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NCLEX NCLEX-RN Sample Question Answers

Question # 1

A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby’s condition. The nurse knows that the pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first? 

A. Call the orthopedist and request that he come to see the baby now.
B. Question the mother and find out what the pediatrician has told her about the baby’scondition.
C. Tell the mother that this is not a serious condition.
D. Tell the mother that this condition has been successfully treated with exercises, casts,and/or braces.

Question # 2

A client states to his nurse that “I was told by the doctor not to take one of my drugsbecause it seems to have caused decreasing blood cells.” Based on this information, whichdrug might the nurse expect to be discontinued?

A. Prednisone
B. Timolol maleate (Blocadren)
C. Garamycin (Gentamicin)
D. Phenytoin (Dilantin)

Question # 3

A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

A. Disorientation  
B. Low-grade fever  
C. Diarrhea  
D. Hypertension  

Question # 4

A 19-month-old child is admitted to the hospital for surgical repair of patent ductusarteriosus. The child is being given digoxin. Prior to administering the medication, the nurseshould:

A. Not give the digoxin if the pulse is_60
B. Not give the digoxin if the pulse is_100
C. Take the apical pulse for a full minute
D. Monitor for visual disturbances, a side effect of digoxin

Question # 5

During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

A. Putting all joints through full range-of-motion twice daily  
B. Massaging the joints briskly with lotion or liniment after bath  
C. Immobilizing the joints in functional position using splints, rolls, and pillows  
D. Applying warm water bottle or heating pads over involved joints  

Question # 6

A 4 year old has an imaginary playmate, which concerns the mother. The nurse’s bestresponse would be:

A. “I understand your concern and will assist you with a referral.”
B. “Try not to worry because you will just upset your child.”
C. “Just ignore the behavior and it should disappear by age 8.”
D. “This is appropriate behavior for a preschooler and should not be a concern.”

Question # 7

One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, “It’s really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.” The nurse’s best response would be: 

A. “That might be a problem. Tell me more about them.”  
B. “Risk factors can often be controlled by self-responsibility.”  
C. “It sounds like you’re intellectualizing your drinking problem.”  
D. “Your grandfather and father were both alcoholics?”  

Question # 8

The nurse writes the following nursing diagnosis for a client in acute renal failure—Impairedgas exchange related to:

A. Decreased red blood cell production
B. Increased levels of vitamin D
C. Increased red blood cell production
D. Decreased production of renin

Question # 9

Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

A. Urine output 22 mL/hr for 2 hours  
B. Serum potassium level of 3.7  
C. Small T wave of ECG  
D. Serum glucose level of 180  

Question # 10

A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She hasbeen admitted to the pediatric unit after surgical repair of the cleft lip. Which of the followingnursing interventions would be appropriate during the first 24 hours?

A. Position on side or abdomen.
B. Maintain elbow restraints in place unless she is being directly supervised.
C. Clean suture line every shift.
D. Offer pacifier when she cries.

Question # 11

The physician decides to prescribe both a short-acting insulin and an intermediate-actinginsulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulinis:

A. Novolin Regular
B. Humulin NPH
C. Lente Beef
D. Protamine zinc insulin

Question # 12

The nurse is admitting a client with folic acid deficiency anemia. Which of the followingquestions is most important for the nurse to ask the client?

A. “Do you take aspirin on a regular basis?”
B. “Do you drink alcohol on a regular basis?”
C. “Do you eat red meat?”
D. “Have your stools been normal?”

Question # 13

The most important goal in the care plan for a child who was hospitalized with anaccidental overdose would be to:

A. Determine child’s activity pattern
B. Reduce mother’s sense of guilt
C. Instruct parents in use of ipecac
D. Teach parents appropriate safety precautions

Question # 14

A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

A. Hematocrit, hemoglobin, and white blood cell (WBC) count  
B. Blood urea nitrogen, electrolytes, and creatinine  
C. Glucose, glucose tolerance test, and random blood sugar  
D. X-rays, electroencephalogram, and electrocardiogram (ECG) 

Question # 15

Which of the following physician’s orders would the nurse question on a client with chronicarterial insufficiency?

A. Neurovascular checks every 2 hours
B. Elevate legs on pillows
C. Arteriogram in the morning
D. No smoking

Question # 16

A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teachher to:

A. Limit activities which require focusing (close vision)
B. Take more frequent naps
C. Use artificial tears
D. Wear a patch over one eye

Question # 17

A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must: 

A. Tell the physician her concerns  
B. Report her suspicions to the authorities  
C. Talk to the child’s father  
D. Confront the child’s mother  

Question # 18

Which of the following nursing orders has the highest priority for a child with epiglottitis? 

A. Vital signs every shift  
B. Tracheostomy set at bedside  
C. Intake and output  
D. Specific gravity every shift  

Question # 19

A client delivered a stillborn male at term. An appropriate action of the nurse would be to: 

A. State, “You have an angel in heaven.”
B. Discourage the parents from seeing the baby.
C. Provide an opportunity for the parents to see and hold the baby for an undeterminedamount of time.
D. Reassure the parents that they can have other children.

Question # 20

In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to: 

A. Give vinegar, lemon juice, or orange juice  
B. Phone the doctor  
C. Take the child to the emergency room  
D. Induce vomiting  

Question # 21

A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

A. The client requests pain medicine every 4 hours.
B. He is asleep 30 minutes after receiving the IV morphine.
C. He asks for pain medication although his blood pressure and pulse rate are normal.
D. He is euphoric for about an hour after each injection.

Question # 22

The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

A. Using a water pik  
B. Rinsing with water  
C. Rinsing with hydrogen peroxide  
D. Rinsing with baking soda  

Question # 23

A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

A. Accepting her present body image
B. Verbalizing realistic feelings about her body
C. Having an improved perception of her body image
D. Exhibiting increased self-esteem

Question # 24

Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?

A. Nifedipine 10 mg SL for B/P 140/90
B. Furosemide 20 mg/PO for decreased urine output
C. Magnesium salicylate to decrease inflammation
D. Nitroglycerin gr 1/150 for chest pain

Question # 25

The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms: 

A. Fever, runny nose, and hyperactivity  
B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes  
C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness 
D. Fever, cough, paleness, and wheezing  

Question # 26

A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg pobid. Which of the following should be included in her discharge teaching concerning thewarfarin therapy?

A. “If you forget to take your morning dose, double the night time dose.”
B. “You should take aspirin instead of acetaminophen (Tylenol) for headaches.”
C. “Carry a medications alert card with you at all times.”
D. “You should use a straight-edge razor when shaving your arms and legs.”

Question # 27

Discharge teaching for the client who has a total gastrectomy should include which of thefollowing?

A. Need for the client to increase fluid intake to 3000 mL/day
B. Follow-up visits every 3 weeks for the first 6 months
C. B12 injections needed for the rest of the client’s life
D. Need to eat three full meals with plenty of fiber per day

Question # 28

A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate theeffectiveness of the warfarin therapy, the nurse must know that this medication:

A. Dissolves any clots already formed in the arteries
B. Prevents the conversion of prothrombin to thrombin
C. Interferes with the synthesis of vitamin K-dependent clotting factors
D. Stimulates the manufacturing of platelets

Question # 29

A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is: 

A. Having a heart attack
B. Wanting attention from the nurses
C. Suffering from complete upper airway obstruction
D. Hyperventilating

Question # 30

A 52-year-old female client is admitted to the hospital in acute renal failure. She has beenon hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the clientyielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mmHg. The nurse would interpret these results as:

A. Compensated metabolic alkalosis
B. Respiratory acidosis
C. Partially compensated metabolic alkalosis
D. Combined respiratory and metabolic acidosis

Question # 31

In discussing the plan of care for a child with chronic nephrosis with the mother, the nurseidentifies that the purpose of weighing the child is to:

A. Measure adequacy of nutritional management
B. Check the accuracy of the fluid intake record
C. Impress the child with the importance of eating well
D. Determine changes in the amount of edema

Question # 32

A child with celiac disease is being discharged from the hospital. The mother demonstratesknowledge of nutritional needs of her child when she is able to state the foods which areincluded in a:

A. Lactose-restricted diet
B. Gluten-restricted diet
C. Phenylalanine-restricted diet
D. Fat-restricted diet

Question # 33

Four days after admission for cirrhosis of the liver, the nurse observes the following whenassessing a male client: increased irritability, asterixis, and changes in his speech pattern.Which of the following foods would be appropriate for his bedtime snack?

A. Fresh fruit
B. A milkshake
C. Saltine crackers and peanut butter
D. A ham and cheese sandwich

Question # 34

Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20years old. It is characterized by an absence of, or marked decrease in, circulating insulin.When teaching a newly diagnosed diabetes client, the nurse includes information on thefunctions of insulin:

A. Transport of glucose into body cells and storage of glycogen in the liver
B. Glycogenolysis and facilitation of glucose use for energy
C. Glycogenolysis and catabolism
D. Catabolism and hyperglycemia

Question # 35

The nurse assesses a postoperative mastectomy client and notes that breath sounds arediminished in both posterior bases. The nurse’s action should be to:

A. Encourage coughing and deep breathing each hour
B. Obtain arterial blood gases
C. Increase O2 from 2–3 L/min
D. Remove the postoperative dressing to check for bleeding

Question # 36

The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

A. The client is more likely to remember to perform the TSE when in the nude  
B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky 
C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate 
D. The examination will be less painful at this time  

Question # 37

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

A. Administering diazepam (Valium) 10–15 mg po q4h and q1h prn for hyperventilating episode 
B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation 
C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
D. Using distraction to help control the client’s hyperventilation episodes  

Question # 38

A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent: 

A. Infection postoperatively  
B. Malignant hyperthermia  
C. Neuroleptic malignant syndrome  
D. Fever postoperatively  

Question # 39

A 27-year-old male client is admitted to the acute care mental health unit for observation.He has recently lost his job, and his wife told him yesterday that she wants a divorce. Theclient is placed on suicide precautions. In assessing suicide potential, the nurse should payclose attention to the client’s:

A. Level of insight
B. Thought processes
C. Mood and affect
D. Abstracting abilities

Question # 40

A 38-year-old female client with a history of chronic schizophrenia, paranoid type, iscurrently an outpatient at the local mental health and mental retardation clinic. The clientcomes in once a week for medication evaluation and/or refills. She self-administershaloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit,she says to the nurse, “I can’t stay still at night. I toss and turn and can’t fall asleep.” Thenurse suspects that she may be experiencing:

A. Akathisia
B. Akinesia
C. Dystonia
D. Opisthotonos

Question # 41

Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:  

A. Otitis media
B. Asthma
C. Conjunctivitis
D. Tonsillitis

Question # 42

Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should: 

A. Check airway, feeling for amount of air exchange noting rate, depth, and quality ofrespirations
B. Obtain pulse and blood pressure readings noting rate and quality of pulse
C. Reassure the client that his surgery is over and that he is in the recovery room
D. Review physician’s orders, administering medications as ordered

Question # 43

A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?

A. Increase your oral intake of fluids to at least 4000 mL every day.  
B. Avoid contact with people who have contagious illnesses.  
C. Brush your teeth at least 4 times a day with a firm toothbrush.  
D. Immediately stop taking the prednisone if you feel depressed.  

Question # 44

The parents of a 9-year-old child with acute lymphocytic leukemia expressed concernabout his alopecia from cranial irradiation. The nurse explains that:

A. Alopecia is an unavoidable side effect.
B. There are several wig makers for children.
C. Most children select a favorite hat to protect their heads.
D. His hair will grow back in a few months.

Question # 45

Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:

A. Remove the potassium from the body by renin exchange  
B. Protect the myocardium from the effects of hypokalemia  
C. Promote rapid protein catabolism  
D. Drive potassium from the serum back into the cells  

Question # 46

The nurse notes multiple bruises on the arms and legs of a newly admitted client withlupus. The client states, “I get them whenever I bump into anything.” The nurse wouldexpect to note a decrease in which of the following laboratory tests?

A. Number of platelets
B. WBC count
C. Hemoglobin level
D. Number of lymphocytes

Question # 47

Three hours postoperatively, a 27-year-old client complains of right leg pain after kneereduction. The first action by the nurse will be to:

A. Assess vital signs
B. Elevate the extremity
C. Perform a lower extremity neurovascular check
D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him onits use

Question # 48

A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion: 

A. The risks of exposure of the visitor to infectious organisms is great.
B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes.
C. The client is at extreme risk of acquiring infections.
D. Adherence to the guidelines are the latest Centers for Disease Control and Preventionrecommendations on use of protective apparel.

Question # 49

A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to: 

A. Provide cathartic action within the colon
B. Reduce the risk of wound infection from anaerobic bacteria
C. Relieve the client’s concern regarding possible infection
D. Reduce the risk of intraoperative fever

Question # 50

A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include: 

A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position 
B. Administering analgesics as ordered  
C. Having the child turn, cough, and deep breathe every 1–2 hours  
D. Remaining with the child and keeping as calm and quiet as possible  

Question # 51

During discharge planning, parents of a child with rheumatic fever should be able to identifywhich of the following as toxic symptoms of sodium salicylate?

A. Tinnitus and nausea
B. Dermatitis and blurred vision
C. Unconsciousness and acetone odor of the breath
D. Chills and an elevation of temperature

Question # 52

A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a “Trendelenburg gait.” This gait is characteristic of: 

A. Scoliosis  
B. Dislocated hip  
C. Fractured femur  
D. Fractured pelvis  

Question # 53

A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include: 

A. Establishing routine tasks and activities around mealtimes  
B. Administering medications such as lithium  
C. Requiring the client to eat more during meals  
D. Checking the client’s room frequently  

Question # 54

A client reports to the nurse that the voices are practically nonstop and that he needs toleave the hospital immediately to find his girlfriend and kill her. The best verbal response tothe client by the nurse at this time is:

A. “I understand that the voices are real to you, but I want you to know I don’t hear them.They are a symptom of your illness.”
B. “Just don’t pay attention to the voices. They’ll go away after some medication.”
C. “You can’t leave here. This unit is locked and the doctor has not ordered yourdischarge.”
D. “We will have to put you in seclusion and restraints for a while. You could hurt someonewith thoughts like that.”

Question # 55

When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash? 

A. Small round or oval reddish brown macules scattered over the entire body
B. Scattered clusters of macules, papules, and vesicles over the body
C. Bright red appearance of the palmar surface of the hands
D. Reddened butterfly shaped rash over the cheeks and nose

Question # 56

A client with a head injury asks why he cannot have something for his headache. Thenurse’s response is based on the understanding that analgesics could:

A. Counteract the effects of antibiotics
B. Elevate the blood pressure
C. Mask symptoms of increasing intracranial pressure
D. Stimulate the central nervous system

Question # 57

The nurse enters the room of a client on which a “do not resuscitate” order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, “please save her!” The nurse’s action would be:

A. Call the physician and inform him that the client has expired.  
B. Remind the husband that the physician wrote an order not to resuscitate.  
C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts. 
D. Call a code and proceed with cardiopulmonary resuscitation.  

Question # 58

To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby’smother to:

A. Avoid touching the baby while in the room.
B. Stay outside of the baby’s room.
C. Wear a gown and gloves and wash her hands before and after leaving the room.
D. Wear a mask while in the room.

Question # 59

A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

A. “When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.” 
B. “If I have any side effects from my medicines, I will take an extra dose of Cogentin.”  
C. “When I get home, I should be able to taper myself off the Haldol because the voices are gone now.” 
D. “As soon as I leave here, I’m throwing away my medicines. I never thought I needed them anyway.” 

Question # 60

The nurse is collecting a nutritional history on a 28- year-old female client with irondeficiency anemia and learns that the client likes to eat white chalk. When implementing ateaching plan, the nurse should explain that this practice:

A. Will bind calcium and therefore interfere with its metabolism
B. Will cause more premenstrual cramping
C. Interferes with iron absorption because the iron precipitates as an insoluble substance 
D. Causes competition at iron-receptor sites between iron and vitamin B1

Question # 61

The physician orders medication for a client’s unpleasant side effects from the haloperidol.The most appropriate drug at this time is:

A. Lorazepam
B. Triazolam (Halcion)
C. Benztropine
D. Thiothixene

Question # 62

During the assessment, the nurse observes a client scratching his skin. He has beenadmitted to rule out Laennec’s cirrhosis of the liver. The nurse knows the pruritus is directlyrelated to:

A. A loss of phagocytic activity
B. Faulty processing of bilirubin
C. Enhanced detoxification of drugs
D. The formation of collateral circulation

Question # 63

The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?

A. Serum electrolytes  
B. Arterial blood gases  
C. Complete blood count  
D. 12-Lead ECG  

Question # 64

A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

A. Dims the lights in her room  
B. Encourages her to breathe slowly and deeply  
C. Offers sips of warm liquids  
D. Places a large, soft pillow under her head

Question # 65

A client develops complications following a hysterectomy. Blood cultures revealPseudomonas aeruginosa. The nurse expects that the physician would order anappropriate antibiotic to treat P. aeruginosa such as:

A. Cefoperazone (Cefobid)
B. Clindamycin (Cleocin)
C. Dicloxacillin (Dycill)
D. Erythromycin (Erythrocin)

Question # 66

A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

A. Orally in the morning and at bedtime  
B. Only one time during the day as long as it is always at the same time of day  
C. Rectally at bedtime  
D. As soon as she awakens, prior to any activity  

Question # 67

A 23-year-old male client is admitted to the chemical dependency unit with a medicaldiagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and thatnow he is starting to “feel kind of shaky.” Based on the information given above, nursingcare goals for this client will initially focus on:

A. Self-concept problems
B. Interpersonal issues
C. Ineffective coping skills
D. Physiological stabilization

Question # 68

A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

A. Weigh the child twice daily on the same scale.  
B. Monitor intake and output.  
C. Check urine specific gravity of each voiding.  
D. Observe for edema.Answer: A Explanation:  

Question # 69

A 44-year-old client had an emergency cholecystectomy 3 days ago for a rupturedgallbladder. She complains of severe abdominal pain. Assessment reveals abdominalrigidity and distention, increased temperature, and tachycardia. Diagnostic testing revealsan elevated WBC count. The nurse suspects that the client has developed:

A. Gastritis
B. Evisceration
C. Peritonitis
D. Pulmonary embolism

Question # 70

The mother of a preschooler reports to the nurse that he frequently tells lies. The admissionassessment of the child indicates possible child abuse. The nurse knows that his:

A. Behavior is not normal, and a child psychiatrist should be consulted.
B. Mother is lying to protect herself.
C. Lying is normal behavior for a preschool child who is learning to separate fantasy fromreality.
D. Behavior indicates a developmental delay, because preschoolers should be able to tellright from wrong.

Question # 71

A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to “Irrigate NG tube with sterile saline q1h and prn.” The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

A. Water will deplete electrolytes resulting in metabolic acidosis.  
B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.  
C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period. 
D. Saline will increase peristalsis in the bowel.  

Question # 72

A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

A. A productive cough  
B. Expiratory stridor  
C. Drooling  
D. Crackles in the lower lobes  

Question # 73

The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

A. Pedal pulses 11 (weak)  
B. Twenty-four-hour intake 1000 mL/day for past 2 days  
C. Serum potassium 3.3  
D. Pulse rate 150 bpm  

Question # 74

Two hours after the second injection of haloperidol, a client complains to the nurse of a stiffneck and inability to sit still. He is experiencing symptoms consistent with:

A. Parkinsonism and dystonia
B. Dystonia and akathisia
C. Akathisia and parkinsonism
D. Neuroleptic malignant syndrome

Question # 75

A 35-year-old client is receiving psychopharmacological treatment of his major depressionwith tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurseteaches the client that while he is taking this type of antidepressant, he needs to restrict hisdietary intake of:

A. Potassium-rich foods
B. Tryptophan
C. Tyramine
D. Saturated fats

Question # 76

A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

A. Thioridazine (Mellaril), lithium, and benztropine  
B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)  
C. Sodium, potassium, and magnesium  
D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)  

Question # 77

Nursing assessment of early evidence of septic shock in children at risk includes: 

A. Fever, tachycardia, and tachypnea
B. Respiratory distress, cold skin, and pale extremities
C. Elevated blood pressure, hyperventilation, and thready pulses
D. Normal pulses, hypotension, and oliguria

Question # 78

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: 

A. Inspiration is longer than expiration  
B. Breath sounds are high pitched  
C. Breath sounds are slightly muffled  
D. Inspiration and expiration are equal  

Question # 79

When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

A. Open discussion and understanding
B. Play-acting out feelings in different roles
C. Storytelling
D. Drawing pictures

Question # 80

A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing: 

A. Grandiose delusions  
B. Paranoid delusions  
C. Auditory hallucinations  
D. Visual hallucinations  

Question # 81

A family by court order undergoes treatment by a family therapist for child abuse. Thenurse, who is the child’s case manager knows that treatment has been effective when:

A. The child is removed from the home and placed in foster care
B. The child’s parents identify the ways in which he is different from the rest of the family
C. The child’s father is arrested for child abuse
D. The child’s parents can identify appropriate behaviors for children in his age group 

Question # 82

Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually: 

A. Subsides in<3 weeks  
B. Is relieved by aspirin  
C. Is responsive to ibuprofen (Motrin)  
D. Subsides in 3–6 days  

Question # 83

The initial focus when providing nursing care for a child with rheumatic fever during theacute phase of the illness should be to:

A. Maintain contact with her parents
B. Provide for physical and psychological rest
C. Provide a nutritious diet
D. Maintain her interest in school

Question # 84

A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis—Alteration in comfort, pain related to: 

A. Increased excretion of lactic acid due to myocardial hypoxia
B. Increased blood flow through the coronary arteries
C. Decreased stimulation of the sympathetic nervous system
D. Decreased secretion of catecholamines secondary to anxiety

Question # 85

The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1–2 hours if needed. The most likely rationale for this order is: 

A. The client will settle down more quickly if he thinks the staff is medicating him
B. The medication will sedate the client until the physician arrives
C. Haloperidol is a minor tranquilizer and will not oversedate the client
D. Rapid neuroleptization is the most effective approach to care for the violent or potentiallyviolent client

Question # 86

Loss of appetite for a child with leukemia is a major recurrent problem. The plan of careshould be designed to:

A. Reinforce attempts to eat
B. Help the child gain weight
C. Increase his appetite
D. Make mealtimes pleasant

Question # 87

A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

A. Altered nutrition: less than body requirements related to inability to take in adequate calories 
B. Altered growth and development related to decreased intake of food  
C. Activity intolerance related to imbalance between oxygen supply and demand  
D. Decreased cardiac output related to ineffective pumping action of the heart  

Question # 88

A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?

A. 0.06 mL
B. 0.38 mL
C. 2.7 mL
D. Information given insufficient to determine the amount of atropine to be administered

Question # 89

A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?

A. Cantaloupe  
B. Rice  
C. Chicken  
D. Green beans  

Question # 90

When preparing insulin for IV administration, the nurse identifies which kind of insulin touse?

B. Human or pork
C. Regular
D. Long acting

Question # 91

The nurse is in the hallway and one of the visitors faints. The nurse should: 

A. Sit the victim up and lightly slap his face  
B. Elevate the victim’s legs  
C. Apply a cool cloth to the victim’s neck and forehead until he recovers  
D. Sit the victim up and place the head between the knees  

Question # 92

A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?

A. Place him on NPO restriction for 4 hours.  
B. Monitor the catheterization site every 15 minutes.  
C. Place him in a high Fowler position.  
D. Ambulate him to the bathroom to void.  

Question # 93

A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery:

A. Has a smaller postoperative infection rate than routine surgery  
B. Will eliminate the need for preoperative sedation  
C. Will result in less operating time  
D. Generally eliminates problems with complications  

Question # 94

In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis: 

A. Becomes progressively debilitating without remission  
B. Has unpredictable remissions and exacerbations  
C. Is rapidly fatal  
D. Responds quickly to antimicrobial therapy  

Question # 95

A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:

A. “You should ask your doctor about this.”  
B. “Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin.” 
C. “No, do not increase your insulin. Exercise will not affect your insulin needs.”  
D. “No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells.” 

Question # 96

The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client’s chief complaint? 

A. “I’ve been having a dull pain at the upper left shoulder.”
B. “My legs have been numb for three months.”
C. “I’ve only been urinating three times a day lately.”
D. “I don’t remember anything in particular, I just haven’t felt well.”

Question # 97

On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking “the blue pill” (haloperidol) in the morning and evening, and “the white pill” (benztropine) right before bedtime. The nurse might suggest to the client that she try: 

A. Doubling the daily dose of benztropine  
B. Decreasing the haloperidol dosage for a few days  
C. Taking the benztropine in the morning  
D. Taking her medication with food or milk  

Question # 98

Which of the following nursing care goals has the highest priority for a child withepiglottitis?

A. Sleep or lie quietly 10 hr/day.
B. Consume foods from all four food groups.
C. Be afebrile throughout her hospital stay.
D. Participate in play activities 4 hr/day.

Question # 99

A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

A. Sensory-perceptual alteration: auditory command hallucinations  
B. Alteration in thought processes: paranoid delusions  
C. Potential for violence directed at others  
D. Impaired verbal communication: loose associations  

Question # 100

The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?  

A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypomagnesemia

Question # 101

On the third postpartum day, the nurse would expect the lochia to be: 

A. Rubra
B. Serosa
C. Alba
D. Scant

Question # 102

The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:  

A. Dandelion leaves
B. Pencils
C. Old paint
D. Stuffing from toy animals

Question # 103

A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U ofregular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon.What time should he expect the greatest risk for hypoglycemia?

A. 9 AM
B. 1 PM
C. 11 AM
D. 3 PM

Question # 104

A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse’s first action when admitting the client will be to: 

A. Obtain vital signs  
B. Connect the client to the cardiac monitor  
C. Ask the client if he is still having chest pain  
D. Complete the history profile  

Question # 105

One of the most reliable assessment tools for adequacy of fluid resuscitation in burnedchildren is:

A. Blood pressure
B. Level of consciousness
C. Skin turgor
D. Fluid intake

Question # 106

A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has splitthickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24–48 hours postburn?

A. Pain related to tissue damage from burns  
B. Potential for infection related to contamination of wounds  
C. Fluid volume deficit related to increased capillary permeability  
D. Potential for impaired gas exchange related to edema of respiratory tract  

Question # 107

A 35-year-old client has returned to her room following surgery on her right femur. She hasan IV of D5 in one-half normal saline infusing at 125 mL/hr and is receiving morphine sulfate10–15 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given herpreoperative medication. In monitoring and promoting return of urinary function aftersurgery, the nurse would:

A. Provide food and fluids at the client’s request
B. Maintain IV, increasing the rate hourly until the client voids
C. Report to the surgeon if the client is unable to void within 8 hours of surgery
D. Hold morphine sulfate injections for pain until the client voids, explaining to her thatmorphine sulfate can cause urinary retention

Question # 108

Four days after admission for cirrhosis of the liver, the nurse observes the following whenassessing a male client: increased irritability, asterixis, and changes in his speech pattern.Which of the following foods would be appropriate for his bedtime snack?

A. Fresh fruit
B. A milkshake
C. Saltine crackers and peanut butter
D. A ham and cheese sandwich

Question # 109

A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most effective response would be:

A. “How can you say that I don’t care? We just met.”
B. “What makes you think the nurses don’t care?”
C. “You will feel differently about us in a few days.”
D. “You seem angry. Tell me more about how you feel.”

Question # 110

Which stage of labor lasts from delivery of the baby to delivery of the placenta?

A. Second
B. Third
C. Fourth
D. Fifth

Question # 111

A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure? 

A. Validate that he is not allergic to iodine or shellfish.  
B. Instruct him to start active range of motion of his left leg immediately following the procedure
C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.  
D. Inform him that vital signs will be taken every hour for 4 hours after the procedure. 

Question # 112

Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in theemergency room with severe chest pain. The nurse administering the morphine sulfateknows which of the following therapeutic actions is related to the morphine sulfate?

A. Increased level of consciousness
B. Increased rate and depth of respirations
C. Increased peripheral vasodilation
D. Increased perception of pain

Question # 113

A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: 

A. Notify the physician immediately
B. Hold the morning lithium dose and continue to observe the client
C. Administer the morning lithium dose as scheduled
D. Obtain an order for benztropine (Cogentin)

Question # 114

The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:

A. Discussing their needs with the nursing staff
B. Discussing their needs with other family members
C. Seeking support from their minister
D. Refusing to participate in the child’s care

Question # 115

The family member of a child scheduled for heart surgery states, “I just don’t understand this open-heart or closed-heart business. I’m so confused! Can you help me understand it?” The nurse explains that patent ductus arteriosus repair is: 

A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed. 
B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery. 
D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery. 

Question # 116

The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:

A. Fewer alveoli, slower respiratory rate
B. Diaphragmatic breathing, larger volume of air
C. Larger number of alveoli, diaphragmatic breathing
D. Rounded shape of chest, smaller volume of air

Question # 117

The nurse will be alert to the most potentially lifethreatening side effect associated with theadministration of monoamine oxidase (MAO) inhibitor. This is:

A. Oculogyric crisis
B. Hypertensive crisis
C. Orthostatic hypotension
D. Tardive dyskinesia

Question # 118

When assessing a female child for Turner’s syndrome, the nurse observes for which of the following symptoms?

A. Tall stature  
B. Amenorrhea  
C. Secondary sex characteristics  
D. Gynecomastia  

Question # 119

Goal setting for a client with Meniere’s disease should include which of the following?

A. Frequent ambulation
B. Prevention of a fall injury
C. Consumption of three meals per day
D. Prevention of infection

Question # 120

A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that: 

A. The test is inconclusive and should be repeated  
B. Further testing is needed  
C. The test is normal and the fetus is reacting appropriately  
D. The fetus is distressed  

Question # 121

Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication? 

A. “I would notify my physician immediately if I experience nausea, vomiting, and doublevision.”
B. “I could stop taking this medication when I begin to feel better.”
C. “I should only take the medication if my heart rate is greater than 100 bpm.”
D. “I should always take this medication with an antacid.”

Question # 122

A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, “Nobody in here seems to really care about the clients. I thought nurses cared about people!” The client is exhibiting the ego defense mechanism:

A. Reaction formation
B. Rationalization
C. Splitting
D. Sublimation

Question # 123

Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: 

A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease

Question # 124

A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. Itis important for the nurse to find out if he has a(n):

A. Allergy to seafood
B. History of seizures
C. Movable metal implant
D. Pin or screw in any bone

Question # 125

Often children are monitored with pulse oximeter. The pulse oximeter measures the:  

A. O2 content of the blood
B. Oxygen saturation of arterial blood
C. PO2
D. Affinity of hemoglobin for O2

Question # 126

An 18-month-old child has been playing in the garage. His mother brings him to a nurse’shome complaining of his mouth being sore. His lips and mouth are soapy and white, withsmall ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid andweak. The nurse suspects that the child has:

A. Inhaled gasoline fumes
B. Ingested a caustic alkali
C. Eaten construction chalk
D. Lead poisoning

Question # 127

The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly—High risk for injury: Increased susceptibility to bleeding related to:

A. Increased absorption of vitamin K  
B. Thrombocytopenia due to hypersplenism  
C. Diminished function of the Kupffer cells  
D. Increased synthesis of the clotting factors  

Question # 128

An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain inhis left leg that started approximately 20 minutes ago. When performing the admissionassessment, the nurse would expect to observe which of the following:

A. Both lower extremities warm to touch with 2_pedal pulses
B. Both lower extremities cyanotic when placed in a dependent position
C. Decreased or absent pedal pulse in the left leg
D. The left leg warmer to touch than the right leg

Question # 129

Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to: 

A. Report the findings to the physician  
B. Assist the client to do range of motion exercises  
C. Check the client’s potassium level  
D. Administer the as-needed dose of phenytoin (Dilantin)  

Question # 130

A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse isdoing preoperative teaching, the client says, “The anesthesiologist said she was going togive me balanced anesthesia. What exactly is that?” The best explanation for the nurse togive the client would be that balanced anesthesia:

A. Is a type of regional anesthesia
B. Uses equal amounts of inhalation agents and liquid agents
C. Does not depress the central nervous system
D. Is a combination of several anesthetic agents or drugs producing a smooth inductionand minimal complications

Question # 131

A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mgq6h via nasogastric tube. The rationale for this therapy is to:

A. Prevent systemic infection
B. Promote diuresis
C. Decrease ammonia formation
D. Acidify the small bowel

Question # 132

Which of the following lab data is representative of a client with aplastic anemia? 

A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000

Question # 133

A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4” and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to: 

A. Obtain an accurate weight
B. Search the client’s purse for pills
C. Assess vital signs
D. Assign her to a room with someone her own age

Question # 134

The nurse assesses a client’s monitor strip and finds the following: uterine contractions every 3–4 minutes, lasting 60–70 seconds; FHR baseline 134–146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate? 

A. Notify physician of nonreassuring FHR pattern.
B. Turn the client to her left side.
C. Start IV for fetal distress and administer O2 at 6–8 liters by mask.
D. Evaluate to see if the monitor strip is reassuring.

Question # 135

A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn: 

A. Mild hypotonia is expected in the upper extremities.  
B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction. 
C. Function progresses in a head-to-toe, proximal-distal fashion.  
D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system. 

Question # 136

The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of the following statements? 

A. “Sometimes these symptoms are caused by an overstimulation of a chemical calleddopamine in the brain.”
B. “Has anyone in your family ever had schizophrenia?”
C. “If your son has a twin, he probably will eventually develop schizophrenia, too.”
D. “Some of his symptoms may be a result of his lack of a strong mother-child bondingrelationship.”

Question # 137

A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, “Isn’t that a lot?” The nurse’s best response is: 

A. “Yes, that does seem like a lot.”
B. “You’ll have to talk to the doctor about that. The physician knows what’s best for theclient.”
C. “Six to 10 treatments are common. Are you concerned about permanent effects?”
D. “Don’t worry. Some clients have lots more than that.”

Question # 138

Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose “just 5 more lb.” Her symptoms are consistent with:

A. Pregnancy  
B. Bulimia  
C. Gastritis  
D. Anorexia nervosa  

Question # 139

A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepaticcoma. Which of the following is an early sign of impending hepatic coma?

A. Hiccups
B. Anorexia
C. Mental confusion
D. Fetor hepaticus

Question # 140

The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client’s diet? 

A. Cream cheese  
B. Fresh fruits  
C. Aged cheese  
D. Yeast bread  

Question # 141

A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm andis at 0 station with the fetus in a right occipitoposterior position. She is complaining ofsevere backache with each contraction. One comfort measure the nurse can employ is to:

A. Place her in knee-chest position during the contraction
B. Use effleurage during the contraction
C. Apply strong sacral pressure during the contraction
D. Have her push with each contraction

Question # 142

Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when: 

A. The physician orders it
B. A therapeutic alliance has been established, and violent behavior subsides
C. The violent behavior subsides, and the client agrees to behave
D. The nurse deems that removal of restraints is necessary

Question # 143

A family is experiencing changes in their lifestyle in many ways. The invalid grandmotherhas moved in with them. The couple have a 2-year-old son by their marriage, and the wifehas two children by her previous marriage. The older children are in high school. Inapplying systems theory to this family, it is important for the nurse to remember which ofthe following principles?

A. The parts of a system are only minimally related.
B. Dysfunction in one part affects every other part.
C. A family system has no boundaries.
D. Healthy families are enmeshed.

Question # 144

A 14-year-old boy fell off his bike while “popping a wheelie” on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:

A. Ask the physician to order a sedative  
B. Have the client describe his headache every 15 minutes  
C. Increase his fluid intake to 3000 mL/24 hr  
D. Offer diversionary activities  

Question # 145

A client at 9 weeks’ gestation comes for an initial prenatal visit. On assessment, the nursediscovers this is her second pregnancy. Her first pregnancy resulted in a spontaneousabortion. She is 28 years old, in good health, and works full-time as an elementary schoolteacher. This information alerts the nurse to which of the following:

A. An increased risk in maternal adaptation to pregnancy
B. The need for anticipatory guidance regarding the pregnancy
C. The need for teaching regarding family planning
D. An increased risk for subsequent abortions

Question # 146

On admission to the postpartal unit, the nurse’s assessment identifies the client’s fundus tobe soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likelyan indication of:

A. Normal involution
B. A full bladder
C. An infection pain
D. A hemorrhage

Question # 147

A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of true labor?

A. Increased bloody show  
B. Progressive dilatation and effacement of the cervix  
C. Uterine contractions  
D. Decreased discomfort with ambulation  

Question # 148

In acute episodes of mania, lithium is effective in 1–2 weeks, but it may take up to 4 weeks,or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent isprescribed during the first few days or weeks of an acute episode to manage severebehavioral excitement and acute psychotic symptoms. In addition to the lithium, which oneof the following medications might the physician prescribe?

A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)

Question # 149

The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:

A. Call the doctor immediately  
B. Help her to blow her nose carefully  
C. Test the discharge for sugar  
D. Turn her to her side  

Question # 150

Degenerative disorders are attributed to many factors. As a nurse assigned to aconvalescent home, one must often educate families about how such conditions occur.Which of the following statements might the nurse need to explore when a daughter tries toexplain to her mother what caused her degenerative disorder?

A. “Some folks believe that aging causes this, Mother.”
B. “Perhaps, it’s the way your parents used those double- bind messages, Mother.”
C. “I know some people who are having this problem and they were exposed to chemicalsat work, Mother.”
D. “It can be caused by lots of things, toxic agents and even alcohol, Mother.”

Question # 151

Before giving methergine postpartum, the nurse should assess the client for: 

A. Decreased amount of lochial flow 
B. Elevated blood pressure 
C. Flushing 
D. Afterpains 

Question # 152

A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), amonoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at thistime?

A. High carbohydrate, low cholesterol
B. High protein, high carbohydrate
C. 1 g sodium
D. Tyramine-free

Question # 153

On morning rounds, the nurse found a manic-depressive client who is taking lithium in aconfused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which oneof the following nursing actions is essential at this time?

A. Administer her next dosage of lithium, and then call the physician.
B. Withhold her lithium, and report her symptoms to the physician.
C. Place her on NPO to decrease the excretion of lithium from her body, and call thephysician.
D. Contact the lab and request a lithium level in 30 minutes, and call the physician.

Question # 154

Due to his prolonged history of alcohol abuse, an alcoholic client will most likely havedeficiencies of which of the following nutrients?

A. Vitamin C and zinc
B. Folic acid and niacin
C. Vitamin A and biotin
D. Thiamine and pyroxidine

Question # 155

A 24-year-old woman who is gravida 1 reports, “I can’t take iron pills because they makeme sick.” She continues, “My bowels aren’t moving either.” In counseling her based onthese complaints, the nurse’s most appropriate response would be, “It would be beneficialfor you to eat . . .

A. prunes.”
B. green leafy vegetables.”
C. red meat.”
D. eggs.”

Question # 156

A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?

A. Always allow the most vocal person to state the problem first.
B. Encourage the mother to speak for the children.
C. Interpret immediately what seems to be going on within the family.
D. Allow family members to assume the seats as they choose.. 

Question # 157

A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. Thedoctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins herdaughter can have for fever. The nurse should:

A. Advise the mother not to give her aspirin
B. Ask if the client is allergic to aspirin before giving further information
C. Assess the function of the client’s cranial nerve VIII
D. Check the aspirin bottle label to determine milligrams per tablet

Question # 158

A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?

A. High fever, tachycardia, stupor, renal failure  
B. Lip smacking, chewing, blinking, lateral jaw movements  
C. Photosensitivity, orthostatic hypotension, dry mouth  
D. Constipation, blurred vision, drowsiness  

Question # 159

The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig’s sign.The nurse expects her to react to discomfort if she:

A. Dorsiflexes her ankle
B. Flexes her spine
C. Plantiflexes her wrist
D. Turns her head to the side

Question # 160

A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

A. Assess level of consciousness  
B. Assess suicide potential  
C. Observe for sedation and hypotension  
D. Orient to her room and unit rules  

Question # 161

Following TURP, which of the following instructions would be appropriate to prevent oralleviate anxiety concerning the client’s sexual functioning?

A. “You may resume sexual intercourse in 2 weeks.”
B. “Many men experience impotence following TURP.”
C. “A transurethral resection does not usually cause impotence.”
D. “Check with your doctor about resuming sexual activity.”

Question # 162

A client presented herself to the mental health center, describing the following symptoms: aweight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences fromwork due to “fatigue,” and not wanting to get dressed in the morning. She leaves herrecorded message on her telephone and has lost interest in answering the phone ordoorbell. The nurse’s assessment of her behavior would most likely be:

A. Deep depression
B. Psychotic depression
C. Severe anxiety
D. Severe depression

Question # 163

A client is a victim of domestic violence. She is now receiving assistance at a shelter forbattered women. She tells the nurse about the cycle of violence that she has beenexperiencing in her relationship with her husband of 5 years. In the “tension-buildingphase,” the nurse might expect the client to describe which of the following?

A. Promises of gifts that her husband made to her. 
B. Acute battering of the client, characterized by his volatile discharge of tension
C. Minor battering incidents, such as the throwing of food or dishes at her
D. A period of tenderness between the couple

Question # 164

On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to: 

A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes 
B. Allow the infant to breast-feed at the next feeding time to empty the breasts  
C. Apply ice packs to the breasts and wear a supportive, well-fitting bra  
D. Take a warm shower and express milk from both breasts until empty  

Question # 165

A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is:

A. “You’ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment.” 
B. “Visitors are not allowed. We will telephone you to inform you of her progress.”  
C. “There’s really no need to stay with her. She’s going to sleep for several hours after the treatment.” 
D. “Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.”  

Question # 166

A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is:

A. “You’ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment.” 
B. “Visitors are not allowed. We will telephone you to inform you of her progress.”  
C. “There’s really no need to stay with her. She’s going to sleep for several hours after the treatment.” 
D. “Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.”  

Question # 167

In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?

A. Backache
B. Leaking of clear yellow fluid from breasts
C. Constipation with hemorrhoids
D. Visual changes

Question # 168

A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct? 

A. “It sounds as though you are coming down with a bad cold. I’ll ask the doctor to prescribe a decongestant for relief of symptoms.” 
B. “A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.” 
C. “These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.” 
D. “This is most unusual. I’m sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.” 

Question # 169

A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:

A. Allow her privacy at mealtimes  
B. Praise her for eating everything  
C. Observe behavior for 1–2 hours after meals to prevent vomiting  
D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes 

Question # 170

A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, “Why did this happen to my baby?” is: 

A. “It’s God’s will. It was probably for the best. There was something probably wrong withyour baby.”
B. “You’re young. You can have other children later.”
C. “I know your other children will be a great comfort to you.”
D. “I can see you’re upset. Would you like to see and hold your baby?”

Question # 171

A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:

A. “I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group.”
B. “I know that I can only drink one or two drinks at social gatherings in the future, but at least I don’t have to continue AA.” 
C. “I really wasn’t addicted to alcohol when I came here, I just needed some help dealing with my divorce.”
D. “It really wasn’t my fault that I had to come here. If my wife hadn’t left, I wouldn’t have needed those drinks.” 

Question # 172

A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:

A. “I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group.”
B. “I know that I can only drink one or two drinks at social gatherings in the future, but at least I don’t have to continue AA.” 
C. “I really wasn’t addicted to alcohol when I came here, I just needed some help dealing with my divorce.”
D. “It really wasn’t my fault that I had to come here. If my wife hadn’t left, I wouldn’t have needed those drinks.” 

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