.

Incorrect. The answer is


Zalepion.

Explanation:
Correct answer:
Zalepion

In addition to eye pain, possible side effects of taking Zalepion include: headache, myalgia and dizziness. Asthenia
and dyspepsia can also occur.

Question 89

A client does not make eye contact with the nurse during an interview. The nurse suspects that the
clients behavior has a cultural basis. What should the nurse do first?

read several articles about the client's culture

ask staff members of a similar culture about the client's behavior

observe how the client and the client's family and friends interact with one another and
with other staff members

accept the client's behavior because it is probably culturally based.

Incorrect. The answer is


observe how the client and the client's family and friends interact with one another and with other staff
members

Explanation:
The correct answer is observe how the client and the client's family and friends interact with one another and with
other staff members. Assessing the client's interactions with others helps to determine whether the behavior is part
of a usual pattern. It also may help the nurse understand the meaning of the behavior for this particular client.
Reading about a different culture, consulting other staff members, and talking with the client are helpful after the
nurse has observed the client's interaction with others. The nurse must be able to accept the client as an individual
but need not accept unhealthy or inappropriate behaviors. The nurse should work with the client to better
understand the cultural differences.

Question 90

The nurse wants to obtain a comprehensive medical history on a client. What is important for the
nurse to do?

Have a family member present

Ask the hardest questions first

document events and dates in a chronologic order

Ask the client about the family dynamics.

Correct. The answer is


document events and dates in a chronologic order
Explanation:
The correct answer is document events and dates in a chronologic order. It is important to create a comprehensive
picture of the medical history of the client. In order to do this, the nurse has to document the events in chronological
order.

Question 91

Which of the following signs and symptoms should the nurse expect to see in a client with
appendicitis?

Diarrhea.

High grade fever.

Weight gain.

Bulimia.

Incorrect. The answer is


Diarrhea.

Explanation:
Correct answer:
Diarrhea

Diarrhea may be present in appendicitis. Anorexia is also a clinical manifestation of appendicitis, so the incidence of
weight gain and the eating disorder bulimia are unlikely to occur. Further, in clients with appendicitis, a low grade
fever is more likely to develop as opposed to a high grade fever.

Question 92

What is the purpose of a diaphragmatic breathing exercise for a client with COPD?

Reduce inflammation.

Reduce the possibility of infection.

Dilate bronchioles.

Increase heart rate.

Incorrect. The answer is


Dilate bronchioles.

Explanation:
Correct answer:
Dilate bronchioles

In COPD, the bronchioles will constrict due to pressure changes. Exercise assists in keeping them open

Question 93

An 86-year-old female client fractured her hip after falling at home. Because of her morbid obesity and on-going
issues with diabetes, surgery isn’t an option. She tells the nurse she doesn’t know how she will recover.
Which response is best on the behalf of the nurse?

“What is your main concern right now?”

“Don’t worry, you’ll be better soon.”


“Can you go stay with a family member?”

“Would you like to see some brochures for a nursing home?”

Incorrect. The answer is


“What is your main concern right now?”

Explanation:
The correct answer is:
“What is your main concern right now?”

The client needs reassurance. By asking open-ended questions, her concerns can be addressed.

Question 94

Which of the following is an important assessment for an infant in sickle cell crisis?

The infant is drinking liquids as usual.

Normal skin turgor.

A temperature of 99 F.

Normal muscle tone.

Incorrect. The answer is


Normal skin turgor.

Explanation:
Correct answer:
Normal skin turgor

Normal skin turgor is used to assess if the infant is in sickle cell crisis. During sickle cell crisis, proper hydration
becomes an issue.

Question 95

You are preparing to care for a child with a diagnosis of intussusception. Upon review of the child's
record, you expect to note which symptom of this disorder documented?

Ribbon-like stools.

Bright red blood and mucus in the stools.

Profuse projectile vomiting.

Watery diarrhea.

Correct. The answer is

Bright red blood and mucus in the stools.

Explanation:
The Correct answer is:
Bright red blood and mucus in the stools.

Intussusception is a telescoping of one portion of the bowel into another. This condition results in an obstruction to
the passage of intestinal contents. A child with this condition will have severe abdominal pain. Ribbon-like stools
and watery diarrhea are not manifestations of this condition and vomiting may be present, but not projectile type.

Question 96

In which of the following stages of reaction toward stress does the body become "exhausted" because it did
not positively respond to the stress?

Exhaustion.

None of these.

Alarm.

Resistance.

Correct. The answer is


Exhaustion.

Explanation:
Correct answer:
Exhaustion

The body undergoes many physiological changes such as taking more air into the lungs in order to prepare for
fight or flight during the resistance stage. During the alarm stage, the body increase in hormone levels in order to
mobilize for a fight.

Question 97

The nurse correctly identifies a urine sample with a pH of 4.3 as being which type of solution?

Neutral.

Alkaline.

Acidic.

Basic.

Incorrect. The answer is


Acidic.

Explanation:
Correct answer:
Acidic

Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or
basic solution. A pH of 7.0 is considered neutral.

Question 98

Which of the following factors does NOT indicate a potential for suicide?

Impulsive behavior.

OCD.

Overwhelming feelings of guilt.

Chronic debilitating illness.


Incorrect. The answer is
OCD.

Explanation:
Correct answer:
OCD

An additional factor is the repression of anger. However, OCD is not an indication of suicidal ideation.

Question 99

Which of the following is true of cerebral spinal fluid?

Mediates between blood vessels and brain tissue in exchange of materials.

Is located outside of the ventricles.

Acts as a shock absorber or cushion.

Both A and C.

Correct. The answer is


Both A and C.

Explanation:
Correct answer:
Both A and C

Medically speaking, the cerebral spinal fluid is the clear bodily fluid that occupies the subarachnoid space and the
ventricular system around the inside of the brain. Simply put, it is the fluid that provides shock absorption for the
brain, the spinal cord and a thin, pliable layer of tissue covering surfaces or separating or connecting regions,
structures, or organs.

Question 100

A goal of the post-operative phase of abdominal surgery is to advance the diet as tolerated. The client
has thus far tolerated ice chips and clear liquids. What would be the next phase in the client’s diet?

Full liquids.

Anything the client wants.

Fruits and vegetables only.

Liquids with one meal of solids daily.

Correct. The answer is


Full liquids.

Explanation:
Correct answer:
Full liquids

The client should now progress to full liquids. Once these are tolerated well, bland solids can be added minimally.