NURS 999_100 item comprehensive exam 2 updated - Community College of Baltimore County | NURS999_100 item comprehensive exam 2 updated (answers-and-rationale)

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NURS 999 100 item comprehensive exam 2 updated - Community College of Baltimore County 1. In a child with suspected coarctation of the aorta, the nurse would expect to find


2. The nurse is ... caring for a child receiving chest physiotherapy (CPT). Which of the following actions by 


3. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for


4. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?


5. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the

6. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be


7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates


8. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?


9. Post-procedure nursing interventions for electroconvulsive therapy include


10. The nurse is talking to parents about nutrition in school aged children. Which of the following is the 



11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?

12. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?


13. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?


14. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should


15. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?


16. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?


17. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is


18. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? 

19. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?


20. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?



21. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?


22. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?


23. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent?


24. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?



25. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?



26. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to


27. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?


28. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client??"


29. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?


30. Which type of accidental poisoning would the nurse expect to occur in children under age 6?


31. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?


32. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?


33. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?


34. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?



35. A nurse is caring for a client with multiple myeloma. Which of the following should be included in the plan of care?


36. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
 37. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?


38. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?


39. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?


40. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? 

41. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?



42. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child?

43. During the evaluation phase for a client, the nurse should focus on


44. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
 
45. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?


46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates


47. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?


48. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to



49. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and


50. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?


51. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?


52. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?



53. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?


54. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? 

55. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?


56. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with


57. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet


58. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?


59. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

60. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client 

61. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

62. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?



63. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of


64. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

65. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?

66. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?


67. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?


68. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?

69. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

70. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?

71. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should

72. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by

73. The nurse, assisting in applying a cast to a client with a broken arm, knows that

74. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to


75. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

76. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?

77. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?


78. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

79. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?



80. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is


81. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:


82. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

83. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have

84. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily

85. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?


86. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?

87. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?


88. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?


89. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?

90. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

91. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

92. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

93. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?

94. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is

95. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?


96. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

97. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating

98. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to

99. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?

100. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
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