QUESTION AND ANSWERS WITH
RATIONALE
GRADED A+ 100% PASS
Q. Nurse Is Monitoring Neurological Vital Signs For a Male Client Who Lost
Consciousness After Falling And Hitting His Head. Which Assessment Finding Is
The Earliest And Most Sensitive Indication Of Altered Cerebral Function?
a. Unequal Pupils.
b. Loss Of Central Reflexes.
c. Inability To Open The Eyes.
d. Change In Level Of Consciousness.
(Neurological Vital Signs Include Serial Assessments Of Tpr, Blood Pressure, And
Components Of The Glasgow Coma Scale (Gcs), Which Includes Verbal,
Musculoskeletal, And Pupillary Responses. A Change In The Client's Level Of
Consciousness, As Indicated By Responses To Commands During The Gcs, Is The
First And The Most Sensitive Sign Of Change In Cerebral Function. The Other
Assessment Data Choices Are Late Signs Of Altered Cerebral Function.)
Q.A Nurse Is Planning To Teach Self-Care Measures To a Female Client About
Prevention Of Yeast Infections. Which Instructions Should The Nurse Provide?
a. Use a Douche Preparation No More Than Once a Month.
b. Increase Daily Intake Of Fiber And Leafy Green Vegetables.
c. Select Nylon Underwear That Is Loose-Fitting, White, And Comfortable.
d. Avoid Tight-Fitting Clothing And Do Not Use Bubble-Bath Or Bath Salts.
(A Common Genital Tract Infection In Females Is Candidiasis, Which Is An
Overgrowth Of The Normal Vaginal Flora Of Candida Albicans That Thrives In An
Environment That Is Warm And Moist And Is Perpetuated By Tight-Fitting Clothing,
Underwear, Or Pantyhose Made Of Nonabsorbent Materials. The Client Should Wear
Clothing That Is Loose Fitting And Absorbent, Such As Cotton Underwear, And
Avoid Using Bubble-Bath Or Bath Salts Which Further Irritate Sensitive Genital
,Tissue. Douching Is Not Recommended Because It Can Irritate Vaginal Tissue, Alter
Ph, And Contribute To Fungal Growth. While Increasing Dietary Fiber Intake
Encourages Healthy, Nutritional Guidelines, It Is Not The Focus Of The Teaching.
Cotton, Not Nylon Undergarments, Provide Absorbancy And Reduce Moisture In The
Perineal Area.)
Q. A Client Who Has Active Tuberculosis (Tb) Is Admitted To The Medical Unit.
What Action Is Most Important For The Nurse To Implement?
a. Place An Isolation Cart In The Hallway.
b. Fit The Client With a Respirator Mask.
c. Don a Clean Gown For Client Care.
d. Assign The Client To a Negative Air-Flow Room.
(Active Tuberculosis Requires Implementation Of Airborne Precautions, So The
Client Should Be Assigned To a Negative Pressure Air-Flow Room. Although
Isolation Gowns And Isolation Carts Should Be Implemented For Clients In Isolation
With Contact Precautions, It Is Most Important That Air Flow From The Room Is
Minimized When The Client Has Tb. The Respirator Mask Should Be Implemented
When The Client Leaves The Isolation Environment.)
Q. The Nurse Is Planning To Conduct Nutritional Assessments And Diet Teaching To
Clients At a Family Health Clinic. Which Individual Has The Greatest Nutritional
And Energy Demands?
a. A Pregnant Woman.
b. A Teenager Beginning Puberty.
c. A 3-Month-Old Infant.
d. A School-Aged Child.
A Pregnant Woman's Metabolic Demands Are 20 To 24% More Than The Basic
Metabolic Rate. The Other Clients Require Only 15 To 20% More Than The Basic
Metabolic Rate.
What Nursing Delivery Of Care Provides The Nurse To Plan And Direct Care Of a
Group Of Clients Over a 24-Hour Period?
a. Team Nursing.
b. Primary Nursing.
c. Case Management.
d. Functional Nursing.
(Primary Nursing Is a Model Of Delivery Of Care Where a Nurse Is Accountable For
Planning Care For Clients Around The Clock. Functional Nursing Is a Care Delivery
Model That Provides Client Care By Assignment Of Functions Or Tasks. Team
Nursing Is a Care Delivery Model Where Assignments To a Group Of Clients Are
Provided By a Mixed-Staff Team. Case Management Is The Delivery Of Care That
Uses a Collaborative Process Of Assessment, Planning, Facilitation, And Advocacy
For Options And Services To Meet An Individual's Health Needs And Promote
Quality Cost-Effective Outcomes.)
Which Approach Should The Nurse Use When Preparing a Toddler For a Procedure?
a. Demonstrate The Procedure Using a Doll.
,b. Avoid Asking The Child To Make Choices.
c. Plan a Teaching Session To Last About 20 Minutes.
d. Show Equipment But Prevent Child From Handling It.
(Imitation Is One Of The Most Distinguishing Characteristics Of Toddler Play, So
Demonstration Of a Procedure On a Doll Enables a Non-Threatening, Dramatic
Experience That Can Help Prepare The Toddler For The Actual Procedure. The
Primary Developmental Task In Toddlerhood Is Acquiring a Sense Of Autonomy, So
Giving Choices Whenever Possible To a Toddler Is Recommended, Not Avoiding
Asking The Toddler To Make a Choice. Since The Toddler's Attention Span Is Short,
Teaching Sessions Should Be Brief And Can Be Repeated For Reinforcement.
Showing The Equipment Before Its Use Helps Relieve Anxiety, But The Child
Should Be Allowed To Handle Some Of The Equipment To Prevent Frustration And
Alleviate Fear.)
The Nurse Is Caring For a Client Who Is The Daughter Of a Local Politician. When
The Nurse Approaches a Man Who Is Reading The Names On The Hall Doors, He
Identifies Himself As a Reporter For The Local Newspaper And Requests
Information About The Client's Status.
Q. Which Standard Of Nursing Practice Should The Nurse Use To Respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.
(Confidentiality Is The Nurse's Primary Responsibility And Is Supported By Hipaa,
Which Mandates That Personal Information Is Not Disclosed And Access To
Sensitive Client Information Is Limited. Caring Involves The Nurse's Concern About
How The Client Experiences The World. Veracity Is The Nurse's Duty To Tell The
Truth And Not Deceive Others. Advocacy Is Support Of The Client's Best Interests.)
A Male Client Diagnosed With Antisocial Personality Disorder Is Morbidly Obese
And Is Placed On a Low Fat, Low Calorie Diet. At Dinner The Nurse Notes That He
Is Trying To Get Other Clients On The Unit To Give Him Part Of Their Meals. What
Intervention Should The Nurse Implement?
a. Remove The Client From The Table And Have Him Sit Alone.
b. Send The Client Back To His Room And Do Not Allow Him To Eat.
c. Report The Behavior To The On-Call Psychologist Immediately.
d. Confront The Client About The Consequences Of The Behavior.
D
(The Nurse Should Provide a Reality Check By Helping The Client Realize That
There Are Consequences To His Behavior. Removing The Client From The Room Or
Table Does Not Help The Client Realize That His Behavior Is Manipulative And
Harmful To Himself As Well As Others. This Behavior Needs To Be Documented,
But Does Not Need To Be Reported Immediately.)
, The Nurse Is Assessing a Client Who Complains Of Weight Loss, Racing Heart Rate,
And Difficulty Sleeping. The Nurse Determines The Client Has Moist Skin With Fine
Hair, Prominent Eyes, Lid Retraction, And a Staring Expression. These Findings Are
Consistent With Which Disorder?
a. Grave's Disease.
b. Cushing Syndrome.
c. Multiple Sclerosis.
d. Addison's Disease.
A
(This Client Is Exhibiting Symptoms Associated With Hyperthyroidism Or Grave's
Disease, Which Is An Autoimmune Condition Affecting The Thyroid. Cushing
Syndrome, Multiple Sclerosis, Or Addison's Disease Are Not Associated With These
Symptoms.)
Which Information Should The Nurse Give a Client With Chronic Kidney Disease
(Ckd)?
a. Restrict Calcium-Rich Foods.
b. Obtain Monthly B12 Injections.
c. Avoid Salt Substitutes.
d. Increase Daily Intake Of Fiber.
C
(A Client With Ckd Should Restrict Sodium And Potassium Dietary Intake, And Salt
Substitutes Usually Contain Potassium, So They Should Avoid Using Them.
Hypocalcemia Is a Complication Of Ckd And Calcium Supplements Are Often
Needed. Anemia Related To Ckd Is Treated With Iron, Folic Acid, And
Erythropoietin, Not B12 Injections. Although Increasing Fiber Is a Common Dietary
Recommendation, It Not An Essential Part Of Client Teaching For Ckd.)
A Young Adult Female Arrives At The Emergency Department With a Black Right
Eye And Is Bleeding From The Left Side Of Her Head. She Reports That Her
Boyfriend Has Been Abusing Her Physically. The Nurse Performs a History And
Physical Examination. How Should The Nurse Document These Findings?
a. Client Alleges That Her Boyfriend Beat Her Up. Client Is Bleeding From The Left
Side Of The Face.
b. Client Reports Her Boyfriend Hit Her In The Eye And On The Head. Bruises And
Lacerations Present On Face.
c. Client Presents With a Right Black Eye And a Cut On The Left Side Of Her Head
That Is Bleeding. Reports Abusive Boyfriend Responsible For Injuries. Needs
Referral To a Safe Place To Stay.
d. Young Adult Female Presents With Periorbital Ecchymosis On Right Side, 3
Cm Laceration On Left Parietal Area, Approximately 1 Cm Deep With Tissue
Bridging. States Her Boyfriend Is Abusive.
(Proper Documentation Of Abuse As Reported By The Victim Is Crucial, And The
Nurse Should Document Specific And Objective Data That Gives An Accurate
Depiction Of The Events Without Documentation Of Judgmental Inferences. All The
Other Choices Lack Specificity And Important Details Related To The Event.)
RATIONALE
GRADED A+ 100% PASS
Q. Nurse Is Monitoring Neurological Vital Signs For a Male Client Who Lost
Consciousness After Falling And Hitting His Head. Which Assessment Finding Is
The Earliest And Most Sensitive Indication Of Altered Cerebral Function?
a. Unequal Pupils.
b. Loss Of Central Reflexes.
c. Inability To Open The Eyes.
d. Change In Level Of Consciousness.
(Neurological Vital Signs Include Serial Assessments Of Tpr, Blood Pressure, And
Components Of The Glasgow Coma Scale (Gcs), Which Includes Verbal,
Musculoskeletal, And Pupillary Responses. A Change In The Client's Level Of
Consciousness, As Indicated By Responses To Commands During The Gcs, Is The
First And The Most Sensitive Sign Of Change In Cerebral Function. The Other
Assessment Data Choices Are Late Signs Of Altered Cerebral Function.)
Q.A Nurse Is Planning To Teach Self-Care Measures To a Female Client About
Prevention Of Yeast Infections. Which Instructions Should The Nurse Provide?
a. Use a Douche Preparation No More Than Once a Month.
b. Increase Daily Intake Of Fiber And Leafy Green Vegetables.
c. Select Nylon Underwear That Is Loose-Fitting, White, And Comfortable.
d. Avoid Tight-Fitting Clothing And Do Not Use Bubble-Bath Or Bath Salts.
(A Common Genital Tract Infection In Females Is Candidiasis, Which Is An
Overgrowth Of The Normal Vaginal Flora Of Candida Albicans That Thrives In An
Environment That Is Warm And Moist And Is Perpetuated By Tight-Fitting Clothing,
Underwear, Or Pantyhose Made Of Nonabsorbent Materials. The Client Should Wear
Clothing That Is Loose Fitting And Absorbent, Such As Cotton Underwear, And
Avoid Using Bubble-Bath Or Bath Salts Which Further Irritate Sensitive Genital
,Tissue. Douching Is Not Recommended Because It Can Irritate Vaginal Tissue, Alter
Ph, And Contribute To Fungal Growth. While Increasing Dietary Fiber Intake
Encourages Healthy, Nutritional Guidelines, It Is Not The Focus Of The Teaching.
Cotton, Not Nylon Undergarments, Provide Absorbancy And Reduce Moisture In The
Perineal Area.)
Q. A Client Who Has Active Tuberculosis (Tb) Is Admitted To The Medical Unit.
What Action Is Most Important For The Nurse To Implement?
a. Place An Isolation Cart In The Hallway.
b. Fit The Client With a Respirator Mask.
c. Don a Clean Gown For Client Care.
d. Assign The Client To a Negative Air-Flow Room.
(Active Tuberculosis Requires Implementation Of Airborne Precautions, So The
Client Should Be Assigned To a Negative Pressure Air-Flow Room. Although
Isolation Gowns And Isolation Carts Should Be Implemented For Clients In Isolation
With Contact Precautions, It Is Most Important That Air Flow From The Room Is
Minimized When The Client Has Tb. The Respirator Mask Should Be Implemented
When The Client Leaves The Isolation Environment.)
Q. The Nurse Is Planning To Conduct Nutritional Assessments And Diet Teaching To
Clients At a Family Health Clinic. Which Individual Has The Greatest Nutritional
And Energy Demands?
a. A Pregnant Woman.
b. A Teenager Beginning Puberty.
c. A 3-Month-Old Infant.
d. A School-Aged Child.
A Pregnant Woman's Metabolic Demands Are 20 To 24% More Than The Basic
Metabolic Rate. The Other Clients Require Only 15 To 20% More Than The Basic
Metabolic Rate.
What Nursing Delivery Of Care Provides The Nurse To Plan And Direct Care Of a
Group Of Clients Over a 24-Hour Period?
a. Team Nursing.
b. Primary Nursing.
c. Case Management.
d. Functional Nursing.
(Primary Nursing Is a Model Of Delivery Of Care Where a Nurse Is Accountable For
Planning Care For Clients Around The Clock. Functional Nursing Is a Care Delivery
Model That Provides Client Care By Assignment Of Functions Or Tasks. Team
Nursing Is a Care Delivery Model Where Assignments To a Group Of Clients Are
Provided By a Mixed-Staff Team. Case Management Is The Delivery Of Care That
Uses a Collaborative Process Of Assessment, Planning, Facilitation, And Advocacy
For Options And Services To Meet An Individual's Health Needs And Promote
Quality Cost-Effective Outcomes.)
Which Approach Should The Nurse Use When Preparing a Toddler For a Procedure?
a. Demonstrate The Procedure Using a Doll.
,b. Avoid Asking The Child To Make Choices.
c. Plan a Teaching Session To Last About 20 Minutes.
d. Show Equipment But Prevent Child From Handling It.
(Imitation Is One Of The Most Distinguishing Characteristics Of Toddler Play, So
Demonstration Of a Procedure On a Doll Enables a Non-Threatening, Dramatic
Experience That Can Help Prepare The Toddler For The Actual Procedure. The
Primary Developmental Task In Toddlerhood Is Acquiring a Sense Of Autonomy, So
Giving Choices Whenever Possible To a Toddler Is Recommended, Not Avoiding
Asking The Toddler To Make a Choice. Since The Toddler's Attention Span Is Short,
Teaching Sessions Should Be Brief And Can Be Repeated For Reinforcement.
Showing The Equipment Before Its Use Helps Relieve Anxiety, But The Child
Should Be Allowed To Handle Some Of The Equipment To Prevent Frustration And
Alleviate Fear.)
The Nurse Is Caring For a Client Who Is The Daughter Of a Local Politician. When
The Nurse Approaches a Man Who Is Reading The Names On The Hall Doors, He
Identifies Himself As a Reporter For The Local Newspaper And Requests
Information About The Client's Status.
Q. Which Standard Of Nursing Practice Should The Nurse Use To Respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.
(Confidentiality Is The Nurse's Primary Responsibility And Is Supported By Hipaa,
Which Mandates That Personal Information Is Not Disclosed And Access To
Sensitive Client Information Is Limited. Caring Involves The Nurse's Concern About
How The Client Experiences The World. Veracity Is The Nurse's Duty To Tell The
Truth And Not Deceive Others. Advocacy Is Support Of The Client's Best Interests.)
A Male Client Diagnosed With Antisocial Personality Disorder Is Morbidly Obese
And Is Placed On a Low Fat, Low Calorie Diet. At Dinner The Nurse Notes That He
Is Trying To Get Other Clients On The Unit To Give Him Part Of Their Meals. What
Intervention Should The Nurse Implement?
a. Remove The Client From The Table And Have Him Sit Alone.
b. Send The Client Back To His Room And Do Not Allow Him To Eat.
c. Report The Behavior To The On-Call Psychologist Immediately.
d. Confront The Client About The Consequences Of The Behavior.
D
(The Nurse Should Provide a Reality Check By Helping The Client Realize That
There Are Consequences To His Behavior. Removing The Client From The Room Or
Table Does Not Help The Client Realize That His Behavior Is Manipulative And
Harmful To Himself As Well As Others. This Behavior Needs To Be Documented,
But Does Not Need To Be Reported Immediately.)
, The Nurse Is Assessing a Client Who Complains Of Weight Loss, Racing Heart Rate,
And Difficulty Sleeping. The Nurse Determines The Client Has Moist Skin With Fine
Hair, Prominent Eyes, Lid Retraction, And a Staring Expression. These Findings Are
Consistent With Which Disorder?
a. Grave's Disease.
b. Cushing Syndrome.
c. Multiple Sclerosis.
d. Addison's Disease.
A
(This Client Is Exhibiting Symptoms Associated With Hyperthyroidism Or Grave's
Disease, Which Is An Autoimmune Condition Affecting The Thyroid. Cushing
Syndrome, Multiple Sclerosis, Or Addison's Disease Are Not Associated With These
Symptoms.)
Which Information Should The Nurse Give a Client With Chronic Kidney Disease
(Ckd)?
a. Restrict Calcium-Rich Foods.
b. Obtain Monthly B12 Injections.
c. Avoid Salt Substitutes.
d. Increase Daily Intake Of Fiber.
C
(A Client With Ckd Should Restrict Sodium And Potassium Dietary Intake, And Salt
Substitutes Usually Contain Potassium, So They Should Avoid Using Them.
Hypocalcemia Is a Complication Of Ckd And Calcium Supplements Are Often
Needed. Anemia Related To Ckd Is Treated With Iron, Folic Acid, And
Erythropoietin, Not B12 Injections. Although Increasing Fiber Is a Common Dietary
Recommendation, It Not An Essential Part Of Client Teaching For Ckd.)
A Young Adult Female Arrives At The Emergency Department With a Black Right
Eye And Is Bleeding From The Left Side Of Her Head. She Reports That Her
Boyfriend Has Been Abusing Her Physically. The Nurse Performs a History And
Physical Examination. How Should The Nurse Document These Findings?
a. Client Alleges That Her Boyfriend Beat Her Up. Client Is Bleeding From The Left
Side Of The Face.
b. Client Reports Her Boyfriend Hit Her In The Eye And On The Head. Bruises And
Lacerations Present On Face.
c. Client Presents With a Right Black Eye And a Cut On The Left Side Of Her Head
That Is Bleeding. Reports Abusive Boyfriend Responsible For Injuries. Needs
Referral To a Safe Place To Stay.
d. Young Adult Female Presents With Periorbital Ecchymosis On Right Side, 3
Cm Laceration On Left Parietal Area, Approximately 1 Cm Deep With Tissue
Bridging. States Her Boyfriend Is Abusive.
(Proper Documentation Of Abuse As Reported By The Victim Is Crucial, And The
Nurse Should Document Specific And Objective Data That Gives An Accurate
Depiction Of The Events Without Documentation Of Judgmental Inferences. All The
Other Choices Lack Specificity And Important Details Related To The Event.)
