1. A nurse is developing a care plan for a 6-month-old infant. Which
nursing intervention is most crucial for fostering the development of
trust according to Erikson's stages of psychosocial development? A)
Providing consistent feeding schedules. B) Ensuring a warm and
comfortable environment. C) Offering predictable and responsive care. D)
Maintaining a safe and secure physical space. Rationale: C) Offering
predictable and responsive care aligns directly with Erikson's stage of trust
vs. mistrust in infancy, where consistent meeting of needs fosters trust.
2. A nurse receives a medication order that is illegible. Which of the
following statements demonstrates assertive communication while
addressing this issue with the prescribing healthcare provider? A) "This
order is impossible to read. What did you even write?" B) "Could you please
clarify this medication order? I want to ensure I transcribe it correctly for the
patient's safety." C) "Your handwriting is really difficult to read. Please be
more careful next time." D) "In the future, please print medication orders so
nurses don't waste time trying to decipher them." Rationale: B) "Could you
please clarify this medication order? I want to ensure I transcribe it correctly
for the patient's safety" is assertive, respectful, and focuses on patient safety.
3. When teaching parents about home safety to reduce the risk of injury,
what is the most critical factor the nurse should consider to tailor the
education effectively? A) The parents' educational background and health
literacy. B) The proximity of the home to emergency medical services. C)
The total number of individuals residing in the household. D) The
developmental stage and mobility of the children living in the home.
Rationale: D) The developmental stage and mobility of the children living
, in the home directly influence the specific safety hazards present and the
appropriate preventative measures.
4. A 35-year-old client with sickle cell crisis is speaking on the phone but
stops when the nurse enters to request pain medication. What is the
most appropriate initial nursing action? A) Offer a placebo to assess the
client's perception of pain. B) Encourage the client to increase oral fluid
intake. C) Administer the prescribed analgesic medication promptly. D)
Suggest non-pharmacological pain management techniques like relaxation
exercises. Rationale: C) Administering the prescribed analgesic promptly
addresses the client's acute pain during a sickle cell crisis, which is the
priority.
5. A nurse is caring for a toddler with croup. Which of the following
assessment findings indicates the need for immediate nursing
intervention? A) A respiratory rate of 42 breaths per minute. B) Reports of
lethargy by the parents over the past hour. C) An apical pulse rate of 54
beats per minute. D) A persistent barking cough with occasional
expectoration of thick mucus. Rationale: A) A respiratory rate of 42 breaths
per minute in a toddler is significantly elevated and could indicate
respiratory distress requiring immediate attention.
6. A client is admitted with laboratory results indicating low
triiodothyronine (T3) and thyroxine (T4) levels and an elevated thyroid-
stimulating hormone (TSH) level. Which of the following clinical
manifestations would the nurse anticipate during the initial assessment?
A) Heat intolerance. B) Diarrhea. C) Skin eruptions. D) Lethargy.
Rationale: D) Lethargy is a common symptom of hypothyroidism, which is
consistent with low T3 and T4 and elevated TSH.
,7. The emergency room nurse is assessing a child who experienced a first-
time seizure at school. The father denies any family history of epilepsy
and expresses concern. What is the most appropriate and informative
response by the nurse? A) "Don't worry too much; epilepsy is often
manageable with medication." B) "A single seizure doesn't always mean
your child has epilepsy. Further evaluation will help determine the cause."
C) "Since this was the first seizure, it's possible it won't happen again." D)
"With consistent long-term treatment, future seizures can usually be
prevented." Rationale: B) "A single seizure doesn't always mean your child
has epilepsy. Further evaluation will help determine the cause" provides
accurate information without making premature diagnoses or guarantees.
8. Alcohol and drug abuse are known to impair judgment and increase
engagement in risky behaviors. Which nursing diagnosis is most directly
associated with these effects? A) Risk for injury. B) Deficient knowledge.
C) Disturbed thought processes. D) Chronic low self-esteem. Rationale: A)
Risk for injury is the most direct consequence of impaired judgment and
increased risk-taking behavior associated with substance abuse.
9. Which of the following clinical findings would the nurse most closely
associate with iron deficiency anemia in a 10-month-old infant? A) A
hemoglobin level of 12 g/dL. B) Pallor of the conjunctiva and oral mucosa.
C) Periods of hyperactivity followed by fatigue. D) A heart rate ranging
from 140 to 160 beats per minute while awake and active. Rationale: B)
Pallor of the conjunctiva and oral mucosa is a classic physical sign of
anemia due to reduced circulating hemoglobin.
10.A nurse is caring for a client in hypertensive crisis in the intensive care
unit. What is the priority assessment the nurse should perform within
the first hour of care? A) Monitoring heart rate and rhythm. B) Assessing
, peripheral pulses and capillary refill. C) Auscultating lung sounds for signs
of fluid overload. D) Evaluating neurological status, including pupillary
responses. Rationale: D) Evaluating neurological status, including pupillary
responses, is critical in hypertensive crisis to detect signs of end-organ
damage such as encephalopathy or stroke.
11.Which of the following clients in the terminal stage of cancer is least
likely to be an appropriate candidate for patient-controlled analgesia
(PCA) with a pump? A) A young adult with a documented history of Down
syndrome and limited understanding of abstract concepts. B) A teenager
who reads at a fourth-grade level and can demonstrate understanding of the
PCA pump operation. C) An elderly client with significant arthritic changes
in their hands that may impair their ability to press the PCA button. D) A
preschool-aged child with fluctuating levels of consciousness and periods of
unresponsiveness. Rationale: D) A preschooler with intermittent episodes of
alertness lacks the consistent cognitive ability to understand and safely
manage a PCA pump.
12.A nurse is about to assess a 6-month-old infant diagnosed with
nonorganic failure to thrive (NOFTT). Upon entering the room, which
of the following observations would the nurse most likely expect? A)
Irritability and excessive crying ("colicky") without any attempts to reach
for toys or pull to standing. B) Alertness, smiling, and engaging with a
nearby rattle while sitting with minimal support. C) Dusky skin color with
tenting of the abdominal skin indicating poor hydration. D) Pale and thin
extremities, appearing withdrawn and showing little interest in their
surroundings. Rationale: D) Pale and thin extremities, appearing withdrawn
and showing little interest in their surroundings are consistent with the
physical and emotional neglect often associated with NOFTT.