,1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
Correct Answer: C) Security
Rationale: Providing security helps the infant develop a sense of trust that their needs
will be met.
2. A nurse has just received a medication order which is not legible. Which statement
best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you
would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read
your writing."
Correct Answer: B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"
Rationale: Assertive communication is respectful, direct, and seeks clarification to
ensure patient safety.
3. What is the most important consideration when teaching parents how to reduce risks
in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
,C) Number of children in the home
D) Age of children in the home
Correct Answer: D) Age of children in the home
Rationale: The age of children determines the specific risks and safety measures needed
in the home.
4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
Correct Answer: C) Administer the prescribed analgesia
Rationale: Pain in sickle cell crisis is severe and requires prompt administration of
prescribed analgesics regardless of other behaviors.
5. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
Correct Answer: A) Respiratory rate of 42
Rationale: An increased respiratory rate is an early sign of respiratory distress and
requires immediate intervention.
, 6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
Correct Answer: A) Lethargy
Rationale: Low T3/T4 and high TSH indicate hypothyroidism, which commonly
presents with lethargy and slowed metabolism.
7. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."
Correct Answer: B) "The seizure may or may not mean your child has epilepsy."
Rationale: A single seizure does not confirm epilepsy, as it can be caused by other
factors like fever or infection.
8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficit
C) Altered thought process
D) Disturbance in self-esteem
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
Correct Answer: C) Security
Rationale: Providing security helps the infant develop a sense of trust that their needs
will be met.
2. A nurse has just received a medication order which is not legible. Which statement
best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you
would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read
your writing."
Correct Answer: B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"
Rationale: Assertive communication is respectful, direct, and seeks clarification to
ensure patient safety.
3. What is the most important consideration when teaching parents how to reduce risks
in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
,C) Number of children in the home
D) Age of children in the home
Correct Answer: D) Age of children in the home
Rationale: The age of children determines the specific risks and safety measures needed
in the home.
4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
Correct Answer: C) Administer the prescribed analgesia
Rationale: Pain in sickle cell crisis is severe and requires prompt administration of
prescribed analgesics regardless of other behaviors.
5. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
Correct Answer: A) Respiratory rate of 42
Rationale: An increased respiratory rate is an early sign of respiratory distress and
requires immediate intervention.
, 6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
Correct Answer: A) Lethargy
Rationale: Low T3/T4 and high TSH indicate hypothyroidism, which commonly
presents with lethargy and slowed metabolism.
7. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."
Correct Answer: B) "The seizure may or may not mean your child has epilepsy."
Rationale: A single seizure does not confirm epilepsy, as it can be caused by other
factors like fever or infection.
8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficit
C) Altered thought process
D) Disturbance in self-esteem
