Questions With Revised Answers & Rationale’s
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THIS TEST CONSISTS OF 600 QUESTIONS AND ANSWERS
1. When evaluating maternal bonding, which of the following maternal behav- iors
exhibited by the client would the nurse most likely expect to see when a new mother
receives her infant for the first time?
She eagerly reaches for the infant, undresses the infant, and examines the infant
completely.
Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
,Her arms and hands receive the infant and she then cuddles the infant to her own body.
She eagerly reaches for the infant and then holds the infant close to her own body
.:Answer> Her arms and hands receive the infant and she then traces the infant's profile
with her fingertips
Attachment/bonding theory indicates that most mothers will demonstrate behaviors such
as tracing the infant's profile with her fingertips during the initial visit with the newborn,
which may be at delivery or later.
2. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal
edema, dyspnea, fatigue, and a moist cough. Which question is most important for the
nurse to ask this client?
"Which symptom did you experience first?" "Are you
eating large amounts of salty foods?" "Have you
visited a foreign country recently?"
"Do you have a history of rheumatic fever?": .:Answer> "Do you have a history of
rheumatic fever?"
Obtaining a client's health history is a priority because clients with a history of rheumatic
fever may develop mitral valve prolapse, which increases the risk for cardiac
,decompensation due to the increased blood volume that occurs during pregnancy.
3. A client is taking danazol (Danocrine) for endometriosis and calls the clinic nurse to
complain of a dark, swollen, and painful leg. What instructions should the nurse provide
the client?
Wear support stockings.
Elevate both legs and apply heat. Proceed to
the closest emergency room.
Walk for 20 to 30 minutes to reduce muscle cramps
.:Answer> Proceed to the closest emergency room.
A dark, swollen, and painful leg is consistent with deep vein thrombosis (DVT), an adverse
effect of danazol, so the client should be instructed to seek immediate emergency care.
4. Which description of symptoms is characteristic of a client diagnosed with trigeminal
neuralgia (tic douloureux)?
Tinnitus, vertigo, and hearing difficulties.
Sudden, stabbing, severe pain over the lip and chin. Facial
weakness and paralysis.
Difficulty in chewing, talking, and swallowing
.:Answer> Sudden, stabbing, severe pain over the lip and chin.
, Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in
the area innervated by one or more branches of the trigeminal nerve (5th cranial). Women
are more often afflicted with this condition and generally occurs in clients over the age of
50 years old.
5. The nurse is planning care for a client with major depression who is ad- mitted to
the unit after a recent suicide attempt. Which intervention has the highest priority for
inclusion in this client's plan of care?
Search the client's personal belongings. Introduce
the client to others on the unit. Ask the client
about recent stressful events.
Move to a room that allows close observation
.:Answer> Search the client's personal belongings.
To safeguard that the client dose not have some means to inflict self harm, a routine
search of personal belongings, which is a common safety policy, should be implemented
until the client stabilizes and suicidal ideations abate. The other interventions are
components of the plan of care that ensure a therapeutic milieu but are not the priority
in ensuring safety from self-harm.