HESI RN EXIT EXAM LEGACY QUESTIONS&ANSWERS LATEST EXAMS

HESI RN EXIT EXAM LEGACY QUESTIONS&ANSWERS LATEST EXAMS 1. Thenurseiscaringforapre- adolescentclientinskeletalDunloptraction.Whichnursinginterventionisappropriatefort hischild? A) Makecertainthechildismaintainedincorrectbodyalignment. B) Besurethetractionweightstouchtheendofthebed. C) Adjusttheheadandfootofthebedforthechild'scomfort D) Releasethetractionfor15-20minutesevery6hoursPRN. ThecorrectanswerisA:Makecertainthechildismaintainedincorrectbodyalignment. 2. Thenurseisassessingahealthychildatthe2yearcheckup.Whichofthefollowingshouldthen ursereportimmediatelytothehealthcareprovider? A) Heightandweightpercentilesvarywidely B) Growthpatternappearstohaveslowed C) Recumbentandstandingheightaredifferent D) Shorttermweightchangesareuneven ThecorrectanswerisA:Heightandweightpercentilesvarywidely 3. Theparentsofa2year- oldchildreportthathehasbeenholdinghisbreathwheneverhehastempertantrums. Whatisthebestactionbythenurse? A) Teachtheparentshowtoperformcardiopulmonaryresuscitation B) Recommendthattheparentsgiveinwhenheholdshisbreathtopreventanoxia C) Advisetheparentstoignorebreathholdingbecausebreathingwillbeginasareflex D) InstructtheparentsonhowtoreasonwiththechildaboutpossibleharmfuleffectsThecorrect answerisC:Advisetheparentstoignorebreathholdingbecausebreathingwillbeginasareflex 4. Thenurseisassessingaclientintheemergencyroom.Whichstatementsuggeststhattheprobl emisacuteangina? A) "Mypainisdeepinmychestbehindmysternum." B) "WhenIsitupthepaingetsworse." C) "AsItakeadeepbreaththepaingetsworse." D) "Thepainisrighthereinmystomacharea." ThecorrectanswerisA:"Mypainisdeepinmychestbehindmysternum." . 5. Thenurseisassessingthementalstatusofaclientadmittedwithpossibleorganicbraindisorder. Whichofthesequestionswillbestassessthefunctionoftheclient'srecent memory? A) "Nametheyear.""Whatseasonisthis?"(pauseforansweraftereachquestion) B) "Subtract7from100andthensubtract7fromthat."(pauseforanswer)"Nowcontinue tosubtract7from thenewnumber." C) "IamgoingtosaythenamesofthreethingsandIwantyoutorepeatthemafterme:blue,ball,pe n." D) "Whatisthisonmywrist?"(pointtoyourwatch)Thenask,"Whatisthepurposeofit?" ThecorrectanswerisC:"IamgoingtosaythenamesofthreethingsandIwantyoutorepeatthem afterme:blue,ball,pen." 6. Inplanningcarefora6month- oldinfant,whatmustthenurseprovidetoassistinthedevelopmentoftrust? A) Food B) Warmth C) Security D) Comfort ThecorrectanswerisC:Security 7. Anursehasjustreceivedamedicationorderwhichisnotlegible.Whichstatementbestreflectsas sertivecommunication? A) "Icannotgivethismedicationasitiswritten.Ihavenoideaofwhatyoumean." B) "WouldyoupleaseclarifywhatyouhavewrittensoIamsureIamreadingitcorrectly? " C) "Iamhavingdifficultyreadingyourhandwriting.Itwouldsavemetimeifyouwouldbemoreca reful." D) "PleaseprintinthefuturesoIdonothavetospendextratimeattemptingtoreadyourwriting." ThecorrectanswerisB)"WouldyoupleaseclarifywhatyouhavewrittensoIamsureIam readingitcorrectly?" 8. Whatisthemostimportantconsiderationwhenteachingparentshowtoreducerisksinthehome ? A) Ageandknowledgeleveloftheparents B) Proximitytoemergencyservices C) Numberofchildreninthehome D) Ageofchildreninthehome ThecorrectanswerisD:Ageofchildreninthehome 9. A35year- oldclientwithsicklecellcrisisistalkingonthetelephonebutstopsasthenurseenterstheroomtor equestsomethingforpain.Thenurseshould A) Administeraplacebo B) Encourageincreasedfluidintake C) Administertheprescribedanalgesia D) Recommendrelaxationexercisesforpaincontrol ThecorrectanswerisC:Administertheprescribedanalgesia 10. Whilecaringforatoddlerwithcroup,whichinitialsignofcrouprequiresthenurse'simmediat eattention? A) Respiratoryrateof42 B) Lethargyforthepasthour C) Apicalpulseof54 D) Coughingupcopioussecretions ThecorrectanswerisA:Respiratoryrateof30 11. AclientisadmittedwithlowT3andT4levelsandanelevatedTSHlevel.Oninitialassessmen t,thenursewouldanticipatewhichofthefollowingassessmentfindings? A) Lethargy B) Heatintolerance C) Diarrhea D) Skineruptions ThecorrectanswerisA:Lethargy 12. Theemergencyroomnurseadmitsachildwhoexperiencedaseizureatschool.Thefatherco mmentsthatthisisthefirstoccurrence,anddeniesanyfamilyhistoryofepilepsy.Whatisthebest responsebythenurse? A) "Donotworry.Epilepsycanbetreatedwithmedications." B) "Theseizuremayormaynotmeanyourchildhasepilepsy." C) "Sincethiswasthefirstconvulsion,itmaynothappenagain." D) "Longtermtreatmentwillpreventfutureseizures." ThecorrectanswerisB:"Theseizuremayormaynotmeanyourchildhasepilepsy." 13. Alcoholanddrugabuseimpairsjudgmentandincreasesrisktakingbehavior.Whatnursing diagnosisbestapplies? A) Riskforinjury B) Riskforknowledgedeficit C) Alteredthoughtprocess D) Disturbanceinself-esteem ThecorrectanswerisA:Riskforinjury 14. Thenurseiscaringfora10month- oldinfantwhoishasoxygenviamask.Itisimportantforthenursetomaintainpatencyofwhi choftheseareas? A) Mouth B) Nasalpassages C) Backofthroat D) Bronchials ThecorrectanswerisB:Nasalpassages 15. Thenurseisprovidinginstructionsforaclientwithpneumonia.Whatisthemostimportan tinformationtoconvey totheclient? A) "Take atleast2weeksofffrom work." B) "You willneedanotherchestx-rayin6weeks." C) "Takeyourtemperatureevery day." D) "Completealloftheantibioticevenifyourfindingsdecrease." ThecorrectanswerisD:"Completealloftheantibioticevenifyourfindingsdecrease." 16. Whencounselinga6yearoldwhoisexperiencingenuresis,whatmustthenurseundersta ndaboutthepathophysiologicalbasisofthisdisorder? A) Hasnoclearetiology B) Maybeassociatedwithsleepphobia C) Hasadefinitegeneticlink D) Isasignofwillfulmisbehavior ThecorrectanswerisA:Hasnoclearetiology 17. Thenurseisdiscussingnegativismwiththeparentsofa30month- oldchild.Howshouldthenursetelltheparentstobestrespondtothis behavior? A) Reprimandthechildandgivea15minute"timeout" B) Maintainapermissiveattitudeforthisbehavior C) Usepatienceandasenseofhumortodealwiththisbehavior D) Assertauthorityoverthechildthroughlimitsetting ThecorrectanswerisC:Usepatienceandasenseofhumortodealwiththisbehavior 18. Thenurseistalkingbytelephonewithaparentofa4year- oldchildwhohaschickenpox.Whichofthefollowingdemonstratesappropriateteachingbyt henurse? A) Chewableaspirinisthepreferredanalgesic B) Topicalcortisoneointmentrelievesitching C) Papules,vesicles,andcrustswillbepresentatonetime D) Theillnessisonlycontagiouspriortolesioneruption ThecorrectanswerisC:Papules,vesicles,andcrustswillbepresentatonetime 19. Thenurseisassignedtoaclientwhohasheartfailure.Duringthemorningroundsthenursese estheclientdevelopsuddenanxiety,diaphoresisanddyspnea.Thenurseauscultates,cracklesb ilaterally. Whichnursinginterventionshouldbeperformedfirst? A) Take theclient'svitalsigns B) Placetheclientinasittingpositionwithlegsdangling C) Contactthehealthcareprovider D) AdministerthePRNantianxietyagent ThecorrectanswerisB:Placetheclientinasittingpositionwithlegsdangling 20. Thenurseiscaringforatoddlerwithatopicdermatitis.Thenurseshouldinstructtheparentsto A) Dressthechildwarmlytoavoidchilling B) Keepthechildawayfromotherchildrenforthedurationoftherash C) Cleantheaffectedareaswithtepidwateranddetergent D) Wrapthechild'shandinmittensorsockstopreventscratching ThecorrectanswerisD:Wrapthechild''shandinmittensorsockstopreventscratching 21. Arecoveringalcoholicaskedthenurse,"Willitbeokformetojustdrinkatspecialfamilygath erings?"Whichinitialresponsebythenursewouldbebest? A) "Arecoveringpersonhastobeverycarefulnottolosecontrol,therefore,confineyourdrinkingj ustatfamilygatherings." B) "AtyournextAAmeetingdiscussthepossibilityoflimiteddrinkingwithyoursponsor. " C) "Arecoveringpersonneedstogetintouchwiththeirfeelings.Doyouwantadrink?" D) "Arecoveringpersoncannotreturntodrinkingwithoutstartingtheaddictionprocessover." ThecorrectanswerisD:"Therecoveringpersoncannotreturntodrinkingwithoutstartingtheaddi ctionprocessover." 22. Intakingthehistoryofapregnantwoman,whichofthefollowingwouldthenurserecognize astheprimarycontraindicationforbreastfeeding? A) Age40years B) Lactoseintolerance C) Familyhistoryofbreastcancer D) Usescocaineonweekends ThecorrectanswerisD:Usescocaineonweekends 23. AclientisreceivingnitroprussideIVforthetreatmentofacuteheartfailurewithpulmonaryed ema.Whatdiagnosticlabvalueshouldthenursemonitorinrelationtothismedication? A) Potassium B) Arterialbloodgasses C) Bloodureanitrogen D) Thiocyanate ThecorrectanswerisD:Thiocyanate 24. Avictimofdomesticviolencetellsthebatterersheneedsalittletimeaway.Howwouldthe nurseexpectthatthebatterermightrespond? A) Withacceptanceandviewsthevictim’scommentasanindicationthattheirmarriageisin trouble B) Withfearofrejectioncausingincreasedragetowardthevictim C) Withanewcommitmenttoseekcounselingtoassistwiththeirmaritalproblems D) Withrelief,andwelcomestheseparationasameanstohavesomepersonaltime ThecorrectanswerisB:Withfearofrejectioncausingincreasedragetowardthevictim 25. Apostpartummotherisunwillingtoallowthefathertoparticipateinthenewborn'scare, althoughheisinterestedindoingso.Shestates,"Iamafraidthebabywillbeconfusedaboutwhoth emotheris.Babyraisingisformothers,notfathers."Thenurse'sinitialinterventionshouldbewh atfocus? A) Discusswiththemothersharingparentingresponsibilities B) Settimeasidetogetthemothertoexpressherfeelingsandconcerns C) Arrangefortheparentstoattendinfantcareclasses D) Talkwiththefatherandhelphimacceptthewife'sdecision ThecorrectanswerisB:Settimeasidetogetthemothertoexpressherfeelingsandconcerns 26. Aclientwithemphysemavisitstheclinic.Whileteachingaboutpropernutrition,thenursesh ouldemphasizethattheclient A) Eatfoodshighinsodiumincreasessputumliquefaction B) Useoxygenduringmealsimprovesgasexchange C) Performexerciseafterrespiratorytherapyenhancesappetite D) Cleansethemouthofdriedsecretionsreducesriskofinfection ThecorrectanswerisB:Useoxygenduringmealsimprovesgasexchange 27. Whichoftheseparents’commentforanewbornwouldmostlikelyrevealaninitialfindingo fasuspectedpyloricstenosis? A) Inoticedalittlelumpalittleabovethebellybutton. B) Thebabyseemshungryallthetime. C) Mildvomitingthatprogressedtovomitingshootingacrosstheroom. D) Irritationandspittingupimmediatelyafterfeedings. ThecorrectanswerisC:Mildemesisprogressingtoprojectilevomiting 28. Thenurseisassessingachildforclinicalmanifestationsofirondeficiencyanemia.Whichfa ctorwouldthenurserecognizeascauseforthefindings? A) Decreasedcardiacoutput B) Tissuehypoxia C) Cerebraledema D) Reducedoxygensaturation ThecorrectanswerisB:Tissuehypoxia 29. Thenursewouldexpectthecysticfibrosisclienttoreceivesupplementalpancreaticenzyme salongwithadiet A) Highincarbohydratesandproteins B) Lowincarbohydratesandproteins C) Highincarbohydrates,lowinproteins D) Lowincarbohydrates,highinproteins ThecorrectanswerisA:Highincarbohydratesandproteins 30. Inevaluatingthegrowthofa12month- oldchild,whichofthesefindingswouldthenurseexpecttobepresentintheinfant? A) Increased10%inheight B) 2deciduousteeth C) Tripledthebirthweight D) Headchestcircumference ThecorrectanswerisC:Tripledthebirthweight 31. AHispanicclientinthepostpartumperiodrefusesthehospitalfoodbecauseitis"cold."T hebestinitialactionbythenurseisto A) Havetheunlicensedassistivepersonnel(UAP)reheatthefoodiftheclientwishes B) Asktheclientwhatfoodsareacceptableorbad C) Encouragehertoeatforhealingandstrength D) SchedulethedietitiantomeetwiththeclientassoonaspossibleThecor rectanswerisB:Asktheclientwhatfoodsareacceptable 32. Thefatherofan8month- oldinfantasksthenurseifhisinfant'svocalizationsarenormalforhisage.Whichofthefollowi ngwouldthenurseexpectatthisage? A) Cooing B) Imitationofsounds C) Throatysounds D) Laughter ThecorrectanswerisB:ImitationofSounds 33. Thenurseshouldrecognizethatphysicaldependenceisaccompaniedbywhatfinding swhenalcoholconsumptionisfirstreducedorended? A) Seizures B) Withdrawal C) Craving D) Markedtolerance ThecorrectanswerisB:Withdrawal 34. Immediatelyfollowinganacutebatteringincidentinaviolentrelationship,thebattere rmay respondtothepartner’sinjuriesby A) Seekingmedicalhelpforthevictim'sinjuries B) Minimizingtheepisodeandunderestimatingthevictim’sinjuries C) Contactingaclosefriendandaskingforhelp D) Beingveryremorsefulandassistingthevictimwithmedicalcare ThecorrectanswerisB:Minimizingtheepisodeandunderestimatingthevictim’sinjuries 35. Thenurseisplanningtogivea3year- oldchildoraldigoxin.Whichofthefollowingisthebestapproachbythenurse? A) "Doyouwanttotakethisprettyredmedicine?" B) "Youwillfeelbetterifyoutakeyourmedicine." C) "Thisisyourmedicine,andyoumusttakeitall rightnow." D) "Wouldyouliketotakeyourmedicinefromaspoonoracup?" ThecorrectanswerisD:"Wouldyouliketotakeyourmedicinefromaspoonoracup?" 36. Inplanningcareforachilddiagnosedwithminimalchangenephroticsyndrome,thenurse shouldunderstandtherelationshipbetweenedemaformationand A) Increasedretentionofalbumininthevascularsystem B) Decreasedcolloidalosmoticpressureinthecapillaries C) Fluidshiftfrominterstitialspacesintothevascularspace D) Reducedtubularreabsorptionofsodiumandwater ThecorrectanswerisB:Decreasedcolloidalosmoticpressureinthecapillaries 37. Aneighteenmonth- oldhasbeenbroughttotheemergencyroomwithirritability,lethargyover2days,dryskinandi ncreasedpulse.Basedupontheevaluationoftheseinitialfindings,thenursewouldassessthech ildforadditionalfindingsof A) Septicemia B) Dehydration C) Hypokalemia D) Hypercalcemia ThecorrectanswerisB:Dehydration 38. Aclientwhohasbeendrinkingforfiveyearsstatesthathedrinkswhenhegetsupsetabout"thing s"suchasbeingunemployedorfeelinglikelifeisnotleadinganywhere.Thenurseunderstandsthat theclientisusingalcoholasawaytodealwith A) Recreationalandsocialneeds B) Feelingsofanger C) Life’sstressors D) IssuesofguiltanddisappointmentThec orrectanswerisC:Life’sstressors 39. Thenurseismonitoringthecontractionsofawomaninlabor.Acontractionisrecordedasbeg inningat10:00A.M.andendingat10:01A.M.Anotherbeginsat10:15 A.M.Whatisthefrequencyofthecontractions? A) 14minutes B) 10minutes C) 15minutes D) Nineminutes ThecorrectanswerisC:15minutes 40. Thenurseisperforminganassessmentonachildwithsevereairwayobstruction.Whichfi ndingwouldthenurseanticipatefinding? A) Retractionsintheintercostaltissuesofthethorax B) Chestpainaggravatedbyrespiratorymovement C) Cyanosisandmottlingoftheskin D) Rapid,shallowrespirations ThecorrectanswerisA:Retractionsinthesofttissuesofthethorax 41. Duringtheevaluationphaseforaclient,thenurseshouldfocuson A) Allfindingofphysicalandpsychosocialstressorsoftheclientandinthefamily B) Theclient'sstatus,progresstowardgoalachievement,andongoingre-evaluation C) Settingshortandlong-termgoalstoinsurecontinuityofcarefromhospitaltohome D) SelectinterventionsthataremeasurableandachievablewithinselectedtimeframesTheco rrectanswerisB:Theclient''sstatus,progresstowardgoalachievement,andongoingreevaluat ion 42. The school nurse suspects that a third grade child might have Attention DeficitHyperactivity Disorder. Prior to referring the child for further evaluation, the nurseshould A) Observethechild'sbehavioronatleast2occasions B) Consultwiththeteacherabouthowtocontrolimpulsivity C) Compileahistoryofbehaviorpatternsanddevelopmentalaccomplishments D) Comparethechild'sbehaviorwithclassicsignsandsymptoms ThecorrectanswerisC:Compileahistoryofbehaviorpatternsanddevelopmentalaccomplishment s 43. WhichoftheactionssuggestedtotheRNbythePNduringaplanningconferencefora 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptabletoaddtotheplanof care? A) Measureheadcircumference B) Placeinairborneisolation C) Providepassiverangeofmotion D) Provideanover-the-cribprotectivetop ThecorrectanswerisA:Measureheadcircumference 44. AclientisadmittedwithadiagnosisofhepatitisB.Inreviewingtheinitiallaboratoryresults,th enursewouldexpecttofindelevationinwhichofthefollowingvalues? A) Bloodureanitrogen B) Acidphosphatase C) Bilirubin D) Sedimentationrate ThecorrectanswerisC:Bilirubin 45. Thenurseisdiscussingnutritionalrequirementswiththeparentsofan18month- oldchild.Whichof thesestatementsaboutmilkconsumptioniscorrect? A) May drinkasmuchmilkasdesired B) Canhavemilkmixedwithotherfoods C) Willbenefitfromfat-freecow'smilk D) Shouldbelimitedto3-4cupsofmilkdaily ThecorrectanswerisD:Shouldbelimitedtothreetofourcupsofmilkdaily 46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon isfull. Astronauts walk on the moon. Walking is a good health habit." The client’s behaviormostlikelyindicates A) Neologisms B) Dissociation * C)Flightofideas D)Wordsalad ThecorrectanswerisC:Flightofideas 47. Amotherasksaboutexpectedmotorskillsfora3year- oldchild.Whichofthefollowingwouldthenurseemphasize as normalatthisage? A) Jumpingrope B) Tyingshoelaces C) Ridingatricycle D) Playinghopscotch ThecorrectanswerisC:Ridingatricycle 48. Ahomehealthnurseiscaringforaclientwithapressuresorethatisred,withserousdrainage,is 2inchesindiameterwithlossofsubcutaneoustissue.Theappropriatedressingfor thiswoundis A) Atransparentfilmdressing B) Wetdressingwithdebridementgranules C) Wettodrywithhydrogenperoxide D) Moistsalinedressing ThecorrectanswerisD:Moistsalinedressing 49. Thenurseentersa2year- oldchild'shospitalroominordertoadministeranoralmedication.Whenthechildisaskedifheisr eadytotakehismedicine,heimmediatelysays,"No!".Whatwouldbethe mostappropriatenextaction? A) Leavetheroomandreturnfiveminuteslaterandgivethemedicine B) Explaintothechildthatthemedicinemustbetakennow C) Givethemedicationtothefatherandaskhimtogiveit D) Mixthemedicationwithicecreamorapplesauce ThecorrectanswerisA:Leavetheroomandreturnfiveminuteslaterandgivethemedicine 50. Anurseisdoingpreconceptualcounselingwithawomanwhoisplanningapregnancy.Wh ichofthefollowingstatementssuggeststhattheclientunderstandstheconnectionbetweenalc oholconsumptionandfetalalcoholsyndrome? A) "Iunderstandthataglassofwinewithdinnerishealthy." B) "Beerisnotreallyhardalcohol,soIguessIcandrinksome." C) "IfIdrink,mybabymaybeharmedbeforeIknowIampregnant." D) "Drinkingwithmealsreducestheeffectsofalcohol." ThecorrectanswerisC:"IfIdrink,mybabymaybeharmedbeforeIknowIampregnant." 51. Theclientwhoisreceivingenteralnutritionthroughagastrostomytubehashad4diarrheas toolsinthepast24hours.Thenurseshould A) Reviewthemedicationstheclientisreceiving B) Increasetheformulainfusionrate C) Increasetheamountofwaterusedtoflushthetube D) Attacharectalbagtoprotecttheskin ThecorrectanswerisA:Reviewthemedicationstheclientisreceiving 52. Anurseisassignedtoaclientwhoisanewadmissionforthetreatmentofafrontallobebraintu mor.Whichhistoryofferedbythefamilymemberswouldbeanticipatedbythenurseasassociated withthediagnosisandcommunicated? A) "Mypartner'sbreathingrateisusuallybelow12." B) "Ifindthemoodswingsandthechangefromacalmpersontobeingangryallthetimehardto dealwith." C) "Itseemsoursexlifeisnonexistantoverthepast6months." D) "InthemorningandeveningIhearcomplaintsthatreadingisnexttoimpossiblefromblurredpri nt." ThecorrectanswerisB:"Ifindthemoodswingsandthechangefromacalmpersonto beingangryallthetimehardtodealwith." 53. ThenursepreparesforaDenverScreeningtestwitha3year- oldchildintheclinic.Themotherasksthenursetoexplainthepurposeofthetest.Whatisthenurse ’sbestresponseaboutthepurposeof theDenver? A) Itmeasuresachild’sintelligence. B) Itassessesachild'sdevelopment. C) Itevaluatespsychologicalresponses. D) Ithelpstodetermineproblems. ThecorrectanswerisB:Itassessesachild''sdevelopment. 54. Thenurseispreparinga5year- oldforascheduledtonsillectomyandadenoidectomy.Theparentsareanxiousandconcernedabo utthechild'sreactiontoimpendingsurgery.Whichnursinginterventionwouldbebesttoprepareth echild? A) Introducethechildtoallstaffthedaybeforesurgery B) Explainthesurgery1weekpriortotheprocedure C) Arrangeatouroftheoperatingandrecoveryrooms D) Encouragethechildtobringafavoritetoytothehospital ThecorrectanswerisB:Explainthesurgery1weekpriortotheprocedure 55. Thenurse,assistinginapplyingacasttoaclientwithabrokenarm,knowsthat A) Thecastmaterialshouldbedippedseveraltimesintothewarmwater B) Thecastshouldbecovereduntilitdries C) Thewetcastshouldbehandledwiththepalmsofhands D) Thecastedextremityshouldbeplacedonacloth-coveredsurface ThecorrectanswerisC:Thewetcastshouldbehandledwiththepalmsofhands 56. Basedonprinciplesofteachingandlearning,whatisthebestinitialapproachtopre- opteachingfora clientscheduledforcoronaryartery bypass? A) Touringthecoronaryintensiveunit B) Mailingavideotapetothehome C) Assessingtheclient'slearningstyle D) Administeringawrittenpre-test ThecorrectanswerisC:Assessingtheclient''slearningstyle 57. A 4 year-old child is recovering from chicken pox (varicella). The parents would liketohavethechildreturntodaycareassoonaspossible.Inordertoensurethattheillnessisnolong er communicable,whatshouldthenurseassessforinthischild? A) Alllesionscrusted B) Elevatedtemperature C) Rhinorrheaandcoryza D) Presenceofvesicles ThecorrectanswerisA:Alllesionscrusted 58. Thenurseisprovidinginstructionstoanewmotheronthepropertechniquesforbreastfeedingh erinfant.Whichstatementbythemotherindicatestheneedforadditionalinstruction? A) "Ishouldpositionmybabycompletelyfacingmewithmybaby'smouthinfrontofmynipple. " B) "Thebabyshouldlatchontothenippleandareolaareas." C) "TheremaybetimesthatIwillneedtomanuallyexpressmilk." D) IcanswitchtoabottleifIneedtotakeabreakfrombreastfeeding. ThecorrectanswerisD:IcanswitchtoabottleifIneedtotakeabreakfrombreastfeeding. 59. Thenurseassessesaclientwhohasbeenre-admittedtothepsychiatricin- patientunitforschizophrenia.Hissymptomshave beenmanagedforseveralmonthswithfluphenazine(Prolixin).Whichshouldbeafocusofthefirst assessment? A) Stressorsinthehome B) Medicationcompliance C) Exposuretohottemperatures D) Alcoholuse ThecorrectanswerisB:Medicationcompliance 60. ThenurseiscaringforaclientwithanunstablespinalcordinjuryattheT7level.Whichinte rventionshouldtakepriority inplanningcare? A) Increasefluidintaketopreventdehydration B) Placeclientonapressurereducingsupportsurface C) Useskincareproductsdesignedforusewithincontinence D) Increasecaloricintaketoaidhealing ThecorrectanswerisB:Placeclientonapressurereducingsupportsurface 61. Anurseisconductingacommunitywideseminaronchildhoodsafetyissues.Whichofthesec hildrenisatthehighestriskforpoisoning? A) 9month-oldwhostayswithasitter5daysaweek B) 20month-oldwhohasjustlearnedtoclimbstairs C) 10year-oldwhooccasionallystaysathomeunattended D) 15year-oldwholikestorepairbicycles ThecorrectanswerisB:Twentymonth-oldwhohasjustlearnedtoclimbstairs 62. Duringanexaminationofa2year- oldchildwithatentativediagnosisofWilm'stumor,thenursewouldbemostconcernedabout whichstatementbythemother? A) Mychildhaslost3poundsinthelastmonth. B) Urinaryoutputseemedtobelessoverthepast2days. C) Allthepantshavebecometightaroundthewaist. D) Thechildpreferssomesaltyfoodsmorethanothers. ThecorrectanswerisC:Clothinghasbecometightaroundthewaist 63. Whatisthemostimportantaspecttoincludewhendevelopingahomecareplanforaclientwith severearthritis? A) Maintainingandpreservingfunction B) Anticipatingsideeffectsoftherapy C) Supportingcopingwithlimitations D) Ensuringcompliancewithmedications ThecorrectanswerisA:Maintainingandpreservingfunction 64. Amotherasksthenurseifsheshouldbeconcernedaboutthetendencyofherchildtostutter.Wh atassessmentdatawillbemostusefulincounselingtheparent? A) Ageofthechild B) Siblingpositioninfamily C) Stressfulfamilyevents D) Parentaldisciplinestrategies ThecorrectanswerisA:Ageofthechild 65. Apre- termnewbornistobefedbreastmilkthroughnasogastrictube.Whyisbreastmilkpreferredoverf ormulaforprematureinfants? A) Containslesslactose B) Ishigherincalories/ounce C) Providesantibodies D) Haslessfattyacid ThecorrectanswerisC:Providesantibodies 66. Whichofthefollowingnursingassessmentsinaninfantismostvaluableinidentifyi ngseriousvisualdefects? A) Redreflextest B) Visualacuity C) Pupilresponsetolight D) Covertest ThecorrectanswerisA:Redreflextest 67. Aclientisadmittedwithapressureulcerinthesacralarea.Thepartialthicknesswoundis4cm by7cm,thewoundbaseisredandmoistwithnoexudateandthesurroundingskinisintact.Whicho fthefollowingcoveringsismostappropriateforthiswound? A) Transparentdressing B) Drysteriledressingwithantibioticointment C) Wettodrydressing D) Occlusivemoistdressing ThecorrectanswerisD:Occlusivemoistdressing 68. A30month- oldchildisadmittedtothehospitalunit.Whichofthefollowingtoyswouldbeappropriateforth enursetoselectfromthetoyroomforthischild? A) Cartoonstickers B) Largewoodenpuzzle C) Bluntscissorsandpaper D) Beachball ThecorrectanswerisB:Largewoodenpuzzle 69. A nurse is to present information about Chinese folk medicine to a group of studentnurses. Based on this cultural belief, the nurse would explain that illness is attributed tothe A) Yang,thepositiveforcethatrepresentslight,warmth,andfullness B) Yin,thenegativeforcethatrepresentsdarkness,cold,andemptiness C) Useofimproperhotfoods,herbsandplants D) Afailuretokeeplifeinbalancewithnatureandothers ThecorrectanswerisB:Yin,thenegativeforcethatrepresentsdarkness,cold,andemptiness 70. A2year- oldchildhasjustbeendiagnosedwithcysticfibrosis.Thechild'sfatherasksthenurse"Whatisour majorconcernnow,andwhatwillwehave todealwithinthefuture?"Whichofthefollowingisthebestresponse? A) "Thereisaprobabilityoflife-longcomplications." B) "Cysticfibrosisresultsinnutritionalconcernsthatcanbedealtwith." C) "Thin,tenacioussecretionsfromthelungsareaconstantstruggleincysticfibrosis." D) "Youwillworkwithateamofexpertsandalsohaveaccesstoasupportgroupthatthefamilycanat tend." ThecorrectanswerisC:"Thin,tenacioussecretionsfromthelungsareaconstantstruggleincysticf ibrosis." 71. Whichtypeofaccidentalpoisoningwouldthenurseexpecttooccurinchildrenunderage6? A) Oralingestion B) Topicalcontact C) Inhalation D) Eyesplashes ThecorrectanswerisA:Oralingestion 72. Aclientwasadmittedtothepsychiatricunitwithadiagnosisofbipolardisorder.Heconstantl ybothersotherclients,triestohelpthehousekeepingstaff,demonstratespressuredspeechandde mands constantattentionfromthestaff.Whichactivitywouldbebestfortheclient? A) Reading B) Checkers C) Cards D) Ping-pong ThecorrectanswerisD:Ping-pong 73. Thenurseiscaringforaclientwhohasdevelopedcardiactamponade.Whichfindingwouldth enurseanticipate? A) Wideningpulsepressure B) Pleuralfrictionrub C) Distendedneckveins D) Bradycardia ThecorrectanswerisC:Distendedneckveins 74. Whichnursingactionisapriorityastheplanofcareisdevelopedfora7year- oldchildhospitalizedforacuteglomerulonephritis? A) Assessforgeneralizededema B) Monitorforincreasedurinaryoutput C) Encouragerestduringhyperactiveperiods D) Notepatternsofincreasedbloodpressure ThecorrectanswerisD:Notepatternsofincreasedbloodpressure 75. Thenurseiscaringforachildreceivingchestphysiotherapy(CPT).Whichofthefollowin gactionsby thenursewouldbeappropriate? A) Schedulethetherapythirtyminutesaftermeals B) Teachthechildnottocoughduringthetreatment C) Confinethepercussiontotheribcagearea D) Placethechildinapronepositionforthetherapy ThecorrectanswerisC:Confinethepercussiontotheribcagearea 76. Apolydruguserhasbeeninrecoveryfor8months.Theclienthasbeganskippingbreakfasta ndnoteatingregulardinners.Theclienthasalsostartedfrequentingbarsto"seeoldbuddies." Thenurseunderstandsthattheclient’sbehaviorisawarningsigntoindicatethattheclientmay be A) headedforrelapse B) feelinghopeless C) approachingrecovery D) inneedofincreasedsocialization ThecorrectanswerisA:headedforrelapse 77. Aclientwasadmittedtothepsychiatricunitwithmajordepressionafterasuicideattempt.I nadditiontofeelingsadandhopeless,thenursewouldassessfor A) Anxiety,unconsciousanger,andhostility B) Guilt,indecisiveness,poorself-concept C) Psychomotorretardationoragitation D) Meticulousattentiontogroomingandhygiene ThecorrectanswerisC:Psychomotorretardationoragitation 78. Aclientisexperiencinghallucinationsthataremarkedlyincreasedatnight.Theclientisveryfri ghtenedbythehallucinations.Theclient’spartneraskedtostayafewhoursbeyondthevisitingtime ,intheclient’sprivateroom.Whatwouldbethebestresponsebythenursedemonstratingemotional supportfortheclient? A) "No,itwouldbebestifyoubroughttheclientsomereadingmaterialthatshecouldreadatnigh t." B) "No,yourpresencemaycausetheclienttobecomemoreanxious." C) "Yes,stayingwiththeclientandorientinghertohersurroundingsmaydecreaseheranxiety." D) "Yes,wouldyouliketospendthenightwhentheclient’sbehaviorindicatesthatsheisfrightened ?" ThecorrectanswerisC:"Yes,stayingwiththeclientandorientinghertohersurroundings may decreaseheranxiety." 79. Atawellbabyclinicthenurseisassignedtoassessan8month- oldchild.Whichofthesedevelopmentalachievementswouldthenurseanticipatethatthechildwo uldbeabletoperform? A) Say2words B) Pulluptostand C) Sitwithoutsupport D) Drinkfromacup ThecorrectanswerisC:Sitwithoutsupport 80. Thenurseistalkingtoparentsaboutnutritioninschoolagedchildren.Whichofthefollowing isthemostcommonnutritionaldisorderinthisagegroup? A) Bulimia B) Anorexia * C)Obesity D)Malnutrition ThecorrectanswerisC:Obesity 81. Atthegeriatricdaycareprogramaclientiscryingandrepeating"Iwanttogohome.Callmydad dytocomeforme."Thenurseshould A) Invitetheclienttojointheexercisegroup B) Telltheclientyouwillcallsomeonetocomeforher C) Givetheclientsimpleinformationaboutwhatshewillbedoing D) FirmlydirecttheclienttoherassignedgroupactivityThec orrectanswerisC:Givetheclientsimpleinformationaboutw hatshe willbedoing 82. Avictimofdomesticviolencestatestothenurse,"IfonlyIcouldchangeandbehowmycompan ionwantsmetobe,Iknowthingswouldbedifferent."Whichwouldbethebestresponseby the nurse? A) "Theviolenceistemporarilycausedbyunusualcircumstances,don’tstophopingforachange." B) "Perhaps,ifyouunderstoodtheneedtoabuse,youcouldstoptheviolence." C) "Noonedeservestobebeaten.Areyoudoinganythingtoprovokeyourspouseintobeatingyo u?" D) "Batterersloseself- controlbecauseoftheirowninternalreasons,notbecauseofwhattheirpartnerdidor didnotdo." ThecorrectanswerisD:"Batterersloseselfcontrolbecauseoftheirowninternal reasons,notbecauseofwhattheirpartnerdidordidnotdo." 83. A38year- oldfemaleclientisadmittedtothehospitalwithanacuteexacerbationofasthma.Thisisherthirda dmissionforasthmain7months.Shedescribeshowshedoesn'treally likehavingtouse hermedicationsallthetime.Whichexplanationbythenursebestdescribesthelong- termconsequenceofuncontrolledairway inflammation? A) Degenerationofthealveoli B) Chronicbronchoconstrictionofthelargeairways C) Lungremodelingandpermanentchangesinlungfunction D) Frequentpneumonia ThecorrectanswerisC:Lungremodelingandpermanentchangesinlungfunction 84. Amotherwantstoswitchher9month- oldinfantfromanironfortifiedformulatowholemilkbecauseoftheexpense.Uponfurtherasse ssment,thenursefindsthatthebabyeatstablefoodswell,butdrinkslessmilkthanbefore.Whati sthebestadvicebythenurse? A) Changethebabytowholemilk B) Addchocolatesyruptothebottle C) Continuewiththepresentformula D) Offerfruitjuicefrequently ThecorrectanswerisC:Continuewiththepresentformula 85. Privacyandconfidentialityofallclientinformationislegallyprotected.Inwhichofthese situationswouldthenursemakeanexceptiontothispractice? A) Whenafamilymemberoffersinformationabouttheirlovedone B) Whentheclientthreatensself-harmandharmtoothers C) Whenthehealthcareproviderdecidesthefamilyhasarighttoknowtheclient'sdiagnosis D) WhenavisitorinsiststhatthevisitorhasbeengivenpermissionbytheclientThecorre ctanswerisB:Whentheclientthreatensself-harmandharmtoothers 86. Thenurseiscaringforaclientwhoisinthelatestageofmultiplemyeloma.Whichofthefollowin gshouldbeincludedintheplanofcare? A) Monitorforhyperkalemia B) Placeinprotectiveisolation C) Precautionswithpositionchanges D) Administerdiureticsasordered ThecorrectanswerisC:Precautionswithpositionchanges 87. Thenurseismakingahomevisittoaclientwithchronicobstructivepulmonarydisease(COP D).Theclienttellsthenursethatheusedtobeabletowalkfromthehousetothemailboxwithout difficulty.Now,hehastopausetocatchhisbreathhalfwaythroughthetrip.Whichdiagnosiswouldbe mostappropriateforthisclientbasedonthisassessment? A) Activityintolerancecausedbyfatiguerelatedtochronictissuehypoxia B) Impairedmobilityrelatedtochronicobstructivepulmonarydisease C) Selfcaredeficitcausedbyfatiguerelatedtodyspnea D) Ineffectiveairwayclearancerelatedtoincreasedbronchialsecretions ThecorrectanswerisA:Activityintolerancecausedbyfatiguerelatedtochronictissuehypoxia 88. Thenurseadmitsaclientnewlydiagnosedwithhypertension.Whatisthebestmethodf orassessingthebloodpressure? A) Standingandsitting B) Inbotharms C) Afterexercising D) Supineposition ThecorrectanswerisB:Inbotharms 89. Thenurseiscaringforresidentsinalongtermcaresettingfortheelderly.Whichofthefollowi ngactivitieswillbemosteffectiveinmeetingthegrowthanddevelopmentneeds forpersonsinthisagegroup? A) Aerobicexerciseclasses B) Transportationforshoppingtrips C) Reminiscencegroups D) Regularlyscheduledsocialactivities ThecorrectanswerisC:Reminiscencegroups 90. Post-procedurenursinginterventionsforelectroconvulsivetherapyinclude A) Applyinghardrestraintsifseizureoccurs B) Expectingclienttosleepfor4to6hours C) Remainingwithclientuntiloriented D) Expectinglong-termmemoryloss ThecorrectanswerisC:Remainingwithclientuntiloriented 91. Thenurseassessesdelayedgrossmotordevelopmentina3year- oldchild.Theinabilityofthechildtodowhichactionconfirmsthisfinding? A) Standon1foot B) Catchaball C) Skiponalternatefeet D) Rideabicycle ThecorrectanswerisA:Standon1foot . 92. Themotherofa15month- oldchildasksthenursetoexplainherchild'slabresultsandhowtheyshowherchildhasirondefic iencyanemia.Thenurse'sbestresponseis A) "Althoughtheresultsarehere,yourdoctorwillexplainthemlater." B) "Yourchildhaslessredbloodcellsthatcarryoxygen." C) "Thebloodcellsthatcarrynutrientstothecellsaretoolarge." D) "Therearenotenoughbloodcellsinyourchild'scirculation." ThecorrectanswerisB:"Yourchildhaslessredbloodcellsthatcarryoxygen." 93. Inachildwithsuspectedcoarctationoftheaorta,thenursewouldexpecttofind A) Strongpedalpulses B) Diminishingcarotidpulses C) Normalfemoralpulses D) Boundingpulsesinthearms ThecorrectanswerisD:Boundingpulsesinthearms 94. AtthedaytreatmentcenteraclientdiagnosedwithSchizophrenia-ParanoidTypesitsalone alertlywatchingtheactivitiesofclientsandstaff. Theclientishostilewhenapproachedandassertsthatthedoctorgiveshermedicationtocontrolher mind.Theclient'sbehaviormostlikelyindicates A) Feelingsofincreasinganxietyrelatedtoparanoia B) Socialisolationrelatedtoalteredthoughtprocesses C) Sensoryperceptualalterationrelatedtowithdrawalfromenvironment D) Impairedverbalcommunicationrelatedtoimpairedjudgment ThecorrectanswerisB:Socialisolationrelatedtoalteredthoughtprocesses 95. A65-year-oldHispanic-Latinoclientwithprostatecancerrateshispainasa6ona0-to- 10scale.TheclientrefusesallpainmedicationotherthanMotrin,whichdoesnotrelievehispain.T henextactionforthenursetotakeisto A) Asktheclientabouttherefusalofcertainpainmedications B) Talkwiththeclient'sfamilyaboutthesituation C) Reportthesituationtothehealthcareprovider D) Documentthesituationinthenotes ThecorrectanswerisA:Asktheclientabouttherefusalofcertainpainmedications 96. Whenteachingadolescentsaboutsexuallytransmitteddiseases,whatshouldthenurseempha sizethatisthemostcommoninfection? A) Gonorrhea B) Chlamydia C) Herpes D) HIV ThecorrectanswerisB:Chlamydia 97. First-timeparentsbringtheir5day- oldinfanttothepediatrician'sofficebecausetheyareextremelyconcernedaboutitsbreathingpatt ern.Thenurseassessesthebabyandfindsthat thebreathsounds areclearwithequalchestexpansion.Therespiratoryrateis38- 42breathsperminutewithoccasionalperiodsofapnealasting10secondsinlength.Whatisthecorre ctanalysisofthesefindings? A) Thepediatricianmustexaminethebaby B) Emergencyequipmentshouldbeavailable C) Thisbreathingpatternisnormal D) Afuturereferralmaybeindicated ThecorrectanswerisC:Thisbreathingpatternisnormal 98. Aclientisadmittedwiththediagnosisofmeningitis.Whichfindingwouldthenurseexpectin assessingthisclient? A) Hyperextensionoftheneckwithpassiveshoulderflexion B) Flexionofthehipandkneeswithpassiveflexionoftheneck C) Flexionofthelegswithreboundtenderness D) Hyperflexionoftheneckwithreboundflexionofthelegs ThecorrectanswerisB:Flexionofthehipandkneeswithpassiveflexionoftheneck 99. Clientstakingwhichofthefollowingdrugsareatriskfordepression? A) Steroids B) Diuretics C) Folicacid D) Aspirin ThecorrectanswerisA:Steroids 100. Whenaclientishavingageneraltonicclonicseizure,thenurseshould A) Holdtheclient'sarmsattheirside B) Placetheclientontheirside C) Insertapaddedtonguebladeinclient'smouth D) Elevatetheheadofthebed ThecorrectanswerisB:Placetheclientontheirside 101Aftertalkingwithherpartner,aclientvoluntarilyadmittedherselftothesubstanceabuseunit. Aftertheseconddayontheunittheclientstatestothenurse,"Myhusbandtoldmetogettreatmentor hewoulddivorceme.Idon’tbelieveIreallyneedtreatmentbutIdon’twantmyhusbandtoleaveme. "Whichresponsebythenursewouldassisttheclient? A) "Inearlyrecovery,it'squitecommontohavemixedfeelings,butunmotivatedpeoplecan’tget well." B) "Inearlyrecovery,it’squitecommontohavemixedfeelings,butIdidn’tknowyouhadbeenp ressuredto come." C) "Inearlyrecoveryit’squitecommontohavemixedfeelings,perhapsitwouldbebesttoseektre atmentonanoutclientbases." D) "Inearlyrecovery,it’squitecommontohavemixedfeelings.Let’sdiscussthebenefits ofsobrietyforyou." ThecorrectanswerisD:"Inearlyrecovery,it’squitecommontohavemixedfeelings.Let’s discussthebenefitsofsobrietyforyou." 102. Aneonateborn12hoursagotoamethadonemaintainedwomanisexhibitingahyperactiv eMOROreflexandslighttremors.Thenewbornpassesloose,waterystool.Whichof theseisanursingpriority? A) Holdtheinfantatfrequentintervals. B) Assessforneonatalwithdrawalsyndrome C) Offerfluidstopreventdehydration D) Administerparegorictostopdiarrhea ThecorrectanswerisB:Assessforneonatalwithdrawalsyndrome 103. Thenurseiscaringforapostmyocardialinfarctionclientinanintensivecareunit.Itisnotedtha turinaryoutputhasdroppedfrom60-70mlperhourto30mlperhour.Thischangeis mostlikely dueto A) Dehydration B) Diminishedbloodvolume C) Decreasedcardiacoutput D) Renalfailure ThecorrectanswerisC:Decreasedcardiacoutput 104. Theprimarynursingdiagnosisforaclientwithcongestiveheartfailurewithpulmon aryedema is A) Pain B) Impairedgasexchange C) Cardiacoutputaltered:decreased D) Fluidvolumeexcess ThecorrectanswerisC:Cardiacoutputaltereddecreased 105. Thenurseisperformingadevelopmentalassessmentonan8month- old.Whichfindingshouldbereportedtothehealthcareprovider? A) Liftsheadfromtheproneposition B) Rollsfromabdomentoback C) Respondstoparents'voices D) Fallsforwardwhensitting ThecorrectanswerisD:Fallsforwardwhensitting.Sittingwithoutsupportisexpectedatthisage. 106. Aclienthasreceivedherfirstdoseoffluphenazine(Prolixin)2hoursago.Shesuddenlyexpe riencestorticollisandinvoluntaryspasticmusclemovement.Inadditiontoadministeringtheorde redanticholinergicdrug,whatothermeasureshouldthenurseimplement? A) Haverespiratorysupportequipmentavailable B) Immediatelyplaceherintheseclusionroom C) Assesstheclientforanxietyandagitation D) AdministerPRNdoseofIMantipsychoticmedication ThecorrectanswerisA:Haverespiratorysupportequipmentavailable 107. Thenursewalksintoaclient'sroomandfindstheclientlyingstillandsilentonthefloor.Then urseshouldfirst A) Assesstheclient'sairway B) Callforhelp C) Establishthattheclientisunresponsive D) Seeifanyonesawtheclientfall ThecorrectanswerisC:Establishthattheclientisunresponsive 108. Thenurseiscaringforaclient2hoursafterarightlowerlobectomy.Duringtheevaluationoft hewater-sealchestdrainagesystem,itisnotedthatthefluidlevelbubblesconstantlyinthewater sealchamber.Oninspectionofthechestdressingandtubing,thenursedoesnotfindanyairleaks inthesystem. Thenextbestactionforthenurseis to A) Checkforsubcutaneousemphysemaintheuppertorso B) Repositiontheclienttoapositionofcomfort C) Callthehealthcareproviderassoonaspossible D) Checkforanyincreaseintheamountofthoracicdrainage ThecorrectanswerisA:Checkforsubcutaneousemphysemaintheuppertorso 109. Thenurseisteachingaclientwithdysrhythmiaabouttheelectricalpathwayofanimpulseasit travelsthroughtheheart.Whichofthesedemonstratesthenormalpathway? A) AVnode,SAnode,BundleofHis,Purkinjefibers B) Purkinjefibers,SAnode,AVnode,BundleofHis C) BundleofHis,Purkinjefibers,SAnode,AVnode D) SAnode,AVnode,BundleofHis,PurkinjefibersThec orrectansweris D:SAnode,AVnode, BundleofHis,Purkinjefibers 110. Whenassessingaclientwhohasjustundergoneacardioversion,thenursefindstherespiratio nsare12.Whichactionshouldthenursetakefirst? A) Trytovigorouslystimulatenormalbreathing B) AsktheRNtoassessthevitalsigns C) Measurethepulseoximetry D) Continuetomonitorrespirations ThecorrectanswerisD:4.Continuetomonitorrespirations 111. Anewnurseontheunitnotesthatthenursemanagerseemstobehighlyrespectedbythenurs ingstaff.Thenewnurseissurprisedwhenoneofthenursesstates:"Themanagermakesalldecisi onsand rarelyasksforourinput."Thebestdescriptionofthenursemanager'smanagementstyleis A) Participativeordemocratic B) Ultraliberalorcommunicative C) Autocraticorauthoritarian D) Laissezfaireorpermissive ThecorrectanswerisC:Autocraticorauthoritarian 112. Adepressedclientwhohasrecentlybeenactingsuicidalisnowmoresocialandenergetict hanusual.Smilinglyhetellsthenurse"I’vemadesomedecisionsaboutmylife."Whatshouldb e thenurse’sinitialresponse? A) "You’vemadesomedecisions." B) "Areyouthinkingaboutkillingyourself?" C) "I’msogladtohearthatyou’vemadesomedecisions." D) "Youneedtodiscussyourdecisionswithyourtherapist." ThecorrectanswerisB:"Areyouthinkingaboutkillingyourself?" 113. Thenursecaringfora14year- oldboywithsevereHemophiliaA,whowasadmittedafterafallwhileplayingbasketball.Inunders tandinghisbehaviorandinplanningcareforthisclient,whatmustthenurseunderstandaboutadole scentswithhemophilia? A) Musthavestructuredactivities B) Oftentakepartinactivesports C) Explainlimitationstopeergroups D) Avoidrisksafterbleedingepisodes ThecorrectanswerisB:Oftentakepartinactivesports 114. Whenanautisticclientbeginstoeatwithherhands,thenursecanbesthandleth eproblem by A) Placingthespoonintheclient’shandandstating,"Usethespoontoeatyourfood." B) Commenting"Ibelieveyouknowbetterthantoeatwithyourhand." C) Jokinglystating,"WellIguessfingerssometimesworkbetterthanspoons." D) Removingthefoodandstating"Youcan’thaveanymorefooduntilyouusethespoon." ThecorrectanswerisA:Placingthespoonintheclient’shandandstating"Usethespoontoeatyour food." 115. Inassessingthehealingofaclient'swoundduringahomevisit,whichofthefollowing isthebestindicatorof goodhealing? A) Whitepatches B) Greendrainage C) Reddenedtissue D) Eschardevelopment ThecorrectanswerisC:Reddenedtissue 116. Whichtherapeuticcommunicationskillismostlikelytoencourageadepressedclientt oventfeelings? A) Directconfrontation B) Realityorientation C) Projectiveidentification D) Activelistening ThecorrectanswerisD:Activelistening 117. Inordertoenhanceaclient'sresponsetomedicationforchestpainfromacuteangina,th enurseshouldemphasize A) Learningrelaxationtechniques B) Limitingalcoholuse C) Eatingsmallermeals D) Avoidingpassivesmoke ThecorrectanswerisA:Learningrelaxationtechniques 118. Thenurseiscaringfor2childrenwhohavehadsurgicalrepairofcongenitalheartdefects.F orwhichdefectisitaprioritytoassessforfindingsofheartconductiondisturbance? A) Arterialseptaldefect B) Patentductusarteriosus C) Aorticstenosis D) Ventricularseptaldefect The correctanswerisD:Ventricularseptaldefect 119. Clientswithmitralstenosiswouldlikelymanifestfindingsassociatedwithconge stionin the A) Pulmonarycirculation B) Descendingaorta C) Superiorvenacava D) BundleofHis ThecorrectanswerisA:Pulmonarycirculation 120. Thenurseisteachingasmokingcessationclassandnoticesthereare2pregnantwomen inthegroup. Whichinformationisapriorityforthesewomen? A) Lowtarcigarettesarelessharmfulduringpregnancy B) Thereisarelationshipbetweensmokingandlowbirthweight C) Theplacentaservesasabarriertonicotine D) Moderatesmokingiseffectiveinweightcontrol ThecorrectanswerisB:Thereisarelationshipbetweensmokingandlowbirthweight 121. Whatisthebestwayforthenursetoaccomplishahealthhistoryona14year-oldclient? A) Havethemotherpresenttoverifyinformation B) Allowanopportunityfortheteentoexpressfeelings C) Usethesametypeoflanguageastheadolescent D) Focusthediscussionofriskfactorsinthepeergroup ThecorrectanswerisB:Allowanopportunityfortheteentoexpressfeelings 122. WhatprincipleofHIVdiseaseshouldthenursekeepinmindwhenplanningcareforanewborn whowasinfectedinutero? A) Thediseasewillincubatelongerandprogressmoreslowlyinthisinfant B) Theinfantisverysusceptibletoinfections C) Growthanddevelopmentpatternswillproceedatanormalrate D) Carefulmonitoringofrenalfunctionisindicated ThecorrectanswerisB:Theinfantisverysusceptibletoinfections 123. Whileplanningcareforapreschoolagedchild,thenurseunderstandsdevelopmentalneeds. Whichofthefollowingwouldbeofthemostconcerntothenurse? A) Playingimaginatively B) Expressingshame C) Identifyingwithfamily D) Exploringtheplayroom ThecorrectanswerisB:Expressingshame 124. Aclienthasbeenreceivinglithium(Lithane)forthepasttwoweeksforthetreatmentofbi polarillness.Whenplanningclientteaching,whatismostimportanttoemphasizetotheclient? A) Maintainalowsodiumdiet B) Takeadiureticwithlithium C) Comeinforevaluationofserumlithiumlevelsevery1-3months D) Havebloodlithiumlevelsdrawnduringthesummermonths ThecorrectanswerisD:Havebloodlithiumlevelsdrawnduringthesummermonths 125. Whileteachingaclientabouttheirmedications,theclientaskshowlongitwilltakebeforethe effectsoflithiumtakeplace.Whatisthebestresponseofthenurse? A) Immediately B) Severaldays C) 2weeks D) 1month ThecorrectanswerisC:2weeks 126. Thenursinginterventionthatbestdescribestreatmenttodealwiththebehaviorsofclientsw ithpersonalitydisordersinclude A) Pointingoutinconsistenciesinspeechpatternstocorrectthoughtdisorders B) Acceptingclientandtheclient'sbehaviorunconditionally C) Encouragingdependencyinordertodevelopegocontrols D) Consistentlimit-settingenforced24hoursperday ReviewInformation:ThecorrectanswerisD:Consistentlimit-settingenforced24hoursperday 127. Followingacocainehigh,theusercommonlyexperiencesanextremelyunpleasantfeeling called A) Craving B) Crashing C) Outwardbound D) Noddingout ThecorrectanswerisB:Crashing 128. The nurse asks a client with a history of alcoholism about the client’s drinkingbehavior. The client states "I didn’t hurt anyone. I just like to have a good time, anddrinkinghelpsmetorelax."Theclientisusingwhichdefensemechanism? A) Denial B) Projection C) Intellectualization D) Rationalization ThecorrectanswerisD:Rationalization 129. Onereasonthatdomesticviolenceremainsextensivelyundetectedis A) Fewbatteredvictimsseekmedicalcare B) Thereistypicallyaseriesofminor,vaguecomplaints C) Expensesduetopoliceandcourtcostsareprohibitive D) VerylittleknowledgeiscurrentlyknownaboutbatterersandbatteringrelationshipsThecor rectanswerisB:Thereistypicallyaseriesofminor,vaguecomplaints 130. AclientdevelopsvolumeoverloadfromanIVthathasinfusedtoorapidly.Whatassessm entwouldthenurseexpecttofind? A) S3heartsound B) Threadypulse C) Flattenedneckveins D) Hypoventilation ThecorrectanswerisA:Auscultationofan 131. Thenurseiscaringforaclientwithendstagerenaldisease.Whatactionshouldthenursetaket oassessforpatency inafistulausedforhemodialysis? A) Observeforedemaproximaltothesite B) Irrigatewith5mlsof0.9%NormalSaline C) Palpateforathrilloverthefistula D) Checkcolorandwarmthintheextremity ThecorrectanswerisC:Palpateforathrilloverthefistula 132. A2year- oldchildisbeingtreatedwithAmoxicillinsuspension,200milligramsperdose,foracuteotitisme dia.Thechildweighs30lb.(15kg)andthedailydoserangeis20- 40mg/kgofbodyweight,inthreedivideddosesevery8hours.Usingprinciplesofsafedrugadmin istration,whatshouldthenursedonext? A) Givethemedicationasordered B) Callthehealthcareprovidertoclarifythedose C) Recognizethatantibioticsareover-prescribed D) Holdthemedicationasthedosageistoolow ThecorrectanswerisA:Givethemedicationasordered 133. Thenurseisparticipatinginacommunityhealthfair.Aspartoftheassessments,thenurse shouldconductamentalstatusexaminationwhen A) Anindividualdisplaysrestlessness B) Thereareobvioussignsofdepression C) Conductinganyhealthassessment D) Theresidentreportsmemorylapses ThecorrectanswerisC:Conductinganyhealthassessment 134. Thenurseiscaringfora12year- oldwithanacuteillness.Whichofthefollowingindicatesthenurseunderstandscommonsiblin greactionstohospitalization? A) Youngersiblingsadaptverywell B) Visitationishelpfulforboth C) Thesiblingsmayenjoyprivacy D) Thosecaredforathomecopebetter ThecorrectanswerisB:Visitationishelpfulforboth 135. Parentsofa7year- oldchildcalltheclinicnursebecausetheirdaughterwassenthomefromschoolbecauseofarash.Th echildhadbeenseenthedaybeforebythehealthcareprovideranddiagnosedwithFifthDisease(ery themainfectiosum).Whatisthemostappropriateactionby thenurse? A) Telltheparentstobringthechildtotheclinicforfurtherevaluation B) Refertheschoolofficialstoprintedmaterialsaboutthisviralillness C) Informtheteacherthatthechildisreceivingantibioticsfortherash D) Explainthatthisrashisnotcontagiousanddoesnotrequireisolation ThecorrectanswerisD:Explainthatthisrashisnotcontagiousanddoesnotrequireisolation 136. Whenmakingahomevisittoaclientwithchronicpyelonephritis,whichnursingactionha sthehighestpriority? A) Follow-uponlabvaluesbeforethevisit B) Observeclientfindingsfortheeffectivenessofantibiotics C) Askforalogofurinaryoutput D) Asforthelogoftheoralintake ThecorrectanswerisC:Askforalogofurinaryoutput 137. Thenurseiscaringforanewbornwhohasjustbeendiagnosedwithhypospadias.Afterdisc ussingthedefectwiththeparents,thenurseshouldexpectthat A) Circumcisioncanbeperformedatanytime B) Initialrepairisdelayeduntilages6-8 C) Post-operativeappearancewillbenormal D) Surgerywillbeperformedinstages ThecorrectanswerisD:Surgerywillbeperformedinstages 138. Thenurseisassessingaclientonadmissiontoacommunitymentalhealthcenter.Theclien tdisclosesthatshehasbeenthinkingaboutendingherlife.Thenurse'sbestresponsewouldbe A) "Doyouwanttodiscussthiswithyourpastor?" B) "Wewillhelpyoudealwiththosethoughts." C) "Isyourlifesoterriblethatyouwanttoendit?" D) "Haveyouthoughtabouthowyouwoulddoit?" ThecorrectanswerisD:"Haveyouthoughtabouthowyouwoulddoit?" 139. Thenursingcareplanforaclientwithdecreasedadrenalfunctionshouldinclude A) Encouragingactivity B) Placingclientinreverseisolation C) Limitingvisitors D) Measurestopreventconstipation ThecorrectanswerisC:Limitingvisitors 140. Thenurseiscaringforaclientwithacutepancreatitis.Afterpainmanagement,whichin terventionshouldbeincludedintheplanof care? A) Coughanddeepbreatheevery2hours B) Placetheclientincontactisolation C) Provideadiethighinprotein D) Instituteseizureprecautions ThecorrectanswerisA:Coughanddeepbreatheevery2hours 141. Whichofthefollowingconditionsassessedbythenursewouldcontraindicatetheuseof benztropine(Cogentin)? A) Neuromalignantsyndrome B) Acuteextrapyramidalsyndrome C) Glaucoma,prostatichypertrophy D) Parkinson'sdisease,atypicaltremors ThecorrectanswerisC:Glaucoma,prostatichypertrophy 142. Thenurseiscaringforaclientinthecoronarycareunit.Thedisplayonthecardiacmonitorind icatesventricularfibrillation.Whatshouldthenursedofirst? A) Performdefibrillation B) Administerepinephrineasordered C) Assessforpresenceofpulse D) InstituteCPR ThecorrectanswerisC:Assessforpresenceofpulse 143. Duringtheuseofaninterpretertoteachaclientaboutaproceduretodointhehomethenursesho uldtakewhichapproach? A) Speakdirectlytotheinterpreterwhilepresentinginformationandusepausesforquestio ns B) Talktotheinterpreterinadvanceandleavetheclientandinterpreteralone C) Includeafamilymemberanddirectcommunicationstothatperson D) Facetheclientwhilepresentingtheinformationastheinterpretertalksinthenativelanguage ThecorrectanswerisD:Facetheclientwhilepresentingtheinformationastheinterpretertalksinth enativelanguage. 144. Aclientisinherthirdmonthofherfirstpregnancy.Duringtheinterview,shetellsthenurseth atshehasseveralsexpartnersandisunsureoftheidentityofthebaby'sfather.Whichofthefollowi ngnursinginterventionsis apriority? A) CounselthewomantoconsenttoHIVscreening B) Performtestsforsexuallytransmitteddiseases C) Discussherhighriskforcervicalcancer D) Refertheclienttoafamilyplanningclinic ThecorrectanswerisA:CounselthewomantoconsenttoHIVscreening 145. Aclientisdischargedfollowinghospitalizationforcongestiveheartfailure.Thenurseteachi ngthefamilysuggeststheyencouragetheclienttorestfrequentlyinwhichofthefollowingposition s? A) HighFowler's B) Supine C) Leftlateral D) LowFowler's ThecorrectanswerisA:HighFowler''s 146. Anursewhoisevaluatingamentallyretarded2year- oldinaclinicshouldstresswhichgoalwhen talkingtothechild'smother? A) Teaching thechildselfcareskills B) Preparingforindependenttoielting C) Promotingthechild'soptimaldevelopment D) Helpingthefamilydecideonlongtermcare ThecorrectanswerisC:Promotingthechild''soptimaldevelopment 147. Thenurseiscaringforaclientwithtrigeminalneuralgia(ticdouloureaux).Toassisttheclient withnutritionneeds,thenurseshould A) Offersmallmealsofhighcaloriesoftfood B) Assisttheclienttositinachairformeals C) Provideadditionalservingsoffruitsandrawvegetables D) Encouragetheclienttoeatfish,liverandchicken ThecorrectanswerisA:Offersmallmealsofhighcaloriesoftfood 148. Thenurseisassessinga2year- oldclientwithapossiblediagnosisofcongenitalheartdisease.Whichoftheseismostlikelytob eseenwiththisdiagnosis? A) Severalotitismediaepisodesinthelastyear B) Weightandheightin10thpercentilesincebirth C) Takesfrequentrestperiodswhileplaying D) Changingfoodpreferencesanddislikes ThecorrectanswerisC: Takesfrequentrestperiodswhileplaying 149. Thenurseiscaringfora10year- oldonadmissiontotheburnunit.Oneassessmentparameterthatwillindicatethatthechildhasade quatefluidreplacementis A) Urinaryoutputof30mlperhour B) Nocomplaintsofthirst C) Increasedhematocrit D) Goodskinturgoraroundburn ThecorrectanswerisA:Urinaryoutputof30mlperhour 150. Uponexaminingthemouthofa3year- oldchild,thenursediscoversthattheteethhavechalkywhite-to- yellowishstainingwithpittingoftheenamel.Whichofthefollowingconditionswouldmost likelyexplainthesefindings? A) Ingestionoftetracycline B) Excessivefluorideintake C) Oralirontherapy D) Poordentalhygiene ThecorrectanswerisB:Excessivefluorideintake 151. The nurse is reassigned to work at the Poison Control Center telephone hotline. Inwhich of these cases of childhood poisoning would the nurse suggest that parents havethechilddrinkorangejuice? A) An18month-oldwhoateanundeterminedamountofcrystaldraincleaner B) A14month-oldwhochewed2leavesofaphilodendronplant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle ofdiazepam(Valium) D) A30month-oldwhohasswallowedamouthfulofcharcoallighterfluid The correct answer is A: An 18 month-old who ate an undetermined amount of crystaldraincleaner 152. Whichoftheseisanexampleofavariationinthenewbornresultingfromthepresence ofmaternalhormones? A) Engorgementofthebreasts B) Mongolianspots C) Edemaofthescrotum D) Lanugo ThecorrectanswerisA:Engorgementofthebreasts 153. A2month- oldchildhashadacleftliprepair.Theselectionofwhichrestraintwouldrequirenofurtheractionbyt hecharge nurse? A) Elbow B) Mummy C) Jacket D) Clovehitch ThecorrectanswerisA:Elbow 154. Aclienttreatedfordepressiontellsthenurseatthementalhealthclinicthatherecentlypu rchasedahandgunbecauseheisthinkingaboutsuicide.Thefirstnursingactionshouldbeto A) Notifythehealthcareproviderimmediately B) Suggestin-patientpsychiatriccare C) Respecttheclient'sconfidentialdisclosure D) Phonethefamilytowarnthemoftherisk ThecorrectanswerisA:Notifythehealthcareproviderimmediately 155. Aclienthasjustbeenadmittedwithportalhypertension.Whichnursingdiagnosiswouldb eapriority inplanningcare? A) Alterednutrition:lessthanbodyrequirements B) Potentialcomplicationhemorrhage C) Ineffectiveindividualcoping D) Fluidvolumeexcess ThecorrectanswerisB:Potentialcomplicationhemorrhage 156. Whileplanningcarefora2year- oldhospitalizedchild,whichsituationwouldthenurseexpecttomostlikelyaffectthebehavior? A) Strangebedandsurroundings B) Separationfromparents C) Presenceofothertoddlers D) Unfamiliartoysandgames ThecorrectanswerisB:Separationfromparents 157. Whichofthefollowingshouldthenurseteachtheclienttoavoidwhentakingchlorpro mazineHCL(Thorazine)? A) Directsunlight B) Foodscontainingtyramine C) Foodsfermentedwithyeast D) Cannedcitrusfruitdrinks ThecorrectanswerisA:Avoiddirectsunlight 158. Theinitialresponsebythenursetoadelusionalclientwhorefusestoeatbecauseofabeliefthat thefoodispoisonedis A) "Youthinkthatsomeonewantstopoisonyou?" B) "Why doyouthinkthefoodispoisoned?" C) "Thesefeelingsareasymptomofyourillness." D) "You’re safehere.Iwon’tletanyonepoisonyou." ThecorrectanswerisA:"Youthinkthatsomeonewantstopoisonyou?" 159. Thenurseiscaringforaclientwithcirrhosisoftheliverwithascites.Wheninstructingnur singassistantsinthecareoftheclient,thenurseshouldemphasizethat A) Theclientshouldremainonbedrestinasemi-Fowler'sposition B) Theclientshouldalternateambulationwithbedrestwithlegselevated C) Theclientmayambulateandsitinchairastolerated D) Theclientmayambulateastoleratedandremaininsemi- FowlerpositioninbedThecorrectanswerisB:Theclientshouldalternateambulationwithbedr estwithlegselevated 160. Thenurseisperformingphysicalassessmentsonadolescents.Whenwouldthenurseanticipa tethatfemalesexperiencegrowthspurts? A) About2yearsearlierthanmales B) Aboutthesametimeasmales C) Justpriortotheonsetofpuberty D) Thatincreaseheightby4incheseachyear ThecorrectanswerisA:About2yearsearlierthanmales