1. A client is admitted with Wernicke's encephaiopathy. The nurse anticipates that the first physician's order will include:
a. Ordering an MRI
b. Administering a steroid medication, such as Decadron
c. Giving thiamine 100 mg IM STAT
d. Ordering an EEG
2. Which of the following statements, if made by a four year old child whose brother just died of cancer, would be age-appropriate?
a. "I know i will never see my mother again."
b. "I'm glad my mother isn't crying anymore."
c. "I can't wait to go get pizza with my brother."
d. "i know where my brother is buried."
3. A patient who has AIzheimer's disease is told by the nurse to brush his teeth. He shouts angrily, "Tomato soup!" Which of the following actions by the nurse would be correct?
a. Focusing on the emotional reaction
b. Clarifying the meaning of his statement
c. Giving him step-by-step directions
d. Doing the procedure for him
4. A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid:
a. Exposure to the sun
b. Swimming in a chlorinated pool
c. Drinking fluids high in sodium
d. Eating foods such as chocolate and aged cheese
5. in caring for a psychotic patient who is experiencing hallucinations, which of the following interventions is considered critical?
a. Setting fewer limits in order to allow for more expressions of feeling
b. Maintaining constant observation.
c. Providing more frequent opportunities for interaction with others.
d. Constantly negating the patient's hallucinatory Ideations.
6. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks ago, his girlfriend broke off their engagement and cancelled the wedding. Given the Diagnosis and Statistical Manual of Mental Disorders, edition, text' revised (DSM-IV-TR) criteria for this disorder the nurse expects to find which of the following data during the interview with the client?
a. Current treatment for pneumonia
b. Regular use of alcohol and marijuana
c. Evidence of delusions and hallucinations
d. A history of chronic depression
7. A set of monozygotic twins who are 23 years old have begun attending groups at mental health center. One twin is diagnosed with schizophrenia. Her twin has no diagnoses but has been experiencing significant anxiety since becoming engaged. In counseling the engaged twin, it would be crucial to include which of the following tacts?
a. Her future children will be at risk for developing schizophrenia
b. She may have a predisposition for schizophrenia
c. One of her parents may develop schizophrenia later in life
d. It is unlikely that she wil! develop schizophrenia, at her age
8. A client tells the nurse that her co-workers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorders?
9. Which of the following types of behavior is expected from a client diagnosed with paranoid personality disorder?
10. A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. The nurse finding that which of the following values is elevated?
a. Hemoglobin F
b. Hemoglobin S
c. Hemoglobin C
d. Hemoglobin a
11. A parent with a daughter with bulimia nervosa asks a nurse, "How can my child have an eating disorder when she isn't underweight?" Which of the following responses is best?
a. "A person with bulimia nervosa can maintain a normal weight."
b. It's hard to face this type of problem in a person you love."
c. "At first there is no weight loss; it comes later In the disease."
d. "This is a serious problem even though there is no weight loss."
12. A nurse is assessing an adolescent girl recently diagnosed with an eating disorder and symptoms of bulimia nervosa. Which of the following findings is expected based on laboratory test results?
13. Which of the following complications of bulimia nervosa Is life threatening?
c. Electrolyte Imbalance
d. Yellow skin
14. A nurse is talking to a client with bulimia nervosa about the complications of Laxative abuse. Which of the foilowing complications should be included?
a. Loss of taste
b. Swollen glands
c. Dental problems
d. Malabsorption of nutrients
15. A nurse is assessing a client to determine the distress experienced after binge eating. Which of the following symptoms are typical after bingeing?
d. Sore throat
16. Which of the following difficulties are frequently found in families with a member who has bulimia nervosa?
a. Mental Illness
b. Multiple losses
c. Chronic anxiety
d. Substance abuse
17. A client with anorexia nervosa tells a nurse, "My parents never hug me or say I've done anything right." Which of the following Interventions is the best to use with this family?
a. Teach the family principles of assertive behavior.
b. Discuss the difficulties the family has in social situations.
c. Help the family convey a positive attitude toward the client.
d. Explore the family's ability to express affection appropriately.
18. A client with anorexia nervosa tells a nurse she always feels fat. Which of the following interventions is the best for this client?
a. Talk about how important the client is.
b. Encourage her to look at herself in a mirror.
c. Address the dynamics of the disorder.
d. Talk about how she's different from her peers.
Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an executive to the hospital director. She is alert, oriented and eager to return to her job as an executive assistant to the hospital director. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing, as well as the feeling of weakness that began this morning.
19. The most likely cause of her chief complaint this morning is
a. A decrease in postoperative stress causing poiyuria
b. The onset of diabetes mellitus, an unusual complication
c. An expected result of the removal of the pituitary gland
d. A frequent complication of the hypophysectomy
20. Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle
a. Abnormal distribution of body hair
b. Lifetime dependency on hormone replacement
c. The need to drink many fluids to replace those lost
d. The need to undergo repeat surgical procedures
21. The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
a. pupil size, response to pain, motor responses
b. Pupil size, verbal response, motor response
c. Eye opening, verbal response, motor response
d. Eye opening, response to pain, motor response
J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
22. The nurse will monitor J.E. for the following signs and symptoms:
a. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
b. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
c. Loss of consciousness, bradycardia, petechiae, and severe leg pain
d. Change in leve! of consciousness, bradycardia, chest pain and oliguria
23. Appropriate nursing interventions for J.E. would be
a. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
b. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
c. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
d. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices
Ms. J., a 34-year old white female, is admitted via the emergency room complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. Her glucose in ER 700 mg/dL. Regular insulin 30 U was given and a repeat glucose were drawn. Results were not avaiIable upon transfer to the unit.
24. Given the above Information, which nursing activities should be highest priority?
a. Monitoring vita i signs
b. Obtaining blood glucose results
c. Assessing neurological status
d. Assessing pedai pulses and feet
25. The nurse received the lab results from the biood sample drawn in ER. Her glucose is now-100. However, her WBC count is 25,000 mm3. What conclusion can the nurse draw basing on this information?
a. Lab results are within normal limits, no action Is necessary
b. Her diabetes is out of control
c. insulin administration increase WBC count
d. Infection has increased her insulin needs
26. Later that evening, Ms. J's abdominal pain increased in intensity. A diagnosis of appendicitis is made and Ms. J is scheduled for surgery in the morning. The physician has written the following orders:
-NPO after midnight
-At 6 AM start-ari iV of D5W to be'infused at 250 ml/hr
-15 U NPH insulin at 6AM
-Draw FBS prior to initiating iV fluids
The statement that best describe the rationale for these orders Is:
a. To provide calories to offset the patient being NPO
b. To prevent a hypoglycemic reaction
c. To prevent a fluid volume deficit
d. To assist with the body's response to stress
27. When ambulating a client following surgical removal of a protruded intervertebral lurnbar disc, the nurse would do which of the following?
a. Maintain proper body alignment
b. Administer anaigesia after walking
c. Provide a cane for support
d. Immobilize the head and neck
28. Which of the following point scores on the post anesthesia chart, indicates that the client has fulfilled minimal criteria for discharge from the PACU?
a. One point In each of the five areas .for a total score of 5.
b. One point in at least three areas" respiratory, circulatory, and consciousness - for a total of 3
c. A total score for the five areas of 7 or.above.
d. Two points each in each of the five areas for a total score of 10.
29. Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
a. "I think you should ask the doctor. Would you like me to cail him for you?"
b. " The blood supply to the brain has decreased causing permanent brain damage."
c. "It Is a temporary interruption in the blood flow to the brain."
d. "TIA means a transient ischemic attack."
30. While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
a. Wash the radiation site vigorously with soap and water to remove dead cells.
b. Eat a diet high in protein and calories to optimize tissue repair.
c. Apply coo! compresses to the radiation site to reduce edema,
d. Drink warm fluids throughout the day to relieve discomfort in swallowing.
31. A client using an over-the counter nasal decongestant spray reports unrelieved and worsening nasal congestion. The nurse should instruct the client to do which of the following?
a. Switch to a stronger dosage of the medication.
b. Discontinue the medication for a few weeks
c. Use the spray more frequently
d. Combine the spray with an oral decongestant.
32. Following a thyroidectomy, the client experiences.hemorrhage. The nurse would prepare for which of the following emergency Interventions?
a. intravenous administration of calcium
b. insertion of an oral airway
c. Creation of a tracheostomy
d. Intravenous administration of thyroid hormone
33. After a client signs the form, giving informed consent for surgery and the physician !eaves the room, the client asks the nurse, "When will this hotel bring me some food?" After confirming that the client is confused, which of the following would be the nurse's priority action?
a. Reporting that the consent has been obtained from a confused client.
b. Teaching preoperative moving, coughing, and deep-breathing,exercises.
c. Inserting a bladder catheter to urine output.
d. Administering preoperative medication immediately ,
34. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant patient. An ultrasound confirmed a hydatidiform molar pregnancy. Which of the following actions should the nurse tell the patient to expect during her one-year follow-up?
a. Multiple serum chorionic gonadotropin levels will be drawn
b. An Intrauterine device will be used to decrease vaginal bleeding
c. Pregnancy will be restricted for another year
d. Oral contraceptives will not be prescribed because they will increase the risk' of cancer
35. Thirty minutes after the nurse removes a nasogastric tube that has been In piace for seven days, the patient experiences epistaxis (nosebleed). Which of the following nursing actions is most appropriate to control the bleeding?
a. Apply pressure by pinching the anterior portion of the for five to ten minutes
b. Place the patient in a sitting position with the neck hyperextended
c. Pack the nostrils with gauze and keep the gauze in piace for four to five days
d. Apply ice compresses to the patient's forehead and back of the neck
36. The staff nurse calls a physician regarding an order to administer digoxin (Lanoxin) to a patient with a pulse of 55 and a serum potassium levei of 2.9 mEq/L The physician says to give the medication, as ordered .The staff nurse's best response would be
a. "I'll give the medication but you wiil still be responsbIe if anything happens to the patient."
b. "I will not give this medication."
c. '"I think we should discuss this with the nursing supervisor."
d. "I'm sorry, but if you want the medication given, you will have to give it yourself."
37. During the night, shift report, the charge nurse learns that an elderly patient has become very confused and is shouting obscenities and undressing himseif. Which of the following actions is the most appropriate Initial nursing response?
a. Restrain the patient with a Posey jacket
b. Medicate the patient with haloperidol (Haldol) as ordered.
c. Notify the physician
d. Complete a nursing assessment of the patient
38. When a woman is 10weeks pregnant which of the following hematology test results would need further Investigation?
a. Hemoglobin level of 9 mg/dL
b. white blood cell count of 15,000/cu mm
c. platelet count of 200,000/cu mm
d. red blood cell count of 4,200,000/ cu mm
39. Which of the foitowing techniques would a nurse use when interviewing a 94-year-old patient?
a. Using a low-pitched voice
b. Enunciating each word .slowly
c. Varying voice intonations
d. Reinforcing the words with pictures .
40. A patient who is receiving total parenteral nutrition has an elevated blood glucose eve! and is to be administered intravenous insulin. Which of the following types of insulin should a nurse has available?
a. Isophane insulin (NPH)
b. Regular insulin (Humulin R)
c. Insulin zinc suspension (Lente)
d. Semi-Lente Insulin (Semiterd)
41. A nurse is taking history from a patient who has just been admitted to the hospital withl an acute myocardia! infarction. Which of the following questions would be most important for the nurse to ask?
a. "At what time did the pain start?"
b. "When did you eat your last meal?"
c. "Have you experienced a pounding headache?"
d. "Did you feel fluttering in your chest"
42. An infant who weighs 11 lbs. is to receive 750 mg of an antibiotic in a 24-hour period. The liquid antibiotic comes in a concentration of 125 mg/5ml. If the antibiotic were to be given three times each day. how many ml would the nurse administer with each dose?
43. Spasm of the neck muscles developed in a patient who is taking phenothiazine (Nemazine). Which of the following medications should the nurse administer?
b. Acetaminophen (Tyienol)
c. Acetylsalicylic acid (Aspirin)
d. Benztropine mesyiate (Cogentin)
Mr. Anthony Malailinelii is a 54-year old truck driver. He is admitted for possible gastric ulcer, He is a heavy smoker.
44. When discussing his smoking habits with Mr. Martinelli. the nurse should advise him to:
a. Smoke low-tar, filter cigarettes
b. Smoke cigars instead
c. Smoke only right after meals
d. Chew gum Instead
45. As the nurse preparing Ivlr. Martinelii for gastric analysis. You should know which of the following Is not.correct concerning this test
a. The patient Is fasting 12 hours prior to test
b. Gastric contents are aspirated via a tube
c. Smoking for 8 hours prior to test is not allowed
d. Various position changes are necessary during the test
46. Mr. Martinelli had an Hgb of 9.8. You would not find which of the following assessments in a patient with severe anemia?
b. Cold sensitivity
d. Dyspnea only on exertion
47. When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
a. moist gurgling respirations
b. Weak, slow pulse
c. Distended neck veins
d. Dyspnea and coughing
48. A new staff nurse is on an orientation tour with the head nurse. A client approaches her and says, "I don't belong here. Please try to get me out." The staff nurse's best response would be:
a. "What would you do if you were out of the hospital?"
b. "I am a. new staff member, and I'm on a tour. I'll come back and talk with you
c. "I think you should talk to the head nurse about that.'
d. "I can't do anything about that."
49. A 50 year-old male client has a history of many hospitalizations for schizophrenic disorder. He has been on long-term phenothiazines (Thorazine), 400 mg/day. The nurse assessing this client observes that he demonstrates a shuffling gait, drooling and exhibits generaj dystonic symptoms.. From these symptoms and his history, the nurse concludes that the client has developed:
a. Tardive dyskinesia
50. A client with antisocial personality disorder tells a nurse "Life has been full of problems since childhood." Which of the following situations or conditions would the nurse explore in the assessment?
a. Birth defects
b. Distracted easily
c. Hypoactive behavior
d. Substance abuse
51. A client with antisocial personality disorder is trying to manipulate the healthcare team. Which of the following strategies is important for the staff to use?
a. Focus on how to teach the client more effective behaviors for meeting basic needs.
b. Help the client verbalize underlying feelings of hopelessness and learn coping skills.
c. Remain calm and don't emotionally respond to the client's manipulative actions.
d. Help the client eliminate the intense desire to have everything in life turn out perfectly.
52. A client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which of the following
outcomes will result from this change?
a. Fewer panic attacks
b. Acceptance of reality
c. Improved self-esteem
d. decreased physical symptoms
53. Which of the following discharge instructions would be most accurate to provide to a female client who has suffered a spinal cord injury at the C4 level?
a. After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant.
b. After a spinal cord injury, women usually are unable to conceive a child.
c. Sexual intercourse shouldn't be different for you.
d. After a spinal cord injury, menstruation usually stops.
54.A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband." Which of the following nursing interventions would be most appropriate?
a. Refer the couple to a sex therapist.
b. Advise the woman to seek a gynecologic consult
c. Suggest methods and measures that facilitate sexual activity.
d. Tell the client, "if you talk this over with your husband, he will understand.
55. A cllent tells the nurse she is having her menstrual period every 2 weeks and it lasts for 1 week. Which of the following conditions is best defined by this menstrual pattern?
56. A nurse has just been toSd by a. physician that an order has been written to administer an iron injection to an adult client. The nurse plans to administer the medication In which of the following locations?
a. In the gluteal muscle using Z-track technique
b. In the deltoid muscle using an air lock
c. In the subcutaneous fesue of the abdomen
d. in the anterior lateral thigh using a 5/8 inch needle '
57. A 59-year-old patient with a diagnosis of delirium is admitted to the hospital. To evaluate the cause of a patient's delirium, blood is sent to the laboratory for analysis. The results are as follows: M,a+ 1.56, Cr 100. K4' 4.0, C0221, BUN 86, glucose 100. Based on these laboratory result, the nurse should record which of the following nursing diagnoses on the patient's care. plan?
a. Alteration in patterns of urinary elimination.
b. Fluid volume deficit
c. Nutritional deficit: less than body requirements
d. Self-care deficit: feeding
58. The nurse knows that gender Is part of one's identity. Which of the following events signifies when gender is first ascribed?
a. A baby is born
b. A child attends school
c. A child receives sex-specific toys
d. A child receives sex-specific clothing
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