FOUNDATIONS AND ADULT HEALTH NURSING

MULTIPLE CHOICE 1. The nurse instructs the mother of a 5-year-old who sustained a mild brain injury that although all neurologic evaluations are normal, her child may exhibit post-concussive syndrome. What are common characteristics of this syndrome? a. Convulsions and high fever b. Irritability and memory deficits c. Muscular twitching and muscle pain d. Paresis of limbs and fatigue ANS: B Mild brain injury is characterized by brief or no loss of consciousness. This type constitute...

MULTIPLE CHOICE 1. What action by a student before taking a test should indicate to a nursing instructor that the student is demonstrating signs of moderate anxiety? a. Studies for 6 hours b. Sleeps 6 hours because of fatigue c. Vomits d. Argues about the scheduling of the test ANS: C Symptoms of anxiety include the following: vocal changes, rapid speech, increased pulse, respirations, and blood pressure, tremors, restlessness, increased perspiration, nausea, decreased appetite, dia...

MULTIPLE CHOICE 1. What is a major difference between rheumatoid arthritis and osteoarthritis? a. Rheumatoid arthritis is degenerative. b. Rheumatoid arthritis only affects patients over 40 years of age. c. Rheumatoid arthritis is inflammatory. d. Rheumatoid arthritis is curable. ANS: C Rheumatoid arthritis is an inflammatory disease; osteoarthritis is degenerative. Rheumatoid arthritis can affect patients at any age. Neither type of arthritis is curable. DIF: Cognitive Level: Ap...

MULTIPLE CHOICE 1. If the patient tells the nurse, “I’m not an alcoholic. I can stop whenever I want to,” what should be the nurse’s most therapeutic response? a. “Well, why don’t you?” b. “Hasn’t alcohol use interfered with your employment?” c. “A positive attitude like that is a good start.” d. “What would you call alcoholism?” ANS: B When the addicted person presents in denial, the nurse should use techniques to set limits on that behavior. DIF: Cog...

MULTIPLE CHOICE 1. A home health nurse has a patient who is taking lithium. What should be included in the teaching plan? a. Examine her skin closely for eruptions. b. Take her blood pressure twice a day to check for hypertension. c. Have her drug blood level checked every month. d. Avoid aged cheese and red wine. ANS: C Lithium has a very narrow therapeutic window. The drug blood levels should be closely monitored. DIF: Cognitive Level: Application REF: p. 1122 OBJ: 6 TOP: ...

MULTIPLE CHOICE 1. A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered? a. Oxygen administration b. Administering large amount of IV fluids c. Positioning the patient on her back d. Encouraging activity between contractions ANS: A Oxygen is administered to increase blood oxygen saturation and decrease the stress on the heart. IV fluid administrati...

MULTIPLE CHOICE 1. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide? a. Mild soap and water b. A cotton ball c. Mineral oil d. Alcohol swabs ANS: C To completely remove ointment, especially zinc oxide, mineral oil should be used. DIF: Cognitive Level: Application REF: p. 1042 OBJ: 15 TOP: Diaper rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological In...

MULTIPLE CHOICE 1. Following a lumbar puncture of a 2-year-old, what should the nurse do? a. Keep the child flat for several hours. b. Allow the child to play quietly at will. c. Hold the child in a flexed position for 5 minutes. d. Stand the child upright immediately. ANS: B Children younger than 3 years of age are usually not affected by postlumbar headache. These children are allowed to play at will following a lumbar puncture. DIF: Cognitive Level: Comprehension REF: p. 966...

MULTIPLE CHOICE 1. What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children? a. Child awareness b. Good manners c. Anticipatory guidance d. Strict discipline ANS: C Anticipatory guidance has been the most widely used approach to educating parents in accident prevention. DIF: Cognitive Level: Application REF: p. 927 OBJ: 9 TOP: Injury prevention KEY: Nursing Process Step: Implementatio...

MULTIPLE CHOICE 1. When the nurse is developing a care plan for a terminally ill patient, what might be a realistic goal? a. The patient will remain pain-free. b. The patient will function optimally. c. The patient will spend time out of bed. d. The patient will demonstrate improved nutritional status. ANS: B The goal of the care plan for a terminally ill patient is to assist the patient to function optimally. The other options are not realistic. DIF: Cognitive Level: Application...