A nurse in an emergency department completes an assessment on an adolescent client that
has conduct disorder. The client threatened suicide to teacher at school. Which of the
following statements should the nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule
c) Tell me how often do you drink alcohol
A nurse is observing bonding to the client her newborn. Which of following actions by the
client requires the nurse to intervene?
a) Holding the newborn in an en face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn's actions to be uncooperative
d) Viewing the newborn's actions to be uncooperative
A nurse is caring for client who is taking levothyroxin. Which of the following findings should
indicate that the medication is effective?
a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation
a) Weight loss (this drug acts as T4 and will normalize the effects of
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which
instructions would you include in the teaching?
a) Contact provider if the cord still turns black (it's going to turn black)
,b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)
A nurse is assessing a client in the PACU. Which of the following findings indicates decreased
cardiac output?
a) Shivering
b) Oliguria
c) Bradypnea
d) Constricted pupils
b) Oliguria
A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the
following client should the nurse identify as the priority?
a) A client that has massive head trauma b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity
c) A client with indications of hypovolemic shock
A nurse is a receiving report on four clients. Which of the following clients should the nurse
assess first?
a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged urine in the bag
c) A client whose chronic kidney disease with cloudy diasylate outflow
,A nurse is caring for a client just received the first dose of lisinopril. The following is an
appropriate nursing intervention?
a) Place's cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium
c) Provide standby assist with the client from bed
A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring.
The nurse is reviewing the monitor tracing and notes early decelerations. Which the following
should the nurse expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression
d) Head Compression
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which
of the following laboratory values as in an indication for hemodialysis?
a) glomerular filtration rate of 14 mL/ minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL
a) glomerular filtration rate of 14 mL/ minute
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The
following is an appropriate action for the nurse to take?
a) Placed infant under radiant warmer
, b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the program
d) Placed a sensor on the index finger
c) Heat the skin one minute prior to placing the program
A nurse in a mental health facility receives a change of shift report on for clients. Which of the
following clients should the nurse plan to assess first?
a) Client placed in restraints to the aggressive behavior
b) A new limited client pleasures history of 4.5 kg weight loss in the past two months
c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
d) Applied he'll be receiving his first ECT treatment today
a) Client placed in restraints to the aggressive behavior
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of
nonpharmacological pain management. Which of the following statements by the nurse is an
appropriate description of the use of hypnosis during labor?
a) Hypnosis focuses on the biofeedback as a relaxation technique
b) Hypnosis promotes increased control of her pain perception during contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain
b) Hypnosis promotes increased control of her pain perception during contractions
A nurse in a County Jail health clinic is leading group therapy session. A client who was
incarcerated for theft is addressing the group. Which of the following is an example of reaction
formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone
you dislike)
a) I steal things because it's the only way I can keep my mind off my bad marriage b) I can't
believe I was accused of something I didn't do
c) I don't want talk about my feelings right now. We will talk more next time
d) I think that people just you're just lazy and should earn money honestly
has conduct disorder. The client threatened suicide to teacher at school. Which of the
following statements should the nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule
c) Tell me how often do you drink alcohol
A nurse is observing bonding to the client her newborn. Which of following actions by the
client requires the nurse to intervene?
a) Holding the newborn in an en face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn's actions to be uncooperative
d) Viewing the newborn's actions to be uncooperative
A nurse is caring for client who is taking levothyroxin. Which of the following findings should
indicate that the medication is effective?
a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation
a) Weight loss (this drug acts as T4 and will normalize the effects of
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which
instructions would you include in the teaching?
a) Contact provider if the cord still turns black (it's going to turn black)
,b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)
A nurse is assessing a client in the PACU. Which of the following findings indicates decreased
cardiac output?
a) Shivering
b) Oliguria
c) Bradypnea
d) Constricted pupils
b) Oliguria
A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the
following client should the nurse identify as the priority?
a) A client that has massive head trauma b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity
c) A client with indications of hypovolemic shock
A nurse is a receiving report on four clients. Which of the following clients should the nurse
assess first?
a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged urine in the bag
c) A client whose chronic kidney disease with cloudy diasylate outflow
,A nurse is caring for a client just received the first dose of lisinopril. The following is an
appropriate nursing intervention?
a) Place's cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium
c) Provide standby assist with the client from bed
A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring.
The nurse is reviewing the monitor tracing and notes early decelerations. Which the following
should the nurse expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression
d) Head Compression
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which
of the following laboratory values as in an indication for hemodialysis?
a) glomerular filtration rate of 14 mL/ minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL
a) glomerular filtration rate of 14 mL/ minute
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The
following is an appropriate action for the nurse to take?
a) Placed infant under radiant warmer
, b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the program
d) Placed a sensor on the index finger
c) Heat the skin one minute prior to placing the program
A nurse in a mental health facility receives a change of shift report on for clients. Which of the
following clients should the nurse plan to assess first?
a) Client placed in restraints to the aggressive behavior
b) A new limited client pleasures history of 4.5 kg weight loss in the past two months
c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
d) Applied he'll be receiving his first ECT treatment today
a) Client placed in restraints to the aggressive behavior
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of
nonpharmacological pain management. Which of the following statements by the nurse is an
appropriate description of the use of hypnosis during labor?
a) Hypnosis focuses on the biofeedback as a relaxation technique
b) Hypnosis promotes increased control of her pain perception during contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain
b) Hypnosis promotes increased control of her pain perception during contractions
A nurse in a County Jail health clinic is leading group therapy session. A client who was
incarcerated for theft is addressing the group. Which of the following is an example of reaction
formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone
you dislike)
a) I steal things because it's the only way I can keep my mind off my bad marriage b) I can't
believe I was accused of something I didn't do
c) I don't want talk about my feelings right now. We will talk more next time
d) I think that people just you're just lazy and should earn money honestly
