EVERGREEN VALLEY
COLLEGE-NUR 101-NCSBN
QUESTION BANK
,Pretest
Question 1
A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes
Question 2
You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing
student and yourself. To whom is it appropriate to assign complete care for
A) Yourself
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
Review Information: The correct answer is:A) Yourself.
While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission.
Only tasks that do not require independent judgment should be delegated.
3Question 3
A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on
the initial history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and restlessness.
,Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and
are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen." D+) "We
notice muscle weakness and some unsteadiness."
Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight
is significant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and
signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent
living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an
appropriate task for an Unlicensed Assistive Personnel (UAP)?
, A) Obtain a history of fluid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review Information: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what
must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be
assigned because they do not require independent judgment.
Question 7
The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related
to this diagnosis?
A) Diagnosis of chickenpox six months ago
B) Exposure to strep throat in daycare last month
C) Treatment for ear infection two months ago
D) Episode of fungal skin infection last week
Review Information: The correct answer is:B) Exposure to strep throat in daycare last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic
fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that
the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no
clinical symptoms.
Question 8
When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is
to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcing the manipulative behavior
C) Confront the client regarding the negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse
must attempt to discover attitudes and feelings in the self that influence the nurse- client relationship.
COLLEGE-NUR 101-NCSBN
QUESTION BANK
,Pretest
Question 1
A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes
Question 2
You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing
student and yourself. To whom is it appropriate to assign complete care for
A) Yourself
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
Review Information: The correct answer is:A) Yourself.
While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission.
Only tasks that do not require independent judgment should be delegated.
3Question 3
A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on
the initial history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and restlessness.
,Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and
are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen." D+) "We
notice muscle weakness and some unsteadiness."
Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight
is significant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and
signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent
living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an
appropriate task for an Unlicensed Assistive Personnel (UAP)?
, A) Obtain a history of fluid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review Information: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what
must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be
assigned because they do not require independent judgment.
Question 7
The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related
to this diagnosis?
A) Diagnosis of chickenpox six months ago
B) Exposure to strep throat in daycare last month
C) Treatment for ear infection two months ago
D) Episode of fungal skin infection last week
Review Information: The correct answer is:B) Exposure to strep throat in daycare last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic
fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that
the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no
clinical symptoms.
Question 8
When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is
to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcing the manipulative behavior
C) Confront the client regarding the negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse
must attempt to discover attitudes and feelings in the self that influence the nurse- client relationship.
