1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction.
Whichnursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body alignment.
2. The nurse is assessing a healthy child at the 2 year check up. Which of the following
should the nurse report immediately to the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
3. The parents of a 2 year-old child report that he has been holding his breath whenever
hehas temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
D) Instruct the parents on how to reason with the child about possible harmful effects
Thecorrect answer is C: Advise the parents to ignore breath holding because breathing
will begin as a reflex
,4. The nurse is assessing a client in the emergency room. Which statement suggests that
theproblem is acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
The correct answer is A: "My pain is deep in my chest behind my sternum."
.
5. The nurse is assessing the mental status of a client admitted with possible organic
braindisorder. Which of these questions will best assess the function of the client's
recent
,memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer)
"Nowcontinue to subtract 7 from the new number."
C) "I am going to say the names of three things and I want you to repeat them after
me:blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose
ofit?"
The correct answer is C: "I am going to say the names of three things and I want you to repeat
them after me: blue, ball, pen."
6. In planning care for a 6 month-old infant, what must the nurse provide to assist in
thedevelopment of trust?
A) Food
B) Warmth
C) Security
D) Comfort
The correct answer is C: Security
7. A nurse has just received a medication order which is not legible. Which statement
bestreflects 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
yourwriting."
, The correct answer is B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"