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Q&ARandom -10
Question Number 1 of 40
The nurse understands that during the "tension building" phase of a
violent relationship, when the batterer makes unreasonable demands,
the battered victim may experience feelings of
A) Anger
B) Helplessness
C) Calm
D) Explosive
Question Number 2 of 40
The nurse is performing an assessment on a client with pneumococcal
pneumonia. Which finding would the nurse anticipate?
Question Number 3 of 40
When counseling parents of a child who has recently been diagnosed
with hemophilia, what must the nurse know about the offspring of a
normal father and a carrier mother?
Question Number 4 of 40
A 7 year-old child is hospitalized following a major burn to the lower
extremities. A diet high in protein and carbohydrates is recommended.
The nurse informs the child and family that the most important reason
for this diet is to
Because of the burn injury, the child has increased metabolism and
catabolism. By providing a high carbohydrate diet, the breakdown of
protein for energy is avoided. Proteins are then used to restore tissue
Question Number 5 of 40
A school nurse is advising a class of unwed pregnant high school
students. What is the most important action they can perform to
deliver a healthy child?
Question Number 6 of 40
A parent has numerous questions regarding normal growth and
development of a 10 month-old infant. Which of the following
parameters is of most concern to the nurse?
Question Number 7 of 40
A client with HIV infection has a secondary herpes simplex type 1
(HSV-1) infection. The nurse knows that the most likely cause of the
HSV-1 infection in this client is
A) Immunosuppression
B) Emotional stress
C) Unprotected sexual activities
D) Contact with saliva
Question Number 8 of 40
The charge nurse on the eating disorder unit instructs a new staff
member to weigh each client in his or her hospital gown only. What is
the rationale for this nursing intervention?
To reduce the risk of the client feeling cold due to decreased fat
A)
and subcutaneous tissue
To cover the bony prominence and areas where there is skin
B)
breakdown
C) So the client knows what type of clothing to wear when weighed
To reduce the tendency of the client to hide objects under his or
D)
her clothing
The client may conceal weights on their body to increase weight gain.
Question Number 9 of 40
The nurse is caring for a post-op colostomy client. The client begins to
cry saying, "I'll never be attractive again with this ugly red thing."
What should be the first action by the nurse?
One of the greatest fears of colostomy clients is the fear that sexual
intimacy is no longer possible. However, the specific concern of the
client needs to be assessed before specific suggestions for dealing with
the sexual concerns are given.
Question Number 10 of 40
In providing care to a 14 year-old adolescent with scoliosis, which of
the following will be most difficult for this client?
".
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support
Your response was "A".
The correct answer is B: Looking different from their peers
Question Number 11 of 40
A client complaining of severe shortness of breath is diagnosed with
congestive heart failure. The nurse observes a falling pulse oximetry.
The client's color changes to gray and she expectorates large amounts
of pink frothy sputum. The first action of the nurse would be which of
the following?
When dealing with a medical emergency, the rule is airway first, then
breathing, and then circulation. Starting oxygen is a priority.
Question Number 12 of 40
Which of the following nursing assessments indicate immediate
discontinuance of an antipsychotic medication?
Question Number 13 of 40
A 3 year-old child is treated in the emergency department after
ingestion of 1ounce of a liquid narcotic. What action should the nurse
do first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids
Question Number 14 of 40
The nurse has been assigned to these clients in the emergency room.
Which client would the nurse go check first?
Question Number 15 of 40
The parents of a 7 year-old tell the nurse their child has started to
"tattle" on siblings. In interpreting this new behavior, how should the
nurse explain the child's actions to the parents?
A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia
Question Number 17 of 40
A 2 year-old child has recently been diagnosed with cystic fibrosis. The
nurse is teaching the parents about home care for the child. Which of
the following information is appropriate for the nurse to include?
".
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house
The correct answer is A: Allow the child to continue their normal
activities
Question Number 18 of 40
A schizophrenic client talks animatedly but the staff are unable to
understand what the client is communicating. The client is observed
mumbling to herself and speaking to the radio. A desirable outcome
for this client’s care will be
Question Number 19 of 40
The nurse is caring for a client with benign prostatic hypertrophy.
Which of the following assessments would the nurse anticipate finding?
Question Number 19 of 40
The nurse is caring for a client with benign prostatic hypertrophy.
Which of the following assessments would the nurse anticipate finding?
Question Number 20 of 40
Which of these principles should the nurse apply when performing a
nutritional assessment on a 2 year-old client?
Question Number 21 of 40
The nurses on a unit are planning for stoma care for clients who have
a stoma for fecal diversion. Which stomal diversion poses the highest
risk for skin breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy
The correct answer is A: Ileostomy
Question Number 22 of 40
During seizure activity which observation is the priority to enhance
further direction of treatment?
Question Number 23 of 40
The nurse is teaching a client who has a hip prostheses following total
hip replacement. Which of the following should be included in the
instructions for home care?
The correct answer is D: Do not cross legs Hip flexion should not
exceed 60 degrees
Question Number 24 of 40
The nurse is assessing a client with delayed wound healing. Which of
the following risk factors is most important in this situation?
Question Number 25 of 40
The nurse is assessing a 4 year-old for possible developmental
dysplasia of the right hip. Which finding would the nurse expect?
Question Number 26 of 40
A client continually repeats phrases that others have just said. The
nurse recognizes this behavior as
A) Autistic
B) Ecopraxic
C) Echolalic
D) Catatonic
Question Number 27 of 40
In teaching parents to associate prevention with the lifestyle of their
child with sickle cell disease, the nurse should emphasize that a
priority for their child is to
Question Number 28 of 40
Which of the following statements describes what the nurse must know
in order to provide anticipatory guidance to parents of a toddler about
readiness for toilet training?
Question Number 29 of 40
An anxious parent of a 4 year-old consults the nurse for guidance in
how to answer the child's question, "Where do babies come from?"
What is the nurse's best response to the parent?
Question Number 30 of 40
At a routine clinic visit, parents express concern that their 4 year-old is
wetting the bed several times a month. What is the nurse's best
response?
Nighttime control should be present by this age, but may not occur
until age 5. Involuntary voiding may occur due to infectious,
anatomical and/or physiological reasons.
Question Number 31 of 40
The nurse is caring for a 7 year-old child who is being discharged
following a tonsillectomy. Which of the following instructions is
appropriate for the nurse to teach the parents?
Question Number 32 of 40
The nurse is caring for a 14 month-old just diagnosed with Cystic
Fibrosis. The parents state this is the first child in either family with
this disease, and ask about the risk to future children. What is the best
response by the nurse?
".
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease
The correct answer is B: 1 in 4 risk for each child to have the disease
Question Number 33 of 40
The nurse is caring for a client with a sigmoid colostomy who requests
assistance in removing the flatus from a 1 piece drainable ostomy
pouch. Which is the correct intervention?
Piercing the plastic of the ostomy pouch with a pin to vent the
A)
flatus
Opening the bottom of the pouch, allowing the flatus to be
B)
expelled
Pulling the adhesive seal around the ostomy pouch to allow the
C)
flatus to escape
Assisting the client to ambulate to reduce the flatus in the
D)
pouch
The only correct way to vent the flatus from a 1 piece drainable
ostomy pouch is to instruct the client to obtain privacy (the release of
the flatus will cause odor), and to open the bottom of the pouch,
release the flatus and dose the bottom of the pouch.
Question Number 34 of 40
A client is unconscious following a tonic-clonic seizure. What should
the nurse do first?
Question Number 35 of 40
The nurse is preparing to perform a physical examination on an 8
month-old who is sitting contentedly on his mother's lap. Which of the
following should the nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears
Question Number 36 of 40
The nurse measures the head and chest circumferences of a 20
month-old infant. After comparing the measurements, the nurse finds
that they are approximately the same. What action should the nurse
take?
Question Number 37 of 40
The nurse is teaching parents of an infant about introduction of solid
food to their baby. What is the first food they can add to the diet?
A) Vegetables
B) Cereal
C) Fruit
D) Meats
Question Number 38 of 40
When teaching a client with chronic obstructive pulmonary disease
about oxygen by cannula, the nurse should also instruct the client's
family to
Question Number 39 of 40
A client was admitted to the psychiatric unit after refusing to get out of
bed. In the hospital the client talks to unseen people and voids on the
floor. The nurse could best handle the problem of voiding on the floor
by
Question Number 40 of 40
A nurse who travels with an agency is uncertain about what tasks can
be performed when working in a different state. It would be best for
the nurse to check which resource?
The correct answer is A: The state nurse practice act in which the
assignment is made
The state nurse practice act is the governing document of what can be
done in the assigned state.