answers 2025
The .nurse .is .teaching .a .group .of .pregnant .women .about .hormonal .changes .during
.pregnancy. .The .nurse .recognizes .that .teaching .was .successful .when .the .women
.identify .which .hormone .as .causing .amenorrhea? .
1. .Progesterone .2. .Estrogen .3. .Follicle-stimulating .hormone .(FSH) .4. .Human
.chorionic .gonadotropin .(hCG) .- .CORRECT .ANSWER-Rationale
1. .Correct: .Progesterone .causes .amenorrhea. .2. .Incorrect: .Estrogen .renders .the
.female .genital .tract .suitable .for .fertilization. .3. .Incorrect: .This .stimulates .the
.growth .of .the .graafian .follicle .in .the .ovary. . 4. .Incorrect: .This .is .the .hormone
.present .in .urine .for .pregnancy .test
The .client .is .admitted .to .the .hospital .following .a .motor .vehicle .accident .and .has
.sustained .a .closed .chest .wound. .The .nurse .notes .paradoxical .chest .wall
.movement. .Which .problem .does .the .nurse .suspect?
1. .Mediastinal .shift .2. .Tension .pneumothorax .3. .Flail .chest .4. .Pulmonary .contusion
.- .CORRECT .ANSWER-Rationale
3. .Correct: .Hallmark .of .flail .chest .is .paradoxical .chest .wall .movement. .This .is .often
.described .as .a .see-saw .effect .when .observing .the .rise .and .fall .of .the .chest. .1.
.Incorrect: .A .closed .or .open .tension .pneumothorax .results .from .the .lung
.collapsing .and .air .entering .into .the .pleural .cavity. .This .results .in .pressure .shifting
.toward .the .unaffected .pleural .cavity. .2. .Incorrect: .Tension .pneumothorax .occurs
.when .there .is .an .accumulation .of .air .in .the .pleural .cavity. .The .client .may .exhibit
.dyspnea, .tachycardia, .or .hypotension. .4. .Incorrect: .A .pulmonary .contusion
.usually .results .from .blunt .trauma. .Bruising .of .lung .would .be .demonstrated .by .pain
.but .not .paradoxical .chest .wall .movement.
Which .client .can .a .nurse .manager .safely .transfer .from .the .telemetry .unit .to .the
.obstetrical .unit .in .order .to .receive .a .new .admit?
,1. .Client .admitted .with .possible .tuberculosis .(TB) .awaiting .skin .test .results. .2.
.Client .diagnosed .with .seizure .disorder. .3. .Client .with .a .new .pacemaker .scheduled
.to .be .discharged .in .the .morning. .4. .Client .with .a .history .of .mild .heart .failure
.prescribed .one .unit .of .packed .red .blood .cells .for .anemia. .- .CORRECT .ANSWER-
Rationale
2. .Correct: .OB .nurses .would .have .the .appropriate .knowledge .needed .to .care .for .a
.client .with .a .seizure .disorders, .because .they .care .for .clients .who .have .eclampsia
.(seizures). .1. .Incorrect: .This .client .might .have .tuberculosis .(TB) .and .is .not .a .good
.choice .to .move .to .the .OB .floor, .because .of .the .risk .for .transmission .of .an
.infectious .disease. .3. .Incorrect: .This .client .is .not .the .best .one .to .be .transferred .to
.the .OB .floor, .because .these .nurses .do .not .routinely .care .for .clients .with .a .new
.pacemaker. .The .client .is .also .likely .to .remain .on .a .cardiac .monitor .until .discharge.
.4. .Incorrect: .This .client .is .at .risk .for .fluid .volume .overload .since .there .is .a .history
.of .heart .failure .and .would .require .close .monitoring .while .receiving .a .blood
.transfusion.
The .nurse .is .teaching .a .group .of .clients .who .have .reduced .peripheral .circulation
.how .to .care .for .their .feet. .What .points .should .the .nurse .include?
1. .Check .shoes .for .rough .spots .in .the .lining. .2. .File .toenails .straight .across. .3.
.Cover .feet .and .between .toes .with .creams .to .moisten .the .skin. .4. .Break .in .new
.shoes .gradually. .5. .Use .pumice .stones .to .treat .calluses. .- .CORRECT .ANSWER-
Rationale
1., .2., .& .4. .Correct: .Rubbing .from .rough .spots .in .the .shoe .can .lead .to .corns .or
.calluses. .File .the .toenails .rather .than .cutting .to .avoid .skin .injury. .File .nails .straight
.across .the .ends .of .the .toes. .If .the .nails .are .too .thick .or .misshapen .to .file, .consult
.podiatrist. .Break .in .new .shoes .gradually .by .increasing .the .wearing .time .30-60
.minutes .each .day. .3. .Incorrect: .Cover .the .feet, .except .between .the .toes, .with
.creams .or .lotions .to .moisten .the .skin. .Lotion .will .also .soften .calluses. .A .lotion .that
.reduces .dryness .effectively .is .a .mixture .of .lanolin .and .mineral .oil. .5. .Incorrect:
.Avoid .self-treatment .of .corns .or .calluses. .Pumice .stones .and .some .callus .and
.corn .applications .are .injurious .to .the .skin. .Do .not .cut .calluses .or .corns. .Consult .a
.podiatrist .or .primary .healthcare .provider .first.
When .caring .for .young .adult .clients, .which .developmental .tasks .would .the .nurse
.expect .to .see?
1. .Satisfying .and .supporting .the .next .generation. .2. .Reflecting .on .life
.accomplishments. .3. .Developing .meaningful .and .intimate .relationships. .4. .Giving
.and .sharing .with .an .individual .without .asking .what .will .be .given .or .shared .in
,.return. .5. .Developing .sense .of .fulfillment .by .volunteering .in .the .community. .-
.CORRECT .ANSWER-Rationale
3. .& .4. .Correct: .In .young .adulthood, .the .developmental .tasks .involve .intimacy
.versus .isolation. .Intimacy .relates .more .to .sharing .than .to .sex. .Intimacy .produces
.feelings .of .safety, .closeness, .and .trust. .1. .Incorrect: .Parenting .is .a .primary .task .of
.middle .adulthood. .This .is .the .middle .adulthood .stage .of .Generativity .versus
.Stagnation, .where .each .adult .must .find .some .way .to .satisfy .and .support .the .next
.generation. .2. .Incorrect: .During .late .adulthood, .there .is .refection .on .life
.accomplishments. .This .is .the .maturity .stage .of .Ego .Integrity .versus .Despair,
.where .there .is .a .reflection .of .one's .life. .5. .Incorrect: .During .middle .age, .a .sense .of
.fulfillment .can .be .found .by .volunteering .in .the .community. .This .is .part .of .middle
.age, .where .the .adult .is .finding .ways .to .support .others.
What .symptoms .does .the .nurse .expect .to .see .in .a .client .with .bulimia .nervosa?
1. .Amenorrhea .2. .Feelings .of .self-worth .unduly .influenced .by .weight .3. .Recurrent
.episodes .of .binge .eating .4. .Recurrent .inappropriate .compensatory .behavior .to
.prevent .weight .gain .5. .Lack .of .exercise .- .CORRECT .ANSWER-Rationale
2., .3. .& .4. .Correct: .Diagnostic .criteria .for .bulimia .nervosa .are .recurrent .episodes .of
.binge .eating: .recurrent .inappropriate .compensatory .behavior .to .prevent .weight
.gain .such .as .laxative, .diuretic, .or .enema .use, .induced .vomiting, .fasting, .and
.excessive .exercise; .and .feeling .of .self-worth .unduly .influenced .by .weight.
.Amenorrhea .is .found .in .anorexia .nervosa. .1. .Incorrect: .Amenorrhea .is .found .in
.anorexia .nervosa. .5. .Incorrect: .Excessive .exercise .is .found .in .bulimia .nervosa .as .a
.means .to .compensate .for .the .binge .eating.
A .client .who .has .had .a .laparoscopic .cholecystectomy .develops .pain .in .the .left
.shoulder. .Vital .signs, .laboratory .studies, .and .an .electrocardiogram .are .within
.normal .limits. .What .does .the .nurse .recognize .as .a .contributing .cause .of .the .pain?
1. .Surgical .cannulation .of .the .bile .duct .is .causing .spasm .and .pain. .2. .Carbon
.dioxide .used .intraperitoneally .is .irritating .the .phrenic .nerve. .3. .Large .abdominal
.retractors .used .in .the .procedure .compressed .a .nerve. .4. .Side .lying .position .in .the
.operating .room .generated .pressure .damage. .- .CORRECT .ANSWER-Rationale
2. .Correct: .Phrenic .nerve .irritation .can .result .in .referred .pain .to .the .left .shoulder.
.Carbon .dioxide .(CO2) .is .used .to .inflate .the .abdominal/chest .wall .during .the
.procedure .for .better .visualization .of .the .internal .organs. .If .the .CO2 .irritates .the
.phrenic .nerve, .it .radiates .to .the .shoulder. .1. .Incorrect: .Surgical .cannulation .of .the
.bile .duct .is .not .performed .during .a .laparoscopic .cholecystectomy. .3. .Incorrect:
.Large .abdominal .retractors .are .not .used .during .this .procedure. .This .is .done .via .a
.small .incision .to .accommodate .a .scope. .4. .Incorrect: .The .client .is .turned .in .several
.directions .during .the .procedure .to .prevent .damage .to .the .abdominal .viscera.
, A .client .is .admitted .to .the .medical .unit .with .an .acute .onset .of .fever, .chills .and .RUQ
.pain. .Vital .signs .are: .T .99.8°F .(37.7°C), .P .132, .RR .34, .B/P .142/82. .ABG .results .are:
.pH-7.53, .PaCO2 .30, .HCO3 .22. .The .nurse .determines .that .this .client .is .in .what
.acid/base .imbalance?
1. .Respiratory .acidosis .2. .Respiratory .alkalosis .3. .Metabolic .acidosis .4. .Metabolic
.alkalosis .- .CORRECT .ANSWER-Rationale
2. .Correct: .This .client .has .a .severe .infection. .Hyperventilation .due .to .anxiety, .pain,
.shock, .severe .infection, .fever, .and .liver .failure .can .lead .to .respiratory .alkalosis. .pH
.> .7.45, .PCO2 .< .35, .HCO3 .normal. .1. .Incorrect: .Not .acidosis .with .hyperventilation
.and .pH .of .7.53. .3. .Incorrect: .Not .a .metabolic .related .acid/base .imbalance .since .the
.HCO3 .is .in .normal .range .and .is .not .acidosis. .4. .Incorrect: .Not .a .metabolic .related
.acid/base .imbalance .since .the .HCO3 .is .in .normal .range.
An .unlicensed .assistive .personnel .(UAP) .has .explained .how .to .prevent .the .spread
.of .infection .to .the .charge .nurse. .Which .statement .by .the .UAP .indicates .that .further
.teaching .is .needed? .
1. ."Soap .and .water .should .be .used .for .hand .washing .when .our .hands .are .visibly
.soiled." .2. ."Gloves .do .not .have .to .be .worn .when .taking .a .client's .vital .signs .or
.passing .out .meal .trays." .3. ."Standard .precautions .should .be .used .on .all .clients."
.4. ."When .caring .for .a .client .who .has .a .suppressed .immune .response, .a .N95 .mask
.should .be .worn." .- .CORRECT .ANSWER-Rationale
4. .Correct: .Standard .precautions .are .needed. .If .there .is .a .risk .for .coming .in .contact
.with .client .secretions .or .excretions, .a .standard .mask .may .be .worn. .Routine
.nursing .care .does .not .warrant .the .use .of .an .N95 .mask. .This .type .mask .is .needed
.for .client's .who .are .placed .on .Airborne .Precautions .such .as .for .tuberculosis .(TB).
.1. .Incorrect: .This .is .a .correct .statement .regarding .the .prevention .of .infection.
.Hand .washing .with .soap .and .water .is .part .of .standard .precautions. .2. .Incorrect:
.This .is .a .correct .statement. .Gloves .are .needed .when .coming .into .contact .with
.body .fluids. .3. .Incorrect: .This .is .a .correct .statement. .Standard .precautions .is .part
.of .the .first .line .of .defense .against .the .spread .of .infection.
The .nurse .is .preparing .to .discharge .a .client .who .has .been .placed .on
.tranylcypromine. .The .nurse .teaches .the .client .about .food .to .avoid .while .taking .this
.medication. .What .food .choice .by .the .client .confirms .appropriate .understanding .of
.the .teaching?
1. .Cottage .cheese .2. .Salami .3. .Baked .chicken .4. .Potatoes .- .CORRECT .ANSWER-
Rationale