Question 1
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating
hormone (TSH) level. On initial assessment, the nurse should anticipate which of these
findings?
A. Lethargy
B. Diarrhea
C. Heat intolerance
D. Skin eruptions
CORRECT ANSWER
A
In hypothyroidism the metabolic activity of all cells of the body decreases, reducing
oxygen consumption, decreasing oxidation of nutrients for energy, and producing less
body heat. Therefore, the nurse can expect the client to report being constipated, tired
and unable to get warm.
Question 2
A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a
hyperactive Moro reflex and slight tremors. The newborn passed one loose, watery stool.
Which of these actions is a nursing priority?
A. Hold the infant at frequent intervals
B. Offer fluids to prevent dehydration
C. Administer paregoric to stop diarrhea
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@THE STUDY VAULT
,D. Assess for neonatal withdrawal syndrome
CORRECT ANSWER
D
Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the
infant from the opiates. The findings seen in methadone withdrawal are often more
severe than for other substances. Initial signs are central nervous system hyperirritability
and gastrointestinal symptoms. If withdrawal signs are severe, there is an increased
mortality risk. Scoring the infant ensures proper treatment during the periods of
withdrawal.
Question 3
Nurse colleagues are discussing their nursing practice during lunch. Which statement is
correct?
A. Each state has specific regulations for licensed registered nurses (RNs) and licensed
practical nurses (LPNs)
B. The employing agency is ultimately responsible to provide practice guidelines for licensed
nurses
C. The federal government ensures the safety of clients by defining the scope of nursing
practice
D. National nurses' associations work collaboratively to update the social policy statement
for nursing
CORRECT ANSWER
A
Boards of nursing are state governmental agencies that are responsible for licensing
nurses in each state/jurisdiction and enforcing the rules and regulations of the nurse
practice act (NPA). The NPA is enacted by the state legislature. The NPA and rules define
the scope of practice and responsibilities for nurses. The scope of practice for nurses,
especially LPN/VNs, varies from state to state.
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@THE STUDY VAULT
,Question 4
An infant who has recently been diagnosed with cystic fibrosis (CF) is being assessed by
the nurse. Which finding of this disease would the nurse not expect to see at this time?
A. Bulky, greasy stools
B. Positive sweat test
C. Moist, productive cough
D. Meconium ileus
CORRECT ANSWER
C
Moist and productive cough is a later sign in CF. Noisy respirations and a dry
nonproductive cough are commonly the first respiratory signs to appear in a newly
diagnosed client with CF. The other options are the earlier findings. CF is an inherited
(genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive
juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes
the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions
plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory
failure is the most dangerous consequence of CF.
Question 5
The nurse is caring for a client with orders for complete bed rest. Which action by the
nurse is most important in the prevention of the formation of deep vein thrombosis
(DVT)?
A. Prevent pressure at back of the knees
B. Elevate the foot of the bed
C. Encourage isometric leg muscle exercises
D. Apply knee high support stockings
CORRECT ANSWER
A
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@THE STUDY VAULT
, Prevention of popliteal pressure will minimize venous stasis and deep vein thrombosis.
The other actions would also be implemented for clients with orders for bed rest.
However, the correct option is the one action directly associated with DVT.
Question 6
The nurse is assessing a client with portal hypertension. Which findings should the nurse
expect during the assessment?
A. Expiratory wheezes
B. Blurred vision
C. Dilated pupils
D. Ascites
CORRECT ANSWER
D
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the
liver. Portal hypertension can lead to ascites from the increased portal pressure as well as
a lowered colloid osmotic pressure because of low albumin. When liver functioning
deteriorates, protein metabolism is decreased with the result of a low serum albumin.
Question 7
The nurse finds a client unconscious, following a tonic-clonic seizure. What should a nurse
do first?
A. Administer the ordered Ativan
B. Place the client in a side-lying position
C. Prepare for suctioning
D. Check the pulse
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@THE STUDY VAULT
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating
hormone (TSH) level. On initial assessment, the nurse should anticipate which of these
findings?
A. Lethargy
B. Diarrhea
C. Heat intolerance
D. Skin eruptions
CORRECT ANSWER
A
In hypothyroidism the metabolic activity of all cells of the body decreases, reducing
oxygen consumption, decreasing oxidation of nutrients for energy, and producing less
body heat. Therefore, the nurse can expect the client to report being constipated, tired
and unable to get warm.
Question 2
A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a
hyperactive Moro reflex and slight tremors. The newborn passed one loose, watery stool.
Which of these actions is a nursing priority?
A. Hold the infant at frequent intervals
B. Offer fluids to prevent dehydration
C. Administer paregoric to stop diarrhea
1
@THE STUDY VAULT
,D. Assess for neonatal withdrawal syndrome
CORRECT ANSWER
D
Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the
infant from the opiates. The findings seen in methadone withdrawal are often more
severe than for other substances. Initial signs are central nervous system hyperirritability
and gastrointestinal symptoms. If withdrawal signs are severe, there is an increased
mortality risk. Scoring the infant ensures proper treatment during the periods of
withdrawal.
Question 3
Nurse colleagues are discussing their nursing practice during lunch. Which statement is
correct?
A. Each state has specific regulations for licensed registered nurses (RNs) and licensed
practical nurses (LPNs)
B. The employing agency is ultimately responsible to provide practice guidelines for licensed
nurses
C. The federal government ensures the safety of clients by defining the scope of nursing
practice
D. National nurses' associations work collaboratively to update the social policy statement
for nursing
CORRECT ANSWER
A
Boards of nursing are state governmental agencies that are responsible for licensing
nurses in each state/jurisdiction and enforcing the rules and regulations of the nurse
practice act (NPA). The NPA is enacted by the state legislature. The NPA and rules define
the scope of practice and responsibilities for nurses. The scope of practice for nurses,
especially LPN/VNs, varies from state to state.
2
@THE STUDY VAULT
,Question 4
An infant who has recently been diagnosed with cystic fibrosis (CF) is being assessed by
the nurse. Which finding of this disease would the nurse not expect to see at this time?
A. Bulky, greasy stools
B. Positive sweat test
C. Moist, productive cough
D. Meconium ileus
CORRECT ANSWER
C
Moist and productive cough is a later sign in CF. Noisy respirations and a dry
nonproductive cough are commonly the first respiratory signs to appear in a newly
diagnosed client with CF. The other options are the earlier findings. CF is an inherited
(genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive
juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes
the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions
plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory
failure is the most dangerous consequence of CF.
Question 5
The nurse is caring for a client with orders for complete bed rest. Which action by the
nurse is most important in the prevention of the formation of deep vein thrombosis
(DVT)?
A. Prevent pressure at back of the knees
B. Elevate the foot of the bed
C. Encourage isometric leg muscle exercises
D. Apply knee high support stockings
CORRECT ANSWER
A
3
@THE STUDY VAULT
, Prevention of popliteal pressure will minimize venous stasis and deep vein thrombosis.
The other actions would also be implemented for clients with orders for bed rest.
However, the correct option is the one action directly associated with DVT.
Question 6
The nurse is assessing a client with portal hypertension. Which findings should the nurse
expect during the assessment?
A. Expiratory wheezes
B. Blurred vision
C. Dilated pupils
D. Ascites
CORRECT ANSWER
D
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the
liver. Portal hypertension can lead to ascites from the increased portal pressure as well as
a lowered colloid osmotic pressure because of low albumin. When liver functioning
deteriorates, protein metabolism is decreased with the result of a low serum albumin.
Question 7
The nurse finds a client unconscious, following a tonic-clonic seizure. What should a nurse
do first?
A. Administer the ordered Ativan
B. Place the client in a side-lying position
C. Prepare for suctioning
D. Check the pulse
4
@THE STUDY VAULT
