NCLEX-PN 250 New-Format Questions and Answers With Rationale. In Five Parts: 1 Fundamentals of nursing; 2 Medical-surgical nursing; 3 Maternal-infant nursing; and Pediatric nursing; 4 Psychiatric and mental; 5 health nursing

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Fundamentals of nursing 1 Basic physical care 1. A nurse is caring for a client who sustained a chemical burn in his right eye. She’s preparing to i... rri- gate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply. # 1. Tilt the client’s head toward his left eye. # 2. Place absorbent pads in the area of the client’s shoulder. # 3. Wash hands and put on gloves. # 4. Place the irrigation syringe directly on the cornea. # 5. Direct the solution onto the exposed conjuncti- val sac from the inner to outer canthus. # 6. Irrigate the eye for 1 minute. 2, 3, 5 2. A nurse is caring for a client who underwent car- diac catheterization. He starts bleeding from his left femoral access site. Identify the area where the nurse should apply pressure. 3. A nurse is preparing to leave a contact isolation room. Place the following steps in ascending chrono- logical order as to how protective wear should be re- moved. Use all the options. 1. Remove eyewear. 2. Remove gloves. 3. Remove mask. 4. Remove gown. 5. Wash hands for a minimum of 10 seconds. 4. A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply. # 1. Chill the solution by placing it in the refrigerator for 10 minutes. # 2. Assist the client into Sims’ position. # 3. Wash hands and put on gloves. # 4. Insert the tip of the container 1⁄2" into the rec- tum. # 5. Allow gravity to instill the solution. # 6. Encourage the client to retain the solution for 5 to 15 minutes. 2, 3, 6 5. A nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for labora- tory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1⁄2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinat- ed coffee, tuna fish sandwich, 1⁄2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz. of 1% milk, 16 oz of water Output: 1,300 ml of urine How many milliliters should the nurse document as the client’s intake? 1380 6. A hospitalized client asks the nurse for “something for pain.” What information is most important for the nurse to gather before administering the medication? Select all that apply. # 1. Administration time of the last dose # 2. Client’s pain level on a scale of 1 to 10 # 3. Type of medication the client has been taking # 4. Beeper number of the client’s physician # 5. Client’s most current height and weight # 6. Effectiveness of prior dose of medication 1, 2, 3, 6 7. A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a “pulling” sensation in his abdominal wound. The nurse assesses the client’s wound and finds that it has sepa- rated and the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply. # 1. Notify the client’s primary physician. # 2. Cover the wound with saline-soaked sterile gauze. # 3. Give the client a dose of antibiotics. # 4. Order an abdominal binder from the supply de- partment. # 5. Push the organs back into the abdomen. # 6. Assess the client for signs of shock. 8. A nurse puts on gloves to perform a fecal occult blood test using a Hemoccult slide. Place these steps in ascending chronological order. Use all the options. 1. Allow the specimens to dry for 3 minutes. 2. Apply a drop of Hemoccult-developing solution to box A and box B on the reverse side of the slide. 3. Apply a smear of stool to box A on the slide. 4. Apply a smear of stool from another part of the speci- men to box B on the slide. 5. Apply a drop of Hemoccult-developing solution to each control dot on the reverse side of the slide. 6. Evaluate the results; remove gloves; wash hands. 1, 2 9. A client suffers a broken leg as a result of a car ac- cident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse pro- vides the client with instructions regarding cast care. Which instructions are most appropriate? Select all that apply. # 1. Support the wet cast with pillows until it dries. # 2. Use a hair dryer to speed the drying process. # 3. Use the fingertips when moving the wet cast. # 4. Apply powder to the inside of the cast after it dries. # 5. Notify the physician if itching occurs under the cast. # 6. Avoid putting straws or hangers inside the cast. 1, 6 10. A nurse is caring for a client with a hiatal hernia. The client complains of abdominal and sternal pain af- ter eating. The pain makes it difficult for the client to sleep. Which instructions should the nurse stress when teaching this client? Select all that apply. # 1. Avoid constrictive clothing. # 2. Lie down for 30 minutes after eating. # 3. Decrease intake of caffeine and spicy foods. # 4. Eat three meals per day. # 5. Sleep in semi-Fowler position. # 6. Maintain a normal body weight. 1, 3, 5, 6 11. A client is admitted to the hospital from an extended care facility with a stage 3 pressure ulcer. Identify the deepest layer of tissue involved in this diagnosis. 12. A nurse investigates the smell of smoke in the hallway of a long-term care unit. She enters a client’s room and finds the wastebasket is on fire. The nurse takes immediate action. Place the nurse’s actions in proper ascending chronological order. Use all the op- tions. 1. Trigger the alarm. 2. Extinguish the fire. 3. Rescue the client. 4. Confine the fire. Basic psychosocial needs 1. A nurse is caring for a client who’s disoriented to time, place, and person and is attempting to get out of bed and pull out an I.V. line that’s supplying hydration and antibiotics. The client has a vest restraint and bilat- eral soft wrist restraints. Which actions by the nurse would be appropriate? Select all that apply. # 1. Recheck and document the behavior that re- quires continued use of restraints. # 2. Tie the restraints in quick-release knots. # 3. Tie the restraints to the side rails of the bed. # 4. Ask the client if he needs to go to the bath- room, and provide range-of-motion (ROM) exercises every 2 hours. # 5. Position the vest restraints so that the straps are crossed in the back. 1, 2, 4 2. A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client’s daughter tells the nurse, “I don’t know what to say to my mother if she asks me if she’s going to die.” Which responses by the nurse would be ap- propriate? Select all that apply. # 1. “Tell your mother not to worry; she still has some time left.” # 2. “Let’s talk about your mother’s illness and how it will progress.” # 3. “You sound like you have some questions about your mother dying. Let’s talk about that.” # 4. “Don’t worry. Hospice will take care of your mother.” # 5. “Tell me how you’re feeling about your mother dying.” 2, 3, 5 3. While providing care to a 26-year-old married fe- male, a nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client re- sponds, “Oh, I tripped.” How should the nurse re- spond? Select all that apply. # 1. Document the client’s statement and complete a body map indicating the size, color, shape, lo- cation, and type of injuries. # 2. Contact the local authorities to report suspicions of abuse. # 3. Assist the client in developing a safety plan for times of increased violence. # 4. Call the client’s husband to arrange a meeting to discuss the situation. # 5. Tell the client that she needs to leave the abu- sive situation as soon as possible. # 6. Provide the client with telephone numbers of local shelters and safe houses. 1, 3, 6 4. A nurse is caring for a client who’s terminally ill. Place the symptoms of the five stages of death and dying described by Elisabeth Kübler-Ross in ascending chronological order. Use all the options. 1. Negotiating, new interest in healthful behaviors 2. Withdrawal, refusal to discuss health issues 3. Calmness, honesty, involved in care management deci- sions 4. Irritability, complaining, adversarial 5. Loss, grief, intense sadness 5. A 26-year-old client with chronic renal failure was recently told by his physician that he’s a poor candi- date for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, “I want to go off dialysis. I’d rather not live than be on this treatment for the rest of my life.” Which responses by the nurse are appropriate? Select all that apply. # 1. Take a seat next to the client and sit quietly to reflect on what was said. # 2. Say to the client, “We all have days when we don’t feel like going on.” # 3. Leave the room to allow the client privacy to collect his thoughts. # 4. Say to the client, “You’re feeling upset about the news you got about a transplant.” # 5. Say to the client, “The treatments are only 3 days a week. You can live with that.” 1, 4 6. A nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client’s family? Select all that apply. # 1. People related by blood or marriage # 2. People whom the client views as family # 3. People who live in the same house # 4. People who the nurse thinks are important to the client # 5. People who live in the same house with the same racial background as the client # 6. People who provide for the physical and emo- tional needs of the client 2, 6 7. A nurse is caring for a client whose cultural back- ground is different from her own. Which actions are appropriate for the nurse? Select all that apply. # 1. Consider that nonverbal cues such as eye con- tact may have a different meaning in different cultures. # 2. Respect the client’s cultural beliefs. # 3. Ask the client if he has cultural or religious re- quirements that should be considered in his care. # 4. Explain the nurse’s beliefs so that the client will understand the differences. # 5. Understand that all cultures experience pain in the same way. 1, 2, 3 8. A nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply. # 1. Illness in one family member can affect all members. # 2. Family roles don’t change because of illness. # 3. A family member may have more than one role at a time in a family. # 4. Children typically aren’t affected by adult illness. # 5. The effects of an illness on a family depend on the stage of the family’s life cycle. # 6. Changes in sleeping and eating patterns may be signs of stress in a family. 1, 3, 5, 6 9. Every client admitted to the hospital must receive information about advance directives. Which state- ments are true about advance directives? Select all that apply. # 1. Every person must complete an advance direc- tive upon admission. # 2. An advance directive includes a living will or a power of health care attorney. # 3. An advance directive is a legal document. # 4. An advance directive must be notarized. # 5. An advance directive should be included with the client’s chart. # 6. An advance directive conveys the client’s directions about his health care upon loss of capacity. 2, 3, 5, 6 10. A nurse is working with the family of a client who has Alzheimer’s disease. The nurse notes that the client’s spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing inter- ventions would be helpful? Select all that apply. # 1. Calling a family meeting to tell the absent chil- dren that they must participate in caregiving # 2. Suggesting the spouse seek psychological coun- seling to help cope with exhaustion # 3. Recommending community resources for adult day care and respite care # 4. Encouraging the spouse to talk about the diffi- culties involved in caring for a loved one # 5. Asking whether friends or church members can help with errands or provide short periods of relief # 6. Recommending that the client be placed in a long-term care facility 3, 4, 5 Medication and I.V. administration 1. A client has just had total hip replacement surgery. The physician orders heparin 8,000 units to be admin- istered subcutaneously. The label on the heparin vial reads: heparin 10,000 units/ml. How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose? 2. After laparoscopic cholecystectomy, a client com- plains of pain and nausea. The nurse is preparing meperidine hydrochloride (Demerol) 75 mg and promethazine hydrochloride (Phenergan) 12.5 mg to be administered I.M. in the same syringe. If the label on the Demerol reads 50 mg/ml and the label on the Phenergan reads 25 mg/ml, how many milliliters should the nurse have in the syringe after the correct doses are drawn up? 0.8 2 3. A nurse is reinforcing a teaching plan with a client who’s prescribed enalapril maleate (Vasotec) for treat- ment of hypertension. Which instructions would the nurse expect to see included in the teaching plan? Se- lect all that apply. # 1. Instruct the client to avoid salt substitutes. # 2. Tell the client that light-headedness is a com- mon adverse effect that need not be reported. # 3. Inform the client that he may have a sore throat for the first few days of therapy. # 4. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically thereafter. # 5. Advise the client to report facial swelling or diffi- culty breathing immediately. # 6. Inform the client not to change position sud- denly to minimize orthostatic hypotension. 4. A nurse is administering ampicillin (Polycillin) 125 mg I.M. every 6 hours to a 10-kg child with a respirato- ry tract infection. The drug label reads, “The recom- mended dosage for a client weighing less than 40 kg is 25 to 50 mg/kg/day I.M. or I.V. in equally divided doses at 6- to 8-hour intervals.” The drug concentra- tion is 125 mg/5 ml. Which nursing interventions are appropriate at this time? Select all that apply. # 1. Draw up 10 ml of ampicillin to administer. # 2. Administer the medication at 1000, 1400, 1800, and 2200. # 3. Assess the client for allergies to penicillin. # 4. Administer the medication because it’s within the dosing recommendations. # 5. Question the physician about the order because it’s more than the recommended dosage. # 6. Obtain a sputum culture before administering the medication. 1, 5, 6 3, 4, 6 5. A nurse is using the Z-track method of I.M. injec- tion to administer iron dextran to a client with iron de- ficiency anemia. Which techniques should the nurse use to give this injection? Select all that apply. # 1. Confirm the client’s identity before administer- ing the iron dextran. # 2. Inject the iron dextran into the deltoid muscle. # 3. Change the needle after drawing up the iron dextran. # 4. Before inserting the needle, displace the skin laterally by pulling it away from the injection site. # 5. Inject the iron dextran after aspirating for a blood return. # 6. After removing the needle, massage the injec- tion site. 1, 3, 4, 5 6. The nurse is preparing to administer regular in- sulin 4 units to a client with type 1 diabetes mellitus. Which equipment does the nurse need to perform the injection? Select all that apply. # 1. Medication administration record # 2. Nursing assessment sheet # 3. 27-gauge, 1⁄2" needle # 4. 22-gauge, 1⁄2" needle # 5. 27-gauge, 1" needle # 6. 22-gauge 1" needle 1, 3 7. A nurse is administering insulin to a client with type 1 diabetes mellitus. Identify the tissue layer where the tip of the needle should be placed to deliv- er this medication to the proper tissue. Skin 8. A client with heart failure is ordered 60 mg of furosemide (Lasix) P.O. daily. Because the client has difficulty swallowing, an oral solution is ordered. The solution dispensed from the pharmacy has a concen- tration of 40 mg/5 ml. How many milliliters should the nurse administer? 7.5 9. A client with an I.V. line in place complains of pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions should the nurse take? Select all that apply. # 1. Slow the infusion rate while notifying the pre- scriber. # 2. Discontinue the infusion at the affected site. # 3. Request restart of the infusion in an I.V. site dis- tal to the discontinued I.V. site. # 4. Check the client for skin sloughing. # 5. Apply warm soaks to the I.V. site. # 6. Document the examination, the nurse’s actions, and the client’s responses. 10. A nurse is administering an I.M. injection into the vastus lateralis muscle. Identify the area where the nurse will inject the medication. 2, 4, 5, 6 11. A physician orders amoxicillin (Amoxil) 250 mg P.O. (by mouth) t.i.d. for a client. Amoxicillin 125 mg/ tsp is available. How many tsp must the nurse admin- ister? 2 12. A client on hemodialysis is prescribed cephalex- in (Keflex) 500 mg P.O. (by mouth) every 6 hours for a group A beta-hemolytic streptococcal infection. The client states that he can’t swallow the large pills and requests a liquid dose. The suspension is available in 250 mg/5 ml. The nurse knows that which statements about this order are true? Select all that apply. # 1. The maximum oral dosage of cephalexin for an adult is 4 g daily. # 2. Hypersensitivity to penicillin and cephalosporin is a contraindication to use of this drug. # 3. The dosage prescribed for the client is within an acceptable range for a client on hemodialysis. # 4. Adverse effects of nausea and anorexia may be relieved by taking the drug with food or milk. # 5. Stevens-Johnson syndrome is an adverse effect of this drug. # 6. Diarrhea is a common but not serious adverse reaction to this drug. 1, 4 13. A nurse transcribes the following physician’s or- der onto the client’s medication record: March 15, 2006 1630 Administer 10 gtt of timolol maleate (Timoptic) ophthalmic solution AU daily. John Bloom, MD Which components of the medication order should the nurse question? Select all that apply. # 1. Number of drops # 2. Route # 3. Type of medication # 4. Signature # 5. Frequency of administration # 6. Date 1, 2 Basic physical assessment 1. An adolescent client seeks medical attention be- cause of a sore throat and probable mononucleosis. The nurse palpates the client’s submandibular lymph nodes for enlargement. Identify the area where the nurse should palpate to best feel these nodes. 2. A client is hospitalized with pneumonia for 2 days. After reading the documentation below, what’s the nurse’s assessment of the arterial blood gas results? 4/16/2006 1530 Arterial blood gases pH 7.48 PCO2 32 mm Hg PO2 88 mm Hg SaO2 90 HCO3 24 mEq/L – # 1. Respiratory acidosis # 2. Respiratory alkalosis # 3. Metabolic acidosis # 4. Metabolic alkalosis 2 3. A client is admitted to the hospital for a fractured hip. He has a history of aortic stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur. 4. A nurse is collecting data on a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to obtain more informa- tion about the client’s rash? Select all that apply. # 1. “When did the rash start?” # 2. “Are you allergic to any medications, foods, or pollen?” # 3. “How old are you?” # 4. “What have you been using to treat the rash?” # 5. “Have you traveled outside of the country?” # 6. “Do you smoke cigarettes or drink alcohol?” 1, 2, 4, 5 5. A client comes to the clinic complaining of hear- ing loss. The nurse performs Weber’s test to assess the client’s ability to hear. Identify the location where the nurse should place the tuning fork to perform this test. 6. A nurse realizes that as a client experiences neu- rologic deterioration, symptoms of “disorientation” usually occur sequentially. Place the following symp- toms in ascending chronological order. Use all the op- tions. 1. Disoriented to familiar people 2. Disoriented to time 3. Disoriented to self 4. Disoriented to place 7. A client is admitted with a diagnosis of new-onset atrial fibrillation. To obtain an accurate pulse count, the nurse counts the apical heart rate. Identify the area where the nurse should place the stethoscope to best hear the apical rate. 8. An elderly client who is 5'4" and weighs 145 lb is admitted to the long-term care facility. The admitting nurse takes this report: The client sits for long periods in his wheelchair and has bowel and bladder inconti- nence. He is able to feed himself and has a fair ap- petite, eating best at breakfast and poorly thereafter. He doesn’t have family members living nearby and is often noted to be crying to sleep. He also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer? Select all that apply. # 1. Weight # 2. Incontinence # 3. Sitting for long periods of time # 4. Sedation # 5. Crying # 6. Eating poorly at lunch and dinner 2, 3, 4 9. A nurse finds a client lying on the floor of the hos- pital corridor. After determining unconsciousness, breathlessness, and providing two ventilations, the nurse checks the client’s carotid artery for a pulse. Identify the area where the nurse can best palpate the carotid pulse. 10. A client with diabetes comes to the clinic for medical attention because of numbness and tingling in his lower extremities. The nurse obtains the client’s vital signs and palpates the dorsalis pedis pulse. Identi- fy the area where the nurse places her fingers to pal- pate the pedal pulse. 11. A client comes to the emergency department seeking medical attention for severe pain in the area of the appendix. Identify the area where the nurse would expect the pain to localize. 12. A client is admitted to the hospital for routine outpatient surgery. Before surgery, the nurse auscul- tates the client’s chest for breath sounds. Identify the area where the nurse should expect to hear bron- chovesicular breath sounds. P A R T T W O Medical-surgical nursing 27 Cardiovascular disorders 1. A client with a history of hypertension has just had a total hip replacement. The physician orders hydro- chlorothiazide (Hydro-Chlor) 35 mg oral solution by mouth, once per day. The label on the solution reads hydrochlorothiazide 50 mg/5 ml. To administer the correct dose, how many ml should the nurse pour? 2. A client on telemetry reports that she’s having chest pain. The hospital unit has standing orders that allow a nurse to begin treating the client before notify- ing the physician. Place the following actions in proper ascending chronological order. Use all the options. 1. Evaluate the client’s response. 2. Administer SL nitroglycerin. 3. Administer oxygen at 2 L/min. 4. Check vital signs. 3.5 3. A nurse is checking a client who’s at risk for car- diac tamponade due to chest trauma sustained in a motorcycle accident. What’s the client’s pulse pressure if his blood pressure is 108/82 mm Hg? 26 4. A nurse is preparing to take the blood pressure of a client. Which actions are appropriate? Select all the apply. # 1. Selecting a cuff that’s 80% of arm circum- ference # 2. Wrapping the cuff so that the lower border is 8 cm above the antecubital space # 3. Centering the bladder of the cuff over the brachial artery # 4. Inflating the cuff to 30 mm above the reading where the brachial pulse disappeared # 5. Quickly releasing the bulb valve so the pressure drops more than 5 mm Hg per second 1, 3, 4 5. A nurse is applying a 3-lead telemetry unit to a client newly admitted to the telemetry unit. The client is to be monitored in a lead MCL1. Identify the area where the nurse would correctly place the positive chest lead. 6. A nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse expect in the care plan for the next 8 hours? Select all that apply. # 1. Maintain pressure over the femoral access site. # 2. Allow the client to sit upright for meals. # 3. Check the dressing and access site for bleeding. # 4. Monitor vital signs every 4 hours. # 5. Keep the extremity straight. # 6. Allow use of the bedside commode. 1, 3, 5 7. A nurse is assisting with preparing a teaching plan for a client who recently underwent surgery for inser- tion of a permanent pacemaker. Which instructions should the nurse include in the teaching plan? Select all that apply. # 1. Check heart rate for 1 minute daily. # 2. Check respiratory rate for 1 minute daily. # 3. Report any bulging at the insertion site. # 4. Report redness, swelling, or discharge at the in- sertion site. # 5. Stay away from airport metal detectors. # 6. Avoid magnetic resonance imaging (MRI) diag- nostic studies. 1, 4, 6 8. A nurse is assisting in admitting a client with sub- sternal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply. # 1. Serum bilirubin # 2. Serum troponin # 3. Serum myoglobin # 4. Urinalysis # 5. Electroencephalogram # 6. 24-hour creatinine clearance 2, 3 9. Which signs and symptoms should the nurse ex- pect to find in a client with angina? Select all that apply. # 1. Chest tightness # 2. General muscle aching # 3. Chest pressure # 4. Jaw pain # 5. Slowed respiratory rate # 6. Bradycardia 1, 3, 4 10. A client is diagnosed with myocardial infarction. Which data collected indicate that the client has devel- oped left-sided heart failure? Select all that apply. # 1. Ascites # 2. Jugular vein distention # 3. Orthopnea # 4. Cough # 5. Hepatomegaly # 6. Crackles 3, 4, 6 11. A nurse is performing a cardiac check on a client with hypertension. Identify the area where the nurse should place the stethoscope to best auscultate the pulmonic valve. 12. The nurse is checking the peripheral pulses of a client who underwent cardiac catheterization through the left groin. Identify the area where the nurse should palpate the left posterior tibial artery. 13. A client with atrial fibrillation is diagnosed with an embolic stroke. Identify the heart chamber that is the most likely source of the fragmented clot responsi- ble for the stroke. Oncologic disorders 1. A client in the terminal stage of cancer is being transferred to hospice care. Which information should the nurse include in the teaching plan regarding hos- pice care? Select all that apply. # 1. Care focuses on controlling symptoms and re- lieving pain. # 2. A multidisciplinary team provides care. # 3. Services are based on the client’s ability to pay. # 4. Hospice care is provided only in hospice cen- ters. # 5. Bereavement care is provided to the family. # 6. Care is provided in the home independent of physicians. 1, 2, 5 2. A physician has ordered filgrastim (Neupogen) 5 mcg/kg subcutaneously for a postchemotherapy client. The client weighs 140 lb. Neupogen comes in a vial of 300 mcg/ml. How many milliliters of Neupogen will a nurse deliver to the client? 1 3. A nurse is teaching a community program on breast self-examination. She tells the group the proper steps to take when palpating each breast. Place the following actions in proper ascending chronological or- der. Use all the options. 1. Use the right hand for the left breast (and vice versa). 2. Lie down with your arm behind your head. 3. Palpate the breast in a perpendicular motion going across the breast from side to side and top to bottom. 4. Use a circular motion to feel breast tissue (with light, medium, and firm pressure). 5. Use the finger pads of the three middle fingers. 4. A client with breast cancer was admitted earlier in the day with sepsis and complaints of nausea, pain, and lethargy. She completed her third round of chemotherapy last week. A physician has just ordered I.V. D5 half normal saline solution at 150 ml/hr. Which notes would the nurse expect to see documented in the client’s chart? Select all that apply. # 1. Skin flushed and warm. # 2. Client groggy but answers questions appropri- ately. # 3. Auscultation of lungs: clear bilaterally. # 4. Abdomen soft and nontender. Bowel sounds present in all quadrants. # 5. BP 96/50, HR 114/min, RR 22/min, T 103.2ºF (39.5ºC). Urine output 150 ml in the past 6 hours. # 6. BUN 35, creatinine 0.4, Na 134, K 4.2, Cl 104. 1, 2, 5, 6 5. A client with laryngeal cancer has undergone laryngectomy and is receiving radiation therapy to the head and neck. The nurse should monitor the client for which adverse effects of external radiation? Select all that apply. # 1. Xerostomia # 2. Stomatitis # 3. Thrombocytopenia # 4. Cystitis # 5. Dysgeusia # 6. Leukopenia 1, 2, 5 6. A client with bladder cancer undergoes surgical removal of the bladder and construction of an ileal conduit. Which data indicate that the client is develop- ing complications? Select all that apply. # 1. Urine output is greater than 30 ml/hr. # 2. The stoma appears dusky. # 3. The stoma protrudes from the skin. # 4. Mucus shreds are in the urine collection bag. # 5. Edema of the stoma is present during the first 24 hours postoperatively. # 6. The client experiences sharp abdominal pain and abdominal rigidity. 2, 3, 6 7. A client receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse expect in the discharge teaching plan? Select all that apply. # 1. Avoid people who have recently received atten- uated vaccines. # 2. Avoid activities that may cause bleeding. # 3. Wash hands frequently. # 4. Increase intake of fresh fruits and vegetables. # 5. Avoid crowded places such as shopping malls. # 6. Treat a sore throat with over-the-counter prod- ucts. 1, 2, 3, 5 8. A client is ordered a dose of epoetin alfa (Procrit). The recommended dosage is 150 units/kg subcuta- neously. The client weighs 60 kg. Epoetin alfa comes in a vial of 10,000 units/ml. How many milliliters of epoetin alfa would the nurse expect to administer? 0.9 Gastrointestinal disorders 1. A nurse is caring for a client who can’t swallow tablets. The client weighs 56 kg. Famotidine (Pepcid) is ordered; it’s dispensed as an oral suspension of 40 mg/5 ml. The order states to give Pepcid 0.7 mg/ kg/day divided twice daily. How many milliliters would the nurse pour into the medication cup for the first dose? 2.5 2. A nurse is teaching a client with an ostomy how to apply a new appliance. Place the nurse’s instruc- tions in ascending chronological order. Use all the op- tions. 1. Add 1⁄16 to 1⁄8 inch to the size of the stoma. 2. Wash stoma area and pat dry. 3. Apply thin layer of paste around stoma. 4. Cut stoma opening into wafer. 5. Apply pouch. 6. Measure the stoma size. 3. As part of a routine screening for colorectal can- cer, a client must undergo fecal occult blood testing. Which foods should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period? Select all that apply. # 1. High-fiber foods # 2. Red meat # 3. Turnips # 4. Cantaloupe # 5. Tomatoes # 6. Peas 2, 3, 4 4. A client with osteoarthritis is admitted to the hos- pital with peptic ulcer disease. Which findings are com- monly associated with peptic ulcer disease? Select all that apply. # 1. Localized, colicky periumbilical pain # 2. History of nonsteroidal anti-inflammatory use # 3. Epigastric pain that’s relieved by antacids # 4. Tachycardia # 5. Nausea and weight loss # 6. Low-grade fever 2, 3, 5 5. A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instruct- ed to take which actions? Select all that apply. # 1. Follow a high-fat, low-fiber diet. # 2. Avoid caffeine and carbonated beverages. # 3. Sleep with the head of the bed flat. # 4. Stop smoking. # 5. Take antacids 1 hour and 3 hours after meals. # 6. Limit alcohol consumption to one drink per day. 2, 4, 5 6. A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when ad- ministering an enema? Select all that apply. # 1. Assist the client into the left-lateral Sims’ posi- tion. # 2. Lubricate the distal end of the rectal catheter. # 3. Warm the solution to 110° F (43.3° C). # 4. Insert the tube 1" to 11⁄2". # 5. Administer 250 to 500 ml of irrigating solution. # 6. Be sure to keep the solution container no high- er than 18" above bed level. 1, 2, 6 7. A client with cirrhosis is ordered to have a daily measurement of his abdominal girth. Identify the anatomic landmark where the tape measure should be placed when obtaining this measurement. 8. A client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colon- oscopy? Select all that apply. # 1. When the client recovers from sedation, tell him he must follow a clear liquid diet. # 2. Instruct the client that he shouldn’t drive for 24 hours. # 3. Observe the client closely for signs and symp- toms of bowel perforation. # 4. Monitor vital signs frequently until they’re stable. # 5. Inform the client that there may be blood in his stool and that he should report excessive blood immediately. # 6. Tell the client to report excessive flatus. 3, 4, 5 9. A client has been hospitalized with pancreatitis for 3 days. A nurse checks the client and documents the results below. The nurse realizes that this information is a manifestation of what finding? # 1. Cullen’s sign # 2. Chvostek’s sign # 3. Trousseau’s sign # 4. Broca’s sign 1 10. A client with a retroperitoneal abscess is receiv- ing gentamicin (Garamycin) I.V. Which levels should the nurse monitor? Select all that apply. # 1. Hearing # 2. Urine output # 3. Hematocrit (HCT) # 4. Blood urea nitrogen (BUN) and creatinine # 5. Serum calcium 1, 2, 4 11. Locate the abdominal quadrant where the nurse would expect to palpate the liver. Integumentary disorders 1. At an outpatient clinic, a medical assistant inter- views a client and documents the findings in the chart below. After reading the chart note, a nurse begins planning based on which nursing diagnoses? 12/13/06 Client very anxious because of new black 0900 mole with shades of brown noted on upper outer right thigh. Asymmetrical in shape with an irregular border. ——— M. Rosenfeld, MA # 1. Deficient knowledge related to potential diag- nosis of basal cell carcinoma # 2. Fear related to potential diagnosis of malignant melanoma # 3. Risk for impaired skin integrity related to poten- tial squamous cell carcinoma # 4. Readiness for enhanced knowledge of skin care precautions related to benign mole 2 2. Despite conventional treatment, a client’s psoriasis has worsened. The physician prescribes methotrexate 25 mg by mouth as a single weekly dose. The phar- macy dispenses 2.5-mg scored tablets. How many tablets should the nurse instruct the client to consume to achieve the prescribed dose? 10 3. Which nursing interventions are effective in pre- venting pressure ulcers? Select all that apply. # 1. Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. # 2. When turning the client, slide him and avoid lift- ing him. # 3. Avoid raising the head of the bed more than 90 degrees. # 4. Turn and reposition the client every 1 to 2 hours unless contraindicated. # 5. If the client uses a wheelchair, seat him on a rubber or plastic doughnut. # 6. Use pillows to position the client and increase his comfort. 1, 4, 6 4. A client has been hospitalized with bacterial pneu- monia and dehydration for 3 days. The client’s right heel reveals a shallow opened area draining clear fluid, which appears to be a skin tear. The nurse would un- derstand which items related to this client’s skin break? Select all that apply. # 1. The heel wound would be classified as a stage 1 pressure ulcer. # 2. Increasing fluid intake would help prevent fur- ther skin injury. # 3. The wound is at risk for infection. # 4. Placing the client on an air mattress will heal the wound. # 5. The client’s caloric requirements are lower than normal because of decreased activity. # 6. The injured area would be painful to the client. 2, 3, 6 . I NTE GU M ENTARY DI S O R DER S 45 5. Which instructions should be included in the teaching plan of a client with acne vulgaris who’s pre- scribed tretinoin, benzoyl peroxide, and tetracycline? Select all that apply. # 1. Expect your skin to look red and start to peel af- ter treatment. # 2. Take tetracycline on an empty stomach. # 3. Use tretinoin and benzoyl peroxide together in the morning and at bedtime. # 4. Maintain the prescribed treatment because it’s more likely to improve acne than a strict diet and frequent scrubbing with soap and water. # 5. Apply tretinoin at least 30 minutes after washing the face and at bedtime. # 6. Avoid exposure to sunlight and don’t use a sun- screen. 6. A client is brought to the emergency department with partial- and full-thickness burns over 15% of his body. His admission vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing in- terventions are appropriate for this client? Select all that apply. # 1. Clean the burns with hydrogen peroxide. # 2. Cover the burns with saline-soaked towels. # 3. Begin an I.V. infusion of lactated Ringer’s solu- tion. # 4. Place ice directly on the burn areas. # 5. Administer 6 mg of morphine I.V. # 6. Administer tetanus prophylaxis, as ordered. 2, 4 3, 5, 6 Immune and hematologic disorders 1. A nurse is assisting in planning care for a client with human immunodeficiency virus (HIV). Which statements by the nurse indicate an understanding of HIV transmission? Select all that apply. # 1. “I will wear a gown, mask, and gloves with all client contact.” # 2. “I don’t need to wear any personal protective equipment due to decreased risk of occupation- al exposure.” # 3. “I will wear a mask if the client has a cough caused by an upper respiratory infection.” # 4. “I will wear a mask, gown, and gloves when splashing of bodily fluids is likely.” # 5. “I will wash my hands after client care.” 4, 5 2. A client is having an anaphylactic reaction. The code team is present and the physician orders epi- nephrine 1:1000 aqueous solution 0.5 mg subcuta- neously stat. A nurse has a prefilled syringe of 1:1000 1 mg/ml epinephrine. The nurse will administer how many milliliters of epinephrine? 0.5 3. A client is admitted with an exacerbation of Crohn’s disease and has a history of lupus erythe- matosus. A maculopapular rash is present over the client’s nose and cheeks. The client denies that the rash itches or is painful. The nurse concludes which of the following? Select all that apply. # 1. The client is overheated and the rash will disap- pear once it’s bathed in cool water. # 2. The rash is normal and doesn’t need to be ad- dressed. # 3. The physician must be notified of the rash im- mediately. # 4. The rash is a consequence of the corticosteroids (that must now be changed) originally ordered to treat Crohn’s disease. # 5. The rash is a result of poor hygiene and will re- solve with proper cleansing. # 6. Contact precautions will need to be ordered for this client’s care. 4. A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse expect in the teaching plan? Select all that apply. # 1. Stay out of direct sunlight. # 2. Refrain from limiting activity between flare-ups. # 3. Monitor body temperature. # 4. Taper the corticosteroid dosage as ordered by the physician, when symptoms are under con- trol. # 5. Apply cold packs to relieve joint pain and stiff- ness. 2 1, 3, 4 5. A nurse is preparing a client for bone marrow biopsy to rule out leukemia. The nurse explains that the sample will be taken from the anterior iliac crest. Identify this area. 6. A client with leukemia has enlarged lymph nodes, liver, and spleen. Identify the quadrant of the ab- domen where the nurse would find the enlarged spleen. Endocrine and metabolic disorders 1. A nurse is obtaining information on a newly ad- mitted client who has been diagnosed with diabetes insipidus. Which data should the nurse expect to col- lect? Select all that apply. # 1. Extreme polyuria # 2. Excessive thirst # 3. Elevated systolic blood pressure # 4. Low urine specific gravity # 5. Bradycardia # 6. Elevated serum potassium level 1, 2, 4 2. A client has vision problems, so his daughter draws up insulin for him on a weekly basis. The client uses U-100 insulin at 10 units/1 ml, 10 ml/vial. If the client’s morning dose of NPH insulin is 5 units, how many syringes can he use before he needs another vial of insulin? 20 3. A client is on NPH 12 units and Humalog 6 units each morning. Place the following actions in ascending chronological order of how a nurse would demon- strate how to mix insulins. Use all the options. 1. Withdraw 12 units of NPH insulin. 2. Inject 12 units of air into NPH vial. 3. Inject 6 units of air into Humalog vial. 4. Wipe off vials with alcohol swab. 5. Withdraw 6 units of Humalog insulin. 4. After falling off a ladder and suffering a brain in- jury, a client develops syndrome of inappropriate an- tidiuretic hormone (SIADH) secretion. Which of the following findings indicate the effectiveness of the treatment he’s receiving? Select all that apply. # 1. Decrease in body weight # 2. Rise in blood pressure and drop in heart rate # 3. Absence of wheezes in the lungs # 4. Increased urine output # 5. Decreased urine osmolarity 1, 4, 5 5. A 48-year-old female client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply. # 1. High-protein, high-calorie diet # 2. High-fiber, low-calorie diet # 3. Plan for a thyroidectomy # 4. Use of stool softeners # 5. Thyroid hormone replacements # 6. Review of the procedure for thyroid radiation therapy 2, 4, 5 6. A client who has been seen in the clinic is sched- uled for an outpatient thyroid scan in 2 weeks. Which instructions should the nurse expect in the client teaching points so that this client is prepared? Select all that apply. # 1. Stop using iodized salt or iodized salt substitutes 1 week before the scan. # 2. Stop eating seafood 1 week before the scan. # 3. Don’t consume any food or fluids after midnight on the night before the scan. # 4. Don’t take prescribed thyroid medication on the day of the scan. # 5. Don’t take prescribed thyroid medication until the results of the scan are known. # 6. Maintain bed rest for 24 hours after the scan. 1, 2, 4 7. A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which findings is the nurse most likely to observe in this client? Select all that apply. # 1. Excessive thirst # 2. Weight gain # 3. Constipation # 4. Excessive hunger # 5. Urine retention # 6. Frequent, high-volume urination 8. A client is being discharged after having a thy- roidectomy. Which discharge instructions are appropri- ate for this client? Select all that apply. # 1. Report any signs and symptoms of hypo- glycemia. # 2. Take thyroid replacement medication, as or- dered. # 3. Watch for lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician. # 4. Avoid over-the-counter medications. # 5. Carry injectable dexamethasone at all times. 1, 4, 6 2, 3 9. A client is seen in the clinic with suspected parathormone (PTH) deficiency. Part of the diagnosis of this condition includes the analysis of serum elec- trolyte levels. The levels of which electrolytes would the nurse expect to be abnormal in a client with PTH deficiency? Select all that apply. # 1. Sodium # 2. Potassium # 3. Calcium # 4. Chloride # 5. Glucose # 6. Phosphorus 3, 6 10. A client is placed on hypocalcemia precautions after removal of the parathyroid gland as a result of cancer. The nurse should observe the client for which symptoms? Select all that apply. # 1. Numbness # 2. Aphasia # 3. Tingling # 4. Muscle twitching and spasms # 5. Polyuria # 6. Polydipsia 1, 3, 4 11. A client is admitted to the hospital with Cush- ing’s syndrome. Which nursing interventions are ap- propriate for this client? Select all that apply. # 1. Assess for peripheral edema. # 2. Stress the need for a high-calorie, high- carbohydrate diet. # 3. Measure intake and output. # 4. Encourage oral fluid intake. # 5. Weigh the client daily. # 6. Instruct the client to avoid foods high in potassium. 1, 3, 5 12. A client with type 2 diabetes mellitus needs in- struction on proper foot care. Which instructions should the nurse expect to review in client teaching? Select all that apply. # 1. Be sure to use scissors to trim toenails. # 2. Wear cotton socks. # 3. Apply foot powder after bathing. # 4. Go barefoot only when you know your home environment. # 5. See a podiatrist regularly to have your feet checked. # 6. Wear loose-fitting shoes. 2, 3, 5 Musculoskeletal disorders 1. A client is diagnosed with osteoporosis. Which statements should a nurse include when teaching the client about the disease? Select all that apply. # 1. It’s common in females after menopause. # 2. It’s a degenerative disease characterized by a decrease in bone density. # 3. It’s a congenital disease caused by poor dietary intake of milk products. # 4. It can cause pain and injury. # 5. Passive range-of-motion (ROM) exercises can promote bone growth. # 6. Weight-bearing exercise should be avoided. 2. A client is preparing for discharge from the hospi- tal after undergoing an above-the-knee amputation. Which instructions should the nurse expect in the teaching plan for this client? Select all that apply. # 1. Massage the residual limb away from the suture line. # 2. Avoid using heat application to ease pain. # 3. Report twitching, spasms, or phantom limb pain immediately. # 4. Avoid exposing the skin around the residual limb to excessive perspiration. # 5. Be sure to perform the prescribed exercises. # 6. Rub the residual limb with a dry washcloth for 4 minutes three times per day if it is sensitive to touch. 1, 2, 4 4, 5, 6 3. A client is scheduled for a laminectomy of L1-L2. The nurse is reviewing the teaching about the proce- dure with the client. Identify the area that the nurse ex- plains will be involved in this client’s surgery. 4. A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid? Select all that apply. # 1. Green leafy vegetables # 2. Liver # 3. Cod # 4. Chocolate # 5. Sardines # 6. Whole milk 2, 3, 5 5. A client is about to undergo total hip replacement surgery. Before the surgery, the nurse reviews preoper- ative teaching with him. The nurse can tell that the teaching her been effective when the client verbalizes the importance of avoiding which actions? Select all that apply. # 1. Keeping the legs apart while lying in bed # 2. Periodically tightening the leg muscles # 3. Internally rotating the feet # 4. Bending to pick items up from the floor # 5. Sleeping in a side-lying position 3, 4 6. A client who was involved in a motor vehicle acci- dent has a fractured femur. The nurse caring for the client identifies Acute pain as one of the nursing diag- noses in his care plan. Which nursing interventions are appropriate? Select all that apply. # 1. Tell the client which pain management option to use. # 2. Encourage the client to use as little pain med- ication as possible to avoid addiction. # 3. Explain that pain management should leave the client pain-free. # 4. Avoid alternative and supplementary pain con- trol techniques. # 5. Assess the client’s perception of pain. # 6. Ask the client about methods he previously used to alleviate pain. 5, 6 7. A client fractured the neck of his femur in a fall. The nurse is using an illustration to explain to the fami- ly where the fracture occurred. Identify the area that the nurse would point out to the family as the site of the fracture. 8. A nurse is caring for a client with osteomyelitis. The nurse understands the intervention listed on the care plan based on knowledge of which facts about osteomyelitis? Select all that apply. # 1. Rapidly growing children are most at risk for the disease. # 2. Liver function enzymes and the erythrocyte sed- imentation rate are elevated. # 3. The disease process is limited to one specific area and doesn’t spread. # 4. Fever and tachycardia are symptoms of the dis- ease. # 5. Amputation and pathologic fractures may result from the disease process. # 6. The best treatment includes rapid return to usu- al activity with the affected area. 1, 4, 5 Neurosensory disorders 1. A client is admitted with a diagnosis of stroke. She has expressive aphasia. Identify the area where the client’s stroke has occurred. 2. A client is experiencing vision disturbances and is diagnosed with cataracts. Identify the area of the eye that’s diseased. 3. A nurse is caring for a client with a T5 complete spinal cord injury. The nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be ap- propriate for this client? Select all that apply. # 1. Elevate the head of the bed 90 degrees. # 2. Loosen constrictive clothing. # 3. Use a fan to reduce diaphoresis. # 4. Check for bladder distention and bowel impaction. # 5. Administer antihypertensive medication as ordered. # 6. Place the client in a supine position with legs elevated. 1, 2, 4, 5 4. A nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience? Select all that apply. # 1. Vision disturbances # 2. Coagulation abnormalities # 3. Balance problems # 4. Immunity compromise # 5. Mood disorders 1, 3, 5 5. A nurse examines a client’s level of responsive- ness. She finds that the client opens his eyes sponta- neously, obeys verbal commands, and is oriented to time, place, and person. What’s the client’s Glasgow Coma Scale score? 15 6. A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. # 1. Assist the client to the floor. # 2. Turn the client to his side. # 3. Place a pillow under the client’s head. # 4. Give the prescribed dose of oral phenytoin (Di- lantin). # 5. Insert an oral suction device to remove secre- tions in the mouth. 1, 2, 3 7. A nurse is preparing to discuss hearing pathways with a client with a new hearing loss. Place the steps in sound wave transmission that allow an individual to hear in ascending chronological order. Use all the op- tions. 1. Interpretation of sound by the cerebral cortex 2. Transmission of vibrations through the air and bone 3. Stimulation of nerve impulses in the inner ear 4. Transmission of vibrations to the auditory area of the cerebral cortex 8. A nurse is assigned to care for a client with early stage Alzheimer’s disease. Which nursing interventions should be included in the client’s care plan? Select all that apply. # 1. Make frequent changes in the client’s routine. # 2. Engage the client in complex discussions to im- prove memory. # 3. Furnish the client’s environment with familiar possessions. # 4. Assist the client with activities of daily living (ADLs) as necessary. # 5. Assign tasks in simple steps. 3, 4, 5 9. A client is admitted to the medical-surgical unit af- ter undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing inter- ventions are appropriate for the client’s postoperative care? Select all that apply. # 1. Place a pillow under the client’s head so that his neck is flexed. # 2. Turn the client on his right side. # 3. Place pillows under the client’s legs to promote hip flexion and venous return. # 4. Maintain the client in the supine position. # 5. Apply a soft collar to keep the client’s neck in a neutral position. 2, 5 10. A client is a quadriplegic secondary to a spinal cord injury from a motor vehicle accident. Identify the area of the spinal cord where the injury most likely occurred. 11. A nurse is reviewing teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he under- stands the instructions? Select all that apply. # 1. “I’ll eat food that is very hot.” # 2. “I’ll try to chew my food on the unaffected side.” # 3. “I can wash my face with cold water.” # 4. “Drinking fluids at room temperature should re- duce pain.” # 5. “If tooth brushing is too painful, I’ll try to rinse my mouth instead.” 2, 4, 5 12. A client is experiencing problems with balance and fine and gross motor function. Identify that area of the client’s brain that’s malfunctioning. Respiratory disorders 1. A nurse is caring for a client with pneumonia. The physician orders 600 mg of ceftriaxone (Rocephin) oral suspension to be given once per day. The med- ication label indicates that the strength is 125 mg/ 5 ml. How many milliliters of medication should the nurse pour to administer the correct dose? 24 2. A nurse is caring for a client who has a chest tube connected to a three-chamber drainage system with- out suction. Identify the chamber that collects drainage from the client. 3. A nurse is caring for a client with stage III emphy- sema. She know that which information about this dis- order is correct? Select all that apply. # 1. Accessory muscle use is often required. # 2. Continuous high-dose oxygen therapy is required. # 3. Bronchodilators and corticosteroids are a main- stay of treatment. # 4. Auscultation reveals normal to decreased breath sounds with wheezes. # 5. Overdistention and overinflation of the lungs are pathophysiologic findings. # 6. Influenza vaccination annually and pneumococ- cal vaccination every 5 years is recommended. 1, 3, 5, 6 4. A nurse is reviewing a staff education module about pulmonary circulation. Trace the path of pul- monary circulation. 5. A nurse observes a pregnant visitor choke on a piece of hot dog in the cafeteria. Place the following steps for removal of a foreign airway obstruction in a pregnant or obese client in ascending chronological or- der. Use all the options. 1. Grab fist with other hand and perform backwards thrusts. 2. Place thumb side of one fist on middle of the client’s breastbone. 3. Encircle the client’s chest with both hands under her armpits. 4. Ask the client if she’s choking and needs assistance. 5. Repeat until foreign body is expelled or the client be- comes unresponsive 6. A nurse is caring for a client who’s scheduled for a bronchoscopy. Which interventions should the nurse expect to perform to prepare the client for this proce- dure? Select all that apply. # 1. Explain the procedure. # 2. Withhold food and fluids for 2 hours before the test. # 3. Provide a clear liquid diet for 6 to 12 hours be- fore the test. # 4. Confirm that a signed informed consent form has been obtained. # 5. Ask the client to remove his dentures. # 6. Administer atropine and a sedative. 1, 4, 5, 6 7. A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. # 1. Keep the client flat for at least 2 hours. # 2. Provide sips of water to moisten the mouth. # 3. Withhold food and fluids until the gag reflex re- turns. # 4. Assess for hemoptysis and frank bleeding. # 5. Resume food and fluids when the client’s voice returns. # 6. Monitor the client’s vital signs. 3, 4, 6 8. A nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms when assessing the client? Select all that apply. # 1. Dry cough # 2. Fever # 3. Bradycardia # 4. Pericardial friction rub # 5. Use of accessory muscles during respiration # 6. Crackles or rhonchi 2, 5, 6 9. A client is admitted with chronic obstructive pul- monary disease (COPD). Which signs and symptoms are characteristic of COPD? Select all that apply. # 1. Decreased respiratory rate # 2. Dyspnea on exertion # 3. Barrel chest # 4. Shortened expiratory phase # 5. Clubbed fingers and toes # 6. Fever 2, 3, 5 10. A client is prescribed continuous positive airway pressure (CPAP) therapy for sleep apnea. The nurse instructs the client about the mechanism designed to maintain positive end-expiratory pressure. Identify the area where this mechanism is located. 11. A nurse is about to perform nasopharyngeal suctioning on a client who recently had a stroke. Iden- tify the area where the tip of the suction catheter should be placed. 12. The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when provid- ing care for this client? Select all that apply. # 1. Wear gloves when handling tissues containing sputum. # 2. Wear a face mask at all times. # 3. When the client leaves the room for tests, have all people in contact with him wear a mask. # 4. Keep the client’s door open to allow fresh air into the room and prevent social isolation. # 5. Wash hands after direct contact with the client or contaminated articles. 1, 2, 5 Genitourinary disorders 1. A nurse is checking a client who has a urinary tract infection (UTI). Which statements should the nurse ex- pect the client to make? Select all that apply. # 1. “I urinate large amounts.” # 2. “I need to urinate frequently.” # 3. “It burns when I urinate.” # 4. “My urine smells sweet.” # 5. “I need to urinate urgently.” 2, 3, 5 2. A nurse is reviewing the procedure for how to col- lect a 24-hour urine specimen for creatinine clearance with the client. Which directions should the nurse give the client? Select all that apply. # 1. “Save the first voiding and record the time.” # 2. “Discard the first voiding and record the time.” # 3. “Clean the perineal area before each voiding.” # 4. “Refrigerate the urine sample or keep it on ice.” # 5. “At the end of 24 hours, void and save the urine.” # 6. “At the end of 24 hours, void and discard the urine.” 2, 4, 5 3. A nurse is caring for a client with chronic renal fail- ure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When checking the client, the nurse should be alert for which signs and symptoms? Select all that apply. # 1. Trousseau’s sign # 2. Cardiac arrhythmias # 3. Constipation # 4. Decreased clotting time # 5. Drowsiness and lethargy # 6. Fractures 1, 2, 6 4. A client is diagnosed with renal calculi and com- plains of severe left flank pain. Scans indicate the cal- culi are lodged in the left renal pelvis. Identify the structure where the renal calculi are located. GEN ITOU R I NARY DI S O R DER S 73 5. A nurse is caring for a client with a cystostomy for urine drainage. Identify the area where the nurse should check for cystostomy placement. 6. A nurse is completing an intake and output record for a client who is receiving continuous bladder irriga- tion after transurethral resection of the prostate. How many milliliters of urine should the nurse record as output for her shift if the client received 1,800 ml of normal saline irrigating solution and the output in the urine drainage bag is 2,400 ml? 600 P A R T T H R E E Maternal-infant nursing 75 Antepartum period 1. A client comes to the office for her first prenatal visit. She reports that October 5 was the first day of her last menstrual period. Which statements represent findings in the first trimester of pregnancy? Select all that apply. # 1. Slow fetal cell differentiation is occurring. # 2. The client’s estimated date of delivery is June 12. # 3. The client may expect to have some nausea and increased urinary frequency. # 4. The client will notice decreased vaginal secretions. # 5. The client’s breasts may become swollen and tender. # 6. Chadwick’s sign will be positive at 9 weeks. 2. A nurse is assisting with a prenatal assessment on a client who is 32 weeks pregnant. She performs Leopold’s maneuvers and determines that the fetus is in the cephalic position. Identify the area where the nurse should place the Doppler to auscultate fetal heart tones. 3, 5, 6 3. A client comes to the office for her first prenatal visit. She asks the nurse what physiological changes she can expect during pregnancy. The nurse knows that changes can be in three categories: presumptive, probable, and positive. The nurse prepares to start the discussion with the probable changes of pregnancy. Put the following probable changes in ascending chronological order. Use all the options. 1. The vagina changes color from pink to violet (Chad- wick’s sign); cervix softens (Goodell’s sign). 2. Serum laboratory tests are positive for human chorionic gonadotropin. 3. Braxton Hicks contractions and fetal outline can be pal- pated through the abdomen. 4. Fetus can be felt to rise against the abdominal wall when lower uterine segment is tapped during a biman- ual examination (Ballottement). 4. Which nutritional instructions should the nurse re- view with a 32-year-old primigravida? Select all that apply. # 1. Caloric intake should be increased by 300 cal/day. # 2. Protein intake should be increased to more than 30 g/day. # 3. Vitamin intake should not increase from prepregnancy requirements. # 4. Folic acid intake should be increased to 400 mg/day. # 5. Intake of all minerals, especially iron, should be increased. 1, 2, 5 5. During a prenatal screening of a client with dia- betes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply. # 1. Still birth # 2. Rh incompatibility # 3. Gestational hypertension # 4. Placenta previa # 5. Spontaneous abortion 1, 3, 5 6. A 30-year-old client comes to the office for a rou- tine prenatal visit. After reading the laboratory test re- sults below, the nurse should prepare the client for which study? # 1. Triple screen # 2. Indirect Coombs’ test # 3. 1-hour glucose tolerance test # 4. Amniocentesis 3 7. Which signs are considered presumptive signs of pregnancy? Select all that apply. # 1. Goodell’s sign # 2. Uterine enlargement # 3. Ballottement # 4. Nausea and vomiting # 5. Quickening # 6. Linea nigra 4, 5, 6 8. A nurse is assisting in teaching a 16-year-old preg- nant client during a home care visit. The client has complained of fatigue and dyspnea on exertion, and has a low serum iron level. Which information should the nurse expect to be included in the teaching care plan of this client? Select all that apply. # 1. Eat red meat, green vegetables, eggs, iron- fortified breads, whole grains, and milk. # 2. Take the iron supplement with milk or an antacid to prevent GI upset. # 3. Stop taking the iron supplement if constipation occurs. # 4. If gastric irritation occurs, take the iron supple- ment on an empty stomach. # 5. Take the iron supplement with foods containing vitamin C such as orange juice, to enhance ab- sorption. # 6. Explain that pregnancy increases the body’s need for iron. 1, 5, 6 9. A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply. # 1. Milk and ice chips # 2. Decaffeinated coffee and scrambled eggs # 3. Tea and gelatin # 4. Ginger ale and apple juice # 5. Cranberry juice and chicken broth # 6. Oatmeal and egg substitutes 3, 4, 5 10. A nurse is palpating the uterus of a client who’s 20 weeks pregnant in order to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus. 11. A nurse is taking a course on the anatomy and physiology of reproduction. In the illustration of the fe- male reproductive organs, identify the area where fer- tilization occurs. 12. A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the pro- cedure? Select all that apply. # 1. Ask the client to void. # 2. Instruct the client to drink 1 L of fluid. # 3. Ask the client to lie on her left side. # 4. Determine fetal heart rate. # 5. Insert an I.V. catheter. # 6. Monitor maternal vital signs. 1, 4, 6 13. In early pregnancy, some clients complain of ab- dominal pain or pulling. Identify the area most com- monly associated with this pain. Intrapartum period 1. A nurse is assisting in monitoring a client who’s re- ceiving oxytocin (Pitocin) to induce labor. The nurse should be alert to which maternal adverse reactions? Select all that apply. # 1. Hypertension # 2. Jaundice # 3. Dehydration # 4. Fluid overload # 5. Uterine tetany # 6. Bradycardia 1, 4, 5 2. A client is being admitted to the labor and delivery unit. She’s GTPAL 5-2-1-1-2. Which statements are true about this client? Select all that apply. # 1. The client has had 4 previous pregnancies. # 2. The client has had 5 previous pregnancies. # 3. The client has had 1 full-term child, 1 abortion, and 1 premature child. # 4. The client has had 2 full-term children, 1 pre- mature child, and 1 abortion. # 5. The client has 3 living children and is pregnant again. # 6. The client has 2 living children and is pregnant again. 1, 4, 6 3. A nurse is assisting in the evaluation of a client who’s 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply. # 1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry # 2. Acidic pH of fluid when tested with nitrazine paper # 3. Presence of amniotic fluid in the vagina # 4. Cervical dilation of 6 cm # 5. Alkaline pH of fluid when tested with nitrazine paper # 6. Contractions occurring every 5 minutes 1, 3, 5 4. A nurse is caring for a client who has been diag- nosed with abruptio placentae. What signs and symp- toms of abruptio placentae should the nurse expect to find when she’s collecting data on this client? Select all that apply. # 1. Vaginal bleeding # 2. Decreased fundal height # 3. Uterine tenderness on palpation # 4. Soft abdomen on palpation # 5. Hypotonic, small uterus # 6. Abnormal fetal heart tones 1, 3, 6 5. A client who’s 29 weeks pregnant comes to the labor and delivery unit. She states that she’s having contractions every 8 minutes. The client is also 3 cm dilated. Which treatments can the nurse expect to ad- minister? Select all that apply. # 1. Folic acid (Folvite) # 2. Terbutaline (Brethine) # 3. Betamethasone # 4. Rho (D) immune globulin (Rhogam) # 5. I.V. fluids # 6. Meperidine (Demerol) 2, 3, 5 6. A nurse is assigned to assist with the admission of a client who’s in labor. Which actions are appropriate? Select all that apply. # 1. Asking about the estimated date of delivery (EDD) # 2. Estimating fetal size # 3. Taking maternal and fetal vital signs # 4. Asking about the woman’s last menses # 5. Administering an analgesic # 6. Asking about the amount of time between con- tractions 1, 3, 6 7. A nurse is assisting in the delivery room. The physician prepares to perform an episiotomy. To do this procedure the physician makes an incision in which part of the client’s external genitalia area? 8. A nurse is assisting in caring for a client who has just given birth to a neonate through vaginal delivery. The nurse is monitoring for signs of placental separa- tion. Which signs indicate that the placenta has sepa- rated? Select all that apply. # 1. Shortening of the umbilical cord # 2. Sudden, sharp abdominal pain # 3. Sudden gush of vaginal blood # 4. Change in shape of the uterus # 5. Lengthening of the umbilical cord 3, 4, 5 9. A client in labor is 8 cm dilated and 75% effaced. The fetus, which is in vertex presentation, is at 0 sta- tion. In the illustration below, identify the level of the fetus’s head. 10. While waiting to receive report at shift change, a nurse reads the chart entry below just written by the previous nurse. After reading this note, the nurse knows her client is in which stage of labor? 7/3/06 0135 Client experienced spontaneous rupture of membranes. Fluid is odorless and clear. Contrac- tions are 50 seconds long and occur every 4 minutes. See flow sheet for details. Client is 4 cm dilated. —— ——————————————————————A. Wilkens, LPN # 1. Stage 1, latent phase # 2. Stage 2 # 3. Stage 1, active phase # 4. Stage 1, transition phase 3 Postpartum period 1. On examining a client who gave birth 3 hours ago, a nurse finds that the client has completely satu- rated a perineal pad within 15 minutes. Which actions should the nurse take? Select all that apply. # 1. Begin an I.V. infusion of lactated Ringer’s solu- tion. # 2. Assess the client’s vital signs. # 3. Palpate the client’s fundus. # 4. Place the client in high Fowler’s position. # 5. Administer a pain medication. 2, 3 2. A nurse observes several interactions between a mother and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. # 1. Talks and coos to her son # 2. Cuddles her son close to her # 3. Doesn’t make eye contact with her son # 4. Requests the nurse to take the baby to the nursery for feedings # 5. Encourages the father to hold the baby # 6. Takes a nap when the baby is sleeping 1, 2 3. A mother with a history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data would lead to this nursing judgment? Select all that apply. # 1. Sudden dyspnea # 2. Chills, fever # 3. Diaphoresis # 4. Hypertension # 5. Confusion 1, 3, 5 4. On a client’s second postpartum visit, the physi- cian reviews the chart below regarding the client’s lochia. What’s the best term for the lochia described? # 1. Alba # 2. Thrombic # 3. Serosa # 4. Rubra 4 5. A nurse is caring for a 1-day postpartum mother. Reading the progress note below (from the previous shift), the nurse notes that the mother is in which phase of the postpartum period? Mother verbalizing labor and delivery experience. Does not appear confident in holding baby or with diaper changes. Asking questions appropriately. ———————— —————————————————————J. Conners, LP # 1. Letting-go # 2. Taking-in # 3. Holding-out # 4. Taking-hold 2 6. A client has received treatment for a warm, red- dened, painful area in the breast as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding. Which interventions should the nurse expect to see on the care plan to prevent a recurrence of the problem? Select all that apply. # 1. Wash the nipples with soap and water. # 2. Change the breast pads frequently. # 3. Expose the nipples to air for part of each day. # 4. Wash hands before handling the breast and breast-feeding. # 5. Make sure that the baby grasps the nipple only. # 6. Release the baby’s grasp on the nipple before removing the baby from the breast. 2, 3, 4, 6 7. A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which state- ments accurately characterize this disorder? Select all that apply. # 1. Symptoms start 2 days after delivery. # 2. The disorder is common in postpartum women. # 3. Symptoms include delusions and hallucinations. # 4. Suicide and infanticide are uncommon in this disorder. # 5. The disorder rarely occurs without psychiatric history. 3, 5 8. A nurse is palpating the uterine fundus of a client who delivered 8 hours ago. Identify the area of the abdomen where the nurse would expect to feel the fundus. 9. A nurse is assisting in developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain relat- ed to perineal sutures? Select all that apply. # 1. Apply an ice pack intermittently to the perineal area for 3 days. # 2. Avoid the use of topical pain gels. # 3. Administer sitz baths three to four times per day. # 4. Encourage the client to do Kegel exercises. # 5. Limit the number of times the perineal pad is changed. 3, 4 The neonate 1. A nurse is administering vitamin K to a neonate after delivery. The medication is supplied in a concen- tration of 2 mg/ml and the ordered dose is 0.5 mg subcutaneously. How many milliliters should the nurse administer? 0.25 2. A 14-day-old neonate is admitted for aspiration pneumonia. The results of a barium swallow confirm a diagnosis of gastroesophageal reflux with resulting as- piration pneumonia. Identify the area of the stomach that’s weakened, contributing to the reflux. 3. In the nursery, a nurse is performing a neurologic examination on a 1-day-old neonate. Which findings would indicate possible asphyxia in utero? Select all that apply. # 1. The neonate grasps the nurse’s finger when she puts it in the palm of his hand. # 2. The neonate does stepping movements when held upright with his sole touching a surface. # 3. The neonate’s toes don’t curl downward when his soles are stroked. # 4. The neonate doesn’t respond when the nurse claps her hands above him. # 5. The neonate turns toward an object when the nurse touches his cheek with it. # 6. The neonate displays weak, ineffective sucking. 3, 4, 6 4. Which instructions should the nurse expect will be provided on discharge from the facility to the par- ents of a neonate who has been circumcised? Select all that apply. # 1. The infant must void before being discharged home. # 2. Apply petroleum jelly to the glans of the penis with each diaper change. # 3. Tub baths for the infant are acceptable while the circumcision heals. # 4. Report any blood on the front of the diaper. # 5. The circumcision requires care for 2 to 4 days after discharge. 1, 2, 5 5. A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area the nurse would touch to elicit a plantar grasp reflex. 6. A nurse is demonstrating cord care to a mother of a neonate. Which actions should the nurse review with the mother? Select all that apply. # 1. Explain that the diaper is kept below the cord. # 2. Tug gently on the cord to remove it as it begins to dry. # 3. Apply antibiotic ointment to the cord twice daily. # 4. Only sponge-bathe the infant until the cord falls off. # 5. Clean the length of the cord with alcohol sever- al times daily. # 6. Wash the cord with mild soap and water. 1, 4, 5 7. A nurse notes that at 5 minutes after birth, a neonate is pink with acrocyanosis, has his knees flexed and fists clenched, has a whimpering cry, has a heart rate of 128 beats/minute, and withdraws his foot to a slap on the sole. What 5-minute Apgar score should the nurse record for this neonate? 8 Sign Apgar Score 8. A nurse is providing care to a neonate. List the steps in ascending chronological order to show how opthalmia neonatorum prophylaxis would be per- formed. Use all the options. 1. Close and manipulate the eyelids to spread the medica- tion over the eye. 2. Shield the neonate’s eyes from direct light and tilt his head slightly to the side that will receive the treatment. 3. Repeat the procedure for the other eye. 4. Wash your hands and put on gloves. 5. Apply the ointment into the lower conjunctival sac. 6. Gently raise the neonate’s upper eyelid with your index finger and pull the lower eyelid down with your thumb. P A R T F O U R Pediatric nursing 97 The infant 1. A physician orders digoxin 0.1 mg orally every morning for a 6-month-old infant with heart failure. Digoxin is available in a 400 mcg/ml concentration. How many milliliters of digoxin should the nurse give? 0.25 2. A nurse is checking an infant on a routine visit. The infant coos and babbles after feeding in response to the mother and nurse talking to him, but doesn’t smack his lips or make “raspberries.” How old is the infant? # 1. 0 to 2 months # 2. 3 to 4 months # 3. 5 to 6 months # 4. 7 to 9 months # 5. 10 to 12 months 2 3. A nurse has received report on her clients and no- tices that they are of varying ages. In order to prepare for the shift, the nurse reviews Erikson’s five stages of psychosocial development. Place the stages listed be- low in ascending chronological order starting with in- fancy, according to Erikson’s definitions of infancy, tod- dlerhood, preschool age, school age, and adolescence. Use all the options. 1. Initiative versus guilt 2. Trust versus mistrust 3. Industry versus inferiority 4. Identity versus role confusion 5. Autonomy versus shame and doubt 4. A nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to determine in a 1-month-old infant? Select all that apply. # 1. Bulging fontanels # 2. Decreased blood pressure # 3. Increased pulse # 4. High-pitched cry # 5. Headache # 6. Irritability 1, 4, 6 5. A nurse is checking a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply. # 1. Holding head erect # 2. Self-feeding # 3. Demonstrating good bowel and bladder control # 4. Sitting on a firm surface without support # 5. Bearing majority of weight on legs # 6. Walking alone 1, 4, 5 6. An 11-month-old is diagnosed with an ear infec- tion—his second one. The mother asks why children experience more ear infections than adults. The nurse shows the mother a diagram of the ear and explains the differences in anatomy. Identify the portion of the infant’s ear that allows fluid to stagnate and act as a medium for bacteria. 7. A nurse is preparing to administer chlorampheni- col (Chloromycetin Otic) to a 2-year-old with an infec- tion of the external auditory canal. The order reads, “2 gtts A.D. t.i.d.” Which steps should the nurse take to administer this medication? Select all that apply. # 1. Wash her hands and arrange supplies at the bedside. # 2. Warm the medication to body temperature. # 3. Lie the child on his right side with his left ear facing up. # 4. Examine the ear canal for drainage. # 5. Gently pull the pinna up and back and instill the drops into the external ear canal. 1, 2, 4 8. A nurse is teaching cardiopulmonary resuscitation (CPR) to the parents of a 1-month-old being dis- charged with an apnea monitor. Which steps are ap- propriate for performing CPR on an infant? Select all that apply. # 1. Open the airway by hyperextending the head. # 2. Pinch the nose before delivering a breath. # 3. Check for a pulse by palpating the brachial artery. # 4. Place the heel of one hand on the lower third of the sternum to perform compressions. # 5. Compress the sternum 1⁄2” to 1”. # 6. Give five compressions to one breath. 3, 5, 6 9. A nurse is providing preoperative teaching to the parents of a 9-month-old infant who’s having surgery to repair a ventricular septal defect. Identify the area of the heart where the defect is located. 10. A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which instructions are appropriate? Select all that apply. # 1. Position the infant on his back after feedings. # 2. Soothe the child by humming and rocking. # 3. Immediately bring the infant to the emergency department. # 4. Burp the infant adequately after feedings. # 5. Provide small but frequent feedings to the infant. # 6. Offer a pacifier if it isn’t time for the infant to eat. 2, 4, 5, 6 11. A 6-month-old is found floating face down in a swimming pool. A neighbor, who’s a nurse, checks for the presence of respirations and a pulse. Identify the area that’s most appropriate to check for a pulse. 12. A nurse is reviewing the teaching plan with the parents of an infant undergoing repair for a cleft lip. Which instructions should the nurse give? Select all that apply. # 1. Offer a pacifier as needed. # 2. Lay the infant on his back or side to sleep. # 3. Sit the infant up for each feeding. # 4. Loosen the arm restraints every 4 hours. # 5. Clean the suture line after each feeding by dab- bing it with saline solution. # 6. Give the infant extra care and support. 2, 3, 5, 6 The toddler 1. A nurse is admitting a 14-month-old to the pedi- atric floor with diagnosis of croup. Which characteristics would the nurse expect the toddler to have if he’s de- veloping normally? Select all that apply. # 1. Strong hand grasp # 2. Tendency to hold one object while looking for another # 3. Recognition of familiar voices (smiles in recogni- tion) # 4. Presence of Moro reflex # 5. Weight that is triple the birth weight # 6. Closed anterior fontanelle 1, 2, 3, 5 2. A 13-month-old is admitted to the pediatric unit with a diagnosis of gastroenteritis. The toddler has ex- perienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal that he’s dehydrated. Which nursing interventions are correct to prevent further de- hydration? Select all that apply. # 1. Encourage the child to eat a balanced diet. # 2. Give clear liquids in small amounts. # 3. Give milk in small amounts. # 4. Encourage the child to eat nonsalty soups and broths. # 5. Monitor the I.V. solution per the physician’s order. # 6. Withhold all solid food and liquids until the symptoms pass. 2, 4, 5 3. An acutely ill, 20-month-old toddler is admitted to the hospital with sickle cell crisis. The child is crying, restless, and appears uncomfortable when touched. Vital signs show slightly elevated heart rate and blood pressure and a temperature of 102ºF (38.8ºC). Which nursing diagnoses would a nurse expect to see includ- ed in the care plan? Select all that apply. # 1. Ineffective airway clearance # 2. Acute pain # 3. Unbalanced nutrition # 4. Risk for infection # 5. Powerlessness # 6. Risk for impaired parent/child attachment 2, 4 4. A toddler is ordered 350 mg of amoxicillin (Aug- mentin) by mouth four times per day. The pharmacy sends a bottle of amoxicillin with a concentration of 250 mg/5 ml. How many milliliters should the nurse administer per dose? 7 TH E TODDLER 105 5. A 3-year-old is admitted to the pediatric unit with pneumonia. He has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the toddler hasn’t been eating or drinking much and has been very inactive. Which interventions to im- prove airway clearance should the nurse expect in the care plan? Select all that apply. # 1. Restrict fluid intake. # 2. Perform chest physiotherapy as ordered. # 3. Encourage coughing and deep breathing. # 4. Keep the head of the bed flat. # 5. Perform postural drainage. # 6. Maintain humidification with a cool mist humid- ifier. 2, 3, 5, 6 The preschooler 1. A nurse is observing the parents of a 4-year-old who has been admitted to the hospital. Which actions indicate that the parents understand how to best mini- mize anxiety during their child’s hospitalization? Select all that apply. # 1. The parents bring the child’s favorite toy to the hospital. # 2. The parents explain all procedures to the child in great detail. # 3. The parents remain at the child’s side during the hospitalization. # 4. The parents bring the child’s siblings for a brief visit. # 5. The parents leave the room when the child un- dergoes a painful procedure. # 6. The parents punish the child if the child isn’t co- operative. 1, 3, 4 2. A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. A bone marrow aspiration is ordered. Place the interventions below in ascending chronological or- der as to how the nurse should perform them, based on importance. Use all the options. 1. Give the child his own biopsy kit: a syringe without a needle, cotton balls, and adhesive bandages, and act out the procedure by using a doll or stuffed animal. 2. Reassure him that the pain will go away quickly. 3. Check the biopsy site for bleeding and inflammation and observe the child for signs and symptoms of hem- orrhage and infection. 4. Discuss the procedure with his parents and the plan for preparing the child. 5. Explain the kinds of pressure and discomfort he’ll feel during the procedure and that it’s OK to cry. 3. A preschooler is in danger of becoming dehydrat- ed as a result of vomiting and diarrhea. The nurse real- izes that dehydration can be prevented if intake is suf- ficient to produce a urine output of 3 ml/kg/hr. The preschooler weighs 44 lb. What is the minimum urine output in milliliters that should be achieved in an 8- hour shift in order to prevent dehydration? 480 4. A preschooler is being admitted to the hospital and isolation precautions need to be implemented. Based on the progress note below, which isolation precautions would be used for this client? 11/8/06 5-year-old with varicella admitted with high 1100 fever, dehydration, and pruritic rash on face and trunk with lesions in all stages. See graphic record for vital signs. I.V. started in Ø arm. Isolation precautions instituted. ———————————————— J. Trump, RN # 1. Standard precautions # 2. Airborne precautions # 3. Droplet precautions # 4. Contact precautions 2 5. A nurse is caring for a 4-year-old who’s in the ter- minal stages of cancer. Which statements are true? Se- lect all that apply. # 1. The parents may be at different stages in deal- ing with the child’s death. # 2. The child is thinking about the future and knows he may not be able to participate. # 3. The dying child may become clingy and act like a toddler. # 4. Whispering in the child’s room will help the child to cope. # 5. The death of a child may have long-term disrup- tive effects on the family. # 6. The child doesn’t fully understand the concept of death. 1, 3, 5, 6 6. A 5-year-old is brought to the emergency depart- ment after being given aspirin for many days for flulike symptoms; he’s diagnosed with Reye’s syndrome. The client has progressed to stage III of the syndrome. A nurse is preparing for the next stages of the syndrome and knows that the syndrome develops in five stages. Place the stages listed below in ascending chronologi- cal order. Use all the options. 1. Brief recovery period: child doesn’t seem ill 2. Coma 3. Viral infection 4. Deep coma, seizures, decreased tendon reflexes, and respiratory failure 5. Intractable vomiting; lethargy; rapidly changing mental status; increasing blood pressure, respiratory, and pulse rate; hyperactive reflexes 7. A school nurse is conducting registration for a first grader. Which immunizations should the school nurse verify the child has had on entering school? Select all that apply. # 1. Hepatitis B series # 2. Diphtheria-tetanus-pertussis series # 3. Haemophilus influenzae type b series # 4. Varicella zoster # 5. Pneumonia vaccine # 6. Oral polio series 1, 2, 3 8. A preschooler is diagnosed with a right Wilms’ tu- mor and the nurse is preparing teaching material for the family. On this drawing of the urinary system, which area would a nurse identify as that in which the tumor can be found? The school-age child 1. A nurse in a pediatrician’s office is determining the cognitive ability of a 7-year-old child who’s in first grade. Using a block test, the child demonstrates an understand- ing of conservation of mass. The nurse, who’s knowl- edgeable in Piaget’s theory of cognitive development, knows the child is in the concrete operational stage of Piaget’s stages. Place the stages listed below in ascending chronological order. Use all the options. 1. Concrete operational stage 2. Sensorimotor stage 3. Preoperational stage 4. Formal operational thought stage 2. An 11-year-old child is brought to the emergency department from a soccer game, complaining of diffi- culty breathing. The mother states that this has oc- curred a few times during recent soccer games, al- though not as severely as the current episode. The client has rapid, labored breathing with expiratory wheezes and a temperature of 98.8º F (37.1º C). A nurse assists with care based on a nursing diagnosis of which symptoms? Select all that apply. # 1. Activity intolerance related to exertional asthma # 2. Ineffective breathing pattern related to pneu- monia # 3. Risk for infection related to possible tuberculo- sis (TB) # 4. Impaired gas exchange related to pulmonary embolus # 5. Ineffective airway clearance related to croup 1 3. An 11-year-old boy is brought to a rural clinic list- less and pale. The parents state that the child had a “bad sore throat” 2 weeks ago and that they had him gargle with salt water. The parents report that they saw improvement but now the child has flulike symptoms. The child is diagnosed with rheumatic fever. Which signs and symptoms are associated with rheumatic fever? Select all that apply. # 1. Nausea and vomiting # 2. Polyarthritis # 3. Chorea # 4. High-grade fever # 5. Carditis # 6. Rash 2, 3, 5, 6 4. A 9-year-old boy with diabetes tests his glucose level before lunch in the nurse’s office. According to his sliding scale of insulin, he’s due for 1 unit of regu- lar insulin. What steps should a nurse follow after con- firming the medication order, washing her hands, drawing up the appropriate dose, verifying the boy’s identity, and putting on gloves? Put the following steps in ascending chronological order. Use all the options. 1. Pinch the skin around the injection site. 2. Release the skin and give the injection. 3. Clean the injection site with alcohol and loosen the needle cover. 4. Select an appropriate injection site, being sure to dis- cuss with the client so the sites are rotated. 5. Cover the site with an alcohol pad. Press but don’t rub the site. 6. Uncover the needle; insert it at a 45- to 90-degree angle. 5. When talking with 10- and 11-year-old children about death, the nurse should incorporate which guidelines? Select all that apply. # 1. Logical explanations aren’t appropriate. # 2. The children will be curious about the physical aspects of death. # 3. The children will know that death is inevitable and irreversible. # 4. The children will be influenced by the attitudes of the adults in their lives. 2, 3, 4 6. A 7-year-old client is admitted to the hospital for treatment of facial cellulitis. He’s admitted for observa- tion and for administration of a 10-day course of I.V. antibiotics. Which interventions would help this client cope with the insertion of a peripheral I.V. line? Select all that apply. # 1. Explain the procedure to the child immediately before the procedure. # 2. Apply a topical anesthetic to the I.V. site before the procedure. # 3. Ask the child which hand he uses for drawing. # 4. Explain the procedure to the child using abstract terms. # 5. Don’t let the child see the equipment to be used in the procedure. # 6. Tell the child that the procedure won’t hurt. 7. When teaching bicycle safety to children and par- ents, a nurse should stress protecting which part of the body? 2, 3 8. A 6-year-old girl is brought to the pediatrician’s of- fice by her mother for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A diag- nosis of a urinary tract infection (UTI) is made and the child is prescribed antibiotics. Which interventions are appropriate? Select all that apply. # 1. Limit fluids for the next few days to decrease the frequency of urination. # 2. Assess the mother’s understanding of UTIs and its causes. # 3. Instruct the mother to administer the antibiotic as prescribed — even if the symptoms diminish. # 4. Provide instructions only to the mother, not the child. # 5. Discourage the use of bubble bath. # 6. Tell the mother to have the child wipe from the back to the front after voiding and defecation. 2, 3, 5 The adolescent 1. Which symptoms reported by an adolescent’s par- ents indicate that the adolescent is abusing ampheta- mines? Select all that apply. # 1. Restlessness # 2. Fatigue # 3. Talkativeness # 4. Excessive perspiration # 5. Watery eyes # 6. Excessive nasal drainage 1, 3, 4 2. A group of 16-year-olds are eating at a restaurant. One adolescent starts to cough then can’t get a breath. He puts his hands around his neck to gesture that he can’t breathe. A friend stands and positions himself to begin the Heimlich maneuver. Identify the area where it’s most appropriate to place the hands when performing the Heimlich maneuver. 3. A 15-year-old boy is admitted to the telemetry unit because of a suspected cardiac arrhythmia. The nurse applies five electrodes to his chest and attaches the leadwires. Identify the area where she would place the chest lead (V1). 4. A 14-year-old diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply. # 1. Chocolates and sweets # 2. Increased hormone levels # 3. Growth of anaerobic bacteria # 4. Caffeine # 5. Heredity # 6. Fatty foods 2, 3, 5 5. A 16-year-old with diabetes is ordered to receive 15 units of NPH insulin and 5 units of regular insulin. Both are dispensed from the pharmacy in 100 units/ ml vials. How many total ml should the nurse admin- ister? 0.2 6. A 13-year-old with cystic fibrosis is admitted to the hospital with a pulmonary infection. A physician orders 2 mg/kg of an oral solution of prednisone daily to be divided into 4 doses. The oral solution has 5 mg/ml and the child weighs 99 lb. How many ml should the nurse administer for one dose? 22.5 7. A nurse is reviewing teaching points with an ado- lescent with inflammatory bowel disease. The topic is the use of corticosteroids. Which adverse effects are concerns for this client? Select all that apply. # 1. Acne # 2. Hirsutism # 3. Mood swings # 4. Osteoporosis # 5. Growth spurts # 6. Adrenal suppression 1, 2, 3, 4, 6 P A R T F I V E Psychiatric and mental health nursing 119 Foundations of psychiatric nursing 1. Knowledge of Maslow’s hierarchy of needs can assist a nurse in understanding client behavior. Place the stages of Maslow’s hierarchy of needs in order from basic to most complex. Use all the options. 1. Safety and security 2. Self-esteem 3. Physiologic needs 4. Love and belonging 5. Self-actualization 2. Electroconvulsive therapy (ECT) is an effective treatment for severe depression when which condi- tions accompany it? Select all that apply. # 1. The client also has dementia. # 2. The client can’t tolerate tricyclic antidepressants. # 3. The client lives in a long-term care facility. # 4. The client is undergoing a stressful life change. # 5. The client is having acute suicidal thoughts. # 6. The client is severely depressed despite taking numerous antidepressants. 2, 5, 6 3. Characteristics of a therapeutic relationship are exemplified by meeting which goals? Select all that apply. # 1. The needs of the client and nurse are identified and met. # 2. The nurse helps the client explore different problem-solving techniques. # 3. The nurse encourages the practice of new cop- ing skills. # 4. The nurse gives advice to the client. # 5. The nurse and client exchange personal infor- mation. # 6. The nurse discusses the client’s feelings with family members. 2, 3 4. A nurse understands that the first step in caring for a client with a mental health illness is to establish a therapeutic relationship to achieve effective communi- cation. Place the phases of a therapeutic relationship in ascending chronological order. Use all the options. 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase FOU N DATION S OF P S Y C H I AT R IC N U R SI NG 121 5. A nurse is explaining the Bill of Rights for psychi- atric clients to a client who has voluntarily sought ad- mission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply. # 1. Right to select health care team members # 2. Right to refuse treatment # 3. Right to a written treatment plan # 4. Right to obtain disability # 5. Right to confidentiality # 6. Right to personal mail 2, 3, 5, 6 6. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, “How long do I have to stay here?” Select all that apply. # 1. “You may leave the hospital at any time unless you are suicidal, homicidal, or unable to meet basic needs.” # 2. “Let’s talk more after the health team has as- sessed you.” # 3. “Once you’ve signed the papers, you have no say.” # 4. “Because you could hurt yourself, you must be safe before being discharged.” # 5. “You need a lawyer to help you make that deci- sion.” # 6. “There must be a court hearing before you leave the hospital.” 1, 2, 4 7. A nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply. # 1. The client addresses how the addiction has con- tributed to family distress. # 2. The client reluctantly shares the family history of addiction. # 3. The client verbalizes difficulty identifying person- al strengths. # 4. The client discusses the financial problems relat- ed to the addiction. # 5. The client expresses uncertainty about meeting with the nurse. # 6. The client acknowledges the addiction’s effects on the children. 1, 3, 6 Anxiety disorders 1. After receiving a referral from the occupational health nurse, a client comes to the mental health clinic with a suspected diagnosis of obsessive-compulsive disorder. The client explains that his compulsion to wash his hands is interfering with his job. Which inter- ventions are appropriate when caring for a client with this disorder? Select all that apply. # 1. Don’t allow the client time to carry out the ritual- istic behavior. # 2. Support the use of appropriate defense mecha- nisms. # 3. Encourage the client to suppress his anxious feelings. # 4. Explore the patterns leading to the compulsive behavior. # 5. Listen attentively, but don’t offer feedback. # 6. Encourage activities such as listening to music. 2, 4, 6 2. After being examined by the forensic nurse in the emergency department, a rape victim is prepared for discharge. Due to the nature of the attack, this client is at risk for posttraumatic stress disorder (PTSD). Which symptoms are associated with PTSD? Select all that apply. # 1. Recurrent, intrusive recollections or nightmares # 2. Gingival and dental problems # 3. Sleep disturbances # 4. Flight of ideas # 5. Unusual talkativeness # 6. Difficulty concentrating 1, 3, 6 3. A physician prescribes clomipramine (Anafranil) for a client diagnosed with obsessive-compulsive disorder. What instructions should the nurse include when teaching the client about this medication? Select all that apply. # 1. Avoid hazardous activities that require alertness or good coordination until adverse central ner- vous system (CNS) effects are known. # 2. Avoid alcohol and other depressants. # 3. Use saliva substitutes or sugarless candy or gum to relieve dry mouth. # 4. Take the drug on an empty stomach. # 5. Avoid using over-the-counter (OTC) products, except antihistamines and decongestants, with- out medical permission. # 6. Discontinue the medication if adverse reactions are troublesome. 1, 2, 3 4. A registered nurse caring for a client with general- ized anxiety disorder identifies a nursing diagnosis of Anxiety. The short-term goal identified is: “The client will identify his physical, emotional, and behavioral re- sponses to anxiety.” Which nursing interventions will help the client achieve this goal? Select all that apply. # 1. Avoid talking about the client’s sources of stress. # 2. Advise the client that consuming one glass of red wine per day may lessen his anxiety. # 3. Explain to the client that expressing his feelings through journal writing may increase his anxiety. # 4. Observe the client for overt signs of anxiety. # 5. Help the client connect anxiety with uncom- fortable physical, emotional, or behavioral responses. # 6. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise. 4, 5, 6 5. A nurse is reviewing information with a client on physical signs and symptoms that may be experienced during a panic attack. Which signs and symptoms should the nurse include? Select all that apply. # 1. Bradycardia # 2. Shortness of breath # 3. Delayed speech # 4. Dizziness # 5. Sweating # 6. GI distress 2, 4, 5, 6 6. A client with a panic disorder is prescribed a monoamine oxidase inhibitor. While reviewing dis- charge teaching, which dietary restrictions related to this medication would the nurse discuss with the client? Select all that apply. # 1. Caffeine # 2. Asparagus # 3. Sour cream # 4. Bananas # 5. Chocolate # 6. Liver 1, 3, 4, 5, 6 Mood, adjustment, and dementia disorders 1. A nurse is caring for a client who talks freely about feeling depressed. During an interaction, the nurse hears the client state, “Things will never change.” What other indications of hopelessness would the nurse look for? Select all that apply. # 1. Bouts of anger # 2. Periods of irritability # 3. Preoccupation with delusions # 4. Feelings of worthlessness # 5. Intense interpersonal relationships 1, 2, 4 2. A nurse interviews the family of a client who’s hospitalized with severe depression and suicidal ideation. Which family assessment information is es- sential to formulating an effective care plan? Select all that apply. # 1. Physical pain # 2. Personal responsibilities # 3. Employment skills # 4. Communication patterns # 5. Role expectations # 6. Current family stressors 4, 5, 6 3. A client is prescribed sertraline (Zoloft), a selective serotonin reuptake inhibitor. Which information about this drug’s adverse effects would the nurse expect when reviewing a medication teaching plan? Select all that apply. # 1. Agitation # 2. Agranulocytosis # 3. Sleep disturbance # 4. Intermittent tachycardia # 5. Dry mouth # 6. Seizures 1, 3, 5 MOOD, AD J U S T M ENT, AN D DEM ENTIA DI S O R DER S 127 4. A nurse is observing a client to determine whether he’s suffering from dementia or depression. Which in- formation helps the nurse to differentiate between the two? Select all that apply. # 1. The progression of symptoms is slow. # 2. The client answers questions with, “I don’t know.” # 3. The client acts apathetic and pessimistic. # 4. The family can’t identify when the symptoms first appeared. # 5. The client’s basic personality has changed. # 6. The client has great difficulty paying attention to others. 1, 4, 5, 6 5. A client has been diagnosed with an adjustment disorder of mixed anxiety and depression. Which nurs- ing diagnoses are associated with a client who has an adjustment disorder? Select all that apply. # 1. Activity intolerance # 2. Impaired social interaction # 3. Self-esteem disturbance # 4. Personal identity disturbance # 5. Acute confusion # 6. Impaired memory 2, 3 6. A physician prescribes lithium for a client diag- nosed with bipolar disorder. The nurse needs to pro- vide appropriate education for the client on this drug. Which topics should the nurse cover? Select all that apply. # 1. The potential for addiction # 2. Signs and symptoms of drug toxicity # 3. The potential for tardive dyskinesia # 4. A low-tyramine diet # 5. The need to consistently monitor blood levels # 6. Changes in his mood that may take 7 to 21 days 2, 5, 6 Psychotic disorders 1. A nurse is monitoring a client who appears to be hallucinating. Paranoid content is noted in the client’s speech and agitated behavior. The client is gesturing at a figure on the television. Which nursing interventions are appropriate? Select all that apply. # 1. In a firm voice, instruct the client to stop the behavior. # 2. Reinforce that the client is not in any danger. # 3. Acknowledge the presence of the hallucinations. # 4. Instruct other team members to ignore the client’s behavior. # 5. Immediately implement physical restraint procedures. # 6. Use a calm voice and simple commands. 2, 3, 6 2. A client with schizophrenia is taking the atypical antipsychotic medication clozapine (Clozaril). Which signs and symptoms indicate the presence of adverse effects associated with this medication? Select all that apply. # 1. Sore throat # 2. Pill-rolling movements # 3. Polyuria # 4. Fever # 5. Polydipsia # 6. Orthostatic hypotension 1, 4 3. A delusional client approaches a nurse, stating, “I am the Easter bunny,” and insisting that the nurse re- fer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply. # 1. Consistently use the client’s name in interaction. # 2. Smile at the humor of the situation. # 3. Agree that the client is the Easter bunny. # 4. Logically point out why the client could not be the Easter bunny. # 5. Provide an as-needed medication. # 6. Provide the client with structured activities. 1, 6 4. A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse ef- fects. Which measures should the nurse take during Haldol administration? Select all that apply. # 1. Review subcutaneous injection technique. # 2. Closely monitor vital signs, especially temp- erature. # 3. Observe for increased pacing and restlessness. # 4. Monitor blood glucose levels. # 5. Provide the client with hard candy. # 6. Monitor for signs and symptoms of urticaria. 2, 3, 5 5. A nurse is aware that a client with schizophrenia often progresses through three distinct phases. Place the three phases in ascending chronological order. 1. Active phase 2. Prodromal phase 3. Residual phase 6. While providing a community class on schizophre- nia, a nurse reviews factors that increase the client’s chances for a positive prognosis. Select all that apply. # 1. Male gender # 2. Early onset (in the teen years) # 3. Sudden disease onset # 4. Minimal cognitive impairment # 5. Paranoid schizophrenia subtype # 6. Good pre-illness functioning 3, 4, 5, 6 7. A nurse is working with a client with schizophrenia who’s experiencing auditory hallucinations. Place the interventions in the order that will decrease the client’s anxiety. Use all the options. 1. The nurse asks, “What are you experiencing right now?” 2. The nurse encourages the client to tell her when he be- gan hearing voices. 3. The nurse asks the client for permission to discuss the hallucinations. 4. The nurse asks the client if he has taken drugs or alco- hol recently. Substance abuse, eating disorders, and impulse control disorders 1. A nurse is assessing a client who has been diag- nosed with bulimia nervosa. The nurse is aware that this disorder is characterized by eating binges accom- panied by which symptoms? Select all that apply. # 1. Guilt # 2. Dental caries # 3. Self-induced vomiting # 4. Weight loss # 5. Normal weight # 6. Introverted behavior 1, 2, 3, 5 2. While checking a client upon arrival to the emer- gency department, a nurse is concerned that the client may be under the influence of amphetamines. Which symptoms may indicate the influence of ampheta- mines? Select all that apply. # 1. Depressed affect # 2. Diaphoresis # 3. Shallow respirations # 4. Hypotension # 5. Tremors # 6. Dilated pupils 2, 3, 5, 6 3. A client admitted for the second time this winter with pneumonia has stated, ”I’m really ready to kick this habit of smoking but I don’t know where to begin.” A nurse explains that there are several options to assist a client in smoking cessation. Select all that apply. # 1. Use of nicotine replacement (nicotine gum, transdermal patches, nasal sprays and inhalers) # 2. Use of clonidine or diazepam (Valium) to mimic the effects of nicotine # 3. Use of alcohol to blunt the effect caused by withdrawal from nicotine # 4. Behavioral therapies and treatments # 5. Acupuncture # 6. Identifying coping skills and then seeking expo- sure to a smoking environment to test these skills 1, 2, 4, 5 4. Which interventions would be supportive for a client with a nursing diagnosis of Imbalanced nutrition: Consuming less than the body requires due to dys- functional eating patterns? Select all that apply. # 1. Provide small, frequent feedings. # 2. Monitor weight fluctuations. # 3. Allow the client to skip meals until the anti- depressant levels are therapeutic. # 4. Encourage journaling to promote the expression of feelings. # 5. Monitor the client at mealtimes and for an hour after meals. # 6. Encourage the client to eat three substantial meals per day. 1, 2, 4, 5 5. While collecting data on a client who was diag- nosed with impulse control disorder (and who dis- plays violent, aggressive, and assaultive behavior), the nurse can expect to find which data? Select all that apply. # 1. The client functions well in other areas of his life. # 2. The degree of aggressiveness is out of propor- tion to the stressor. # 3. The client often uses a stressor to justify the vio- lent behavior. # 4. The client has a history of parental alcoholism and a chaotic, abusive family life. # 5. The client shows no remorse about his inability to control his behavior. 1 Basic physical care 1. A nurse is caring for a client who sustained a chemical burn in his right eye. She’s preparing to irri- gate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply. # 1. Tilt the client’s head toward his left eye. # 2. Place absorbent pads in the area of the client’s shoulder. # 3. Wash hands and put on gloves. # 4. Place the irrigation syringe directly on the cornea. # 5. Direct the solution onto the exposed conjuncti- val sac from the inner to outer canthus. # 6. Irrigate the eye for 1 minute. 2, 3, 5 2. A nurse is caring for a client who underwent car- diac catheterization. He starts bleeding from his left femoral access site. Identify the area where the nurse should apply pressure. 3. A nurse is preparing to leave a contact isolation room. Place the following steps in ascending chrono- logical order as to how protective wear should be re- moved. Use all the options. 1. Remove eyewear. 2. Remove gloves. 3. Remove mask. 4. Remove gown. 5. Wash hands for a minimum of 10 seconds. 4. A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply. # 1. Chill the solution by placing it in the refrigerator for 10 minutes. # 2. Assist the client into Sims’ position. # 3. Wash hands and put on gloves. # 4. Insert the tip of the container 1⁄2" into the rec- tum. # 5. Allow gravity to instill the solution. # 6. Encourage the client to retain the solution for 5 to 15 minutes. 2, 3, 6 5. A nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for labora- tory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1⁄2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinat- ed coffee, tuna fish sandwich, 1⁄2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz. of 1% milk, 16 oz of water Output: 1,300 ml of urine How many milliliters should the nurse document as the client’s intake? 1380 6. A hospitalized client asks the nurse for “something for pain.” What information is most important for the nurse to gather before administering the medication? Select all that apply. # 1. Administration time of the last dose # 2. Client’s pain level on a scale of 1 to 10 # 3. Type of medication the client has been taking # 4. Beeper number of the client’s physician # 5. Client’s most current height and weight # 6. Effectiveness of prior dose of medication 1, 2, 3, 6 7. A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a “pulling” sensation in his abdominal wound. The nurse assesses the client’s wound and finds that it has sepa- rated and the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply. # 1. Notify the client’s primary physician. # 2. Cover the wound with saline-soaked sterile gauze. # 3. Give the client a dose of antibiotics. # 4. Order an abdominal binder from the supply de- partment. # 5. Push the organs back into the abdomen. # 6. Assess the client for signs of shock. 8. A nurse puts on gloves to perform a fecal occult blood test using a Hemoccult slide. Place these steps in ascending chronological order. Use all the options. 1. Allow the specimens to dry for 3 minutes. 2. Apply a drop of Hemoccult-developing solution to box A and box B on the reverse side of the slide. 3. Apply a smear of stool to box A on the slide. 4. Apply a smear of stool from another part of the speci- men to box B on the slide. 5. Apply a drop of Hemoccult-developing solution to each control dot on the reverse side of the slide. 6. Evaluate the results; remove gloves; wash hands. 1, 2 9. A client suffers a broken leg as a result of a car ac- cident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse pro- vides the client with instructions regarding cast care. Which instructions are most appropriate? Select all that apply. # 1. Support the wet cast with pillows until it dries. # 2. Use a hair dryer to speed the drying process. # 3. Use the fingertips when moving the wet cast. # 4. Apply powder to the inside of the cast after it dries. # 5. Notify the physician if itching occurs under the cast. # 6. Avoid putting straws or hangers inside the cast. 1, 6 10. A nurse is caring for a client with a hiatal hernia. The client complains of abdominal and sternal pain af- ter eating. The pain makes it difficult for the client to sleep. Which instructions should the nurse stress when teaching this client? Select all that apply. # 1. Avoid constrictive clothing. # 2. Lie down for 30 minutes after eating. # 3. Decrease intake of caffeine and spicy foods. # 4. Eat three meals per day. # 5. Sleep in semi-Fowler position. # 6. Maintain a normal body weight. 1, 3, 5, 6 11. A client is admitted to the hospital from an extended care facility with a stage 3 pressure ulcer. Identify the deepest layer of tissue involved in this diagnosis. 12. A nurse investigates the smell of smoke in the hallway of a long-term care unit. She enters a client’s room and finds the wastebasket is on fire. The nurse takes immediate action. Place the nurse’s actions in proper ascending chronological order. Use all the op- tions. 1. Trigger the alarm. 2. Extinguish the fire. 3. Rescue the client. 4. Confine the fire. Basic psychosocial needs 1. A nurse is caring for a client who’s disoriented to time, place, and person and is attempting to get out of bed and pull out an I.V. line that’s supplying hydration and antibiotics. The client has a vest restraint and bilat- eral soft wrist restraints. Which actions by the nurse would be appropriate? Select all that apply. # 1. Recheck and document the behavior that re- quires continued use of restraints. # 2. Tie the restraints in quick-release knots. # 3. Tie the restraints to the side rails of the bed. # 4. Ask the client if he needs to go to the bath- room, and provide range-of-motion (ROM) exercises every 2 hours. # 5. Position the vest restraints so that the straps are crossed in the back. 1, 2, 4 2. A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client’s daughter tells the nurse, “I don’t know what to say to my mother if she asks me if she’s going to die.” Which responses by the nurse would be ap- propriate? Select all that apply. # 1. “Tell your mother not to worry; she still has some time left.” # 2. “Let’s talk about your mother’s illness and how it will progress.” # 3. “You sound like you have some questions about your mother dying. Let’s talk about that.” # 4. “Don’t worry. Hospice will take care of your mother.” # 5. “Tell me how you’re feeling about your mother dying.” 2, 3, 5 3. While providing care to a 26-year-old married fe- male, a nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client re- sponds, “Oh, I tripped.” How should the nurse re- spond? Select all that apply. # 1. Document the client’s statement and complete a body map indicating the size, color, shape, lo- cation, and type of injuries. # 2. Contact the local authorities to report suspicions of abuse. # 3. Assist the client in developing a safety plan for times of increased violence. # 4. Call the client’s husband to arrange a meeting to discuss the situation. # 5. Tell the client that she needs to leave the abu- sive situation as soon as possible. # 6. Provide the client with telephone numbers of local shelters and safe houses. 1, 3, 6 4. A nurse is caring for a client who’s terminally ill. Place the symptoms of the five stages of death and dying described by Elisabeth Kübler-Ross in ascending chronological order. Use all the options. 1. Negotiating, new interest in healthful behaviors 2. Withdrawal, refusal to discuss health issues 3. Calmness, honesty, involved in care management deci- sions 4. Irritability, complaining, adversarial 5. Loss, grief, intense sadness 5. A 26-year-old client with chronic renal failure was recently told by his physician that he’s a poor candi- date for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, “I want to go off dialysis. I’d rather not live than be on this treatment for the rest of my life.” Which responses by the nurse are appropriate? Select all that apply. # 1. Take a seat next to the client and sit quietly to reflect on what was said. # 2. Say to the client, “We all have days when we don’t feel like going on.” # 3. Leave the room to allow the client privacy to collect his thoughts. # 4. Say to the client, “You’re feeling upset about the news you got about a transplant.” # 5. Say to the client, “The treatments are only 3 days a week. You can live with that.” 1, 4 6. A nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client’s family? Select all that apply. # 1. People related by blood or marriage # 2. People whom the client views as family # 3. People who live in the same house # 4. People who the nurse thinks are important to the client # 5. People who live in the same house with the same racial background as the client # 6. People who provide for the physical and emo- tional needs of the client 2, 6 7. A nurse is caring for a client whose cultural back- ground is different from her own. Which actions are appropriate for the nurse? Select all that apply. # 1. Consider that nonverbal cues such as eye con- tact may have a different meaning in different cultures. # 2. Respect the client’s cultural beliefs. # 3. Ask the client if he has cultural or religious re- quirements that should be considered in his care. # 4. Explain the nurse’s beliefs so that the client will understand the differences. # 5. Understand that all cultures experience pain in the same way. 1, 2, 3 8. A nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply. # 1. Illness in one family member can affect all members. # 2. Family roles don’t change because of illness. # 3. A family member may have more than one role at a time in a family. # 4. Children typically aren’t affected by adult illness. # 5. The effects of an illness on a family depend on the stage of the family’s life cycle. # 6. Changes in sleeping and eating patterns may be signs of stress in a family. 1, 3, 5, 6 9. Every client admitted to the hospital must receive information about advance directives. Which state- ments are true about advance directives? Select all that apply. # 1. Every person must complete an advance direc- tive upon admission. # 2. An advance directive includes a living will or a power of health care attorney. # 3. An advance directive is a legal document. # 4. An advance directive must be notarized. # 5. An advance directive should be included with the client’s chart. # 6. An advance directive conveys the client’s directions about his health care upon loss of capacity. 2, 3, 5, 6 10. A nurse is working with the family of a client who has Alzheimer’s disease. The nurse notes that the client’s spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing inter- ventions would be helpful? Select all that apply. # 1. Calling a family meeting to tell the absent chil- dren that they must participate in caregiving # 2. Suggesting the spouse seek psychological coun- seling to help cope with exhaustion # 3. Recommending community resources for adult day care and respite care # 4. Encouraging the spouse to talk about the diffi- culties involved in caring for a loved one # 5. Asking whether friends or church members can help with errands or provide short periods of relief # 6. Recommending that the client be placed in a long-term care facility 3, 4, 5 Medication and I.V. administration 1. A client has just had total hip replacement surgery. The physician orders heparin 8,000 units to be admin- istered subcutaneously. The label on the heparin vial reads: heparin 10,000 units/ml. How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose? 2. After laparoscopic cholecystectomy, a client com- plains of pain and nausea. The nurse is preparing meperidine hydrochloride (Demerol) 75 mg and promethazine hydrochloride (Phenergan) 12.5 mg to be administered I.M. in the same syringe. If the label on the Demerol reads 50 mg/ml and the label on the Phenergan reads 25 mg/ml, how many milliliters should the nurse have in the syringe after the correct doses are drawn up? 0.8 2 3. A nurse is reinforcing a teaching plan with a client who’s prescribed enalapril maleate (Vasotec) for treat- ment of hypertension. Which instructions would the nurse expect to see included in the teaching plan? Se- lect all that apply. # 1. Instruct the client to avoid salt substitutes. # 2. Tell the client that light-headedness is a com- mon adverse effect that need not be reported. # 3. Inform the client that he may have a sore throat for the first few days of therapy. # 4. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically thereafter. # 5. Advise the client to report facial swelling or diffi- culty breathing immediately. # 6. Inform the client not to change position sud- denly to minimize orthostatic hypotension. 4. A nurse is administering ampicillin (Polycillin) 125 mg I.M. every 6 hours to a 10-kg child with a respirato- ry tract infection. The drug label reads, “The recom- mended dosage for a client weighing less than 40 kg is 25 to 50 mg/kg/day I.M. or I.V. in equally divided doses at 6- to 8-hour intervals.” The drug concentra- tion is 125 mg/5 ml. Which nursing interventions are appropriate at this time? Select all that apply. # 1. Draw up 10 ml of ampicillin to administer. # 2. Administer the medication at 1000, 1400, 1800, and 2200. # 3. Assess the client for allergies to penicillin. # 4. Administer the medication because it’s within the dosing recommendations. # 5. Question the physician about the order because it’s more than the recommended dosage. # 6. Obtain a sputum culture before administering the medication. 1, 5, 6 3, 4, 6 5. A nurse is using the Z-track method of I.M. injec- tion to administer iron dextran to a client with iron de- ficiency anemia. Which techniques should the nurse use to give this injection? Select all that apply. # 1. Confirm the client’s identity before administer- ing the iron dextran. # 2. Inject the iron dextran into the deltoid muscle. # 3. Change the needle after drawing up the iron dextran. # 4. Before inserting the needle, displace the skin laterally by pulling it away from the injection site. # 5. Inject the iron dextran after aspirating for a blood return. # 6. After removing the needle, massage the injec- tion site. 1, 3, 4, 5 6. The nurse is preparing to administer regular in- sulin 4 units to a client with type 1 diabetes mellitus. Which equipment does the nurse need to perform the injection? Select all that apply. # 1. Medication administration record # 2. Nursing assessment sheet # 3. 27-gauge, 1⁄2" needle # 4. 22-gauge, 1⁄2" needle # 5. 27-gauge, 1" needle # 6. 22-gauge 1" needle 1, 3 7. A nurse is administering insulin to a client with type 1 diabetes mellitus. Identify the tissue layer where the tip of the needle should be placed to deliv- er this medication to the proper tissue. Skin 8. A client with heart failure is ordered 60 mg of furosemide (Lasix) P.O. daily. Because the client has difficulty swallowing, an oral solution is ordered. The solution dispensed from the pharmacy has a concen- tration of 40 mg/5 ml. How many milliliters should the nurse administer? 7.5 9. A client with an I.V. line in place complains of pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions should the nurse take? Select all that apply. # 1. Slow the infusion rate while notifying the pre- scriber. # 2. Discontinue the infusion at the affected site. # 3. Request restart of the infusion in an I.V. site dis- tal to the discontinued I.V. site. # 4. Check the client for skin sloughing. # 5. Apply warm soaks to the I.V. site. # 6. Document the examination, the nurse’s actions, and the client’s responses. 10. A nurse is administering an I.M. injection into the vastus lateralis muscle. Identify the area where the nurse will inject the medication. 2, 4, 5, 6 11. A physician orders amoxicillin (Amoxil) 250 mg P.O. (by mouth) t.i.d. for a client. Amoxicillin 125 mg/ tsp is available. How many tsp must the nurse admin- ister? 2 12. A client on hemodialysis is prescribed cephalex- in (Keflex) 500 mg P.O. (by mouth) every 6 hours for a group A beta-hemolytic streptococcal infection. The client states that he can’t swallow the large pills and requests a liquid dose. The suspension is available in 250 mg/5 ml. The nurse knows that which statements about this order are true? Select all that apply. # 1. The maximum oral dosage of cephalexin for an adult is 4 g daily. # 2. Hypersensitivity to penicillin and cephalosporin is a contraindication to use of this drug. # 3. The dosage prescribed for the client is within an acceptable range for a client on hemodialysis. # 4. Adverse effects of nausea and anorexia may be relieved by taking the drug with food or milk. # 5. Stevens-Johnson syndrome is an adverse effect of this drug. # 6. Diarrhea is a common but not serious adverse reaction to this drug. 1, 4 13. A nurse transcribes the following physician’s or- der onto the client’s medication record: March 15, 2006 1630 Administer 10 gtt of timolol maleate (Timoptic) ophthalmic solution AU daily. John Bloom, MD Which components of the medication order should the nurse question? Select all that apply. # 1. Number of drops # 2. Route # 3. Type of medication # 4. Signature # 5. Frequency of administration # 6. Date 1, 2 Basic physical assessment 1. An adolescent client seeks medical attention be- cause of a sore throat and probable mononucleosis. The nurse palpates the client’s submandibular lymph nodes for enlargement. Identify the area where the nurse should palpate to best feel these nodes. 2. A client is hospitalized with pneumonia for 2 days. After reading the documentation below, what’s the nurse’s assessment of the arterial blood gas results? 4/16/2006 1530 Arterial blood gases pH 7.48 PCO2 32 mm Hg PO2 88 mm Hg SaO2 90 HCO3 24 mEq/L – # 1. Respiratory acidosis # 2. Respiratory alkalosis # 3. Metabolic acidosis # 4. Metabolic alkalosis 2 3. A client is admitted to the hospital for a fractured hip. He has a history of aortic stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur. 4. A nurse is collecting data on a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to obtain more informa- tion about the client’s rash? Select all that apply. # 1. “When did the rash start?” # 2. “Are you allergic to any medications, foods, or pollen?” # 3. “How old are you?” # 4. “What have you been using to treat the rash?” # 5. “Have you traveled outside of the country?” # 6. “Do you smoke cigarettes or drink alcohol?” 1, 2, 4, 5 5. A client comes to the clinic complaining of hear- ing loss. The nurse performs Weber’s test to assess the client’s ability to hear. Identify the location where the nurse should place the tuning fork to perform this test. 6. A nurse realizes that as a client experiences neu- rologic deterioration, symptoms of “disorientation” usually occur sequentially. Place the following symp- toms in ascending chronological order. Use all the op- tions. 1. Disoriented to familiar people 2. Disoriented to time 3. Disoriented to self 4. Disoriented to place 7. A client is admitted with a diagnosis of new-onset atrial fibrillation. To obtain an accurate pulse count, the nurse counts the apical heart rate. Identify the area where the nurse should place the stethoscope to best hear the apical rate. 8. An elderly client who is 5'4" and weighs 145 lb is admitted to the long-term care facility. The admitting nurse takes this report: The client sits for long periods in his wheelchair and has bowel and bladder inconti- nence. He is able to feed himself and has a fair ap- petite, eating best at breakfast and poorly thereafter. He doesn’t have family members living nearby and is often noted to be crying to sleep. He also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer? Select all that apply. # 1. Weight # 2. Incontinence # 3. Sitting for long periods of time # 4. Sedation # 5. Crying # 6. Eating poorly at lunch and dinner 2, 3, 4 9. A nurse finds a client lying on the floor of the hos- pital corridor. After determining unconsciousness, breathlessness, and providing two ventilations, the nurse checks the client’s carotid artery for a pulse. Identify the area where the nurse can best palpate the carotid pulse. 10. A client with diabetes comes to the clinic for medical attention because of numbness and tingling in his lower extremities. The nurse obtains the client’s vital signs and palpates the dorsalis pedis pulse. Identi- fy the area where the nurse places her fingers to pal- pate the pedal pulse. 11. A client comes to the emergency department seeking medical attention for severe pain in the area of the appendix. Identify the area where the nurse would expect the pain to localize. 12. A client is admitted to the hospital for routine outpatient surgery. Before surgery, the nurse auscul- tates the client’s chest for breath sounds. Identify the area where the nurse should expect to hear bron- chovesicular breath sounds. P A R T T W O Medical-surgical nursing 27 Cardiovascular disorders 1. A client with a history of hypertension has just had a total hip replacement. The physician orders hydro- chlorothiazide (Hydro-Chlor) 35 mg oral solution by mouth, once per day. The label on the solution reads hydrochlorothiazide 50 mg/5 ml. To administer the correct dose, how many ml should the nurse pour? 2. A client on telemetry reports that she’s having chest pain. The hospital unit has standing orders that allow a nurse to begin treating the client before notify- ing the physician. Place the following actions in proper ascending chronological order. Use all the options. 1. Evaluate the client’s response. 2. Administer SL nitroglycerin. 3. Administer oxygen at 2 L/min. 4. Check vital signs. 3.5 3. A nurse is checking a client who’s at risk for car- diac tamponade due to chest trauma sustained in a motorcycle accident. What’s the client’s pulse pressure if his blood pressure is 108/82 mm Hg? 26 4. A nurse is preparing to take the blood pressure of a client. Which actions are appropriate? Select all the apply. # 1. Selecting a cuff that’s 80% of arm circum- ference # 2. Wrapping the cuff so that the lower border is 8 cm above the antecubital space # 3. Centering the bladder of the cuff over the brachial artery # 4. Inflating the cuff to 30 mm above the reading where the brachial pulse disappeared # 5. Quickly releasing the bulb valve so the pressure drops more than 5 mm Hg per second 1, 3, 4 5. A nurse is applying a 3-lead telemetry unit to a client newly admitted to the telemetry unit. The client is to be monitored in a lead MCL1. Identify the area where the nurse would correctly place the positive chest lead. 6. A nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse expect in the care plan for the next 8 hours? Select all that apply. # 1. Maintain pressure over the femoral access site. # 2. Allow the client to sit upright for meals. # 3. Check the dressing and access site for bleeding. # 4. Monitor vital signs every 4 hours. # 5. Keep the extremity straight. # 6. Allow use of the bedside commode. 1, 3, 5 7. A nurse is assisting with preparing a teaching plan for a client who recently underwent surgery for inser- tion of a permanent pacemaker. Which instructions should the nurse include in the teaching plan? Select all that apply. # 1. Check heart rate for 1 minute daily. # 2. Check respiratory rate for 1 minute daily. # 3. Report any bulging at the insertion site. # 4. Report redness, swelling, or discharge at the in- sertion site. # 5. Stay away from airport metal detectors. # 6. Avoid magnetic resonance imaging (MRI) diag- nostic studies. 1, 4, 6 8. A nurse is assisting in admitting a client with sub- sternal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply. # 1. Serum bilirubin # 2. Serum troponin # 3. Serum myoglobin # 4. Urinalysis # 5. Electroencephalogram # 6. 24-hour creatinine clearance 2, 3 9. Which signs and symptoms should the nurse ex- pect to find in a client with angina? Select all that apply. # 1. Chest tightness # 2. General muscle aching # 3. Chest pressure # 4. Jaw pain # 5. Slowed respiratory rate # 6. Bradycardia 1, 3, 4 10. A client is diagnosed with myocardial infarction. Which data collected indicate that the client has devel- oped left-sided heart failure? Select all that apply. # 1. Ascites # 2. Jugular vein distention # 3. Orthopnea # 4. Cough # 5. Hepatomegaly # 6. Crackles 3, 4, 6 11. A nurse is performing a cardiac check on a client with hypertension. Identify the area where the nurse should place the stethoscope to best auscultate the pulmonic valve. 12. The nurse is checking the peripheral pulses of a client who underwent cardiac catheterization through the left groin. Identify the area where the nurse should palpate the left posterior tibial artery. 13. A client with atrial fibrillation is diagnosed with an embolic stroke. Identify the heart chamber that is the most likely source of the fragmented clot responsi- ble for the stroke. Oncologic disorders 1. A client in the terminal stage of cancer is being transferred to hospice care. Which information should the nurse include in the teaching plan regarding hos- pice care? Select all that apply. # 1. Care focuses on controlling symptoms and re- lieving pain. # 2. A multidisciplinary team provides care. # 3. Services are based on the client’s ability to pay. # 4. Hospice care is provided only in hospice cen- ters. # 5. Bereavement care is provided to the family. # 6. Care is provided in the home independent of physicians. 1, 2, 5 2. A physician has ordered filgrastim (Neupogen) 5 mcg/kg subcutaneously for a postchemotherapy client. The client weighs 140 lb. Neupogen comes in a vial of 300 mcg/ml. How many milliliters of Neupogen will a nurse deliver to the client? 1 3. A nurse is teaching a community program on breast self-examination. She tells the group the proper steps to take when palpating each breast. Place the following actions in proper ascending chronological or- der. Use all the options. 1. Use the right hand for the left breast (and vice versa). 2. Lie down with your arm behind your head. 3. Palpate the breast in a perpendicular motion going across the breast from side to side and top to bottom. 4. Use a circular motion to feel breast tissue (with light, medium, and firm pressure). 5. Use the finger pads of the three middle fingers. 4. A client with breast cancer was admitted earlier in the day with sepsis and complaints of nausea, pain, and lethargy. She completed her third round of chemotherapy last week. A physician has just ordered I.V. D5 half normal saline solution at 150 ml/hr. Which notes would the nurse expect to see documented in the client’s chart? Select all that apply. # 1. Skin flushed and warm. # 2. Client groggy but answers questions appropri- ately. # 3. Auscultation of lungs: clear bilaterally. # 4. Abdomen soft and nontender. Bowel sounds present in all quadrants. # 5. BP 96/50, HR 114/min, RR 22/min, T 103.2ºF (39.5ºC). Urine output 150 ml in the past 6 hours. # 6. BUN 35, creatinine 0.4, Na 134, K 4.2, Cl 104. 1, 2, 5, 6 5. A client with laryngeal cancer has undergone laryngectomy and is receiving radiation therapy to the head and neck. The nurse should monitor the client for which adverse effects of external radiation? Select all that apply. # 1. Xerostomia # 2. Stomatitis # 3. Thrombocytopenia # 4. Cystitis # 5. Dysgeusia # 6. Leukopenia 1, 2, 5 6. A client with bladder cancer undergoes surgical removal of the bladder and construction of an ileal conduit. Which data indicate that the client is develop- ing complications? Select all that apply. # 1. Urine output is greater than 30 ml/hr. # 2. The stoma appears dusky. # 3. The stoma protrudes from the skin. # 4. Mucus shreds are in the urine collection bag. # 5. Edema of the stoma is present during the first 24 hours postoperatively. # 6. The client experiences sharp abdominal pain and abdominal rigidity. 2, 3, 6 7. A client receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse expect in the discharge teaching plan? Select all that apply. # 1. Avoid people who have recently received atten- uated vaccines. # 2. Avoid activities that may cause bleeding. # 3. Wash hands frequently. # 4. Increase intake of fresh fruits and vegetables. # 5. Avoid crowded places such as shopping malls. # 6. Treat a sore throat with over-the-counter prod- ucts. 1, 2, 3, 5 8. A client is ordered a dose of epoetin alfa (Procrit). The recommended dosage is 150 units/kg subcuta- neously. The client weighs 60 kg. Epoetin alfa comes in a vial of 10,000 units/ml. How many milliliters of epoetin alfa would the nurse expect to administer? 0.9 Gastrointestinal disorders 1. A nurse is caring for a client who can’t swallow tablets. The client weighs 56 kg. Famotidine (Pepcid) is ordered; it’s dispensed as an oral suspension of 40 mg/5 ml. The order states to give Pepcid 0.7 mg/ kg/day divided twice daily. How many milliliters would the nurse pour into the medication cup for the first dose? 2.5 2. A nurse is teaching a client with an ostomy how to apply a new appliance. Place the nurse’s instruc- tions in ascending chronological order. Use all the op- tions. 1. Add 1⁄16 to 1⁄8 inch to the size of the stoma. 2. Wash stoma area and pat dry. 3. Apply thin layer of paste around stoma. 4. Cut stoma opening into wafer. 5. Apply pouch. 6. Measure the stoma size. 3. As part of a routine screening for colorectal can- cer, a client must undergo fecal occult blood testing. Which foods should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period? Select all that apply. # 1. High-fiber foods # 2. Red meat # 3. Turnips # 4. Cantaloupe # 5. Tomatoes # 6. Peas 2, 3, 4 4. A client with osteoarthritis is admitted to the hos- pital with peptic ulcer disease. Which findings are com- monly associated with peptic ulcer disease? Select all that apply. # 1. Localized, colicky periumbilical pain # 2. History of nonsteroidal anti-inflammatory use # 3. Epigastric pain that’s relieved by antacids # 4. Tachycardia # 5. Nausea and weight loss # 6. Low-grade fever 2, 3, 5 5. A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instruct- ed to take which actions? Select all that apply. # 1. Follow a high-fat, low-fiber diet. # 2. Avoid caffeine and carbonated beverages. # 3. Sleep with the head of the bed flat. # 4. Stop smoking. # 5. Take antacids 1 hour and 3 hours after meals. # 6. Limit alcohol consumption to one drink per day. 2, 4, 5 6. A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when ad- ministering an enema? Select all that apply. # 1. Assist the client into the left-lateral Sims’ posi- tion. # 2. Lubricate the distal end of the rectal catheter. # 3. Warm the solution to 110° F (43.3° C). # 4. Insert the tube 1" to 11⁄2". # 5. Administer 250 to 500 ml of irrigating solution. # 6. Be sure to keep the solution container no high- er than 18" above bed level. 1, 2, 6 7. A client with cirrhosis is ordered to have a daily measurement of his abdominal girth. Identify the anatomic landmark where the tape measure should be placed when obtaining this measurement. 8. A client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colon- oscopy? Select all that apply. # 1. When the client recovers from sedation, tell him he must follow a clear liquid diet. # 2. Instruct the client that he shouldn’t drive for 24 hours. # 3. Observe the client closely for signs and symp- toms of bowel perforation. # 4. Monitor vital signs frequently until they’re stable. # 5. Inform the client that there may be blood in his stool and that he should report excessive blood immediately. # 6. Tell the client to report excessive flatus. 3, 4, 5 9. A client has been hospitalized with pancreatitis for 3 days. A nurse checks the client and documents the results below. The nurse realizes that this information is a manifestation of what finding? # 1. Cullen’s sign # 2. Chvostek’s sign # 3. Trousseau’s sign # 4. Broca’s sign 1 10. A client with a retroperitoneal abscess is receiv- ing gentamicin (Garamycin) I.V. Which levels should the nurse monitor? Select all that apply. # 1. Hearing # 2. Urine output # 3. Hematocrit (HCT) # 4. Blood urea nitrogen (BUN) and creatinine # 5. Serum calcium 1, 2, 4 11. Locate the abdominal quadrant where the nurse would expect to palpate the liver. Integumentary disorders 1. At an outpatient clinic, a medical assistant inter- views a client and documents the findings in the chart below. After reading the chart note, a nurse begins planning based on which nursing diagnoses? 12/13/06 Client very anxious because of new black 0900 mole with shades of brown noted on upper outer right thigh. Asymmetrical in shape with an irregular border. ——— M. Rosenfeld, MA # 1. Deficient knowledge related to potential diag- nosis of basal cell carcinoma # 2. Fear related to potential diagnosis of malignant melanoma # 3. Risk for impaired skin integrity related to poten- tial squamous cell carcinoma # 4. Readiness for enhanced knowledge of skin care precautions related to benign mole 2 2. Despite conventional treatment, a client’s psoriasis has worsened. The physician prescribes methotrexate 25 mg by mouth as a single weekly dose. The phar- macy dispenses 2.5-mg scored tablets. How many tablets should the nurse instruct the client to consume to achieve the prescribed dose? 10 3. Which nursing interventions are effective in pre- venting pressure ulcers? Select all that apply. # 1. Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. # 2. When turning the client, slide him and avoid lift- ing him. # 3. Avoid raising the head of the bed more than 90 degrees. # 4. Turn and reposition the client every 1 to 2 hours unless contraindicated. # 5. If the client uses a wheelchair, seat him on a rubber or plastic doughnut. # 6. Use pillows to position the client and increase his comfort. 1, 4, 6 4. A client has been hospitalized with bacterial pneu- monia and dehydration for 3 days. The client’s right heel reveals a shallow opened area draining clear fluid, which appears to be a skin tear. The nurse would un- derstand which items related to this client’s skin break? Select all that apply. # 1. The heel wound would be classified as a stage 1 pressure ulcer. # 2. Increasing fluid intake would help prevent fur- ther skin injury. # 3. The wound is at risk for infection. # 4. Placing the client on an air mattress will heal the wound. # 5. The client’s caloric requirements are lower than normal because of decreased activity. # 6. The injured area would be painful to the client. 2, 3, 6 . I NTE GU M ENTARY DI S O R DER S 45 5. Which instructions should be included in the teaching plan of a client with acne vulgaris who’s pre- scribed tretinoin, benzoyl peroxide, and tetracycline? Select all that apply. # 1. Expect your skin to look red and start to peel af- ter treatment. # 2. Take tetracycline on an empty stomach. # 3. Use tretinoin and benzoyl peroxide together in the morning and at bedtime. # 4. Maintain the prescribed treatment because it’s more likely to improve acne than a strict diet and frequent scrubbing with soap and water. # 5. Apply tretinoin at least 30 minutes after washing the face and at bedtime. # 6. Avoid exposure to sunlight and don’t use a sun- screen. 6. A client is brought to the emergency department with partial- and full-thickness burns over 15% of his body. His admission vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing in- terventions are appropriate for this client? Select all that apply. # 1. Clean the burns with hydrogen peroxide. # 2. Cover the burns with saline-soaked towels. # 3. Begin an I.V. infusion of lactated Ringer’s solu- tion. # 4. Place ice directly on the burn areas. # 5. Administer 6 mg of morphine I.V. # 6. Administer tetanus prophylaxis, as ordered. 2, 4 3, 5, 6 Immune and hematologic disorders 1. A nurse is assisting in planning care for a client with human immunodeficiency virus (HIV). Which statements by the nurse indicate an understanding of HIV transmission? Select all that apply. # 1. “I will wear a gown, mask, and gloves with all client contact.” # 2. “I don’t need to wear any personal protective equipment due to decreased risk of occupation- al exposure.” # 3. “I will wear a mask if the client has a cough caused by an upper respiratory infection.” # 4. “I will wear a mask, gown, and gloves when splashing of bodily fluids is likely.” # 5. “I will wash my hands after client care.” 4, 5 2. A client is having an anaphylactic reaction. The code team is present and the physician orders epi- nephrine 1:1000 aqueous solution 0.5 mg subcuta- neously stat. A nurse has a prefilled syringe of 1:1000 1 mg/ml epinephrine. The nurse will administer how many milliliters of epinephrine? 0.5 3. A client is admitted with an exacerbation of Crohn’s disease and has a history of lupus erythe- matosus. A maculopapular rash is present over the client’s nose and cheeks. The client denies that the rash itches or is painful. The nurse concludes which of the following? Select all that apply. # 1. The client is overheated and the rash will disap- pear once it’s bathed in cool water. # 2. The rash is normal and doesn’t need to be ad- dressed. # 3. The physician must be notified of the rash im- mediately. # 4. The rash is a consequence of the corticosteroids (that must now be changed) originally ordered to treat Crohn’s disease. # 5. The rash is a result of poor hygiene and will re- solve with proper cleansing. # 6. Contact precautions will need to be ordered for this client’s care. 4. A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse expect in the teaching plan? Select all that apply. # 1. Stay out of direct sunlight. # 2. Refrain from limiting activity between flare-ups. # 3. Monitor body temperature. # 4. Taper the corticosteroid dosage as ordered by the physician, when symptoms are under con- trol. # 5. Apply cold packs to relieve joint pain and stiff- ness. 2 1, 3, 4 5. A nurse is preparing a client for bone marrow biopsy to rule out leukemia. The nurse explains that the sample will be taken from the anterior iliac crest. Identify this area. 6. A client with leukemia has enlarged lymph nodes, liver, and spleen. Identify the quadrant of the ab- domen where the nurse would find the enlarged spleen. Endocrine and metabolic disorders 1. A nurse is obtaining information on a newly ad- mitted client who has been diagnosed with diabetes insipidus. Which data should the nurse expect to col- lect? Select all that apply. # 1. Extreme polyuria # 2. Excessive thirst # 3. Elevated systolic blood pressure # 4. Low urine specific gravity # 5. Bradycardia # 6. Elevated serum potassium level 1, 2, 4 2. A client has vision problems, so his daughter draws up insulin for him on a weekly basis. The client uses U-100 insulin at 10 units/1 ml, 10 ml/vial. If the client’s morning dose of NPH insulin is 5 units, how many syringes can he use before he needs another vial of insulin? 20 3. A client is on NPH 12 units and Humalog 6 units each morning. Place the following actions in ascending chronological order of how a nurse would demon- strate how to mix insulins. Use all the options. 1. Withdraw 12 units of NPH insulin. 2. Inject 12 units of air into NPH vial. 3. Inject 6 units of air into Humalog vial. 4. Wipe off vials with alcohol swab. 5. Withdraw 6 units of Humalog insulin. 4. After falling off a ladder and suffering a brain in- jury, a client develops syndrome of inappropriate an- tidiuretic hormone (SIADH) secretion. Which of the following findings indicate the effectiveness of the treatment he’s receiving? Select all that apply. # 1. Decrease in body weight # 2. Rise in blood pressure and drop in heart rate # 3. Absence of wheezes in the lungs # 4. Increased urine output # 5. Decreased urine osmolarity 1, 4, 5 5. A 48-year-old female client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply. # 1. High-protein, high-calorie diet # 2. High-fiber, low-calorie diet # 3. Plan for a thyroidectomy # 4. Use of stool softeners # 5. Thyroid hormone replacements # 6. Review of the procedure for thyroid radiation therapy 2, 4, 5 6. A client who has been seen in the clinic is sched- uled for an outpatient thyroid scan in 2 weeks. Which instructions should the nurse expect in the client teaching points so that this client is prepared? Select all that apply. # 1. Stop using iodized salt or iodized salt substitutes 1 week before the scan. # 2. Stop eating seafood 1 week before the scan. # 3. Don’t consume any food or fluids after midnight on the night before the scan. # 4. Don’t take prescribed thyroid medication on the day of the scan. # 5. Don’t take prescribed thyroid medication until the results of the scan are known. # 6. Maintain bed rest for 24 hours after the scan. 1, 2, 4 7. A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which findings is the nurse most likely to observe in this client? Select all that apply. # 1. Excessive thirst # 2. Weight gain # 3. Constipation # 4. Excessive hunger # 5. Urine retention # 6. Frequent, high-volume urination 8. A client is being discharged after having a thy- roidectomy. Which discharge instructions are appropri- ate for this client? Select all that apply. # 1. Report any signs and symptoms of hypo- glycemia. # 2. Take thyroid replacement medication, as or- dered. # 3. Watch for lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician. # 4. Avoid over-the-counter medications. # 5. Carry injectable dexamethasone at all times. 1, 4, 6 2, 3 9. A client is seen in the clinic with suspected parathormone (PTH) deficiency. Part of the diagnosis of this condition includes the analysis of serum elec- trolyte levels. The levels of which electrolytes would the nurse expect to be abnormal in a client with PTH deficiency? Select all that apply. # 1. Sodium # 2. Potassium # 3. Calcium # 4. Chloride # 5. Glucose # 6. Phosphorus 3, 6 10. A client is placed on hypocalcemia precautions after removal of the parathyroid gland as a result of cancer. The nurse should observe the client for which symptoms? Select all that apply. # 1. Numbness # 2. Aphasia # 3. Tingling # 4. Muscle twitching and spasms # 5. Polyuria # 6. Polydipsia 1, 3, 4 11. A client is admitted to the hospital with Cush- ing’s syndrome. Which nursing interventions are ap- propriate for this client? Select all that apply. # 1. Assess for peripheral edema. # 2. Stress the need for a high-calorie, high- carbohydrate diet. # 3. Measure intake and output. # 4. Encourage oral fluid intake. # 5. Weigh the client daily. # 6. Instruct the client to avoid foods high in potassium. 1, 3, 5 12. A client with type 2 diabetes mellitus needs in- struction on proper foot care. Which instructions should the nurse expect to review in client teaching? Select all that apply. # 1. Be sure to use scissors to trim toenails. # 2. Wear cotton socks. # 3. Apply foot powder after bathing. # 4. Go barefoot only when you know your home environment. # 5. See a podiatrist regularly to have your feet checked. # 6. Wear loose-fitting shoes. 2, 3, 5 Musculoskeletal disorders 1. A client is diagnosed with osteoporosis. Which statements should a nurse include when teaching the client about the disease? Select all that apply. # 1. It’s common in females after menopause. # 2. It’s a degenerative disease characterized by a decrease in bone density. # 3. It’s a congenital disease caused by poor dietary intake of milk products. # 4. It can cause pain and injury. # 5. Passive range-of-motion (ROM) exercises can promote bone growth. # 6. Weight-bearing exercise should be avoided. 2. A client is preparing for discharge from the hospi- tal after undergoing an above-the-knee amputation. Which instructions should the nurse expect in the teaching plan for this client? Select all that apply. # 1. Massage the residual limb away from the suture line. # 2. Avoid using heat application to ease pain. # 3. Report twitching, spasms, or phantom limb pain immediately. # 4. Avoid exposing the skin around the residual limb to excessive perspiration. # 5. Be sure to perform the prescribed exercises. # 6. Rub the residual limb with a dry washcloth for 4 minutes three times per day if it is sensitive to touch. 1, 2, 4 4, 5, 6 3. A client is scheduled for a laminectomy of L1-L2. The nurse is reviewing the teaching about the proce- dure with the client. Identify the area that the nurse ex- plains will be involved in this client’s surgery. 4. A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid? Select all that apply. # 1. Green leafy vegetables # 2. Liver # 3. Cod # 4. Chocolate # 5. Sardines # 6. Whole milk 2, 3, 5 5. A client is about to undergo total hip replacement surgery. Before the surgery, the nurse reviews preoper- ative teaching with him. The nurse can tell that the teaching her been effective when the client verbalizes the importance of avoiding which actions? Select all that apply. # 1. Keeping the legs apart while lying in bed # 2. Periodically tightening the leg muscles # 3. Internally rotating the feet # 4. Bending to pick items up from the floor # 5. Sleeping in a side-lying position 3, 4 6. A client who was involved in a motor vehicle acci- dent has a fractured femur. The nurse caring for the client identifies Acute pain as one of the nursing diag- noses in his care plan. Which nursing interventions are appropriate? Select all that apply. # 1. Tell the client which pain management option to use. # 2. Encourage the client to use as little pain med- ication as possible to avoid addiction. # 3. Explain that pain management should leave the client pain-free. # 4. Avoid alternative and supplementary pain con- trol techniques. # 5. Assess the client’s perception of pain. # 6. Ask the client about methods he previously used to alleviate pain. 5, 6 7. A client fractured the neck of his femur in a fall. The nurse is using an illustration to explain to the fami- ly where the fracture occurred. Identify the area that the nurse would point out to the family as the site of the fracture. 8. A nurse is caring for a client with osteomyelitis. The nurse understands the intervention listed on the care plan based on knowledge of which facts about osteomyelitis? Select all that apply. # 1. Rapidly growing children are most at risk for the disease. # 2. Liver function enzymes and the erythrocyte sed- imentation rate are elevated. # 3. The disease process is limited to one specific area and doesn’t spread. # 4. Fever and tachycardia are symptoms of the dis- ease. # 5. Amputation and pathologic fractures may result from the disease process. # 6. The best treatment includes rapid return to usu- al activity with the affected area. 1, 4, 5 Neurosensory disorders 1. A client is admitted with a diagnosis of stroke. She has expressive aphasia. Identify the area where the client’s stroke has occurred. 2. A client is experiencing vision disturbances and is diagnosed with cataracts. Identify the area of the eye that’s diseased. 3. A nurse is caring for a client with a T5 complete spinal cord injury. The nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be ap- propriate for this client? Select all that apply. # 1. Elevate the head of the bed 90 degrees. # 2. Loosen constrictive clothing. # 3. Use a fan to reduce diaphoresis. # 4. Check for bladder distention and bowel impaction. # 5. Administer antihypertensive medication as ordered. # 6. Place the client in a supine position with legs elevated. 1, 2, 4, 5 4. A nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience? Select all that apply. # 1. Vision disturbances # 2. Coagulation abnormalities # 3. Balance problems # 4. Immunity compromise # 5. Mood disorders 1, 3, 5 5. A nurse examines a client’s level of responsive- ness. She finds that the client opens his eyes sponta- neously, obeys verbal commands, and is oriented to time, place, and person. What’s the client’s Glasgow Coma Scale score? 15 6. A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. # 1. Assist the client to the floor. # 2. Turn the client to his side. # 3. Place a pillow under the client’s head. # 4. Give the prescribed dose of oral phenytoin (Di- lantin). # 5. Insert an oral suction device to remove secre- tions in the mouth. 1, 2, 3 7. A nurse is preparing to discuss hearing pathways with a client with a new hearing loss. Place the steps in sound wave transmission that allow an individual to hear in ascending chronological order. Use all the op- tions. 1. Interpretation of sound by the cerebral cortex 2. Transmission of vibrations through the air and bone 3. Stimulation of nerve impulses in the inner ear 4. Transmission of vibrations to the auditory area of the cerebral cortex 8. A nurse is assigned to care for a client with early stage Alzheimer’s disease. Which nursing interventions should be included in the client’s care plan? Select all that apply. # 1. Make frequent changes in the client’s routine. # 2. Engage the client in complex discussions to im- prove memory. # 3. Furnish the client’s environment with familiar possessions. # 4. Assist the client with activities of daily living (ADLs) as necessary. # 5. Assign tasks in simple steps. 3, 4, 5 9. A client is admitted to the medical-surgical unit af- ter undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing inter- ventions are appropriate for the client’s postoperative care? Select all that apply. # 1. Place a pillow under the client’s head so that his neck is flexed. # 2. Turn the client on his right side. # 3. Place pillows under the client’s legs to promote hip flexion and venous return. # 4. Maintain the client in the supine position. # 5. Apply a soft collar to keep the client’s neck in a neutral position. 2, 5 10. A client is a quadriplegic secondary to a spinal cord injury from a motor vehicle accident. Identify the area of the spinal cord where the injury most likely occurred. 11. A nurse is reviewing teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he under- stands the instructions? Select all that apply. # 1. “I’ll eat food that is very hot.” # 2. “I’ll try to chew my food on the unaffected side.” # 3. “I can wash my face with cold water.” # 4. “Drinking fluids at room temperature should re- duce pain.” # 5. “If tooth brushing is too painful, I’ll try to rinse my mouth instead.” 2, 4, 5 12. A client is experiencing problems with balance and fine and gross motor function. Identify that area of the client’s brain that’s malfunctioning. Respiratory disorders 1. A nurse is caring for a client with pneumonia. The physician orders 600 mg of ceftriaxone (Rocephin) oral suspension to be given once per day. The med- ication label indicates that the strength is 125 mg/ 5 ml. How many milliliters of medication should the nurse pour to administer the correct dose? 24 2. A nurse is caring for a client who has a chest tube connected to a three-chamber drainage system with- out suction. Identify the chamber that collects drainage from the client. 3. A nurse is caring for a client with stage III emphy- sema. She know that which information about this dis- order is correct? Select all that apply. # 1. Accessory muscle use is often required. # 2. Continuous high-dose oxygen therapy is required. # 3. Bronchodilators and corticosteroids are a main- stay of treatment. # 4. Auscultation reveals normal to decreased breath sounds with wheezes. # 5. Overdistention and overinflation of the lungs are pathophysiologic findings. # 6. Influenza vaccination annually and pneumococ- cal vaccination every 5 years is recommended. 1, 3, 5, 6 4. A nurse is reviewing a staff education module about pulmonary circulation. Trace the path of pul- monary circulation. 5. A nurse observes a pregnant visitor choke on a piece of hot dog in the cafeteria. Place the following steps for removal of a foreign airway obstruction in a pregnant or obese client in ascending chronological or- der. Use all the options. 1. Grab fist with other hand and perform backwards thrusts. 2. Place thumb side of one fist on middle of the client’s breastbone. 3. Encircle the client’s chest with both hands under her armpits. 4. Ask the client if she’s choking and needs assistance. 5. Repeat until foreign body is expelled or the client be- comes unresponsive 6. A nurse is caring for a client who’s scheduled for a bronchoscopy. Which interventions should the nurse expect to perform to prepare the client for this proce- dure? Select all that apply. # 1. Explain the procedure. # 2. Withhold food and fluids for 2 hours before the test. # 3. Provide a clear liquid diet for 6 to 12 hours be- fore the test. # 4. Confirm that a signed informed consent form has been obtained. # 5. Ask the client to remove his dentures. # 6. Administer atropine and a sedative. 1, 4, 5, 6 7. A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. # 1. Keep the client flat for at least 2 hours. # 2. Provide sips of water to moisten the mouth. # 3. Withhold food and fluids until the gag reflex re- turns. # 4. Assess for hemoptysis and frank bleeding. # 5. Resume food and fluids when the client’s voice returns. # 6. Monitor the client’s vital signs. 3, 4, 6 8. A nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms when assessing the client? Select all that apply. # 1. Dry cough # 2. Fever # 3. Bradycardia # 4. Pericardial friction rub # 5. Use of accessory muscles during respiration # 6. Crackles or rhonchi 2, 5, 6 9. A client is admitted with chronic obstructive pul- monary disease (COPD). Which signs and symptoms are characteristic of COPD? Select all that apply. # 1. Decreased respiratory rate # 2. Dyspnea on exertion # 3. Barrel chest # 4. Shortened expiratory phase # 5. Clubbed fingers and toes # 6. Fever 2, 3, 5 10. A client is prescribed continuous positive airway pressure (CPAP) therapy for sleep apnea. The nurse instructs the client about the mechanism designed to maintain positive end-expiratory pressure. Identify the area where this mechanism is located. 11. A nurse is about to perform nasopharyngeal suctioning on a client who recently had a stroke. Iden- tify the area where the tip of the suction catheter should be placed. 12. The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when provid- ing care for this client? Select all that apply. # 1. Wear gloves when handling tissues containing sputum. # 2. Wear a face mask at all times. # 3. When the client leaves the room for tests, have all people in contact with him wear a mask. # 4. Keep the client’s door open to allow fresh air into the room and prevent social isolation. # 5. Wash hands after direct contact with the client or contaminated articles. 1, 2, 5 Genitourinary disorders 1. A nurse is checking a client who has a urinary tract infection (UTI). Which statements should the nurse ex- pect the client to make? Select all that apply. # 1. “I urinate large amounts.” # 2. “I need to urinate frequently.” # 3. “It burns when I urinate.” # 4. “My urine smells sweet.” # 5. “I need to urinate urgently.” 2, 3, 5 2. A nurse is reviewing the procedure for how to col- lect a 24-hour urine specimen for creatinine clearance with the client. Which directions should the nurse give the client? Select all that apply. # 1. “Save the first voiding and record the time.” # 2. “Discard the first voiding and record the time.” # 3. “Clean the perineal area before each voiding.” # 4. “Refrigerate the urine sample or keep it on ice.” # 5. “At the end of 24 hours, void and save the urine.” # 6. “At the end of 24 hours, void and discard the urine.” 2, 4, 5 3. A nurse is caring for a client with chronic renal fail- ure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When checking the client, the nurse should be alert for which signs and symptoms? Select all that apply. # 1. Trousseau’s sign # 2. Cardiac arrhythmias # 3. Constipation # 4. Decreased clotting time # 5. Drowsiness and lethargy # 6. Fractures 1, 2, 6 4. A client is diagnosed with renal calculi and com- plains of severe left flank pain. Scans indicate the cal- culi are lodged in the left renal pelvis. Identify the structure where the renal calculi are located. GEN ITOU R I NARY DI S O R DER S 73 5. A nurse is caring for a client with a cystostomy for urine drainage. Identify the area where the nurse should check for cystostomy placement. 6. A nurse is completing an intake and output record for a client who is receiving continuous bladder irriga- tion after transurethral resection of the prostate. How many milliliters of urine should the nurse record as output for her shift if the client received 1,800 ml of normal saline irrigating solution and the output in the urine drainage bag is 2,400 ml? 600 P A R T T H R E E Maternal-infant nursing 75 Antepartum period 1. A client comes to the office for her first prenatal visit. She reports that October 5 was the first day of her last menstrual period. Which statements represent findings in the first trimester of pregnancy? Select all that apply. # 1. Slow fetal cell differentiation is occurring. # 2. The client’s estimated date of delivery is June 12. # 3. The client may expect to have some nausea and increased urinary frequency. # 4. The client will notice decreased vaginal secretions. # 5. The client’s breasts may become swollen and tender. # 6. Chadwick’s sign will be positive at 9 weeks. 2. A nurse is assisting with a prenatal assessment on a client who is 32 weeks pregnant. She performs Leopold’s maneuvers and determines that the fetus is in the cephalic position. Identify the area where the nurse should place the Doppler to auscultate fetal heart tones. 3, 5, 6 3. A client comes to the office for her first prenatal visit. She asks the nurse what physiological changes she can expect during pregnancy. The nurse knows that changes can be in three categories: presumptive, probable, and positive. The nurse prepares to start the discussion with the probable changes of pregnancy. Put the following probable changes in ascending chronological order. Use all the options. 1. The vagina changes color from pink to violet (Chad- wick’s sign); cervix softens (Goodell’s sign). 2. Serum laboratory tests are positive for human chorionic gonadotropin. 3. Braxton Hicks contractions and fetal outline can be pal- pated through the abdomen. 4. Fetus can be felt to rise against the abdominal wall when lower uterine segment is tapped during a biman- ual examination (Ballottement). 4. Which nutritional instructions should the nurse re- view with a 32-year-old primigravida? Select all that apply. # 1. Caloric intake should be increased by 300 cal/day. # 2. Protein intake should be increased to more than 30 g/day. # 3. Vitamin intake should not increase from prepregnancy requirements. # 4. Folic acid intake should be increased to 400 mg/day. # 5. Intake of all minerals, especially iron, should be increased. 1, 2, 5 5. During a prenatal screening of a client with dia- betes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply. # 1. Still birth # 2. Rh incompatibility # 3. Gestational hypertension # 4. Placenta previa # 5. Spontaneous abortion 1, 3, 5 6. A 30-year-old client comes to the office for a rou- tine prenatal visit. After reading the laboratory test re- sults below, the nurse should prepare the client for which study? # 1. Triple screen # 2. Indirect Coombs’ test # 3. 1-hour glucose tolerance test # 4. Amniocentesis 3 7. Which signs are considered presumptive signs of pregnancy? Select all that apply. # 1. Goodell’s sign # 2. Uterine enlargement # 3. Ballottement # 4. Nausea and vomiting # 5. Quickening # 6. Linea nigra 4, 5, 6 8. A nurse is assisting in teaching a 16-year-old preg- nant client during a home care visit. The client has complained of fatigue and dyspnea on exertion, and has a low serum iron level. Which information should the nurse expect to be included in the teaching care plan of this client? Select all that apply. # 1. Eat red meat, green vegetables, eggs, iron- fortified breads, whole grains, and milk. # 2. Take the iron supplement with milk or an antacid to prevent GI upset. # 3. Stop taking the iron supplement if constipation occurs. # 4. If gastric irritation occurs, take the iron supple- ment on an empty stomach. # 5. Take the iron supplement with foods containing vitamin C such as orange juice, to enhance ab- sorption. # 6. Explain that pregnancy increases the body’s need for iron. 1, 5, 6 9. A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply. # 1. Milk and ice chips # 2. Decaffeinated coffee and scrambled eggs # 3. Tea and gelatin # 4. Ginger ale and apple juice # 5. Cranberry juice and chicken broth # 6. Oatmeal and egg substitutes 3, 4, 5 10. A nurse is palpating the uterus of a client who’s 20 weeks pregnant in order to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus. 11. A nurse is taking a course on the anatomy and physiology of reproduction. In the illustration of the fe- male reproductive organs, identify the area where fer- tilization occurs. 12. A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the pro- cedure? Select all that apply. # 1. Ask the client to void. # 2. Instruct the client to drink 1 L of fluid. # 3. Ask the client to lie on her left side. # 4. Determine fetal heart rate. # 5. Insert an I.V. catheter. # 6. Monitor maternal vital signs. 1, 4, 6 13. In early pregnancy, some clients complain of ab- dominal pain or pulling. Identify the area most com- monly associated with this pain. Intrapartum period 1. A nurse is assisting in monitoring a client who’s re- ceiving oxytocin (Pitocin) to induce labor. The nurse should be alert to which maternal adverse reactions? Select all that apply. # 1. Hypertension # 2. Jaundice # 3. Dehydration # 4. Fluid overload # 5. Uterine tetany # 6. Bradycardia 1, 4, 5 2. A client is being admitted to the labor and delivery unit. She’s GTPAL 5-2-1-1-2. Which statements are true about this client? Select all that apply. # 1. The client has had 4 previous pregnancies. # 2. The client has had 5 previous pregnancies. # 3. The client has had 1 full-term child, 1 abortion, and 1 premature child. # 4. The client has had 2 full-term children, 1 pre- mature child, and 1 abortion. # 5. The client has 3 living children and is pregnant again. # 6. The client has 2 living children and is pregnant again. 1, 4, 6 3. A nurse is assisting in the evaluation of a client who’s 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply. # 1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry # 2. Acidic pH of fluid when tested with nitrazine paper # 3. Presence of amniotic fluid in the vagina # 4. Cervical dilation of 6 cm # 5. Alkaline pH of fluid when tested with nitrazine paper # 6. Contractions occurring every 5 minutes 1, 3, 5 4. A nurse is caring for a client who has been diag- nosed with abruptio placentae. What signs and symp- toms of abruptio placentae should the nurse expect to find when she’s collecting data on this client? Select all that apply. # 1. Vaginal bleeding # 2. Decreased fundal height # 3. Uterine tenderness on palpation # 4. Soft abdomen on palpation # 5. Hypotonic, small uterus # 6. Abnormal fetal heart tones 1, 3, 6 5. A client who’s 29 weeks pregnant comes to the labor and delivery unit. She states that she’s having contractions every 8 minutes. The client is also 3 cm dilated. Which treatments can the nurse expect to ad- minister? Select all that apply. # 1. Folic acid (Folvite) # 2. Terbutaline (Brethine) # 3. Betamethasone # 4. Rho (D) immune globulin (Rhogam) # 5. I.V. fluids # 6. Meperidine (Demerol) 2, 3, 5 6. A nurse is assigned to assist with the admission of a client who’s in labor. Which actions are appropriate? Select all that apply. # 1. Asking about the estimated date of delivery (EDD) # 2. Estimating fetal size # 3. Taking maternal and fetal vital signs # 4. Asking about the woman’s last menses # 5. Administering an analgesic # 6. Asking about the amount of time between con- tractions 1, 3, 6 7. A nurse is assisting in the delivery room. The physician prepares to perform an episiotomy. To do this procedure the physician makes an incision in which part of the client’s external genitalia area? 8. A nurse is assisting in caring for a client who has just given birth to a neonate through vaginal delivery. The nurse is monitoring for signs of placental separa- tion. Which signs indicate that the placenta has sepa- rated? Select all that apply. # 1. Shortening of the umbilical cord # 2. Sudden, sharp abdominal pain # 3. Sudden gush of vaginal blood # 4. Change in shape of the uterus # 5. Lengthening of the umbilical cord 3, 4, 5 9. A client in labor is 8 cm dilated and 75% effaced. The fetus, which is in vertex presentation, is at 0 sta- tion. In the illustration below, identify the level of the fetus’s head. 10. While waiting to receive report at shift change, a nurse reads the chart entry below just written by the previous nurse. After reading this note, the nurse knows her client is in which stage of labor? 7/3/06 0135 Client experienced spontaneous rupture of membranes. Fluid is odorless and clear. Contrac- tions are 50 seconds long and occur every 4 minutes. See flow sheet for details. Client is 4 cm dilated. —— ——————————————————————A. Wilkens, LPN # 1. Stage 1, latent phase # 2. Stage 2 # 3. Stage 1, active phase # 4. Stage 1, transition phase 3 Postpartum period 1. On examining a client who gave birth 3 hours ago, a nurse finds that the client has completely satu- rated a perineal pad within 15 minutes. Which actions should the nurse take? Select all that apply. # 1. Begin an I.V. infusion of lactated Ringer’s solu- tion. # 2. Assess the client’s vital signs. # 3. Palpate the client’s fundus. # 4. Place the client in high Fowler’s position. # 5. Administer a pain medication. 2, 3 2. A nurse observes several interactions between a mother and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. # 1. Talks and coos to her son # 2. Cuddles her son close to her # 3. Doesn’t make eye contact with her son # 4. Requests the nurse to take the baby to the nursery for feedings # 5. Encourages the father to hold the baby # 6. Takes a nap when the baby is sleeping 1, 2 3. A mother with a history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data would lead to this nursing judgment? Select all that apply. # 1. Sudden dyspnea # 2. Chills, fever # 3. Diaphoresis # 4. Hypertension # 5. Confusion 1, 3, 5 4. On a client’s second postpartum visit, the physi- cian reviews the chart below regarding the client’s lochia. What’s the best term for the lochia described? # 1. Alba # 2. Thrombic # 3. Serosa # 4. Rubra 4 5. A nurse is caring for a 1-day postpartum mother. Reading the progress note below (from the previous shift), the nurse notes that the mother is in which phase of the postpartum period? Mother verbalizing labor and delivery experience. Does not appear confident in holding baby or with diaper changes. Asking questions appropriately. ———————— —————————————————————J. Conners, LP # 1. Letting-go # 2. Taking-in # 3. Holding-out # 4. Taking-hold 2 6. A client has received treatment for a warm, red- dened, painful area in the breast as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding. Which interventions should the nurse expect to see on the care plan to prevent a recurrence of the problem? Select all that apply. # 1. Wash the nipples with soap and water. # 2. Change the breast pads frequently. # 3. Expose the nipples to air for part of each day. # 4. Wash hands before handling the breast and breast-feeding. # 5. Make sure that the baby grasps the nipple only. # 6. Release the baby’s grasp on the nipple before removing the baby from the breast. 2, 3, 4, 6 7. A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which state- ments accurately characterize this disorder? Select all that apply. # 1. Symptoms start 2 days after delivery. # 2. The disorder is common in postpartum women. # 3. Symptoms include delusions and hallucinations. # 4. Suicide and infanticide are uncommon in this disorder. # 5. The disorder rarely occurs without psychiatric history. 3, 5 8. A nurse is palpating the uterine fundus of a client who delivered 8 hours ago. Identify the area of the abdomen where the nurse would expect to feel the fundus. 9. A nurse is assisting in developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain relat- ed to perineal sutures? Select all that apply. # 1. Apply an ice pack intermittently to the perineal area for 3 days. # 2. Avoid the use of topical pain gels. # 3. Administer sitz baths three to four times per day. # 4. Encourage the client to do Kegel exercises. # 5. Limit the number of times the perineal pad is changed. 3, 4 The neonate 1. A nurse is administering vitamin K to a neonate after delivery. The medication is supplied in a concen- tration of 2 mg/ml and the ordered dose is 0.5 mg subcutaneously. How many milliliters should the nurse administer? 0.25 2. A 14-day-old neonate is admitted for aspiration pneumonia. The results of a barium swallow confirm a diagnosis of gastroesophageal reflux with resulting as- piration pneumonia. Identify the area of the stomach that’s weakened, contributing to the reflux. 3. In the nursery, a nurse is performing a neurologic examination on a 1-day-old neonate. Which findings would indicate possible asphyxia in utero? Select all that apply. # 1. The neonate grasps the nurse’s finger when she puts it in the palm of his hand. # 2. The neonate does stepping movements when held upright with his sole touching a surface. # 3. The neonate’s toes don’t curl downward when his soles are stroked. # 4. The neonate doesn’t respond when the nurse claps her hands above him. # 5. The neonate turns toward an object when the nurse touches his cheek with it. # 6. The neonate displays weak, ineffective sucking. 3, 4, 6 4. Which instructions should the nurse expect will be provided on discharge from the facility to the par- ents of a neonate who has been circumcised? Select all that apply. # 1. The infant must void before being discharged home. # 2. Apply petroleum jelly to the glans of the penis with each diaper change. # 3. Tub baths for the infant are acceptable while the circumcision heals. # 4. Report any blood on the front of the diaper. # 5. The circumcision requires care for 2 to 4 days after discharge. 1, 2, 5 5. A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area the nurse would touch to elicit a plantar grasp reflex. 6. A nurse is demonstrating cord care to a mother of a neonate. Which actions should the nurse review with the mother? Select all that apply. # 1. Explain that the diaper is kept below the cord. # 2. Tug gently on the cord to remove it as it begins to dry. # 3. Apply antibiotic ointment to the cord twice daily. # 4. Only sponge-bathe the infant until the cord falls off. # 5. Clean the length of the cord with alcohol sever- al times daily. # 6. Wash the cord with mild soap and water. 1, 4, 5 7. A nurse notes that at 5 minutes after birth, a neonate is pink with acrocyanosis, has his knees flexed and fists clenched, has a whimpering cry, has a heart rate of 128 beats/minute, and withdraws his foot to a slap on the sole. What 5-minute Apgar score should the nurse record for this neonate? 8 Sign Apgar Score 8. A nurse is providing care to a neonate. List the steps in ascending chronological order to show how opthalmia neonatorum prophylaxis would be per- formed. Use all the options. 1. Close and manipulate the eyelids to spread the medica- tion over the eye. 2. Shield the neonate’s eyes from direct light and tilt his head slightly to the side that will receive the treatment. 3. Repeat the procedure for the other eye. 4. Wash your hands and put on gloves. 5. Apply the ointment into the lower conjunctival sac. 6. Gently raise the neonate’s upper eyelid with your index finger and pull the lower eyelid down with your thumb. P A R T F O U R Pediatric nursing 97 The infant 1. A physician orders digoxin 0.1 mg orally every morning for a 6-month-old infant with heart failure. Digoxin is available in a 400 mcg/ml concentration. How many milliliters of digoxin should the nurse give? 0.25 2. A nurse is checking an infant on a routine visit. The infant coos and babbles after feeding in response to the mother and nurse talking to him, but doesn’t smack his lips or make “raspberries.” How old is the infant? # 1. 0 to 2 months # 2. 3 to 4 months # 3. 5 to 6 months # 4. 7 to 9 months # 5. 10 to 12 months 2 3. A nurse has received report on her clients and no- tices that they are of varying ages. In order to prepare for the shift, the nurse reviews Erikson’s five stages of psychosocial development. Place the stages listed be- low in ascending chronological order starting with in- fancy, according to Erikson’s definitions of infancy, tod- dlerhood, preschool age, school age, and adolescence. Use all the options. 1. Initiative versus guilt 2. Trust versus mistrust 3. Industry versus inferiority 4. Identity versus role confusion 5. Autonomy versus shame and doubt 4. A nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to determine in a 1-month-old infant? Select all that apply. # 1. Bulging fontanels # 2. Decreased blood pressure # 3. Increased pulse # 4. High-pitched cry # 5. Headache # 6. Irritability 1, 4, 6 5. A nurse is checking a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply. # 1. Holding head erect # 2. Self-feeding # 3. Demonstrating good bowel and bladder control # 4. Sitting on a firm surface without support # 5. Bearing majority of weight on legs # 6. Walking alone 1, 4, 5 6. An 11-month-old is diagnosed with an ear infec- tion—his second one. The mother asks why children experience more ear infections than adults. The nurse shows the mother a diagram of the ear and explains the differences in anatomy. Identify the portion of the infant’s ear that allows fluid to stagnate and act as a medium for bacteria. 7. A nurse is preparing to administer chlorampheni- col (Chloromycetin Otic) to a 2-year-old with an infec- tion of the external auditory canal. The order reads, “2 gtts A.D. t.i.d.” Which steps should the nurse take to administer this medication? Select all that apply. # 1. Wash her hands and arrange supplies at the bedside. # 2. Warm the medication to body temperature. # 3. Lie the child on his right side with his left ear facing up. # 4. Examine the ear canal for drainage. # 5. Gently pull the pinna up and back and instill the drops into the external ear canal. 1, 2, 4 8. A nurse is teaching cardiopulmonary resuscitation (CPR) to the parents of a 1-month-old being dis- charged with an apnea monitor. Which steps are ap- propriate for performing CPR on an infant? Select all that apply. # 1. Open the airway by hyperextending the head. # 2. Pinch the nose before delivering a breath. # 3. Check for a pulse by palpating the brachial artery. # 4. Place the heel of one hand on the lower third of the sternum to perform compressions. # 5. Compress the sternum 1⁄2” to 1”. # 6. Give five compressions to one breath. 3, 5, 6 9. A nurse is providing preoperative teaching to the parents of a 9-month-old infant who’s having surgery to repair a ventricular septal defect. Identify the area of the heart where the defect is located. 10. A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which instructions are appropriate? Select all that apply. # 1. Position the infant on his back after feedings. # 2. Soothe the child by humming and rocking. # 3. Immediately bring the infant to the emergency department. # 4. Burp the infant adequately after feedings. # 5. Provide small but frequent feedings to the infant. # 6. Offer a pacifier if it isn’t time for the infant to eat. 2, 4, 5, 6 11. A 6-month-old is found floating face down in a swimming pool. A neighbor, who’s a nurse, checks for the presence of respirations and a pulse. Identify the area that’s most appropriate to check for a pulse. 12. A nurse is reviewing the teaching plan with the parents of an infant undergoing repair for a cleft lip. Which instructions should the nurse give? Select all that apply. # 1. Offer a pacifier as needed. # 2. Lay the infant on his back or side to sleep. # 3. Sit the infant up for each feeding. # 4. Loosen the arm restraints every 4 hours. # 5. Clean the suture line after each feeding by dab- bing it with saline solution. # 6. Give the infant extra care and support. 2, 3, 5, 6 The toddler 1. A nurse is admitting a 14-month-old to the pedi- atric floor with diagnosis of croup. Which characteristics would the nurse expect the toddler to have if he’s de- veloping normally? Select all that apply. # 1. Strong hand grasp # 2. Tendency to hold one object while looking for another # 3. Recognition of familiar voices (smiles in recogni- tion) # 4. Presence of Moro reflex # 5. Weight that is triple the birth weight # 6. Closed anterior fontanelle 1, 2, 3, 5 2. A 13-month-old is admitted to the pediatric unit with a diagnosis of gastroenteritis. The toddler has ex- perienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal that he’s dehydrated. Which nursing interventions are correct to prevent further de- hydration? Select all that apply. # 1. Encourage the child to eat a balanced diet. # 2. Give clear liquids in small amounts. # 3. Give milk in small amounts. # 4. Encourage the child to eat nonsalty soups and broths. # 5. Monitor the I.V. solution per the physician’s order. # 6. Withhold all solid food and liquids until the symptoms pass. 2, 4, 5 3. An acutely ill, 20-month-old toddler is admitted to the hospital with sickle cell crisis. The child is crying, restless, and appears uncomfortable when touched. Vital signs show slightly elevated heart rate and blood pressure and a temperature of 102ºF (38.8ºC). Which nursing diagnoses would a nurse expect to see includ- ed in the care plan? Select all that apply. # 1. Ineffective airway clearance # 2. Acute pain # 3. Unbalanced nutrition # 4. Risk for infection # 5. Powerlessness # 6. Risk for impaired parent/child attachment 2, 4 4. A toddler is ordered 350 mg of amoxicillin (Aug- mentin) by mouth four times per day. The pharmacy sends a bottle of amoxicillin with a concentration of 250 mg/5 ml. How many milliliters should the nurse administer per dose? 7 TH E TODDLER 105 5. A 3-year-old is admitted to the pediatric unit with pneumonia. He has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the toddler hasn’t been eating or drinking much and has been very inactive. Which interventions to im- prove airway clearance should the nurse expect in the care plan? Select all that apply. # 1. Restrict fluid intake. # 2. Perform chest physiotherapy as ordered. # 3. Encourage coughing and deep breathing. # 4. Keep the head of the bed flat. # 5. Perform postural drainage. # 6. Maintain humidification with a cool mist humid- ifier. 2, 3, 5, 6 The preschooler 1. A nurse is observing the parents of a 4-year-old who has been admitted to the hospital. Which actions indicate that the parents understand how to best mini- mize anxiety during their child’s hospitalization? Select all that apply. # 1. The parents bring the child’s favorite toy to the hospital. # 2. The parents explain all procedures to the child in great detail. # 3. The parents remain at the child’s side during the hospitalization. # 4. The parents bring the child’s siblings for a brief visit. # 5. The parents leave the room when the child un- dergoes a painful procedure. # 6. The parents punish the child if the child isn’t co- operative. 1, 3, 4 2. A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. A bone marrow aspiration is ordered. Place the interventions below in ascending chronological or- der as to how the nurse should perform them, based on importance. Use all the options. 1. Give the child his own biopsy kit: a syringe without a needle, cotton balls, and adhesive bandages, and act out the procedure by using a doll or stuffed animal. 2. Reassure him that the pain will go away quickly. 3. Check the biopsy site for bleeding and inflammation and observe the child for signs and symptoms of hem- orrhage and infection. 4. Discuss the procedure with his parents and the plan for preparing the child. 5. Explain the kinds of pressure and discomfort he’ll feel during the procedure and that it’s OK to cry. 3. A preschooler is in danger of becoming dehydrat- ed as a result of vomiting and diarrhea. The nurse real- izes that dehydration can be prevented if intake is suf- ficient to produce a urine output of 3 ml/kg/hr. The preschooler weighs 44 lb. What is the minimum urine output in milliliters that should be achieved in an 8- hour shift in order to prevent dehydration? 480 4. A preschooler is being admitted to the hospital and isolation precautions need to be implemented. Based on the progress note below, which isolation precautions would be used for this client? 11/8/06 5-year-old with varicella admitted with high 1100 fever, dehydration, and pruritic rash on face and trunk with lesions in all stages. See graphic record for vital signs. I.V. started in Ø arm. Isolation precautions instituted. ———————————————— J. Trump, RN # 1. Standard precautions # 2. Airborne precautions # 3. Droplet precautions # 4. Contact precautions 2 5. A nurse is caring for a 4-year-old who’s in the ter- minal stages of cancer. Which statements are true? Se- lect all that apply. # 1. The parents may be at different stages in deal- ing with the child’s death. # 2. The child is thinking about the future and knows he may not be able to participate. # 3. The dying child may become clingy and act like a toddler. # 4. Whispering in the child’s room will help the child to cope. # 5. The death of a child may have long-term disrup- tive effects on the family. # 6. The child doesn’t fully understand the concept of death. 1, 3, 5, 6 6. A 5-year-old is brought to the emergency depart- ment after being given aspirin for many days for flulike symptoms; he’s diagnosed with Reye’s syndrome. The client has progressed to stage III of the syndrome. A nurse is preparing for the next stages of the syndrome and knows that the syndrome develops in five stages. Place the stages listed below in ascending chronologi- cal order. Use all the options. 1. Brief recovery period: child doesn’t seem ill 2. Coma 3. Viral infection 4. Deep coma, seizures, decreased tendon reflexes, and respiratory failure 5. Intractable vomiting; lethargy; rapidly changing mental status; increasing blood pressure, respiratory, and pulse rate; hyperactive reflexes 7. A school nurse is conducting registration for a first grader. Which immunizations should the school nurse verify the child has had on entering school? Select all that apply. # 1. Hepatitis B series # 2. Diphtheria-tetanus-pertussis series # 3. Haemophilus influenzae type b series # 4. Varicella zoster # 5. Pneumonia vaccine # 6. Oral polio series 1, 2, 3 8. A preschooler is diagnosed with a right Wilms’ tu- mor and the nurse is preparing teaching material for the family. On this drawing of the urinary system, which area would a nurse identify as that in which the tumor can be found? The school-age child 1. A nurse in a pediatrician’s office is determining the cognitive ability of a 7-year-old child who’s in first grade. Using a block test, the child demonstrates an understand- ing of conservation of mass. The nurse, who’s knowl- edgeable in Piaget’s theory of cognitive development, knows the child is in the concrete operational stage of Piaget’s stages. Place the stages listed below in ascending chronological order. Use all the options. 1. Concrete operational stage 2. Sensorimotor stage 3. Preoperational stage 4. Formal operational thought stage 2. An 11-year-old child is brought to the emergency department from a soccer game, complaining of diffi- culty breathing. The mother states that this has oc- curred a few times during recent soccer games, al- though not as severely as the current episode. The client has rapid, labored breathing with expiratory wheezes and a temperature of 98.8º F (37.1º C). A nurse assists with care based on a nursing diagnosis of which symptoms? Select all that apply. # 1. Activity intolerance related to exertional asthma # 2. Ineffective breathing pattern related to pneu- monia # 3. Risk for infection related to possible tuberculo- sis (TB) # 4. Impaired gas exchange related to pulmonary embolus # 5. Ineffective airway clearance related to croup 1 3. An 11-year-old boy is brought to a rural clinic list- less and pale. The parents state that the child had a “bad sore throat” 2 weeks ago and that they had him gargle with salt water. The parents report that they saw improvement but now the child has flulike symptoms. The child is diagnosed with rheumatic fever. Which signs and symptoms are associated with rheumatic fever? Select all that apply. # 1. Nausea and vomiting # 2. Polyarthritis # 3. Chorea # 4. High-grade fever # 5. Carditis # 6. Rash 2, 3, 5, 6 4. A 9-year-old boy with diabetes tests his glucose level before lunch in the nurse’s office. According to his sliding scale of insulin, he’s due for 1 unit of regu- lar insulin. What steps should a nurse follow after con- firming the medication order, washing her hands, drawing up the appropriate dose, verifying the boy’s identity, and putting on gloves? Put the following steps in ascending chronological order. Use all the options. 1. Pinch the skin around the injection site. 2. Release the skin and give the injection. 3. Clean the injection site with alcohol and loosen the needle cover. 4. Select an appropriate injection site, being sure to dis- cuss with the client so the sites are rotated. 5. Cover the site with an alcohol pad. Press but don’t rub the site. 6. Uncover the needle; insert it at a 45- to 90-degree angle. 5. When talking with 10- and 11-year-old children about death, the nurse should incorporate which guidelines? Select all that apply. # 1. Logical explanations aren’t appropriate. # 2. The children will be curious about the physical aspects of death. # 3. The children will know that death is inevitable and irreversible. # 4. The children will be influenced by the attitudes of the adults in their lives. 2, 3, 4 6. A 7-year-old client is admitted to the hospital for treatment of facial cellulitis. He’s admitted for observa- tion and for administration of a 10-day course of I.V. antibiotics. Which interventions would help this client cope with the insertion of a peripheral I.V. line? Select all that apply. # 1. Explain the procedure to the child immediately before the procedure. # 2. Apply a topical anesthetic to the I.V. site before the procedure. # 3. Ask the child which hand he uses for drawing. # 4. Explain the procedure to the child using abstract terms. # 5. Don’t let the child see the equipment to be used in the procedure. # 6. Tell the child that the procedure won’t hurt. 7. When teaching bicycle safety to children and par- ents, a nurse should stress protecting which part of the body? 2, 3 8. A 6-year-old girl is brought to the pediatrician’s of- fice by her mother for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A diag- nosis of a urinary tract infection (UTI) is made and the child is prescribed antibiotics. Which interventions are appropriate? Select all that apply. # 1. Limit fluids for the next few days to decrease the frequency of urination. # 2. Assess the mother’s understanding of UTIs and its causes. # 3. Instruct the mother to administer the antibiotic as prescribed — even if the symptoms diminish. # 4. Provide instructions only to the mother, not the child. # 5. Discourage the use of bubble bath. # 6. Tell the mother to have the child wipe from the back to the front after voiding and defecation. 2, 3, 5 The adolescent 1. Which symptoms reported by an adolescent’s par- ents indicate that the adolescent is abusing ampheta- mines? Select all that apply. # 1. Restlessness # 2. Fatigue # 3. Talkativeness # 4. Excessive perspiration # 5. Watery eyes # 6. Excessive nasal drainage 1, 3, 4 2. A group of 16-year-olds are eating at a restaurant. One adolescent starts to cough then can’t get a breath. He puts his hands around his neck to gesture that he can’t breathe. A friend stands and positions himself to begin the Heimlich maneuver. Identify the area where it’s most appropriate to place the hands when performing the Heimlich maneuver. 3. A 15-year-old boy is admitted to the telemetry unit because of a suspected cardiac arrhythmia. The nurse applies five electrodes to his chest and attaches the leadwires. Identify the area where she would place the chest lead (V1). 4. A 14-year-old diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply. # 1. Chocolates and sweets # 2. Increased hormone levels # 3. Growth of anaerobic bacteria # 4. Caffeine # 5. Heredity # 6. Fatty foods 2, 3, 5 5. A 16-year-old with diabetes is ordered to receive 15 units of NPH insulin and 5 units of regular insulin. Both are dispensed from the pharmacy in 100 units/ ml vials. How many total ml should the nurse admin- ister? 0.2 6. A 13-year-old with cystic fibrosis is admitted to the hospital with a pulmonary infection. A physician orders 2 mg/kg of an oral solution of prednisone daily to be divided into 4 doses. The oral solution has 5 mg/ml and the child weighs 99 lb. How many ml should the nurse administer for one dose? 22.5 7. A nurse is reviewing teaching points with an ado- lescent with inflammatory bowel disease. The topic is the use of corticosteroids. Which adverse effects are concerns for this client? Select all that apply. # 1. Acne # 2. Hirsutism # 3. Mood swings # 4. Osteoporosis # 5. Growth spurts # 6. Adrenal suppression 1, 2, 3, 4, 6 P A R T F I V E Psychiatric and mental health nursing 119 Foundations of psychiatric nursing 1. Knowledge of Maslow’s hierarchy of needs can assist a nurse in understanding client behavior. Place the stages of Maslow’s hierarchy of needs in order from basic to most complex. Use all the options. 1. Safety and security 2. Self-esteem 3. Physiologic needs 4. Love and belonging 5. Self-actualization 2. Electroconvulsive therapy (ECT) is an effective treatment for severe depression when which condi- tions accompany it? Select all that apply. # 1. The client also has dementia. # 2. The client can’t tolerate tricyclic antidepressants. # 3. The client lives in a long-term care facility. # 4. The client is undergoing a stressful life change. # 5. The client is having acute suicidal thoughts. # 6. The client is severely depressed despite taking numerous antidepressants. 2, 5, 6 3. Characteristics of a therapeutic relationship are exemplified by meeting which goals? Select all that apply. # 1. The needs of the client and nurse are identified and met. # 2. The nurse helps the client explore different problem-solving techniques. # 3. The nurse encourages the practice of new cop- ing skills. # 4. The nurse gives advice to the client. # 5. The nurse and client exchange personal infor- mation. # 6. The nurse discusses the client’s feelings with family members. 2, 3 4. A nurse understands that the first step in caring for a client with a mental health illness is to establish a therapeutic relationship to achieve effective communi- cation. Place the phases of a therapeutic relationship in ascending chronological order. Use all the options. 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase FOU N DATION S OF P S Y C H I AT R IC N U R SI NG 121 5. A nurse is explaining the Bill of Rights for psychi- atric clients to a client who has voluntarily sought ad- mission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply. # 1. Right to select health care team members # 2. Right to refuse treatment # 3. Right to a written treatment plan # 4. Right to obtain disability # 5. Right to confidentiality # 6. Right to personal mail 2, 3, 5, 6 6. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, “How long do I have to stay here?” Select all that apply. # 1. “You may leave the hospital at any time unless you are suicidal, homicidal, or unable to meet basic needs.” # 2. “Let’s talk more after the health team has as- sessed you.” # 3. “Once you’ve signed the papers, you have no say.” # 4. “Because you could hurt yourself, you must be safe before being discharged.” # 5. “You need a lawyer to help you make that deci- sion.” # 6. “There must be a court hearing before you leave the hospital.” 1, 2, 4 7. A nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply. # 1. The client addresses how the addiction has con- tributed to family distress. # 2. The client reluctantly shares the family history of addiction. # 3. The client verbalizes difficulty identifying person- al strengths. # 4. The client discusses the financial problems relat- ed to the addiction. # 5. The client expresses uncertainty about meeting with the nurse. # 6. The client acknowledges the addiction’s effects on the children. 1, 3, 6 Anxiety disorders 1. After receiving a referral from the occupational health nurse, a client comes to the mental health clinic with a suspected diagnosis of obsessive-compulsive disorder. The client explains that his compulsion to wash his hands is interfering with his job. Which inter- ventions are appropriate when caring for a client with this disorder? Select all that apply. # 1. Don’t allow the client time to carry out the ritual- istic behavior. # 2. Support the use of appropriate defense mecha- nisms. # 3. Encourage the client to suppress his anxious feelings. # 4. Explore the patterns leading to the compulsive behavior. # 5. Listen attentively, but don’t offer feedback. # 6. Encourage activities such as listening to music. 2, 4, 6 2. After being examined by the forensic nurse in the emergency department, a rape victim is prepared for discharge. Due to the nature of the attack, this client is at risk for posttraumatic stress disorder (PTSD). Which symptoms are associated with PTSD? Select all that apply. # 1. Recurrent, intrusive recollections or nightmares # 2. Gingival and dental problems # 3. Sleep disturbances # 4. Flight of ideas # 5. Unusual talkativeness # 6. Difficulty concentrating 1, 3, 6 3. A physician prescribes clomipramine (Anafranil) for a client diagnosed with obsessive-compulsive disorder. What instructions should the nurse include when teaching the client about this medication? Select all that apply. # 1. Avoid hazardous activities that require alertness or good coordination until adverse central ner- vous system (CNS) effects are known. # 2. Avoid alcohol and other depressants. # 3. Use saliva substitutes or sugarless candy or gum to relieve dry mouth. # 4. Take the drug on an empty stomach. # 5. Avoid using over-the-counter (OTC) products, except antihistamines and decongestants, with- out medical permission. # 6. Discontinue the medication if adverse reactions are troublesome. 1, 2, 3 4. A registered nurse caring for a client with general- ized anxiety disorder identifies a nursing diagnosis of Anxiety. The short-term goal identified is: “The client will identify his physical, emotional, and behavioral re- sponses to anxiety.” Which nursing interventions will help the client achieve this goal? Select all that apply. # 1. Avoid talking about the client’s sources of stress. # 2. Advise the client that consuming one glass of red wine per day may lessen his anxiety. # 3. Explain to the client that expressing his feelings through journal writing may increase his anxiety. # 4. Observe the client for overt signs of anxiety. # 5. Help the client connect anxiety with uncom- fortable physical, emotional, or behavioral responses. # 6. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise. 4, 5, 6 5. A nurse is reviewing information with a client on physical signs and symptoms that may be experienced during a panic attack. Which signs and symptoms should the nurse include? Select all that apply. # 1. Bradycardia # 2. Shortness of breath # 3. Delayed speech # 4. Dizziness # 5. Sweating # 6. GI distress 2, 4, 5, 6 6. A client with a panic disorder is prescribed a monoamine oxidase inhibitor. While reviewing dis- charge teaching, which dietary restrictions related to this medication would the nurse discuss with the client? Select all that apply. # 1. Caffeine # 2. Asparagus # 3. Sour cream # 4. Bananas # 5. Chocolate # 6. Liver 1, 3, 4, 5, 6 Mood, adjustment, and dementia disorders 1. A nurse is caring for a client who talks freely about feeling depressed. During an interaction, the nurse hears the client state, “Things will never change.” What other indications of hopelessness would the nurse look for? Select all that apply. # 1. Bouts of anger # 2. Periods of irritability # 3. Preoccupation with delusions # 4. Feelings of worthlessness # 5. Intense interpersonal relationships 1, 2, 4 2. A nurse interviews the family of a client who’s hospitalized with severe depression and suicidal ideation. Which family assessment information is es- sential to formulating an effective care plan? Select all that apply. # 1. Physical pain # 2. Personal responsibilities # 3. Employment skills # 4. Communication patterns # 5. Role expectations # 6. Current family stressors 4, 5, 6 3. A client is prescribed sertraline (Zoloft), a selective serotonin reuptake inhibitor. Which information about this drug’s adverse effects would the nurse expect when reviewing a medication teaching plan? Select all that apply. # 1. Agitation # 2. Agranulocytosis # 3. Sleep disturbance # 4. Intermittent tachycardia # 5. Dry mouth # 6. Seizures 1, 3, 5 MOOD, AD J U S T M ENT, AN D DEM ENTIA DI S O R DER S 127 4. A nurse is observing a client to determine whether he’s suffering from dementia or depression. Which in- formation helps the nurse to differentiate between the two? Select all that apply. # 1. The progression of symptoms is slow. # 2. The client answers questions with, “I don’t know.” # 3. The client acts apathetic and pessimistic. # 4. The family can’t identify when the symptoms first appeared. # 5. The client’s basic personality has changed. # 6. The client has great difficulty paying attention to others. 1, 4, 5, 6 5. A client has been diagnosed with an adjustment disorder of mixed anxiety and depression. Which nurs- ing diagnoses are associated with a client who has an adjustment disorder? Select all that apply. # 1. Activity intolerance # 2. Impaired social interaction # 3. Self-esteem disturbance # 4. Personal identity disturbance # 5. Acute confusion # 6. Impaired memory 2, 3 6. A physician prescribes lithium for a client diag- nosed with bipolar disorder. The nurse needs to pro- vide appropriate education for the client on this drug. Which topics should the nurse cover? Select all that apply. # 1. The potential for addiction # 2. Signs and symptoms of drug toxicity # 3. The potential for tardive dyskinesia # 4. A low-tyramine diet # 5. The need to consistently monitor blood levels # 6. Changes in his mood that may take 7 to 21 days 2, 5, 6 Psychotic disorders 1. A nurse is monitoring a client who appears to be hallucinating. Paranoid content is noted in the client’s speech and agitated behavior. The client is gesturing at a figure on the television. Which nursing interventions are appropriate? Select all that apply. # 1. In a firm voice, instruct the client to stop the behavior. # 2. Reinforce that the client is not in any danger. # 3. Acknowledge the presence of the hallucinations. # 4. Instruct other team members to ignore the client’s behavior. # 5. Immediately implement physical restraint procedures. # 6. Use a calm voice and simple commands. 2, 3, 6 2. A client with schizophrenia is taking the atypical antipsychotic medication clozapine (Clozaril). Which signs and symptoms indicate the presence of adverse effects associated with this medication? Select all that apply. # 1. Sore throat # 2. Pill-rolling movements # 3. Polyuria # 4. Fever # 5. Polydipsia # 6. Orthostatic hypotension 1, 4 3. A delusional client approaches a nurse, stating, “I am the Easter bunny,” and insisting that the nurse re- fer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply. # 1. Consistently use the client’s name in interaction. # 2. Smile at the humor of the situation. # 3. Agree that the client is the Easter bunny. # 4. Logically point out why the client could not be the Easter bunny. # 5. Provide an as-needed medication. # 6. Provide the client with structured activities. 1, 6 4. A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse ef- fects. Which measures should the nurse take during Haldol administration? Select all that apply. # 1. Review subcutaneous injection technique. # 2. Closely monitor vital signs, especially temp- erature. # 3. Observe for increased pacing and restlessness. # 4. Monitor blood glucose levels. # 5. Provide the client with hard candy. # 6. Monitor for signs and symptoms of urticaria. 2, 3, 5 5. A nurse is aware that a client with schizophrenia often progresses through three distinct phases. Place the three phases in ascending chronological order. 1. Active phase 2. Prodromal phase 3. Residual phase 6. While providing a community class on schizophre- nia, a nurse reviews factors that increase the client’s chances for a positive prognosis. Select all that apply. # 1. Male gender # 2. Early onset (in the teen years) # 3. Sudden disease onset # 4. Minimal cognitive impairment # 5. Paranoid schizophrenia subtype # 6. Good pre-illness functioning 3, 4, 5, 6 7. A nurse is working with a client with schizophrenia who’s experiencing auditory hallucinations. Place the interventions in the order that will decrease the client’s anxiety. Use all the options. 1. The nurse asks, “What are you experiencing right now?” 2. The nurse encourages the client to tell her when he be- gan hearing voices. 3. The nurse asks the client for permission to discuss the hallucinations. 4. The nurse asks the client if he has taken drugs or alco- hol recently. Substance abuse, eating disorders, and impulse control disorders 1. A nurse is assessing a client who has been diag- nosed with bulimia nervosa. The nurse is aware that this disorder is characterized by eating binges accom- panied by which symptoms? Select all that apply. # 1. Guilt # 2. Dental caries # 3. Self-induced vomiting # 4. Weight loss # 5. Normal weight # 6. Introverted behavior 1, 2, 3, 5 2. While checking a client upon arrival to the emer- gency department, a nurse is concerned that the client may be under the influence of amphetamines. Which symptoms may indicate the influence of ampheta- mines? Select all that apply. # 1. Depressed affect # 2. Diaphoresis # 3. Shallow respirations # 4. Hypotension # 5. Tremors # 6. Dilated pupils 2, 3, 5, 6 3. A client admitted for the second time this winter with pneumonia has stated, ”I’m really ready to kick this habit of smoking but I don’t know where to begin.” A nurse explains that there are several options to assist a client in smoking cessation. Select all that apply. # 1. Use of nicotine replacement (nicotine gum, transdermal patches, nasal sprays and inhalers) # 2. Use of clonidine or diazepam (Valium) to mimic the effects of nicotine # 3. Use of alcohol to blunt the effect caused by withdrawal from nicotine # 4. Behavioral therapies and treatments # 5. Acupuncture # 6. Identifying coping skills and then seeking expo- sure to a smoking environment to test these skills 1, 2, 4, 5 4. Which interventions would be supportive for a client with a nursing diagnosis of Imbalanced nutrition: Consuming less than the body requires due to dys- functional eating patterns? Select all that apply. # 1. Provide small, frequent feedings. # 2. Monitor weight fluctuations. # 3. Allow the client to skip meals until the anti- depressant levels are therapeutic. # 4. Encourage journaling to promote the expression of feelings. # 5. Monitor the client at mealtimes and for an hour after meals. # 6. Encourage the client to eat three substantial meals per day. 1, 2, 4, 5 5. While collecting data on a client who was diag- nosed with impulse control disorder (and who dis- plays violent, aggressive, and assaultive behavior), the nurse can expect to find which data? Select all that apply. # 1. The client functions well in other areas of his life. # 2. The degree of aggressiveness is out of propor- tion to the stressor. # 3. The client often uses a stressor to justify the vio- lent behavior. # 4. The client has a history of parental alcoholism and a chaotic, abusive family life. # 5. The client shows no remorse about his inability to control his behavior. [Show More]

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