Exam UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS
A 6 year old girl with severe birth defects who is mentally disabled is brought to the
emergency room because of a broken arm. The caregiver reports that the girl sustained the
injury when she fell from her wheelchair. Which intervention is most important for the nurse
to implement? - CORRECT ANSWER Evaluate the child for other injuries. Rationale:
Because a 6 year old child with low level fall that results in a fracture should be considered a
possible victim of child abuse, until proven otherwise.
The community health nurse facilitates a substance abuse prevention group for a homeless
population. Which statement demonstrates that a client has a realistic understanding of the
recovery process? - CORRECT ANSWER "By learning what led to my latest relapse, I
know what to do in the future." Rationale: Recovery is a lifelong process in which clients
must constantly learn and apply new behaviors to replace ineffective ones. Every attempt
toward recovery improves long-term chances of success, so those who learn from their
relapses demonstrate an understanding of the process.
A woman admitted to the Emergency Department is bleeding profusely from a patch where
her hair was lost from her scalp. She is accompanies by her husband who tells the nurse that
his wife caught her hair on the railing and pulled it out when she fell down the stairs. The
husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to
comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart."
What is the priority nursing intervention? - CORRECT ANSWER Require the husband
to leave the cubicle while the client is being treated. Rationale: This client should be
questioned about the possibility of spousal abuse and cannot answer truthfully in the presence
of the perpetrator, so separating the couple is a priority.
While assessing a 70-year old male client, a nurse working in the outpatient clinic notices
bruises on the client's chest. The client admits that his daughter, who is his caregiver,
becomes frustrated and sometimes hits him. What is the priority outcome for the elderly
client who sustained the abuse? - CORRECT ANSWER Expresses his feelings of
satisfaction with care. Rationale: Abuse cessation should result in the client feeling satisfied
with his care.
, The nurse is assessing a client who is believed to have a borderline personality disorder.
Which question is most important to include in this assessment? - CORRECT
ANSWER "Do you frequently have temper tantrums?" Rationale: Those with a
borderline personality disorder demonstrate intense outbursts of anger.
A nurse is teaching a female client who is in a homosexual relationship about women's
health. Which topic is the most important for the nurse to address? - CORRECT
ANSWER Domestic violence interventions. Rationale: Since all women, regardless of
sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the
most important topic for the nurse to address.
A client who abuses alcohol says to the nurse, "I am glad I went in for treatment. Now my
problems with alcohol are all behind me." Which response is best for the nurse to provide? -
CORRECT ANSWER "Can you tell me more about what you mean when you say that
your problems with alcohol are now behind you?" Rationale: Those who attend alcohol
treatment programs and Alcoholics Anonymous never put drinking problems behind them
and describe alcoholics as only one step away from a slip with maintaining sobriety. The
nurse should use reflection and encourage the client to further describe his feelings.
A male client who is on the liver transplant list is called to the unit for a possible transplant.
When learning that the donor organ is no longer available, the client slams doors and shouts
vulgarities about his situation. What action should the nurse implement first? - CORRECT
ANSWER Express concern over his disappointment. Rationale: Addressing the client's
disappointment enables the client to express feelings of frustration in a safe environment.
A client is told that her infant will be stillborn. What is the most important action for the
nurse to implement after the birth? - CORRECT ANSWER Ask the family if they
would like to see and hold the infant after birth. Rationale: Interventions and support from the
nursing staff during a prenatal loss are extremely important in the grief process and healing of
the patients. Research had shown it is most helpful for a mother and father to see and hold
their deceased infant after delivery, so the parents should be given this opportunity initially
after birth.
A client who has a miscarriage at 10-weeks gestation tells the nurse that she already
purchased some baby things and picked out a name. After the surgical dilation and curettage
(D&C), the client wants to go home as soon as possible. Based on the client's statements,
which action should the nurse implement? - CORRECT ANSWER Ask the client what