1. A client being treated for hypertension returns to the community clinic for follow up.
The client says, "I know these pills are important, but I just can't take these water pills
anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to
the bathroom." Which of these is the best nursing diagnosis?
A) Noncompliance related to medication side effects
B) Knowledge deficit related to misunderstanding of disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation - CORRECT ANSWERS-A:
Noncompliance related to medication side effects
2. The nurse has been teaching adult clients about cardiac risks when they visit the
hypertension clinic. Which form of evaluation would best measure learning?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes - CORRECT ANSWERS-D: Reported behavioral
changes
3. The nurse is planning care for an 18 month-old child. Which action should be
included in the child's care?
A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
C) Allow the child to walk independently on the nursing unit
D) Engage the child in games with other children - CORRECT ANSWERS-B:
Encourage the child to feed himself finger food
4. A partner is concerned because the client frequently daydreams about moving to
Arizona to get away from the pollution and crowding in southern California. The nurse
explains that
A) Such fantasies can gratify unconscious wishes or prepare for anticipated future
events
B) Detaching or dissociating in this way postpones painful feelings
C) This conversion or transferring of a mental conflict to a physical symptom can lead to
marital conflict
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,D) To isolate the feelings in this way reduces conflict within the client and with others -
CORRECT ANSWERS-A: Such fantasies can gratify unconscious wishes or prepare for
anticipated future events
5. An appropriate goal for a client with anxiety would be to
A) Ventilate anxious feelings to the nurse
B) Establish contact with reality
C) Learn self-help techniques
D) Become desensitized to past trauma - CORRECT ANSWERS-C: Learn self-help
techniques
6. While the nurse is administering medications to a client, the client states "I do not
want to take that medicine today." Which of the following responses by the nurse would
be best?
A) "That's OK, its all right to skip your medication now and then."
B) "I will have to call your doctor and report this."
C) "Is there a reason why you don't want to take your medicine?"
D) "Do you understand the consequences of refusing your prescribed treatment?" -
CORRECT ANSWERS-C: "Is there a reason why you don't want to take your
medicine?"
7. While caring for a client, the nurse notes a pulsating mass in the client's peri umbilical
area. Which of the following assessments is appropriate for the nurse to perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass - CORRECT ANSWERS-B: Auscultate the mass
8. A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which
statement would provide the best reality orientation for this client?
A) "Good morning. Do you remember where you are?"
B) "Hello. My name is Elaine Jones and I am your nurse for today."
C) "How are you today? Remember, you're in the hospital."
D) "Good morning. You're in the hospital. I am your nurse Elaine Jones." - CORRECT
ANSWERS-D: "Good morning. You're in the hospital. I am your nurse Elaine Jones."
9. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the
main source of fluids for an infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
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,D) Fluoridated tap water - CORRECT ANSWERS-A: Formula or breast milk
10. The family of a 6 year-old with a fractured femur asks the nurse if the child's height
will be affected by the injury. Which statement is true concerning long bone fractures in
children?
A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child's normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures -
CORRECT ANSWERS-B: Epiphyseal fractures often interrupt a child''s normal growth
pattern
11. The nurse is assessing a client who states her last menstrual period was March 16,
and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated
date of delivery (EDD)?
A) April 8
B) January 15
C) February 11
D) December 23 - CORRECT ANSWERS-D: December 23
12. When screening children for scoliosis, at what time of development would the nurse
expect early signs to appear?
A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt - CORRECT ANSWERS-D: During the
preadolescent growth spurt
13. A client with congestive heart failure is newly admitted to home health care. The
nurse discovers that the client has not been following the prescribed diet. What would
be the most appropriate nursing action?
A) Discharge the client from home health care related to noncompliance
B) Notify the health care provider of the client's failure to follow prescribed diet
C) Discuss diet with the client to learn the reasons for not following the diet
D) Make a referral to Meals-on-Wheels - CORRECT ANSWERS-C: Discuss diet with
client to learn the reasons for not following the diet
14. A client states, "People think I'm no good, you know what I mean?" Which of these
responses would be most therapeutic?
A) "Well people often take their own feelings of inadequacy out on others."
3|Page
, B) "I think you're good. So you see, there's one person who likes you."
C) "I'm not sure what you mean. Tell me a bit more about that."
D) "Let's discuss this to see the reasons to create this impression on people?" -
CORRECT ANSWERS-C: "I'm not sure what you mean. Tell me a bit more about that."
15. A 64 year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What would be
the most appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out as they may get lost or broken
in the operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client's refusal
D) Ask the client if the preference would be to remove the dentures in the operating
room receiving area - CORRECT ANSWERS-D: Ask the client if the preference would
be to remove the dentures in the operating room receiving area
16. When teaching effective stress management techniques to a client 1 hour before
surgery, which of the following should the nurse recommend?
A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery - CORRECT ANSWERS-B: Deep breathing
17. When observing 4 year-old children playing in the hospital playroom, what activity
would the nurse expect to see the children participating in?
A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers - CORRECT ANSWERS-D: Playing
cooperatively with other preschoolers
18. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye" - CORRECT ANSWERS-A: Hold a rattle
19. When teaching a 10 year-old child about their impending heart surgery, which form
of explanation meets the developmental needs of this age child?
4|Page
The client says, "I know these pills are important, but I just can't take these water pills
anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to
the bathroom." Which of these is the best nursing diagnosis?
A) Noncompliance related to medication side effects
B) Knowledge deficit related to misunderstanding of disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation - CORRECT ANSWERS-A:
Noncompliance related to medication side effects
2. The nurse has been teaching adult clients about cardiac risks when they visit the
hypertension clinic. Which form of evaluation would best measure learning?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes - CORRECT ANSWERS-D: Reported behavioral
changes
3. The nurse is planning care for an 18 month-old child. Which action should be
included in the child's care?
A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
C) Allow the child to walk independently on the nursing unit
D) Engage the child in games with other children - CORRECT ANSWERS-B:
Encourage the child to feed himself finger food
4. A partner is concerned because the client frequently daydreams about moving to
Arizona to get away from the pollution and crowding in southern California. The nurse
explains that
A) Such fantasies can gratify unconscious wishes or prepare for anticipated future
events
B) Detaching or dissociating in this way postpones painful feelings
C) This conversion or transferring of a mental conflict to a physical symptom can lead to
marital conflict
1|Page
,D) To isolate the feelings in this way reduces conflict within the client and with others -
CORRECT ANSWERS-A: Such fantasies can gratify unconscious wishes or prepare for
anticipated future events
5. An appropriate goal for a client with anxiety would be to
A) Ventilate anxious feelings to the nurse
B) Establish contact with reality
C) Learn self-help techniques
D) Become desensitized to past trauma - CORRECT ANSWERS-C: Learn self-help
techniques
6. While the nurse is administering medications to a client, the client states "I do not
want to take that medicine today." Which of the following responses by the nurse would
be best?
A) "That's OK, its all right to skip your medication now and then."
B) "I will have to call your doctor and report this."
C) "Is there a reason why you don't want to take your medicine?"
D) "Do you understand the consequences of refusing your prescribed treatment?" -
CORRECT ANSWERS-C: "Is there a reason why you don't want to take your
medicine?"
7. While caring for a client, the nurse notes a pulsating mass in the client's peri umbilical
area. Which of the following assessments is appropriate for the nurse to perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass - CORRECT ANSWERS-B: Auscultate the mass
8. A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which
statement would provide the best reality orientation for this client?
A) "Good morning. Do you remember where you are?"
B) "Hello. My name is Elaine Jones and I am your nurse for today."
C) "How are you today? Remember, you're in the hospital."
D) "Good morning. You're in the hospital. I am your nurse Elaine Jones." - CORRECT
ANSWERS-D: "Good morning. You're in the hospital. I am your nurse Elaine Jones."
9. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the
main source of fluids for an infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
2|Page
,D) Fluoridated tap water - CORRECT ANSWERS-A: Formula or breast milk
10. The family of a 6 year-old with a fractured femur asks the nurse if the child's height
will be affected by the injury. Which statement is true concerning long bone fractures in
children?
A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child's normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures -
CORRECT ANSWERS-B: Epiphyseal fractures often interrupt a child''s normal growth
pattern
11. The nurse is assessing a client who states her last menstrual period was March 16,
and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated
date of delivery (EDD)?
A) April 8
B) January 15
C) February 11
D) December 23 - CORRECT ANSWERS-D: December 23
12. When screening children for scoliosis, at what time of development would the nurse
expect early signs to appear?
A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt - CORRECT ANSWERS-D: During the
preadolescent growth spurt
13. A client with congestive heart failure is newly admitted to home health care. The
nurse discovers that the client has not been following the prescribed diet. What would
be the most appropriate nursing action?
A) Discharge the client from home health care related to noncompliance
B) Notify the health care provider of the client's failure to follow prescribed diet
C) Discuss diet with the client to learn the reasons for not following the diet
D) Make a referral to Meals-on-Wheels - CORRECT ANSWERS-C: Discuss diet with
client to learn the reasons for not following the diet
14. A client states, "People think I'm no good, you know what I mean?" Which of these
responses would be most therapeutic?
A) "Well people often take their own feelings of inadequacy out on others."
3|Page
, B) "I think you're good. So you see, there's one person who likes you."
C) "I'm not sure what you mean. Tell me a bit more about that."
D) "Let's discuss this to see the reasons to create this impression on people?" -
CORRECT ANSWERS-C: "I'm not sure what you mean. Tell me a bit more about that."
15. A 64 year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What would be
the most appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out as they may get lost or broken
in the operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client's refusal
D) Ask the client if the preference would be to remove the dentures in the operating
room receiving area - CORRECT ANSWERS-D: Ask the client if the preference would
be to remove the dentures in the operating room receiving area
16. When teaching effective stress management techniques to a client 1 hour before
surgery, which of the following should the nurse recommend?
A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery - CORRECT ANSWERS-B: Deep breathing
17. When observing 4 year-old children playing in the hospital playroom, what activity
would the nurse expect to see the children participating in?
A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers - CORRECT ANSWERS-D: Playing
cooperatively with other preschoolers
18. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye" - CORRECT ANSWERS-A: Hold a rattle
19. When teaching a 10 year-old child about their impending heart surgery, which form
of explanation meets the developmental needs of this age child?
4|Page
