ANSWERS 2024/2025
Question 1. When assessing an adolescent with conduct disorder who has made
suicide threats, what is a crucial question for the nurse to ask?
• Options:
o a) Inquire about their siblings.
o b) Ask about their musical preferences.
o c) Determine their alcohol consumption frequency.
o d) Discuss their school timetable.
Correct Answer: c) Determine their alcohol consumption frequency.
Rationale: When assessing an adolescent with conduct disorder who has threatened
suicide, it is vital to inquire about substance use, as it can be a significant
contributing factor to suicidal ideation and impulsivity.
Tip: In mental health assessments, especially when suicide risk is present, always
prioritize questions that identify immediate safety concerns or contributing risk
factors like substance abuse.
Question 2. During an observation of mother-newborn bonding, which
maternal behavior would necessitate a nurse's intervention?
• Options:
o a) Cradling the infant facing her own.
o b) Delegating diaper changes to the father.
o c) Asking for the baby to be taken to the nursery for rest.
, o d) Perceiving the newborn's actions as uncooperative.
Correct Answer: d) Perceiving the newborn's actions as uncooperative.
Rationale: Viewing the newborn's actions as "uncooperative" can indicate a
potential issue with maternal-infant bonding or unrealistic expectations, which
requires nursing intervention to facilitate healthy attachment.
Tip: Promoting positive maternal-infant bonding is crucial. Nurses should
intervene when a parent exhibits behaviors that suggest a lack of attachment,
negative perceptions of the infant, or an inability to meet the infant's needs.
Question 3. A client is prescribed levothyroxine. What observable outcome
signifies the medication is working as intended?
• Options:
o a) The client experiences weight loss.
o b) The client asks the father to change the newborn's diaper.
o c) Seizures are no longer present.
o d) There is a reduction in inflammation.
Correct Answer: a) The client experiences weight loss.
Rationale: Levothyroxine acts as thyroid hormone (T4) to normalize the effects of
hypothyroidism. Weight loss is a common and expected outcome when
hypothyroidism is effectively treated, as slowed metabolism often leads to weight
gain in untreated individuals.
Tip: When evaluating the effectiveness of thyroid hormone replacement therapy,
observe for the reversal of hypothyroidism symptoms, such as weight gain, fatigue,
cold intolerance, and constipation.
Question 4. When providing discharge education on umbilical cord care for a
newborn's parent, which instruction is most appropriate?
• Options:
o a) Advise contacting the provider if the cord turns black.
, o b) Suggest daily cleaning of the cord's base with hydrogen peroxide.
o c) Emphasize keeping the cord dry until it detaches naturally.
o d) Inform them the cord stump will fall off within five days.
Correct Answer: c) Emphasize keeping the cord dry until it detaches naturally.
Rationale: The umbilical cord should be kept clean and dry to prevent infection. It
is normal for the cord to turn black as it dries, and it typically falls off within 10-14
days (not necessarily five days). Cleaning with hydrogen peroxide is generally not
recommended; a neutral pH cleanser or plain water, followed by thorough drying,
is preferred.
Tip: The primary goal of newborn umbilical cord care is to prevent infection and
promote natural drying and detachment. Keep the area clean and dry, and avoid
applying substances that could irritate the skin or delay healing.
Question 5. What clinical manifestation should a nurse anticipate when
assessing a client experiencing a fluid volume deficit?
• Options:
o a) A slower heart rate.
o b) A reduced respiratory rate.
o c) A drop in blood pressure upon standing.
o d) An elevation in blood pressure.
Correct Answer: c) A drop in blood pressure upon standing.
Rationale: Fluid volume deficit leads to decreased circulating blood volume. When
a client with fluid volume deficit changes position, especially to an upright
position, the body's compensatory mechanisms may not be sufficient to maintain
blood pressure, resulting in orthostatic hypotension.
Tip: Orthostatic hypotension is a key indicator of fluid imbalance. Always assess
blood pressure in different positions (lying, sitting, standing) when fluid volume
deficit is suspected.
, Question 6. Before administering lithium carbonate, which laboratory test
result is crucial for the nurse to review?
• Options:
o a) Thyroid hormone levels.
o b) Blood urea nitrogen (BUN) levels.
o c) Potassium levels.
o d) Calcium levels.
Correct Answer: a) Thyroid hormone levels.
Rationale: Lithium can interfere with thyroid function and potentially cause
hypothyroidism. Therefore, it is essential for the nurse to assess thyroid-stimulating
hormone (TSH) and thyroxine (T4) levels before initiating lithium therapy and
regularly during treatment.
Tip: Lithium has a narrow therapeutic range and can affect various organ systems,
including the thyroid and kidneys. Regular monitoring of lithium levels, renal
function, and thyroid function is vital for client safety.
Question 7. When educating a client about a new captopril prescription, what
important instruction should the nurse provide?
• Options:
o a) Advise taking the medication with food.
o b) Inform them they can discontinue the medication when feeling
better.
o c) Instruct them to take a double dose if a dose is missed.
o d) Recommend remaining in bed for 3 hours after the first dose.
Correct Answer: d) Recommend remaining in bed for 3 hours after the first dose.
Rationale: Captopril, an ACE inhibitor, can cause a significant drop in blood
pressure (orthostatic hypotension) with the initial dose. Staying in bed for a few