and Answers A+ Graded
1. The .nurse .is .has .just .admitted .a .client .with .severe .depression. .From .which
.focus .should .the .nurse .identify .a .priority .nursing .diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety
The .correct .answer .is .D: . Safety
2. While .explaining .an .illness .to .a .10 .year-old, .what .should .the .nurse .keep .in .mind
.about .the .cognitive .development .at .this .age?
A) They .are . able . to . make .simple . association . of . ideas
B) They .are .able . to .think .logically .in . organizing .facts
C) Interpretation . of . events . originate . from . their . own . perspective
D) Conclusions .are .based .on .previous .experiences
The .correct . answer . is .B: .Think . logically . in . organizing . facts
3. The .nurse .enters .the .room .as .a .3 .year-old .is .having .a .generalized .seizure.
.Which .intervention .should .the .nurse .do .first?
A) Clear .the .area .of .any .hazards
B) Place .the .child .on .the .side
C) Restrain . the . child
D) Give . the . prescribed . anticonvulsant
The .correct .answer .is .B: .Place .the .child .on .the .side
4. The .nurse .is .reviewing .a .depressed .client's .history .from .an .earlier .admission.
.Documentation .of .anhedonia .is .noted. .The .nurse .understands .that .this .finding .refers
.to
A) Reports .of .difficulty .falling . and .staying .asleep
B) Expression . of . persistent . suicidal . thoughts
C) Lack .of . enjoyment . in . usual . pleasures
D) Reduced . senses .of .taste .and .smell
The .correct . answer .is .C: .Lack . of . enjoyment .in . usual .pleasures
,5. A .client .has .just .returned .to .the .medical-surgical .unit .following .a .segmental
.lung .resection. .After .assessing .the .client, .the .first .nursing .action .would .be .to
A) Administer . pain . medication
B) Suction . excessive . tracheobronchial . secretions
C) Assist .client . to . turn, . deep . breathe . and .cough
,D) Monitor . oxygen . saturation
The . correct .answer . is .B: . Suction . excessive . tracheobronchial . secretions
6. While .assessing .a .client .in .an .outpatient .facility .with .a .panic .disorder, .the .nurse
.completes .a .thorough .health .history .and .physical .exam. .Which .finding .is .most
.significant .for .this .client?
A) Compulsive . behavior
B) Sense . of . impending . doom
C) Fear .of .flying
D) Predictable . episodes
The .correct .answer .is .B: .Sense .of .impending .doom
7. A .16 .month-old .child .has .just .been .admitted .to .the .hospital. .As .the .nurse .assigned .to
.this .child .enters .the .hospital .room .for .the .first .time, .the .toddler .runs .to .the .mother,
.clings .to .her .and .begins .to .cry. .What .would .be .the .initial .action .by .the .nurse?
A) Arrange .to .change .client .care .assignments
B) Explain .that .this .behavior .is .expected
C) Discuss . the . appropriate . use . of . "time-out"
D) Explain .that .the .child .needs .extra .attention
The .correct .answer .is .B: .Explain .that .this .behavior .is .expected
8. A .15 .year-old .client .with .a .lengthy .confining .illness .is .at .risk .for .altered .growth
.and .development .of .which .task?
A) Loss .of .control
B) Insecurity
C) Dependence
D) Lack .of .trust
The .correct .answer .is .C: .Dependence
9. Which .playroom .activities .should .the .nurse .organize .for .a .small .group .of .7 .year-
old .hospitalized .children?
A) Sports .and .games . with .rules
B) Finger .paints .and .water .play
C) "Dress-up" .clothes . and .props
D) Chess . and . television . programs
The .correct .answer .is .A: .Sports .and .games .with .rules
10. The .nurse .is .discussing .dietary .intake .with .an .adolescent .who .has .acne. .The .most
, appropriate .statement . for . the . nurse . is
A) "Eat .a .balanced .diet .for .your .age."
B) "Increase .your .intake .of .protein .and .Vitamin .A."
C) "Decrease .fatty .foods .from .your .diet."
D) "Do .not .use .caffeine .in .any .form, .including .chocolate."
.The .correct .answer .is .A: ."Eat .a .balanced .diet .for .your
.age."
11. The .nurse .is .assigned .to .a .newly .delivered .woman .with .HIV/AIDS. .The .student
.asks .the .nurse .about .how .it .is .determined .that .a .person .has .AIDS .other .than .a .positive
.HIV .test. .The .nurse .responds
A) "The .complaints .of .at .least .3 .common .findings."
B) "The . absence . of . any . opportunistic . infection."
C) "CD4 .lymphocyte . count .is . less . than .200."
D) "Developmental . delays . in . children."
The .correct .answer .is .C: ."CD4 .lymphocyte .count .is .less .than .200."
12. The .nurse .is .caring .for .a .child .who .has .just .returned .from .surgery .following
.a .tonsillectomy .and .adenoidectomy. .Which .action .by .the .nurse .is .appropriate?
A) Offer .ice .cream .every .2 .hours
B) Place .the .child .in .a .supine .position
C) Allow .the .child .to .drink .through .a .straw
D) Observe . swallowing . patterns
The .correct .answer . is .D: . Observe .swallowing .patterns
13. A .23 .year-old .single .client .is .in .the .33rd .week .of .her .first .pregnancy. .She .tells
.the .nurse .that .she .has .everything .ready .for .the .baby .and .has .made .plans .for .the .first
.weeks .together .at .home. .Which .normal .emotional .reaction .does .the .nurse .recognize?
A) Acceptance .of .the .pregnancy
B) Focus .on .fetal .development
C) Anticipation . of . the . birth
D) Ambivalence . about . pregnancy
The .correct .answer .is .C: .Anticipation .of .the .birth
14. The .nurse .is .planning .care .for .a .client .with .pneumococcal .pneumonia. .Which .of
.the .following .would .be .most .effective .in .removing .respiratory .secretions?
A) Administration . of . cough . suppressants
B) Increasing .oral .fluid .intake .to .3000 .cc .per .day
C) Maintaining . bed . rest . with . bathroom . privileges
D) Performing . chest . physiotherapy . twice . a . day