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Question 1 

The nurse is taking a health history from a Native American client. In order to be culturally sensitive when speaking to the client and family, the nurse MUST remember that eye contact is considered

 A)  Critical

 B)  Rude

 C)  Professional

 D)  Valued

Review Information: The correct answer is:

B) Rude.

Native Americans consider direct eye contact to be impolite or aggressive among strangers.

Andrews, M. & Boyle, J. (1998).

Transcultural Concepts in Nursing Care.

Philadelphia: Lippincott.

Bell, R. (1994).

Prominence of Women in Navajo Healing Beliefs and Values.

Nursing & Health Care, 15(5), 232-240.

Question 2 

Which of the following is MOST likely to ensure the safety of the nurse while making a home visit?

 A)  Seeing no evidence of weapons in the home

 B)  Reading no entries about previous violence in the client's record

 C)  Staying alert at all times and leaving if cues suggest the home is not safe

 D)  Carrying a cell phone, pager, and/or hand held alarm

Review Information: The correct answer is:

C) Staying alert at all times and leaving if cues suggest the home is not safe.

No person or equipment can guarantee nurses'' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards and sources of assistance. Become acquainted with neighbors. Be alert and confident while parking the car, walking to the client''s door, making the visit, walking to the car, and driving away. LISTEN to clients; if they tell you to leave, do so.

Leahy, L. (1997).

Decrease Violence--Increase Safety.

Home Health FOCUS, 4, 1, 4.

National Association for Home Care Staff. (1998).

Protecting Employees Against Violence.

Home Care News, 12, 40, 38.

Question 3 

An 80 year-old nursing home resident has a temperature of 101.6 rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess FIRST?

 A)  Lung sounds

 B)  Urine output

 C)  Level of alertness

 D)  Appetite

Review Information: The correct answer is:

C) Level of alertness.

Assessing level of consciousness (alert vs. lethargic vs. unresponsive) will help the health care provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.

Potter, P. & Perry, A. (2000).

Fundamentals of Nursing: Concepts, Process and Practice.

St. Louis: Mosby.

Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993).

Mosby''s Clinical Nursing. (3rd ed.).

St. Louis: Mosby.

Question 4 

The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for ADDITIONAL teaching if the client stated

 A)  "I can only wear cotton socks."

 B)  "I cannot go barefoot around my house."

 C)  "I will trim corns and calluses regularly."

 D)  "I should ask a family member to inspect my feet daily."

Review Information: The correct answer is:

C) "I will trim corns and calluses regularly.".

Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their physician, nurse, or other provider who specializes in foot care.

Nunnelee, J.D. (1996).

Foot Care for Vascular clients.

Home Care Provider, 1, 33-36, 54.

Harrison, B. (1997).

Nursing Care of Clients with Peripheral Vascular Disorders.

In Black, J.M. and Matassarin-Jacobs, E. Medical-surgical nursing: Clinical management for continuity of care (5th ed.).

Philadelphia, W. B. Saunders.

Question 5 

The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The BEST response by the nurse is

 A)  "The top layer of the skin is destroyed."

 B)  "The skin layers are swollen and reddened."

 C)  "All layers of the skin were destroyed in the burn."

 D)  "Muscle, tissue and bone have been injured."

Review Information: The correct answer is:

C) "All layers of the skin were destroyed in the burn.".

A third degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.

Betz, C., Hunsberger, M. & Wright, S. (1994).

Family-Centered Nursing Care of Children. (2nd ed.).

Philadelphia: Saunders.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children.

St. Louis: Mosby.

Question 6 

As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid

 A)  Surfing

 B)  Scuba diving

 C)  Parasailing

 D)  Swimming

Review Information: The correct answer is:

B) Scuba diving.

The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.

Nettina, Sandra (2000). (1996).

The Lippincott Manual of Nursing Practice.

Philadelphia-New York: Lippincott.

Luckmann, Joan. (1997).

Saunders Manual of Nursing Care.

Philadelphia: W.B.Saunders Company.

Question 7 

Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the BEST initial approach?

 A)  Consider a liquid supplement to increase calories

 B)  Discuss consequences of an unbalanced diet with the child

 C)  Provide fruit, vegetable and protein snacks

 D)  Encourage the child to keep a daily log of foods eaten

Review Information: The correct answer is:

B) Discuss consequences of an unbalanced diet with the child.

It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.

Pipes & Trahms. (1993).

Nutrition in Infancy and Childhood.

St. Louis: Mosby.

Wong, D. (1999).

Whaley and Wong''s Nursing Care of Infants and Children. (5th ed.).

St. Louis: Mosby.

Question 8 

The nurse is providing home care for a client with heart failure and pulmonary edema. Which of the following nursing diagnoses should have PRIORITY in planning care?

 A)  Impaired Skin Integrity related to dependent edema

 B)  Activity Intolerance related to oxygen supply and demand imbalance

 C)  Constipation related to immobility

 D)  Risk for infection related to ineffective mobilization of secretions

Review Information: The correct answer is:

B) Activity Intolerance related to oxygen supply and demand imbalance.

This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen and complaints of dyspnea and fatigue.

Potter, P. & Perry, A. (2001).

Mosby’s Clinical Nursing Skills and Techniques.

St. Louis: Mosby.

Nettina, Sandra (2000).

Lippincott Manual of Nursing Practice. (6th ed.).

Philadelphia: Lippincott.

Question 9 

The incidence of a Hepatitis B refers to

 A)  The number of persons in a population who develop Hepatitis B during a specific period of time

 B)  The total number of persons in a population who have Hepatitis B at a particular time

 C)  The death rate resulting from Hepatitis B

 D)  The occurrence of Hepatitis B in the population

Review Information: The correct answer is:

A) The number of persons in a population who develop Hepatitis B during a specific period of time.

This is the correct definition of incidence of the disease.

Stanhope, M. & Lancaster, J. (1998).

Community Health Nursing: Process and Practice for Promoting Health. (4th ed.).

St. Louis: Mosby.

Anderson, E. & McFarlane, J. (April 2000).

Community as Partner.

Philadelphia: Lippincott.

Question 10 

The client is experiencing symptoms of tardive dyskinesia. The nurse would expect to see

 A)  Rapid tongue movements

 B)  Uncontrolled hand tremors during meals

 C)  Behavioral changes

 D)  Repetitive slapping movements

Review Information: The correct answer is:

A) Rapid tongue movements.

This symptom is identified with tardive dyskinesia.

Potter, P. & Perry, A. (2000).

Fundamentals of Nursing: Concepts, Process and Practice.

St. Louis: Mosby.

Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993).

Mosby''s Clinical Nursing. (3rd ed.).

St. Louis: Mosby.

Question 11 

A fifteen month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?

 A)  MMR

 B)  Hib

 C)  IPV

 D)  DtaP

Review Information: The correct answer is:

A) MMR.

Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body''s ability to form antibodies.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Atkinson, W., Furphy, L., Gantt, J., Mayfield, M. & Rhyne, G. (1996).

Epidemiology and Prevention of Vaccine-Preventable Diseases. (3rd ed.).

Question 12 

The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state that they remain concerned about the possible occurrence of sudden infant death syndrome (SIDS). In order to take appropriate action, the nurse must understand that

 A)  The child is within the age group most susceptible to SIDS

 B)  The peak age for occurrence of SIDS is 8-12 months of age

 C)  The apnea monitor is not effective on a child in this age group

 D)  Ninety-five percent of all SIDS cases occur before 6 months

Review Information: The correct answer is:

D) Ninety-five percent of all SIDS cases occur before 6 months.

Peak age of SIDS occurrence is 2-4 months and 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Bowden, V., Dickey, S., & Greenberg, C. (1998).

Children and Their Families: The Continuum of Care.

Philadelphia: Saunders.

Question 13 

In assessing a post partum client, the nurse palpates a firm fundus. Also observed is a constant trickle of bright red blood from the vagina. The nurse suspects

 A)  Uterine atony

 B)  Genital lacerations

 C)  Retained placenta

 D)  Clotting disorder

Review Information: The correct answer is:

B) Genital lacerations.

Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.

Babcock, I., Lowdermilk, D., and Jensen, M. (1995).

Maternity Nursing.

St. Louis: Mosby.

Wong, D. and Perry, S. (1998).

Maternal Child Nursing Care.

St. Louis: Mosby.

Question 14 

The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe?

 A)  Hypertonic neuro reflex

 B)  Immediate CNS depression

 C)  Lethargy and sleepiness

 D)  Jitteriness at 24-48 hours

Review Information: The correct answer is:

D) Jitteriness at 24-48 hours.

Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.

Lowdermilk, D., Perry, S., Bobak, I. (1997).

Maternal and Women''s Health Care. (6th ed.).

St. Louis, Mosby.

Wong, D. (1999).

Whaley and Wong''s Nursing Care of Infants and Children. (5th ed.).

St. Louis: Mosby.

Question 15 

The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which of the following recent illnesses would the nurse recognize as increasing the risk to develop Reye's Syndrome?

 A)  Rubeola

 B)  Meningitis

 C)  Varicella

 D)  Hepatitis

Review Information: The correct answer is:

C) Varicella.

Varicella (chicken pox) and influenza are viral illnesses that have been identified as increasing the risk for Reye''s Syndrome. Use of aspirin is contraindicated for children with these infections.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Ashwill, J. & Droske, S. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: Saunders.

Question 16 

The nurse is teaching a mother who will breast feed for the first time. Which of the following is a PRIORITY?

 A)  Show her films on the physiology of lactation

 B)  Give the client several illustrated pamphlets

 C)  Assist her to position the newborn at the breast

 D)  Give her privacy for the initial feeding

Review Information: The correct answer is:

C) Assist her to position the newborn at the breast.

While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.

Reeder, S., Martin, L., Koniak, D. (1997).

Maternity Nursing.

Philadelphia: Lippincott.

Lowdermilk, D., Perry, S., Bobak, I. (1997).

Maternal and Women''s Health Care. (6th ed.).

St. Louis, Mosby.

Question 17 

The nurse is teaching a 27 year-old client with asthma about management of their therapeutic regime. Which of the following statements would indicate the need for ADDITIONAL instruction?

 A)  "I should monitor my peak flow every day."

 B)  "I should contact the clinic if I am using my medication more often."

 C)  "I need to limit my exercise, especially activities such as walking and running."

 D)  "I should learn stress reduction and relaxation techniques."

Review Information: The correct answer is:

C) "I need to limit my exercise, especially activities such as walking and running.".

Limiting physical activity in an otherwise healthy, young client should not be necessary. If exercise intolerance exists, the asthma management plan should include specific medications to treat the problem such as using an inhaled beta-agonist 5 minutes before exercise. The goal is always to return to a normal lifestyle.

Evans, R.M., Brown, E.F., Chamberlain, J., & Morain, C. (1997).

Managing Asthma Today : Integrating New Concepts.

Chicago:American Medical Association.

Guidelines for the diagnosis and management of asthma, Expert panel report 2. (1997).

Clinical Practice Guidelines, NIH Publication No. 97-4051. Bethesda, MD.

Question 18 

An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this condition was caused by

 A)  Tachypnea

 B)  Acidic byproducts

 C)  Vomiting and dehydration

 D)  Hyperpyrexia

Review Information: The correct answer is:

A) Tachypnea.

Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Ashwill, J. W. & Droske, S. C. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: W. B. Saunders.

Question 19 

The physician has ordered daily high doses of aspirin for a client with rheumatoid arthritis. The nurse instructs the client to discontinue the medication and contact the physician if which of the following symptoms occurs?

 A)  Infection of the gums

 B)  Diarrhea for more than one day

 C)  Numbness in the lower extremities

 D)  Ringing in the ears

Review Information: The correct answer is:

D) Ringing in the ears.

Aspirin stimulates the central nervous system which may result in ringing in the ears.

Luckmann, Joan. (1997).

Saunders Manual of Nursing Care.

Philadelphia: W.B. Saunders Company.

Springhouse. (1997).

Diseases. (2nd ed.).

Springhouse PA: Springhouse Corporation.

Question 20 

When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by

 A)  Reduced oxygen capacity of cells due to lack of iron

 B)  An imbalance between red cell destruction and production

 C)  Depression of red and white cells and platelets

 D)  Inability of sickle shaped cells to regenerate

Review Information: The correct answer is:

B) An imbalance between red cell destruction and production.

Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (life span shortened from 120 days to 12-20 days).

Ball, J. & Bindler, R. (2000).

Pediatric Nursing: Caring for Children.

Norwalk, CN: Applet‎on & Lange.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Question 21 

While giving care to a two year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of

 A)  Stubborn behavior

 B)  Rejection of parents

 C)  Frustration with adults

 D)  Assertion of control

Review Information: The correct answer is:

D) Assertion of control.

Negativism is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child''s progress from dependency to autonomy and independence.

Wong, D. (1999).

Whaley and Wong''s Nursing Care of Infants and Children. (5th ed.).

St. Louis: Mosby.

Ashwill, J. & Droske, S. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: Saunders.

Question 22 

For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering Rh0 (D) immune globulin within 72 hours of birth?

 A)  Rh negative mother with Rh positive baby

 B)  Rh negative mother with Rh negative baby

 C)  Rh positive mother with Rh positive baby

 D)  Rh positive mother with Rh negative baby

Review Information: The correct answer is:

A) Rh negative mother with Rh positive baby.

An Rh - mother who delivers an Rh + baby may develop antibodies to the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has occurred. The Rh0(D) immune globulin is given to block antibody formation in the mother.

Babcock, I., Lowdermilk, D., and Jensen, M. (1995).

Maternity Nursing.

St. Louis: Mosby.

Wong, D. and Perry, S. (1998).

Maternal Child Nursing Care.

St. Louis: Mosby.

Question 23 

An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which of the following orders should be questioned by the nurse?

 A)  Passive range of motion

 B)  Replacement of factor VIII

 C)  Aspirin for pain management

 D)  Immobilization splint

Review Information: The correct answer is:

C) Aspirin for pain management.

Aspirin is contraindicated in any client who is actively bleeding. Ibuprofen is a more common pain medication.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Ashwill, J. W. & Droske, S. C. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: W. B. Saunders.

Question 24 

A client with a fracture of the radius had a plaster cast applied two days ago. The client complains of constant pain and swelling of the fingers. The FIRST action of the nurse should be

 A)  Elevate the arm no higher than heart level

 B)  Remove the cast

 C)  Assess capillary refill of the exposed hand and fingers

 D)  Apply a warm soak to the hand

Review Information: The correct answer is:

C) Assess capillary refill of the exposed hand and fingers.

A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure reducing interventions.

Beare, P.G., Myers, J.L. (1998).

Adult Health Nursing. (3rd ed.).

New York-St. Louis: Mosby.

Smeltzer, S.G., Bare, B.G. (1999).

Brunner and Suddarth''s Textbook of Medical - Surgical Nursing. (8th ed.).

New York: Lipppincott.

Question 25 

The nurse is caring for a client with congestive heart failure. Which of the following assessments requires the nurse's IMMEDIATE attention?

 A)  Pulse oximetry of 85%

 B)  Nocturia

 C)  Crackles in lungs

 D)  Diaphoresis

Review Information: The correct answer is:

A) Pulse oximetry of 85%.

An oxygen saturation of 88% or less indicates hypoxemia and requires the nurse''s immediate attention.

Bordow, R.A. & Moser, K.M. (1991).

Manual of Clinical Problems in Pulmonary Medicine.

Boston: Little Brown.

Ewald, G.A. & McKenzie, C.R. (1995).

The Washington Manual. (28th ed.).

Boston: Little Brown.

Question 26 

The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnsosis for this client?

 A)  Alteration in body image

 B)  High risk for infection

 C)  Altered growth and development

 D)  Impaired physical mobility

Review Information: The correct answer is:

B) High risk for infection.

Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.

Deglin, J. H. & Vallerand, A. H. (1997).

Davis''s Drug Guide for Nurses. (5th ed.).

Philadelphia: F. A. Davis.

Black, M. & Matassarin-Jacobs, E. (1997).

Medical Surgical Nursing: Clinical Management for Continuity of Care. (5th ed.).

Philadelphia: Saunders

Question 27 

When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which of the following findings would be of GREATEST concern to the nurse?

 A)  Sero sanginous drainage from gums

 B)  Hematemesis

 C)  Pink frothy sputum

 D)  Slight red color at urine

Review Information: The correct answer is:

B) Hematemesis.

Frank bleeding should be of the greatest concern to the nurse.

Black, J., Matassarin-Jacobs, E. (1997).

Medical-Surgical Nursing: Clinical Management for Continuity of Care (5th ed.).

Philadelphia: Saunders.

Lewis, S., Collier, I., & Heitkemper, M. (1996).

Medical-Surgical nursing: Assessment and management of clinical problems. (4th ed).

St. Louis: Mosby

Question 28 

The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should

 A)  Irrigate it as ordered with distilled water

 B)  Irrigate it as ordered with normal saline

 C)  Place the end of the tube in water to see if the water bubbles

 D)  Withdraw the tube several inches and reposition it

Review Information: The correct answer is:

B) Irrigate it as ordered with normal saline.

Nasogastric tubes are only irrigated with normal saline to maintain patency.

Nettina, Sandra (2000).

The Lippincott Manual of Nursing Practice.

Philadelphia-New York: Lippincott.

Luckmann, Joan. (1997).

Saunders Manual of Nursing Care.

Philadelphia: W.B. Saunders Company.

Question 29 

When providing discharge teaching to a client with asthma, the nurse will warn against the use of which of the following over-the-counter medications?

 A)  Cortisone ointments for skin rashes

 B)  Aspirin products for pain relief

 C)  Cough medications containing guaifenesin

 D)  Histamine blockers for gastric distress

Review Information: The correct answer is:

B) Aspirin products for pain relief.

Aspirin is known to induce asthma attacks. Aspirin can also cause nasal polyps and rhinitis. Warn individuals with asthma about signs and symptoms resulting from complications due to aspirin ingestion.

Nettina, Sandra (2000).

The Lippincott Manual of Nursing Practice.

Philadelphia-New York: Lippincott.

Luckmann, Joan. (1997).

Saunders Manual of Nursing Care.

Philadelphia: W.B.Saunders Company.

Question 30 

An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks the nurse when the tube can be used for feeding. The nurse's BEST response is that

 A)  Feedings can begin in 5-7 days

 B)  Use of feeding tube can begin immediately

 C)  Stomach contents and air must be drained first

 D)  Incision healing must be complete before feeding

Review Information: The correct answer is:

C) Stomach contents and air must be drained first.

After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more.

Wong, D. (1999).

Whaley and Wong''s Nursing Care of Infants and Children. (5th ed.).

St. Louis: Mosby.

Ashwill, J. & Droske, S. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: Saunders.

Question 31 

A nursing assistant asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital following a motor vehicle accident. The BEST response emphasizes the importance to the believer of

 A)  Spiritual healing

 B)  Dietary practices

 C)  Fasting and prayer

 D)  Meditation

Review Information: The correct answer is:

A) Spiritual healing.

For the Christian Scientist, a mind cure uses spiritual healing methods. For the believer, medical treatments interfere with drawing closer to God.

Spector, R. (1999).

Cultural Diversity in Health and Illness.

Stamford, CT: Applet‎on & Lange.

Andrews, M. & Boyle, J. (1998).

Transcultural Concepts in Nursing Care.

Philadelphia: Lippincott.

Question 32 

The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What should the nurse do FIRST?

 A)  Explain the stages of death and dying to the family

 B)  Recommend an easy-to-read book on grief

 C)  Assess the family's patterns for dealing with death

 D)  Ask about their religious affiliations

Review Information: The correct answer is:

C) Assess the family''s patterns for dealing with death.

When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that the client and their family''s needs are adequately identified in order to select the best nursing care approaches.

Balzer-Riley, J. (1996).

Communications in Nursing.

St. Louis: Mosby.

Potter, P. & Perry, A. (2000).

Fundamentals of Nursing: Concepts, Process and Practice.

St. Louis: Mosby

Question 33 

In providing care for a client with pain from a sickle cell crisis, which one of the following medication orders for pain control should be questioned by the nurse?

 A)  Demerol

 B)  Morphine

 C)  Methadone

 D)  Codeine

Review Information: The correct answer is:

A) Demerol.

Meperidine is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Ashwill, J. W. & Droske, S. C. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: W. B. Saunders.

Question 34 

The nurse is providing diet instruction to the parents of a child with Cystic Fibrosis. The nurse would emphasize that the diet should be

 A)  High calorie, low fat, low sodium

 B)  High protein, low fat, low carbohydrate

 C)  High protein, high calorie, unrestricted fat

 D)  High carbohydrate, low protein, moderate fat

Review Information: The correct answer is:

C) High protein, high calorie, unrestricted fat.

The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.

Wong, D. (1999).

Whaley & Wong''s Nursing Care of Infants and Children..

St. Louis: Mosby.

Ashwill, J. W. & Droske, S. C. (1997).

Nursing Care of Children: Principles and Practice.

Philadelphia: W. B. Saunders.

Question 35 

The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?

 A)  Tuberculin skin testing

 B)  Sputum culture

 C)  White blood cell count

 D)  Chest x-ray

Review Information: The correct answer is:

B) Sputum culture.

The sputum culture is the most accurate method for determining the presence of active TB.

Lewis, S.M., Collier, I.C., & Heitkemper, M.M. (1996).

Medical-Surgical Nursing: Assessment and Management of Clinical Problems. (4th ed.).

St. Louis: Mosby

Harrington, J.T. (1997).

Consultation in Internal Medicine.

St. Louis: Mosby.

Question 36 

The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on FIRST?

 A)  Weight reduction

 B)  Stress management

 C)  Physical exercise

 D)  Smoking cessation

Review Information: The correct answer is:

D) Smoking cessation.

Stopping smoking is the priority for clients at risk for cardiac disease, because of the effect to reduce oxygenation and constrict blood vessels.

Potter, P. & Perry, A. (2000).

Fundamentals of Nursing: Concepts, Process and Practice.

St. Louis: Mosby.

Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993).

Mosby''s Clinical Nursing. (3rd ed.).

St. Louis: Mosby.

Question 37 

The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is MOST likely due to

 A)  Sexually transmitted infection

 B)  Exposure to teratogens

 C)  Maternal hypertension

 D)  Chromosomal abnormalities

Review Information: The correct answer is:

C) Maternal hypertension.

Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.

Lowdermilk, D., Perry, S., Bobak, I. (1997).

Maternal and Women''s Health Care. (6th ed.).

St. Louis, Mosby.

Wong, D. (1999).

Whaley and Wong''s Nursing Care of Infants and Children. (5th ed.).

St. Louis: Mosby.

Question 38 

A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which of the following expected effects of the drug?

 A)  Tranquilization, numbing of emotions

 B)  Sedation, analgesia

 C)  Relief of insomnia and phobias

 D)  Diminished tachycardia and tremors associated with anxiety

Review Information: The correct answer is:

A) Tranquilization, numbing of emotions.

The anti-anxiety drugs produce tranquilizing effects and may numb the emotions.

Shives, L. (1998).

Basic Concepts of Psychiatric-Mental Health Nursing.

Philadelphia: J.B. Lippincott Co.

Varcarolis, E.(1998).

Foundations of Psychiatric Mental Health Nursing.

Philadelphia: W.B. Saunders.

Question 39 

Which of the following assessments by the nurse would indicate that the client is having a possible adverse response to the INH?

 A)  Severe headache

 B)  Appearance of jaundice

 C)  Tachycardia

 D)  Decreased hearing

Review Information: The correct answer is:

B) Appearance of jaundice.

Clients receiving INH therapy are at risk for developing drug induced hepatitis. The appearance of jaundice may indicate that the client has liver damage.

Ford, L.C. (1996).

Nurse Practitioner''s Drug Handbook.

Springhouse, PA: Springhouse Corporation.

Deglin, J. H. & Vallerand, A. H. (1997).

Davis''s Drug Guide for Nurses. (5th ed.).

Philadelphia: F. A. Davis.

Question 40 

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

 A)  Calcium

 B)  Fiber

 C)  Sodium

 D)  Carbohydrate

Review Information: The correct answer is:

C) Sodium.

The client with Meniere''s disease has an excess accumulation of fluid in the inner ear. A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

Nettina, Sandra (2000).

The Lippincott Manual of Nursing Practice.

Philadelphia-New York: Lippincott.

Luckmann, Joan. (1997).

Saunders Manual of Nursing Care.

Philadelphia: W.B.Saunders Company.