(ACTUAL 2025) QUESTIONS AND VERIFIED .
During a one-to-one session with the nurse, a female admitted
for chronic depression and attempted suicide discloses
experiences of sexual promiscuity and prostitution. When the
nurse asks the client if she was ever sexually abused as a
child, the client says, "I don't remember, but my mother ran
my father off when I was five." The nurse should recognize
that the client may be using which defense mechanism?
A. Denial
B. Repression
C. Regression
D. Projection
A. Denial
Two days after an abscess of the chin was drained, the client
returns to the clinic with fever, chills, and a maculopapular
rash with pruritus. The client has taken an oral antibiotic and
cleaned wound today with providone-iodine solution. Which
intervention should the nurse implement first?
A. Review recent mediation history and allergies
B. Assess airway latency and oxygen saturation
,C. Obtain samples for complete blood count and cultures.
D. Determine if the client has a history of diabetes
B. Assess airway latency and oxygen saturation
The nurse orients a client with depression to a new room on
the mental health unit. The client states, "It seems strange that
I don't have a TV in my room." Which statement is best for
the nurse to provide?
A. It's important to be out of your room and talking to others.
B. You can watch TV as much as you want outside of your
room.
C. Watching TV is a passive activity and we want you to be
active.
D. Sometimes clients feel like the TV is sending them
messages.
A. It's important to be out of your room and talking to others.
The registered nurse (RN) directs the unlicensed assistive
personnel (UAP) to administer PO fluids int he ambulatory
surgical center. Which adult client should the RN assign to the
UAP?
,A. An obtunded client who requires tactile stimulation to
respond.
B. A sedated client asking for ice chips when questioned
C. An awake client with a gag reflex who is asking for water
D. A disoriented client requesting medication upon arrival
from PACU
B. A sedated client asking for ice chips when questioned
A nurse arrives at the scene of a motor vehicle collision, and
finds that the male driver is sitting in the car screaming about
severe knee pain. He is alert and oriented, but his knee is
crushed into the dashboard. A bystander reports that a 911 call
has been made and help is on the way. What intervention
should the nurse implement?
A. Place a rolled pillow behind the driver's neck to stabilize
the spinal cord.
B. Carefully assist the driver out of the car to assess and treat
the injury.
C. Tell the driver to try to see if he can move his toes on the
affected leg.
D. Instruct the driver to stay in the car and try not to move
unnecessarily.
, B. Carefully assist the driver out of the car to assess and treat
the injury.
The nurse is counseling a client who is at 6-weeks gestation
and is experiencing morning sickness, but does not want to
take any drugs for discomfort. Which herbal supplement if
likely to help this client with nausea she is experiencing?
A. Chamomile
B. Ginko
C. Ginger
D. Peppermint
D. Peppermint
Which client requires immediate intervention by the nurse?
A. A child with acute renal failure and hyperkalemia
B. A child with cystic fibrosis who is constipated
C. A toddler with chicken pox who is scratching
D. An adolescent with a migraine and photophobia
A. A child with acute renal failure and hyperkalemia