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A nurse in an emergency department
completes an assessment on an ado-
lescent client that has conduct disorder.
The client threatened suicide to teacher
at school. Which of the following state-
ments should the c) Tell me how often do you drink alcohol
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
A nurse is observing bonding to the client
her newborn. Which of following actions
by the client requires the nurse to inter-
vene?
a) Holding the newborn in face position
d) Viewing the newborn's actions to be
b) Asking the father to change the new-
uncooperative
born's diaper
c) Requesting the nurse take the new-
born nursery so she can rest
d) Viewing the newborn's actions to be
uncooperative
A nurse is caring for client who is taking
levothyroxin. Which of the following find-
ings should indicate that the medication
is effective?
a) Weight loss
a) Weight loss
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation
A nurse is planning discharge teaching
for cord care for the parent of a newborn.
Which instructions would you include in
the teaching?
c) Keep the cord dry until it falls off
a) Contact provider if the cord still turns
black
b) Clean the base of the cord with hydro-
gen peroxide daily
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c) Keep the cord dry until it falls off
d) The cord stump will fall off in five days
A nurse is assessing a client in the PACU.
Which of the following findings indicates
decreased cardiac output?
a) Shivering b) Oliguria
b) Oliguria
c) Bradypnea
d) Constricted pupils
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
c) A client with indications of hypov-
b) A client has full thickness burns to face
olemic shock
and trunk
c) A client with indications of hypov-
olemic shock
d) A client with open fracture of the lower
extremity
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 addi- c) A client whose chronic kidney disease
tional vibration palpated with cloudy diasylate outflow
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
A nurse is caring for a client just received
the first dose of lisinopril. The following is
an appropriate nursing intervention? c) Provide standby assist with the client
a) Place's cardiac monitoring from bed
b) Monitor the clients oxygen saturation
level
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c) Provide standby assist with the client
from bed
d) Encourage foods high in potassium
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 de-
celerations. Which the following should
d) Head Compression
the nurse expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression
A nurse is caring for a client who
has chronic kidney disease. The nurse
should identify which of the following lab-
oratory values as in an indication for he-
modialysis? a) glomerular filtration rate of 14 mL/
a) glomerular filtration rate of 14 mL/ minute
minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL
A nurse is caring for an infant who has a
prescription for continuous pulse oxime-
try. The following is an appropriate action
for the nurse to take?
c) Heat the skin one minute prior to plac-
a) Placed infant under radiant warmer
ing the program
b) Move the probe site every 3 hours
c) Heat the skin one minute prior to plac-
ing the program
d) Placed a sensor on the index finger
A nurse in a mental health facility re-
ceives 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 ag-
gressive behavior
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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 a) Client placed in restraints to the ag-
health heard all two hours ago for in- gressive behavior
creased anxiety
d) Applied he'll be receiving his first ECT
treatment today
A nurse working at the clinic is teaching a
group of clients who are pregnant on the
use of non-pharmacological pain man-
agement. Which of the following state-
ments by the nurse is an appropriate
description of the use of hypnosis during
labor?
b) Hypnosis promotes increased control
a) Hypnosis focuses on the biofeedback
of her pain perception during contrac-
as a relaxation technique
tions
b) Hypnosis promotes increased control
of her pain perception during contrac-
tions
c) Hypnosis uses therapeutic touch to
reduce anxiety during labor
d) Hypnosis provides instruction to mini-
mize pain
A nurse in a County Jail health clinic is
leading group therapy session. A client
who was incarcerated for theft is ad-
dressing the group. Which of the follow-
ing is an example of reaction formation?
a) I steal things because it's the only way
d) I think that people just you're just lazy
I can keep my mind off my bad marriage
and should earn money honestly
b) I can't believe I was accused of some-
thing 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