Question 1

The nurse is assessing a newborn. Which of the following findings, if observed by the nurse, should be a cause for concern?
A)Blood pressure difference between the upper arms and thighs is wide
B)A newborn with an apical heart rate of 170 beats per minute when crying
C)Symmetric blue or cyanotic discoloration of the feet and hands
D)Brief periods of apnea during sleep

Accepted Answer

A wide difference of blood pressure measurements between the upper arms and thighs is suggestive of coarctation of the aorta. The normal range of the apical rate of newborns is between 120 and 160, or up to 180 during crying. Symmetric cyanotic discoloration of extremities and periods of apnea are commonly seen in newborn babies.

Question 2

As the nurse assesses a six-month-old female infant, the nurse notices that when the infant's feet are placed on a firm surface, she pushes down with her legs. Which of the following is the nurse's initial action?
A)Document the finding as normal.
B)Instruct the parents to stretch the infant's legs when lying on her stomach.
C)Inform the parents about possible treatment options for cerebral palsy.
D)Notify the physician.

Accepted Answer

Stepping reflex should be resolved by about 4 months of age. A developmental or neurological evaluation is necessary with continued stepping reflex at 6 months; therefore, notifying the doctor is the best initial action. Cerebral palsy is a possible cause, but it is necessary to refer the child to a specialist.

Question 3

A female teenaged client comes to the emergency room following an assault. The client is extremely anxious and is hyperventilating. Which of the following interventions is the most appropriate nursing action?
A)Teach the patient how to do deep breathing exercises.
B)Stay with the client until the level of anxiety decreases.
C)Place the patient in a quiet room alone to decrease stimulation.
D)Encourage the client to verbalize her feelings and fears.

Accepted Answer

The client is severely anxious. When a client is in a severe state of anxiety, it is crucial to stay with the client until anxiety decreases. Leaving the client alone and encouraging verbalization of feelings at this point can increase her level of anxiety. A client would not be able to learn any relaxation techniques when severely anxious.

Question 4

A client undergoes a radical mastectomy of the right breast. The nurse interprets that the client is beginning to adjust to the physical change if which of the following behaviors is noted?
A)The client refuses to look at her chest.
B)The client is actively participating in caring for the surgical drain.
C)The client is surfing on her laptop and reading about breast reconstruction surgery on the Internet.
D)The client asks for pain medications.

Accepted Answer

Participation to personal care, including caring for the surgical drain, demonstrates good adjustment to physical changes resulting from the surgery. Getting more information about breast reconstruction and asking for pain medications do not relate to the adaptation to the changes. Refusing to look at the wound does not demonstrate acceptance.

Question 5

A newlyadmitted male client in an acute manic state kisses a female nurse and asks her to go on a dinner date with him. The nurse's best response is to:
A)Ignore the client.
B)Directly tell the client that his behavior is not acceptable.
C)Ask the client to help clean the dayroom.
D)Isolate or seclude the client.

Accepted Answer

A manic client in the acute phase is extremely active; therefore, it is essential that this energy is channeled into constructive or positive activities like asking the client to help clean the dayroom. The other responses would not assist the client in controlling his behavior.

Question 6

A female client has just been admitted with a diagnosis of major depression. Which of the following is the most appropriate question for the nurse to ask at this time?
A)"What is bothering you?"
B)"Why do feel this way?"
C)"How do you feel about yourself?"
D)"Do you need help?"

Accepted Answer

The nurse makes the nursing care plan based on the perceived feelings, needs, or problems of the client. Why questions can overwhelm the client, which can lead to withdrawal. Asking the client what is bothering her can be too difficult for her at this time. Asking the client if she needs help is a closed-ended question, resulting in very scant information.

Question 7

A client with schizophrenia refuses to leave his room to have dinner. The client tells the nurse that the Queen of England will be seeing him in his room. The nurse's best response is:
A)"Anyone in this unit who refuses to follow our schedule shall be placed in seclusion."
B)"It is dinner time. Let's go to the dining hall so you can eat."
C)"The Queen of England asked me to inform you that she's meeting you in the dining hall instead."
D)"The Queen of England is not meeting you. You don't know her personally."

Accepted Answer

A delusional client is so deeply engaged in his false beliefs that he tends to forget about eating, drinking, and taking a bath; therefore, these needs are a priority for the nurse. Instructions must be clear, concise, and firm. Option A threatens the client, which does not address the needs of the client. Option C deceives the client, which could possibly cause mistrust. The last option challenges and belittles the client and does not address his needs.

Question 8

The fifteen-year-old daughter of a client diagnosed with schizophrenia asks the nurse about her chances of having the same disorder. Which of the following statements, if made by the client, would be an indication that the girl should be evaluated further?
A)"My mood swings have been unpredictable for the past week."
B)"I look and feel fat. I'm so ashamed to go out looking like this."
C)"I'd rather spend most hours of the day at my friend's house."
D)"I've been having a difficult time falling and staying asleep."

Accepted Answer

Changes in sleeping patterns are distinct initial signs of schizophrenia. The other options are behaviors that are normally seen in adolescents.

Question 9

A client asks the nurse if she can hear the voice of a woman who is giving her some important orders. The nurse's most appropriate response is:
A)"No, I don't hear her. No one is in your room except you and me."
B)"No, I don't hear her, but I know you do. What is she telling you?"
C)"What is she instructing you to do? Are the orders demanding? "
D)"Yes, I hear her. Tell her to leave you alone. If she talks to you again, ignore her."

Accepted Answer

This response emphasizes reality and at the same time, conveys support. Arguing with the client can embed her belief more firmly, causing the client to feel more out of control. The other responses are non-therapeutic.

Question 10

A nurse is closely monitoring a female client who is admitted due for depression. The nurse determines which behavior as an indicator that the client is suicidal?
A)The client tells the nurse that she wants to be alone and she's too tired to interact with other clients.
B)The client gets angry at her roommate who woreher shirt without asking.
C)The client swears at the nurse who was facilitating a group therapy session.
D)The client gives away her favorite book signed by the book's author.

Accepted Answer

When a depressed client starts giving away her favorite or cherished material possessions, the nurse takes it as a sign that she has finalized a plan for suicide. The nurse must increase suicide precautions. Clients who are depressed are often isolated and fatigued.

Question 11

A nurse in the emergency room is caring for an eighteen-year-old girl who is a victim of sexual assault. The client is withdrawn and at times, becomes physically immobile. The nurse determines that:
A)The client is at risk for suicide.
B)The client is demonstrating normal reactions.
C)The client is showing signs of traumatic disorder.
D)An admission to the facility is necessary.

Accepted Answer

Immediately after a crisis, in this case a sexual assault, the client can demonstrate a wide range of emotions and responses. The symptoms listed are normal reactions after a devastating experience.

Question 12

A nurse is giving discharge instructions to a client with depression. During evaluation, which of the following, if stated by the client, suggests a need for further teaching?
A)"It is important that I take my medications on time so I won't be depressed again."
B)"I need to deal with stresses in my life constructively."
C)"If my medications make me sick, I should not stop taking them unless I contact my physician."
D)"I am taking everything one step at a time."

Accepted Answer

Depression can recur for certain individuals; therefore, the client must identify the symptoms and recognize the need for treatment, if necessary. The other options are appropriate.

Question 13

A male client with an obsessive-compulsive behavior is admitted to the mental health facility. He is unable to finish schoolbecause his repetitive behavior caused him to missmost of his classes. The nurse understands that the client's behavior is mainly caused by which of the following:
A)The client is responding to a psychologically traumatic event and re-experiencing intrusive dreams.
B)The client is responding to auditory hallucinations and is attempting to overcome them.
C)The client is constantly preoccupied with intrusive thoughts and ideas and he is unconsciously attempting to reduce his anxiety.
D)The client has an altered self-perception in which his own reality is temporarily lost.

Accepted Answer

The client with an obsessive-compulsive behavior is constantly preoccupied with intrusive thoughts and ideas. The client is attempting to control the environment and anxiety level by repetitive actions.

Question 14

A client tells the nurse that her officemates are trying to sabotage her work because they do not want her to get a promotion. As the nurse assesses the situation, the client becomes aggressive. This behavior of the client shows personality traits associated with which of the following personality disorders?
A)Schizoid
B)Paranoid
C)Borderline
D)Antisocial

Accepted Answer

Mistrust and suspiciousness characterize clients with paranoid personality disorder. These clients interpret the actions of others as personal threats. A schizoid client lacks desire for close relationships. A client with a borderline personality disorder has problems with identity, self-image, and relationships.

Question 15

A nurse is caring for a client with paranoid personality disorder who misinterprets everything that the staff says. The most appropriate approach of the nurse is:
A)Ask the client to verbalize anxious situations.
B)Speak to the client in simple and short messages.
C)Ignore the client.
D)Restrict interaction to ADLs.

Accepted Answer

The nurse should speak with the client using clear and simple messages to reduce the chances of being misinterpreted. Asking the client to verbalize anxious situations gives the client more information to misinterpret. Ignoring does not address the issue and restricting interaction can interfere with the treatment goals.

Question 16

A twelve-year-old girl just had surgery, and an incision was made in the abdominal area. The nurse would expect which of the following questions from the client?
A)"When can I go back to school?"
B)"Are there any complications?"
C)"When is my mother coming back?"
D)"Will I have a large scar?"

Accepted Answer

Adolescent clients are constantly preoccupied with their body image and how they appear to others. Therefore, a nurse caring for a postoperative adolescent client must expect this question. The other options are not an adolescent's priority.

Question 17

The nurse places the client in this position immediately after a percutaneous liver biopsy:
A)Semi-Fowler's position
B)Left-side lying position
C)Right-side lying position
D)Supine position.

Accepted Answer

Placing the patient on the right side applies pressure to the site of biopsy, preventing bleeding. The liver is located on the right upper side of the abdomen. The other options are not appropriate for a post-percutaneous liver biopsy client.

Question 18

A nurse is receiving a client from the postanesthesia unit. Which of the following nursing actions would be the nurse's immediate priority?
A)Assess the client's vital signs.
B)Assess the patency of the client's airway.
C)Assess for bleeding and check the dressings.
D)Check the client's neurovascular status.

Accepted Answer

Assessing the patency of the airway should be the nurse's first priority. The other options are appropriate, but the airway takes priority above everything else.

Question 19

A physician orders the removal of the client's nasogastric tube. The nurse would instruct the client to do which of the following during tube removal?
A)Ask the client to take a deep breath and exhale through pursed lips.
B)Instruct the client to bear down.
C)Instruct the client to take and hold a deep breath.
D)Ask the client to relax and take normal breaths.

Accepted Answer

The client should be instructed to take and hold a deep breath to close the epiglottis, obstructing the airway. This allows easier removal of the tube. The other options are inappropriate.

Question 20

An eighty-year-old male client diagnosed with benign prostatic hypertrophy complains of pain as the nurse inflates the balloon of the indwelling urethral catheter that has been inserted. What is the best action of the nurse?
A)Aspirate the fluid, withdraw the catheter, and reinflate the balloon.
B)Aspirate the fluid, advance the catheter, and reinflate the balloon.
C)Remove the syringe and begin aftercare. Pain is an expected response.
D)Aspirate the fluid, remove the catheter, and replace it with a smaller catheter.

Accepted Answer

If pain occurs during balloon inflation, it indicates that the balloon needs to be repositioned. The best action is to aspirate the fluid, advance the catheter further, and reinflate the balloon. Advancing the catheter would allow some space for balloon inflation.

Quiz 1: Changes in Health

The nurse is assessing a newborn. Which of the following findings, if observed by the nurse, should be a cause for concern?

As the nurse assesses a six-month-old female infant, the nurse notices that when the infant's feet are placed on a firm surface, she pushes down with her legs. Which of the following is the nurse's initial action?

A female teenaged client comes to the emergency room following an assault. The client is extremely anxious and is hyperventilating. Which of the following interventions is the most appropriate nursing action?

A client undergoes a radical mastectomy of the right breast. The nurse interprets that the client is beginning to adjust to the physical change if which of the following behaviors is noted?

A newlyadmitted male client in an acute manic state kisses a female nurse and asks her to go on a dinner date with him. The nurse's best response is to:

A female client has just been admitted with a diagnosis of major depression. Which of the following is the most appropriate question for the nurse to ask at this time?

A client with schizophrenia refuses to leave his room to have dinner. The client tells the nurse that the Queen of England will be seeing him in his room. The nurse's best response is:

The fifteen-year-old daughter of a client diagnosed with schizophrenia asks the nurse about her chances of having the same disorder. Which of the following statements, if made by the client, would be an indication that the girl should be evaluated further?

A client asks the nurse if she can hear the voice of a woman who is giving her some important orders. The nurse's most appropriate response is:

A nurse is closely monitoring a female client who is admitted due for depression. The nurse determines which behavior as an indicator that the client is suicidal?

A nurse in the emergency room is caring for an eighteen-year-old girl who is a victim of sexual assault. The client is withdrawn and at times, becomes physically immobile. The nurse determines that:

A nurse is giving discharge instructions to a client with depression. During evaluation, which of the following, if stated by the client, suggests a need for further teaching?

A male client with an obsessive-compulsive behavior is admitted to the mental health facility. He is unable to finish schoolbecause his repetitive behavior caused him to missmost of his classes. The nurse understands that the client's behavior is mainly caused by which of the following:

A nurse is caring for a client with paranoid personality disorder who misinterprets everything that the staff says. The most appropriate approach of the nurse is:

A twelve-year-old girl just had surgery, and an incision was made in the abdominal area. The nurse would expect which of the following questions from the client?

The nurse places the client in this position immediately after a percutaneous liver biopsy:

A nurse is receiving a client from the postanesthesia unit. Which of the following nursing actions would be the nurse's immediate priority?

A physician orders the removal of the client's nasogastric tube. The nurse would instruct the client to do which of the following during tube removal?

An eighty-year-old male client diagnosed with benign prostatic hypertrophy complains of pain as the nurse inflates the balloon of the indwelling urethral catheter that has been inserted. What is the best action of the nurse?