Verified Answers
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 answers ✔✔C) Security
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 answers ✔✔B) "Would you please clarify what you have written so I am sure I
am reading it
correctly?"
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 answers ✔✔D) Age of children in the home
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 answers ✔✔C) Administer the
prescribed analgesia
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 answers ✔✔A) Respiratory rate of 42
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 answers ✔✔A) Lethargy
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 answers ✔✔B) "The seizure
may or may not mean your child has epilepsy."
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 - correct answers ✔✔A) Risk for injury
Which these findings would the nurse more closely associate with anemia in a 10 month-old
infant?
A) Hemoglobin level of 12 g/dI
B) Pale mucosa of the eyelids and lips
C) Hypoactivity
D) A heart rate between 140 to 160 - correct answers ✔✔B) Pale mucosa of the eyelids and lips
The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority
assessment in the first hour of care is
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses - correct answers ✔✔D) Pupil responses
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest
the use of patient controlled analgesia (PCA) with a pump?
, A) A young adult with a history of Down's syndrome
B) A teenager who reads at a 4th grade level
C) An elderly client with numerous arthritic nodules on the hands
D) A preschooler with intermittent episodes of alertness - correct answers ✔✔D) A preschooler
with intermittent episodes of alertness
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT).
Upon entering the room, the nurse would expect the baby to be
A) Irritable and "colicky" with no attempts to pull to standing
B) Alert, laughing and playing with a rattle, sitting with support
C) Skin color dusky with poor skin turgor over abdomen
D) Pale, thin arms and legs, uninterested in surroundings - correct answers ✔✔D) Pale, thin
arms and legs, uninterested in surroundings
As the nurse is speaking with a group of teens which of these side effects of chemotherapy for
cancer would the nurse expect this group to be more interested in during the discussion?
A) Mouth sores
B) Fatigue
C) Diarrhea
D) Hair loss - correct answers ✔✔D) Hair loss
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse
notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius). The appropriate
nursing intervention is to
A) Call the health care provider immediately
B) Administer acetaminophen as ordered as this is normal at this time
C) Send blood, urine and sputum for culture