PRACTICE TEST 8

NAME: Score:____/100 Percentage:____%

1.Which of the following observations would be most 4. Which of the following pieces of equipment should a
significant when assessing the parents of a child who is nurse have available when caring for a patient who has
suspected of being physically abused? bleeding esophageal varices?

A. The parents appear distraught and upset when asked A. Chest tube
about the injuries B. Endotracheal tube
B. The parents give a history of the injuries that is not C. Salem sump tube
compatible of the actual injuries D. Sengstaken – Blakemore tube
C. The parents seem eager to take the child home as
soon as possible. Key: D Client Need: Physiological Integrity
D. The parents cannot recall when the last series of D. If bleeding is not controlled by other methods,
immunizations was given. balloon tamponade of varices may be
instituted. The esophagogastric tubes (Sengtaken-
Key: B Client Need: Psychosocial Integrity Blakemore or Minnesota) are three-lumen or four
B. Incompatibility between the history and the injury lumen tubes with two balloon attachments. One
is probably the most important lumen serves as a nasogastric suction tube; the
criterion on which to base the decision to report second is used to inflate the esophageal balloon.
suspected abuse. When the tube is in the stomach, the gastric balloon
A, C and D is inflated and the lumen clamped; the tube is then
All of these actions by the parents are appropriate pulled slowly so that the balloon is held tightly against
and do not necessarily indicate child the cardioesophageal junction. A football helmet-
abuse. shaped devices is used to keep traction on the tube,
which keeps it in the proper position. If bleeding
2.A nurse witness a two – years – old child experiencing a continues after the gastric balloon is inflated, the
generalized seizure while being evaluated in the emergency esophageal balloon is inflated to the desired amount
department for a high fever. Which of the following actions of pressure, as determined by the physician, and then
would a nurse take first? clamped. To stop the bleeding, the pressure must be
greater than the individual’s portal pressure.
A. Protect the child from physical in fury A. Chest tubes allow air and fluid to drain from the
B. Administer an antipyretic medication rectally pleural space. They also prevent air or fluid from
C. Apply cool compresses to the axilla and groin entering the pleural space. Chest tubes are not
D. Reassure the parents that this is a common required for treatment of bleeding esophageal
occurrence varices.
B. Endotraceal tubes are artificial airways necessary
Key: A Client Need: Physiological Integrity when normal airway patency and protection cannot
A. It is impossible to halt a seizure once it has begun be maintained. These tubes are placed in the nose or
and no attempt should be made to do mouth and passed to just above the tracheal carina.
so. The nurse must remain calm, stay with the child Unless airway patency is an issue, an endotracheal
and prevent the child from tube is not needed to treat bleeding esophageal
sustaining any harm during the seizure. varices.
B. Attempts to lower the child’s temperature will not C. The Salem sump is a double lumen tube used for
prevent or stop the seizure Sponging gastric decompression and can be used as a route for
is indicated for elevated temperatures from gastric suctioning and sampling. Since the
hyperthermia rather than fever. Ice water Sengstaken- Blakemore and Minnesota tubes provide
and alcohol are inappropriate, potentially dangerous for suction, the Salem sump is not required.
solutions. Sponging or tepid baths
are ineffective in treating febrile children, either when 5.A nurse is assessing patient for discharge to a residential
used alone or in combination treatment center. To which of the following factors should a
with antipyretics and cause considerable discomfort. nurse give highest priority?
D. Parents need to be educated about febrile seizures
but this is not an initial priority A. Family history of mental illness
during a seizure. B. Developmental history
C. Individual strengths
3.The nurse should teach a patient who has cirrhosis of the D. Social support systems
liver to avoid which of the following foods in the diet?
Key: C Client Need: Psychosocial Integrity
A. Baked chicken C. The individual’s strengths are those effective
B. Apple pie coping mechanisms on which the
C. Spinach individual can draw when encountering difficulty. The
D. enhance mental acuity patient needs a repertoire of
effective coping mechanisms in order to function
Key: A Client Need: Physiological Integrity more independently in the residential
A. The diet for cirrhosis includes restricting protein to treatment center.
approximately 35 to 50 grams per A. Although family history of mental illness may
day. Carbohydrate intake should be 300 to 400 grams influence the style of coping a patient
per day. Baked chicken = 27 grams uses, assessment of present coping abilities and
of protein. strengths is essential to determining the
B. Apple pie = 3 grams of protein patient’s readness for discharge.
C. Macaroni = 5 grams of protein B. Developmental history may influence the type of
D. Spinach = 5 grams of protein program in which the patient is
placed. Individual strengths are not necessarily
dependent upon one’s developmental
 history. B. When preparing the preschool child for a
D. The patient’s social support system is important to procedure, it is important to allow choices
success in the residential treatment when possible and encourage parental presence.
program. However, a patient’s strengths determine Other strategies for diverting attention
how that patient uses and maintains the so that the child will be less focused on the procedure
support system. include having the child tightly
squeeze the hands of a parent or an assistant, count
6.When the nurse is assessing a patient who has cirrhosis of aloud, sing a familiar song such as
the liver, which of the following findings would indicate that a nursery rhyme or verbally express discomfort.
the patient‘s condition is worsening?
10.Immediately after a femoral artery cardiac catheterization
A. Positive Babinski sign of a nine year old child, all of the following orders are written.
B. Visual field loss Which one should a nurse question?
C. Flapping hand tremors
D Bibasilar lung crackles A. Maintain pressure dressing for 24 hours
B. Assess brachial pulses q 1hr x 4
Key: C Client Need: Physiological Integrity C. Maintain recumbent position for eight hours
C. Clinical manifestations of impending hepatic coma D. Assess color of lower extremities q 1hr x 4
include disorientation and asterixis
or flapping hand tremors. Key: B Client Need: Safe Effective Care Environment
A, B and D B. Pulses distal to the catheterization site should be
These options are not identified as impending signs of checked for equality and symmetry.
hepatic coma, encephalopathy, The nurse should question checking of the brachial
ascites or esophageal varices. pulse.
A. The child will have a pressure dressing over the
7.A patient who is human immunodeficiency virus (HIV) catheterization site.
positive has a CD – 4 counts of 200. To which of the following C. Depending upon the hospital policy, the child may
measures should patient’s plan of care? be kept in bed with the affected extremity in a
straight position for four to six hours after venous
A. Implement reverse isolation catheterization and six to eight hours after arterial
B. Limit the number of venipunctures catheterization to facilitate healing of the cannulated
C. Institute regular position changes vessel.
D. Monitor intake and output D. The nurse should assess the temperature and color
of the affected extremity
Key: A Client Need: Safe Effective Care Environment
A. As immune system depletion progresses, CD- 4 11.A 36 hour old newborn infant appears slightly jaundiced
counts decrease and patients are at and has a bilirubin level of 10 mg/ dL. A nurse would give the
higher risk for opportunistic infectious, cancers and parent which of the following instructions?

B, C and D A. “Feed the baby at least every three hours”

Limiting the number of venipuntures, instituting B. “Give the baby formula instead of breastfeeding for
regular position changes and monitoring 48 hours”
intake and output are important in the treatment plan C. “Check the baby’s temperature every four hours”
of the patient with a decreased D. “Exposure the baby’s skin to direct sunlight daily for
CD- 4 count, but protection from infection would be one hour”
the priority.
Key: A Client Need: Health Promotion and Maintenance
8.When assessing the psychiatric patient, a nurse should A. The newborn should be fed eight or more
recognize which of the following strengthens as essential to times per day. The mother is encouraged to feed her
successful living? infant around the clock. Early, frequent nursing will
enhance meconium excratin and decrease bilibrubin
A. Knowledge about medications levels. Nurseries now initiate early first feeding.
B. Ability to work Feeding of the new born soon after birth stimulates
C. Ability to drive the gastrocolic reflex and the passage of meconium.
D. Social skills Because bilirubin is excreted in meconium, early
feeding may help to prevent jaundice.
Key: D Client Need: Psychosocial Integrity B. Breastfeeding and the need for cessation of
D. Social skills consist of simple interactions such as breastfeeding to decrease hyperbilirubenemia are not
introducing one’s self, starting and ending a well documented in the nursing research.
conversation and asking for help. The patient must be C. There is no need to check the temperature
able to effectively interact to get basic needs met. unless the infant is under photography
A, B and C D. Expose to direct sunlight is advice given to
The ability to work and to drive and knowledge about parent of an infant only slightly elevated bilirubin
medications may enhance the levels but its relative success in decreasing bilirubin
patient’s success in the community, but these skills levels is not known.
are not essential to successful
living. 12.Filgrastim (Neupogen) should be administered to a patient
who has aplastic anemia to
9.Which of the following statements is most appropriate for a
nurse to make when initiating a painful procedure on a four A. stimulate synthesis of erythropoietin
year old boy? B. elevate the white blood cell count
C. enhance maturation of red blood cells
A. “You are a bug boy. I know you can handle this” D. increase the production of platelets
B. “You can have your mom hold your hand”
C. “You are not a baby. I know you won’t cry” Key: B Client Need: Physiological Integrity
D. “You will get a treat if your are good” B. Filgrastim (Neupogen) stimulates proliferation and
differentiation of neutrophils. It is
Key: B Client Need: Health Promotion and Maintenance used to increase the white blood cell count in patients
with neutropenia.
 A. The drug does not stimulate the production of 16.A nurse caring for a patient who is being treated with
erythropoietin lithium carbonate (Eskalith) should be alert for which of the
C. Filgrastim has no action on red blood cell following signs and symptoms?
maturation
D. An adverse reaction of the drug is A. Fine motor tremors
thrombocytopenia, or a decrease in platelets. B. Vomiting and diarrhea
C. Still neck and shoulders
13.The nurse caring for a patient who is receiving furosemide D. Seeing halos around lights
(Lasix) should monitor the patient’s serum level of
Key: B Client Need: Physiological Integrity
A. Potassium B. Vomiting and diarrhea are early signs of lithium
B. glucose toxicity. Vomiting and diarrhea
C. protein deplete sodium. Since Lithium is similar in chemical
D. creatinine structure to sodium, as the
kidneys attempt to compensate for sodium loss by
Key: A Client Need: Physiological Integrity reabsorption of sodium, they also
A. Electrolyte imbalances may occur with the reabsorb lithium, increasing the risk of lithium toxicity.
administration of Lasix. Side effects of A, C and D
Lasix inlcude hypovolemia, dehydration, Fine motor tremors, stiff neck and shoulders and
hyponatremia, hypokalemia, hypochloremia, seeing halos around lights are not
metabolic alkalosis, hypomagnesemia and indicative of lithium toxicity.
ypocalcemia. Nursing measures include
monitoring the patient for hypkalemia. 17.When a newborns is nurse, “I’m, too depressed to talk to
B. While glucose may also be elevated with the you, leave hours old, the nurse is to give him his first bath.
administration of Lasix, potassium values The nurse should initially obtain which of the following
are more critical. Sudden death from cardiac arrest assessments?
has been reported with the
administration of Lasix A. Temperature
C and D B. Weight loss since birth
Protein and creatinine alterations are not identified as C. Size of posterior fontanel
adverse effects of Lasix therapy D. Passage of meconium

14.When preparing to discharge an infant who is born to a
known cocaine abuser, the nurse’s teaching plan would include
information about the infant’s
A. need to restrict fluids
B. tendency to sleep for long periods
C. potential for developing congestive heart failure
D. increased risk for sudden infant death syndrome
Key: D Client Need: Health Promotion and Maintenance
D. There may be an increased risk of sudden infant
death syndrome (SIDS) in infants
whose mothers abused cocaine while pregnant.
A. In light of diarrhea, fluids may need to be
increased to prevent dehydration and
electrolyte imbalances.
B. Infants born to cocaine abusing mother’s sleep for
short periods.
C. Infants born to cocaine- abusing mothers
often experience irritability, marked
nervousness, rapid changes in mood and
hypersensitivity to noise and external stimuli.
These neonates exhibits poor feeding, irregular sleep
patterns, tachypnea, trachycardia
and, often, diarrhea.
15.The nurse is receiving the American Dietetic Association
(ADA) diet with a 10 year old child who has diabetes mellitus.
The child’s selection of which of the following foods in
exchange for a serving of meat indicates that the child
correctly understands the instructions?
A. Cheese omelet
B. Bacon
C. Chocolate milk
D. Baked beans
Key: A Client Need: Physiological Integrity
A. The diabetic exchange list for meat includes the
choice of cheese and eggs.
B, C and D
Bacon, chocolate milk and baked beans are not
included under the meat exchange list as
equal substitutes.
Key: A Client Need: Health Promotion and Maintenance
A. The infant’s temperature must be stable prior to
bathing.
B. Infant’s typically lose 5 to 10 percent of their birth
weight prior to discharge. This
weight loss is within normal limits.
C. The posterior fontanel is triangular in shape (0.5 to
1.0 cm). The fontanel should not be
depressed or bulging but soft and flat. Its size does
not determine the timing of the first
birth.
D. Infants may not pass stool within the first 12 hours
of life but should pass meconium
within 24 hours. Passage of meconium does not
influence the timing of the first bath.
18.When caring a patient who is one hour postpartum, which
of the following assessments requires immediate intervention?
A. Uterine funds 2 cm below umbilicus
B. Lower abdominal cramping
C. Bright red vaginal bleeding
D. Temperature elevation of 100.6 OF (38.1 OC)
Key: C Client Need: Health Promotion and Maintenance
C. During the first three days after delivery, vaginal
discharge is usually bright red.
Abnormal bleeding from lacerations usually spurt,
instead of trickling. In the first hour
postpartum, the bleeding will be bright red or rubra.
The amount of bleeding is more
significant than the color at this time.
A. At the end of the third stage of labor the fundus is
approximately two centimeters
below the level of the umbilicus. Within 12 hours, the
fundus may be one centimeter
above the umbilicus.
B. The intensity of uterine contraction increases
immediately after birth.
D. During the first 24 hours after delivery the
woman’s temperature may rise to 100.4 OF
(38 OC) due to the dehydrating effects of labor.
19.A patient who is scheduled to begin peritoneal dialysis
treatments in the home asks a nurse what to expect. Which of
these responses by the nurse would be most accurate?
A. “Fluid will be instilled into your abdominal cavity on a
routine basis”
B. “You will need to be admitted to an acute care center
for this treatment”
C. “You will have a permanent vascular access site
created in your arm”
D. “You will be restricted to bed while this procedure is
being carried out”
Key: A Client Need: Physiological Integrity
A. Peritoneal dialysis involves repeated cycles
of instilling dialysate into the peritoneal cavity,
allowing time for substance exchange and then
removing the dialysate.
B. One of the primary advantages of peritoneal
dialysis is the relative ease of administration that
allows it to be used in community health centers
without elaborate and sophisticated equipment. It can
be easily managed and often provides the patient
with greater independence and mobility than
hemodialysis.
C. Different types of catheters are used in
peritoneal dialysis. The catheters are usually tunneled
under the skin and inserted into the peritoneum to
allow exchange of fluids. Permanent vascular access
is used in hemodialysis.
D. In continuous ambulatory peritoneal dialysis
the dialysate is instilled into the abdomen and left in
place for four to eight hours. The empty dialysis bag
is folded up and carried in a pouch or pocket until it is
time to drain the dialysate. The patient’s activities are
not restricted.
20.When teaching an obese patient about a diet for weight
reduction, which of the following instructions should the nurse
include?
A. “Divide your daily calories into six small meals”
B. “Decrease your daily intake to 700 calories”
C. “Select 90 percent of your daily calories”
D. “Consume half of your daily caloric allotment at
dinner”
Key: A Client Need: Physiological Integrity
A. Some nutritionists recommend eating several
small meals a day because the body’s metabolic rate
is temporarily increased immediately after eating.
When several small meals a day are ingested, more
calories are burned due to an increased metabolic
rate.
B. The caloric intake may need to be reduced
to 800-1200 calories daily, but the person will need
frequent professional monitoring. The nurse should
not instruct a patient to reduce his/her intake to this
level without medical supervision.
C. An obese person needs to follow a well-
balanced, low-caloric diet.
D. There is general agreement that consuming
most of the daily caloric intake at a large evening
meal results in less weight loss than when the calories
are more evenly distribute throughout the day.
21.When caring for an adolescent who is diagnosed with
idiopathic scoliosis, a nurse should recognize that the priority
concern for the adolescent is related to
A. body image
B. activity limitations
C. financial burden
D. imposed dependence
Key: D Client Need: Physiological Integrity
D. It is difficult for a child to be restricted at
any phase of development, but the teenager needs
continual positive reinforcement, encouragement, and
as much independence as can be safely assumed
during this time. Guidance and assistance regarding
participation in social activities are appreciated by
adolescent feel worthwhile.
A, B and D.
Body image, activity limitation and financial burdens
may be concerns of the adolescent with scoliosis, but
the need for independence takes priority at this stage
of development.
22.Which of the following statements, if made by a patient
who has hypertension, would indicate the need for further
teaching about antihypertensive medications?
A. “I should arise slowly from chair after taking my blood
pressure medicine”
B. “I will not need my blood pressure medicine when my
headaches go away”
C. “The water pills I take will make me go tot eh
bathroom often”
D. “My water pills are most effective when a take them
first thing in the morning”
Key: B Client Need: Physiological Integrity
B. It is important to help the patient understand that
hypertension is a chronic condition
that cannot be cured but can be controlled with drug
therapy, diet therapy, an exercise
program, periodic evaluation and other lifestyle
changes. The patient’s statement
indicates an need for further instruction.
A. The patient is aware that to decrease orthostatic
hypotension, he/she should arise slowly
from the bed and stand slowly.
C and D.
The patient is aware that since frequent urination can
interrupt sleep, diuretics work
best when taken early in the morning rather than at
night.
23.A patient who is admitted to the emergency department
reports visual hallucinations and appears disoriented. To
determine whether the patient is delirious or demented, a
nurse should assess for
A. memory impairment
B. level of consciousness
C. auditory hallucinations
D. cognitive functioning
Key: B Client Need: Physiological Integrity
B. Clouding of consciousness and fluctuating level of
awareness are symptoms seen in
delirium but not dementia.
A, B and D.
Memory impairment, auditory hallucinations and
cognitive disturbances are
manifestations of both dementia and delirium.
24.The nurse should instruct a patient who has a diagnosis of
folic acid deficiency anemia to increase intake of which of the
following foods?
A. Dairy products
B. Green, leafy vegetables
C. Citrus juices
D. Fish and poultry
Key: B Client Need: Physiological Integrity
B. Foods high in folic acid include green and yellow
vegetables, liver, citrus fruits,
whole grains yeast and legumes.
A, C and D.
Dairy products, citrus juices, and fish and poultry are
not high in folic acid.
25.A patient who has a pituitary adenoma is scheduled for a
transsphenoidal hypophysectomy. A nurse is teaching the
patient about what to expect in the immediate postoperative
period. Which of these statements by the nurse would be
accurate?
A. “You will have a pressure dressing on your head”
B. “You will have to lie flat in bed”
C. “You will be unable to suck through a straw”
D. “You will be unable to brush your teeth”
Key: D Client Need: Physiological Integrity
D. The patient has a suture line at the junction
of the gums and upper lip. Toothbrushes with bristles
may irritate the suture line and delay healing.
A. The patient has nasal packing and a gauze
dressing under the nose.
B. The head of the bed should be elevated 30
degrees at all times to reduce cerebral edema.
C. The patient should avoid sneezing, coughing,
bending, vigorous hair brushing, or any activity that
will increase intracranial pressure.
26.A patient who has a sustained a fracture of the femur is at
risk for which of the following complications in the immediate
post- fracture period?
A. Electrolyte imbalance
B. Fat embolus
C. Fluid volume deficit
D. Disuse syndrome
Key: B Client Need: Physiological Integrity
B. Complications of fractures include infection,
compartment syndrome, venous
thrombosis and fat embolism.
A and C.
Electrolyte imbalance and fluid volume deficit may
occur post-surgery but they are
not evident in the immediate post-fracture period.
D. Disuse syndrome may occur late into the post-
fracture period but is not seen
immediately.
27.A patient who has a long leg cast says to the nurse. “My
thigh is itching under the cast.” To provide relief, the nurse
should
A. teach the patient guided imagery techniques
B. apply heat to the cast at the site of the itching
C. elevate the patient’s affected leg on pillows
D. encourage the patient to move his/ her toes
Key: A Client Need: Physiological Integrity
A. Itching under the cast can be extremely
uncomfortable. The patient may be tempted to slip an
object under the cast to scratch. This is a dangerous
practice because of the possibility of breakage and/or
skin irritation. Guided imagery is a way to help
patients distract themselves from their pain and may
produce a relaxation response.
B. Heat increase itching due to vasodilatation.
C. Elevation prevents dependent edema.
D. Inability to move the toes indicates
compression. The cast may be too tight if the patient
is unable to move his/her toes.
28.A nurse is caring for a patient who is receiving lithium
carbonate (Eskalith). Prior to administration of the next dose,
the nurse finds that the patient’s lithium blood level is 1.6
mEq/ L. Which of the following actions should the nurse take
first?
A. Call the patient’s physician
B. Withhold the dose
C. Take the patient’s vital signs
D. Repeat the blood lithium level
Key: B Client Need: Safe Effective Care Environment
B. The first step a nurse should take when a
blood lithium level is 1.6 mEq/dL or above
is to withhold the lithium dose.
A. The physician should be called to re-evaluate
the dose after the nurse has the results of a redrawn
lithium level.
C. Vital signs may be helpful in assessing if the
patient is dehydrated, which can cause an increase in
lithium levels. However, this should not be the initial
action by the nurse.
D. The nurse should re-check the lithium level
after withholding the dose of lithium.
29.A nurse should recognize that a patient who has coronary
artery disease is receiving acetylsalicylic acid (Aspirin) to
A. relieve pain
B. reduce fever
C. diminish inflammation
D. decrease platelet adhesion
Key: D Client Need: Physiological Integrity
D. Aspirin prevents platelet aggregation. It is used to
prevent the recurrence of
transient ischemic attacks (TIAs) and myocardial
infarction (MI) and as
prophylaxis against myocardial infarction due to fibrin
platelet emboli.
A, B and C.
While Aspirin can be used to relieve pain, and reduce
fever and inflammation,
these are not desired outcomes for a patient with
coronary artery disease (CAD).
30.To which of the following nursing diagnoses should a nurse
give priority in the care of a patient who has sustained severe
burns?
A. Hyperthermia
B. Risk for infection
C. Body image disturbance
D. Impaired physical mobility
Key: B Client Need: Safe Effective Care Environment
B. All burn patients are considered at risk for an
often-fatal infection with Clostridium
tetani. A routine prophylactic procedure when a
patient is admitted to the hospital is the
administration of tetanus toxic intramuscularly. Burn
wound infection occurs through either auto-
contamination or cross-contamination. The high risk
for infection is related to loss of the barrier, an
impaired immune response, the presence of invasive
catheters and invasive procedures. Medical
management of the patient during the acute burn
phase focuses on infection control, wound care,
wound closure, nutritional support, pain management
and physical therapy.
A. Hypothermia is a problem for the burn
patient because skin assists in maintaining body
temperature.
C. Body image disturbance is an appropriate
nursing diagnosis but does not have higher priority
then risk for infection.
D. Impaired physical mobility is a nursing
diagnosis secondary to pain and immobility, but does
not have a higher priority than risk for infection.
31.A child has morphine sulfate (Roxanol) and acetaminophen
(Tylenol) ordered for postoperative pain. The parent asks the
nurse. “Why is my child getting two medications for pain at the
same time?” The nurse’s response would be based on the
understanding that
A. children are more sensitive to the effects of opiates
and non- opiates help to counteract this effect.
B. non- opiates stimulate the respiratory system thereby
minimizing the depressant effects of opiates
C. children often experience nausea form opiates, and
non- opiates reduce this effect.
D. non- opiates affect the peripheral nervous system,
and opiates affect the central nervous system
Key: D Client Need: Physiological Integrity
 D. Non-opioids, including acetaminophen, and non-
steroidal anti-inflammatory agents
are suitable for mild to moderate pain. Opiates are
required for moderate to severe
pain. A combination of the two analgesics attacks
pain on two levels: non-opioids at
the level of the peripheral nervous system and opiates
at the central nervous system.
This approach provides increased analgesia without
increase side effects.
A, B and C.
These options do not indicate the purpose for
administering a combination of opiates and non-
opiates to control pain.
32.Which of the following snacks is most appropriate for
meeting the nutritional needs of a patient with severe burns?
A. Vanilla milk shake
B. Carrot sticks
C. Apple slices
D. Flavored gelatin
Key: A Client Need: Physiological Integrity
A. The nurse should provide a high-
carbohydrate, high-protein diet to meet the increased
nutritional needs of the burn patient and to prevent
malnutrition. A milk shake contains 11 grams of
protein and 60 grams of carbohydrate.
B. Carrot sticks contain one gram of protein
and seven grams of carbohydrate.
C. Apple slices contain a trace of protein and 17
grams of carbohydrate.
D. Flavored gelatin contains four grams of
protein and 34 grams of carbohydrate.
33.A patient has severe burns involving the hands, chest and
head. Which of the following nursing actions will prevent
contractures in this patient?
A. Maintaining the patient in a semi- Flowler’s position
B. Applying splints to the patient’s hands and wrists.
C. Placing sandbags on either side of the patient’s chest
D. Placing two pillows under the patient’s head
Key: B Client Need: Physiological Integrity
B. Contractures and joint deformities are prevented
by exercise, positioning and splinting
throughout the healing process.
A and D.
Placing pillows under the head or maintaining semi-
Fowler’s position contributes to
flexion contractures.
C. Sandbags on either side of the chest will no
prevent contractures.
34.To which of the following nursing actions would a nurse
give priority in the emergency care of a patient who has
sustained a compound fracture of the femur?
A. Splint the leg in its present position
B. Place the leg in neutral alignment
C. Irrigate the wound with normal saline
D. Apply pressure directly over the wound
Key: A Client Need: Physiological Integrity
A. It is important to immobilize the body part before
the patient is moved. Adequate splinting is essential
to prevent damage to the soft tissue by the bony
fragments. No attempt is made to reduce an open
fracture, even if bone fragments are protruding
through the wound.
B and D.
The leg should be splinted in its present position
rather than in a neutral position.
Pressure should not be applied directly over the
wound.
C. In an open fracture the wound is covered with a
clean (sterile) dressing to prevent contamination of
deeper tissues.
35.A nurse is caring for a patient who has balanced skeletal
traction applied to the femur. Which of the following findings
requires immediate nursing intervention?
A. The foot of the bed is elevated 30 degrees
B. The traction weighs are resting on the bed frame.
C. The patient’s leg is suspended above the bed
D. The over bed trapeze is above the patient’s chest
Key: B Client Need: Physiological Integrity
B. When skeletal traction is being used, the
apparatus is checked to see that the weights hang
freely.
A. Balanced suspension provides counter
traction so that the pulling force of the traction is not
altered when the bed or patient is moved.
C. Alignment of the patient’s body in traction
must be maintained as prescribed to promote an
effective line of pull.
D. The covered trapeze should be above the
patient’s chest.
36.A child is being treated for acute lymphocytes leukemia and
has a plated count of 50,000 cells/cu mm. Which of the
following measures would a nurse include in the care plan?
A. No rectal temperatures
B. Respiratory isolation
C. Bland diet
D. Strict bedrest
Key: A Client Need: Physiological Integrity
A. Infection increases the tendency toward
hemorrhage, and since bleeding sites become more
easily infected, special care is taken to avoid
performing skin punctures whenever possible. When
finger sticks, venipunctures, intramuscular injections
and bone marrow tests are performed, aseptic
technique must be employed with continued
observation for bleeding. Since the rectal area is
prone to ulceration from various drugs, hygiene is
essential. To prevent additional trauma, rectal
temperatures and suppositories are avoided.
B. Respiratory isolation is not indicated for a
decreased platelet count.
C. Meticulous mouth care, rather than a bland
diet, is essential since gingival bleeding with resultant
mucositis is a frequent problem.
D. Most bleeding episodes can be controlled
with judicious administration of platelet concentrates
or platelet-rich plasma. Severe spontaneous internal
hemorrhage usually does not occur until the platelet
count is less than 20,000/mm.
37. A nurse observes a coworker being verbally abusive
to a demented patient. The nurse should report the incident to
the
A. patient’s family
B. physician
C. co-worker’s supervisor
D. state board of nursing
Key: C Client Need: Safe Effective Care Environment
C. The supervisor is the person next in the chain of
command. It is the supervisor’s
responsibility to call together the interdisciplinary
team to decide on the appropriate
intervention.
A and D.
The interdisciplinary team will decide, based on
policy, if and when it is appropriate
to notify the family and/or the state board of nursing.
B. The physician will be notified by the supervisor
since the physician is part of the
 interdisciplinary team. wide-brimmed hat and long sleeves when out-of-
doors.
38. A nurse makes all of the following observation when A, B and D.
assessing a patient who is in cervical traction with a halo Bleeding gums, seeing halos around lights and a
apparatus. Which finding would require immediate tingling sensation around the
intervention? mouth are not associated with administration of
Azulfidine.
A. The halo pins have
B. The halo pin insertion sites are crusted 42. A two year old child who has a 48 hour history of
C. The halo vest is snug-fitting loose stools is diagnosed with mild dehydration. As part of the
D. The straps of the halo vest are loose child’s treatment plan, which of the following oral re-hydration
solutions would a nurse recommend to the child’s parent?
Key: A Client Need: Safe Effective Care Environment
A. The nurse should check the pins and screws A. Uncarbonated cola
for loosening since the halo apparatus is to remain B. Apple juice
intact without movement. The nurse would notify the C. Rice- based oral solution
physician if there is any sign of loosening in the D. Mineral water
apparatus and keep a wrench at the bedside.
B. The halo pin insertion sites should be kept
clean and free from crusts. However, crusting would Key: C Client Need: Physiological Integrity
not require immediate intervention. C. Rice-based oral rehydration solution (ORS) has
C and D. been developed as an alternative
Halo traction is usually anchored to a body cast and to the standard glucose oral rehydration solution.
not contained within a vest. These nutrient-based solutions may
decrease diarrheal volume loss and shorten the
39. Which of the following instruction should a nurse give duration of the disease.
to a patient who has a prescription for cimcetidine (Tagamet) A, B and D.
to treat gastroesophageal reflux? Diarrhea is not managed by encouraging intake of
clear fluids such as fruit
A. “Take this medication on an empty stomach” juices, uncarbonated soft drinks and mineral water,
B. “You will have to take these pills for the rest of your since these fluids usually have a
life.” high carbohydrate content, a low electrolyte content
C. “Inform your health care providers before taking any and high osmolality.
other drugs.”
D. “this drug may cause ringing in your ears.” 43. Which of the following statements would a nurse
include in the preoperative instruction of a patient who is
Key: C Client Need: Physiological Integrity scheduled for n ileostomy?
C. To prevent drug interactions the patient
should be instructed to notify his/her physician prior A. “You will have one bowel movement per day”
to taking other medications. B. “The school drainage will be of liquid consistency”
A. Tagamet does not need to be taken on an C. “The pouch will be located on the left side of your
empty stomach. abdomen.”
B. Tagamet does not have to be taken for the D. “You will be taught how to irrigate your bowel
rest of the patient’s life. through the stoma”
D. Tagamet does not cause ringing in the ears.
Key: B Client Need: Physiological Integrity
40. Which of the following teaching instructions would a B. The nurse should make the patient aware
nurse include for a patient who has regional enteritis? that after surgery, the fecal drainage from the
ileostomy is liquid and may be constant.
A. “Limit your dietary protein intake” A. The drainage from an ileostomy is liquid
B. “Reduce stress in your lifestyle” rather than formed.
C. “Decrease your activity level” C. The stoma site for an ileostomy is right
D. “Avoid drinking fruit juices” midline.
D. Ileostomy stomas should not be irrigated.
Key: B Client Need: Psychosocial Integrity
B. The patient with regional enteritis or Crohn’s 44. A patient experiences nausea following the removal of
disease must identify stressors and a nasogastric tube. Which of the following actions would a
methods to eliminate or reduce them. nurse take first?
A and D.
The nurse should assist the patient in selecting high- A. Teach the patient relaxation techniques
calorie, high-protein, low-fiber B. Auscultate the patient for bowel sounds
meals. Adequate intake of vitamins and minerals, C. Reinsert the nasogastric tube
especially vitamin C found in citrus D. Administer the prescribed medication
fruits and juices should be encouraged. Strained
juices are permitted on a low-fiber diet. Key: B Client Need: Safe Effective Care Environment
B. The patient should be assessed for nausea,
41. Which of the following statements, if made by a abdominal discomfort and the presence of bowel
patient who is administered sulfasalazine (Azulfidine), indicates sounds.
a correct understanding of the medication? A, C and D.
Before removal of a gastrointestinal tube, GI function
A. “I will brush my teeth with a soft toothbrush.” is assessed. Bowel sounds are
B. “I will report greenish halos around lights.” auscultated, the abdomen is observed for distention,
C. “I will need to wear a hat while I am outdoors.” the patient is asked whether
D. “I will expect a tingling sensation around my mouth” flatus has been passed and the patient’s tolerance of
tube clamping and ice chips in
Key: C Client Need: Physiological Integrity noted. Relaxation techniques, reinserting the tube
C. Photosensitivity may occur as a side effect of and administering medication may
Azulfidine. The patient should be instructed to wear a be logical interventions but would not be the first
priority.
 B, C and D.
45. Which of the following statements, if made by a Therapeutic nursing responses to sexual advances by
patient who is scheduled for a sigmoid colostomy, would a patient include clarifying
indicate to a nurse that the patient needs further instruction? nurse-patient roles, setting limits on expected
behaviors and exploring the meaning of
A. “I will have one formed bowel movement daily” the patient’s behavior.
B. “I will have continuous drainages of liquid stool”
C. “The pouch will be located on the left side of my 49. Which of the following orders in a patient’s chart
abdomen” immediately following a total gastrectomy would a nurse
D. “I will be taught how to irrigate my bowel through the question?
stoma”
A. “Infuse intravenous fluids at the rate of 150 ml/hr”
Key: B Client Need: Physiological Integrity B. “Turn, cough and deep breathe every two hours.”
B. The stool from a sigmoid colostomy will be C. “Advance nasogastric tube one inch every hour.”
formed rather than liquid, Liquid stool is expected D. “Maintain the head of the bed at a 30-degree
with an ileostomy. The patient should have additional elevation.”
teaching in this regard.
A, C and D. Key: C Client Need: Physiological Integrity
These patient statements indicate a correct C. To protect the healing suture line, the nurse
understanding of the surgery. should not routinely irrigate or reposition the
nasogastric tube. This order should be questioned by
46. Which of the following statements, if made by a the nurse.
patient who has diverticulosis, would indicate to a nurse that A. Fluids are given parenterally until the
the patient is following the diet plan correctly? nasogastric tube is removed and the patient is able to
drink enough fluids orally. Generally, 1000 ml
A. “I eat meat five times a week” intravenous solutions are infused at a rate of 125
B. “I do not eat fried foods” ml/hr over eight hours.
C. “I drink decaffeinated coffee” B. Turning, deep breathing, incentive
D. “I eat a green salad every day” spirometry and ambulation are stressed during the
period when the pain medication is at its peak
Key: D Client Need: Physiological Integrity effectiveness.
D. Treatment of diverticulosis involves adherence to a D. The patient should never lie flat in bed. The
high-fiber diet. Foods high in fiber accepted position is mid-to-Fowler’s
include bran, whole wheat and fresh vegetables.
A, B and C. 50. When taking a history from the parent of an eight-
Eating meat five times a week, eliminating fat year-old child who has rheumatic fever, a nurse would expect
from the diet and drinking the child’s parent to report a recent episode of
decaffeinated beverages are not identified as part of
the management of diverticular A. unary tract infection
disease. B. acute gastroenteritis
C. contact dermatitis
47. Which of the following actions should the nurse take D. acute pharyngitis
first following a violent episode on a psychiatric unit?

A. Conduct a staff debriefing

B. Contact hospital administration
C. Discuss the incident with the other patients
D. Call hospital security
Key: A Client Need: Psychosocial Integrity
A. After the crisis (violent episode) is over, it is
recommended that the team discuss any concerns
they may have during the crisis, since this type of
occurrence can be stressful for staff as well as
patients.
B. The nursing supervisor would be notified of
the violent episode. Hospital administration would
not be notified unless serious complications arose
from the situation.
C. The incident would be discussed with other
patients as a group but would not be done until staff
reviewed the situation.
D. Hospital security may be called during the
violent episode but is not usually called afterward.
48. A patient makes sexually inappropriate comments to
the nurse. Which of the following measures would most likely
prevent such behavior?
A. Clarify nurse patient roles with the patient
B. Refrain from being alone with the patient
C. Avoid sexual topics of discussion with the patient
D. Assign a staff member of the same gender to care for
the patient
Key: A Client Need: Psychosocial Integrity
A. Frequently restating the nurse’s role
throughout the relationship can help the patient to
maintain boundaries.
Key: D Client Need: Physiological Integrity
D. Strong evidence supports a relationship
between upper respiratory infection with group A
streptococci and subsequent development of
rheumatic fever.
A. Urinary tract infections are mostly cause by
E-coli bacteria.
B. Organisms causing acute gastroenteritis do
not cause rheumatic fever.
C. Contact dermatitis is an inflammatory
reaction, not an infectious process.
51. A patient has had a total gastretomy. Which of the
following instruction should nurse give to the patient about
how to avoid dumping syndrome?
A. “Add polyunsaturated fats to your daily meals”
B. “Eat three balanced meals per day.”
C. “Include complex carbohydrate with your meals”
D. “Limit fluid intake with your meals.”
Key: D Client Need: Physiological Integrity
D. Prevention is the most effective means of
controlling dumping syndrome. The nurse should
instruct the patient to follow a moderate-fat, high-
protein diet, with limited carbohydrates. Simple
sugars should be avoided, and fluids with meals are
discouraged because they increase total volume. The
patient should eat small, frequent meals.
A. A diet with moderate fat is encouraged to
delay gastric emptying. Adding polyunsaturated fats
to daily meals is not necessary.
 B. Small frequent meals rather than three large
meals should be encouraged to decrease total
volume.
C. Complex carbohydrates are limited and
simple sugars should be avoided because they leave
the stomach more quickly than fats and proteins.
52. When taking a history from a patient who has a
diagnosis of pyelonephritis, a nurse should expect the patient
to report which of the following symptoms?
A. Pain referred to the left shoulder
B. Low back pain
C. Flank pain
D. Right upper quadrant pain
Key: C Client Need: Physiological Integrity
C. Clinical manifestation of pyelonephritis
include acute flank pain, fever, chills, malaise,
leukocytosis and bacteria in the urine.
A. Pain referred to the left shoulder may be the
result of “gas” pains and abdominal distention.
B. Flank pain, rather than low back pain, is
symptomatic of pyelonephritis.
D. Right upper quadrant pain is indicative of
liver or gall bladder disease.
53. A patient who has pyclonephritis is given homecare
instructions by a nurse. Which of the following statements
indicates that the patient understands the instructions?
A. “I will need to take antibiotics for at least three
months.”
B. “I will have to drink cranberry juice every day.
C. “I will need to strain my morning urine.”
D. “I will have to weigh myself daily.”
Key: A Client Need: Physiological Integrity
A. The course of antibiotic therapy for
pyelonephritis may extend over weeks. If the
infection becomes chronic, maintenance drug therapy
may continue indefinitely.
B. Cranberry juice in large amounts will acidify
the urine and prevent urinary tract infections. It is not
used in the treatment of pyelonephritis.
C. Straining of urine is indicated for patients
with renal calculi.
D. Daily weight would be indicated for patients
with urinary retention and/or renal failure.
54. Which of the following comments, if made by patient
who is administered phenazopyridene hydrochloride
(Pyridium), would indicate to a nurse that the medication is
effective?
A. “There is no swelling in my ankles.”
B. “It does not hurt me to urinate.”
C. “I do not have diarrhea.”
D. “My head is not spinning.”
Key: B Client Need: Physiological Integrity
B. Pyridium is prescribed for symptomatic relief
of pain, burning, frequency and urgency arising from
irritation of the urinary tract.
A, C and D.
Ankle edema, absence of diarrhea and absence of
vertigo are not intended effects of Pyridium.
55. Which of the following statements, if made by a
patient who is administered doxorubicin hydrochloride
(Adriamycin), would indicate to a nurse that the patient needs
further instruction about the adverse effects of the drug?
A. “My hair is going to fall out.”
B. “My urine will turn red.”
C. “I can expect to become constipated.”
D. “I may develop an irregular heartbeat.”
Key: C Client Need: Physiological Integrity
C. Administration of Adriamycin would cause
diarrhea rather than constipation. The patient needs
additional instruction about the medication.
A. Administration of Adriamycin will cause
complete alopecia that is reversible.
B. Adriamycin will cause the urine to be reddish
in color for one to two days after administration.
D. Administration of Adriamycin can cause
ventricular disrhythmias and cardiotoxicity.
56. Which of the following strategies would be
appropriate for a nurse to include in the rehabilitation teaching
plan of a patient who is paraplegic?
A. Self-catheterization
B. Assisted coughing
C. Adaptive feeding techniques
D. Compensatory swallowing
Key: A Client Need: Psychological Integrity
A. Following a spinal cord injury, the bladder
becomes atonic and cannot contract reflexively. The
patient should be instructed in self-catheterization to
avoid over-distention of the bladder.
B. The paraplegic patient is able to cough, deep
breathe and perform chest physiotherapy. There is no
indication that assisted coughing is necessary.
C and D.
Paraplegia involves dysfunction of the lower
extremities, bowel and bladder. There is no indication
that adaptive feeding devices or compensatory
swallowing techniques are necessary.
57. A three-year-old child is brought to the emergency
department with a suspected diagnosis of acute epiglottitis.
Which of the following actions would be most appropriate for a
nurse to take when caring for this child?
A Place the child in an upright position in the parent’s
lap
B. Inspect the oropharynx with a lighted instrument
C. Obtain the child’s weight on an upright scale
D. Encourage small amounts of liquid frequently
Key: A Client Need: Physiological Integrity
A. Epiglottitis is frightening for both child and
parents. The child is allowed to remain in the position
that provides the most comfort and security. The child
generally insists on sitting upright, leaning forward.
This is easily accomplished by the child sitting in the
parent’s lap to reduce distress.
B. Throat inspection should only be attempted
when immediate intubation can be performed if
needed.
C. Obtaining the child’s weight is not a priority
at this time. Epiglottitis is an emergency situation.
D. The child should be kept NPO.
58. A patient who has a spinal cord injury report
symptoms of autonomic dysreflexia to a nurse. Which of the
following assessments should the nurse make immediately?
A. Pedal pulses
B. Skin inspection
C. Breath sounds
D. Pupillary response
Key: B Client Need: Safe Effective Care Environment
B. The manifestations of autonomic dysreflexia
result from an exaggerated sympathetic response to a
noxious stimuli. Stimuli are commonly bladder and
bowel distention, but can be pressure ulcers, spasms,
pain and pressure on the penis or uterine
contractions. The nurse should assess for pressure
areas on the skin.
A, C and D.
Pedal pulses, breath sounds and papillary response
are not priority assessments for autonomic
dysreflexia.

59. A patient is suspended of having a susbarachnoid
hemorrhage. A nurse should prepare the patient for which of
the following diagnostic tests?
A. Cerebral arteriogram
B. Intravenous pyelogram (IVP)
C. Gallium scan
D. Carotid Doppler study
Key: A Client Need: Physiological Integrity
A. Cerebral arteriogram or angiogram
illuminates the cerebral circulation. This test is used
for the diagnosis of vascular aneurysms,
malformations, displacements and occluded or leaking
blood vessels.
B. An intravenous pyelogram (IVP) provides
information about the number, size and location of
the kidneys ureters.
C. A gallium scan is useful in detecting bone
problems, and can also be useful in the examination
of brain, heart, liver and breast tissue.
D. Carotid Doppler studies are use to determine
narrowing or occlusion of the carotid arteries.
60. A patient who has mental retardation is admitted to a
general psychiatric unit. Which of the following actions should
the nurse include initially in the patient’s plan of care?
A. Provide reality orientation
B. Asses the patient’s level of functioning
C. Involve the patient in cognitive
D. Encourage participation in the existing program
Key: B Client Need: Psychosocial Integrity
B. Assessing several areas of functioning such
as intellectual functioning, activities of daily living and
coping mechanisms helps the nurse to fully develop
the plan of care.
A, C and D.
The nurse cannot know the patient’s needs or if the
patient is capable of participating in these
interventions until the level of functioning is
determined.
61. Which of the following statements, if made by a
patient who has stress-induced asthma, indicates a need for
further teaching?
A. “The doctor told me that my asthma is all in my
head.”
B. “I understand that my attacks are related to my
mood.”
C. “I need to use my inhaler before I start exercising.”
D. “The doctor told me that biofeedback might be helpful
for my condition.”
Key: A Client Need: Physiological Integrity
A. Emotional stress is not only component of
asthma. Allergic, immunologic and emotional input
can be responsible for asthma attacks. The patient
should have further instruction regarding the cause of
asthmatic episodes.
B. Mood does play an important role in asthma
attacks. The patient’s statement indicates an
understanding of the patient does not require further
teaching.
C. With exercise-induced asthma, use of an
inhaler prior to exercise decreases the risk of, and the
symptoms of, an asthma attacks. The patient’s
statement indicates an understanding of this and the
patient does not require further teaching.
D. Biofeedback in helpful in teaching a patient
to manage stress before physiological problems occur.
The patient’s statement indicates an understanding of
this and the patient does not require further teaching.
62. Which of the following actions would a nurse take
when caring for a patient who is brought to the emergency
department with a potential spinal cord injury?
A. Taping the patient’s eyelids closed
B. Elevating the head of the patient’s bed
C. Placing the patient in a side-lying position
D. Maintaining the patient’s neck in extension
Key: D Client Need: Physiological Integrity
D. The patient must always be maintained in an
extended position. No part of the body should be
twisted or turned, and the patient cannot be allowed
to assume a sitting position. A head immobilizer is
used to secure the head and neck in alignment.
A. There is not indication that taping the eyelids
shut is necessary in this situation.
B and C.
Use of these positions could cause severance of the
spinal cord from bone fragments.
63. A patient with a head injury is admitted to the
hospital with a B/P of 130/70, a heart rate of 100 and
respiratory rate of 16.The patient’s increase to 24 and the
heart rate decreases to 60. Which of the following medication
orders should a nurse anticipate?
A. Phenytoin (Dilantin)
B. Mannitol (Osmitrol)
C. Theophylline (Theo-Dur)
D. Atropine sulfate (Atopisol)
Key: B Client Need: Physiological Integrity
B. Patient manifestations indicate the
decompensation phase of increased intracranial
pressure. Osmotic diuretics, such as mannitol, are
given to reduce cerebral edema.
A. Dilantin is an anticonvulsant and is not used
to reduce cerebral edema.
C. Theophylline in a bronchodilator and is not
used to reduce cerebral edema. D. Atropine sulfate is
an autonomic nervous system agent and is not used
in the
treatment of cerebral edema.
64. A patient says to the nurse, “I’m less of a man since
I’ve taking my Elavil.” Which of the following responses by the
nurse would be therapeutic?
A. “Are you saying that the medication interferes with
sexual intimacy”
B. “Compliance with your medication regimen is the
most important issue here.”
C. “When was the last time you had sex”
D. “Are you involved in an intimate relationship?”
Key: A Client Need: Psychosocial Integrity
A. Some antidepressants interfere with libido.
The nurse should clarify the meaning of the patient’s
statement and convey to the patient a willingness to
talk about sexual intimacy concerns with the patient.
B. This response by the nurse negates the
patient’s concerns and does not allow for open
discussion.
C. The nurse should clarify the meaning of the
patient’s comment before asking for additional
information.
D. The should first clarify the patient’s original
statement.
65. A mother asks a nurse why hemophilus b conjugate
vaccine (Hibtiter) immunization is required for her two-month-
old infant. That nurse should respond that Hibtiter will protect
the infant against certain diseases, which include
A. hepatitis
B. encephalitis
C. epiglottitis
D. bronchiolitis
 at risk for injury. However, the priority of care is
Key: C Client Need: Health Promotion and Maintenance maintenance of a patient airway.
C. Hemophilus influenza type B conjugate vaccines
are routinely administered to 69. Which of following findings would a nurse expect of
children beginning at two months of age to protect observe when assessing a patient who has myasthenia gravis?
against epiglottitis.
A, B and D. A. Tongue deviation
Hibtiter does not protect against hepatitis, B. Intention tremor
encephalitis or bronchiolitis. C. Plantar flexion
D. Drooping eyelids
66. A patient in an ambulatory care center is suspected of
having an acoustic neuroma. Which of the following findings, if Key: D Client Need: Physiological Integrity
identified in the patient, would support this diagnosis? D. Because of involvement of the ocular
muscles, diplopia and ptosis are early symptoms of
A. Diplopia myasthenia gravis.
B. Dysphagia A, B and C.
C. Tinnitus These options are not identified as clinical
D. Ataxia manifestations of myasthenia gravis but are found in
other neuromuscular diseases.
Key: C Client Need: Physiological Integrity
C. Clinical manifestations of acoustic neuroma 70. A parent ask a nurse for guidance regarding a
begin with tinnitus, or ringing in the ears, and homosexual child. Which of the following actions should the
progress to gradual sensorineural hearing loss. nurse take?
A. Diplopia is double vision and is not
associated with acoustic neuroma. A. Teach the parent that homosexuality is not a mental
B. Dysphagia is difficulty swallowing and is not illness
symptomatic of acoustic neuroma. B. Refer the parent to the local community mental
D. Ataxia is lack of coordination in performing a health center.
planned, purposeful motion, such as walking. It is not C. Teach the parent about sexual deviations.
associated with acoustic neuroma. D. Refer the parent for religious guidance.

67. Which of the following statements, if made by a Key: A Client Need: Psychosocial Integrity
patient who is scheduled for a lumbar puncture, indicates that A. The majority of people who lead homosexual
the patient understands the procedure? lifestyle are well-adjusted and have satisfying and
productive lives.
A. “The speed of my nerve impulses will be measured.” B and D.
B. “Fluid will be removed from my spinal canal.” The parent may need mental health or religious
C. “Dye will be injected into my arm.” support and counseling to accept the homosexuality
D. “My brain waves will be studied.” of a child. The priority is to help the parent
understand that homosexuality is not mental illness.
Key: B Client Need: Physiological Integrity C. Teaching the parent about sexual deviations
B. A lumbar puncture is carried out by inserting is not appropriate.
a needle into the subarachnoid space to withdraw
cerebrospinal fluid for diagnostic and therapeutic 71. A patient who is receiving pyridostigmine bromide
purposes. The patient’s statement indicates a correct (Mestinon) makes all of the following statements. Which one
understanding of the procedure. should indicate to a nurse that the Mestinon is having a
A. Electromyography measures electrical therapeutic effect?
activity associated with innervation of skeletal muscle.
C. No dyes are used in a lumbar puncture. A. “ My urine has no odor.”
D. Studying brain waves is accomplished B. “My headaches are gone.”
through electroencephalography. C. “My vision is less blurry.”
D. “My chewing is stronger.”
68. To which of the following nursing diagnoses would a
nursing give priority in the treated for Guillain Barre syndrome? Key: D Client Need: Physiological Integrity
D. Anticholinesterase agents, such as pyridostigmine
A. Ineffective airways clearance bromide, act by increasing the
B. Self – care deficit relative concentration of available acetylcholine at the
C. Fluid volume neuromuscular junction.
D. Risk for injury They increase the response of the muscle to nerve
impulses and improve strength.
The dosage of pyridostigmine bromide is gradually
increased until maximal
benefits are achieve (additional strength and less
Key: A Client Need: Safe Effective Care Environment fatigue). The patient is instructed
A. The patient is at particularly high risk if to take the medication 30 minutes before meals for
he/she is unable to cough effectively to clear the maximal muscle strength.
airway and has difficulty is swallowing, which may A, B and C.
cause aspiration of saliva and precipitate acute Pyridostigmine bromide does not affect the urine,
respiratory failure. does nor relieve headache and
B. Later in the course of the disease motor does not improve vision.
paralysis or weakness will affect the patient’s ability
to self-feed. 72. A nurse has given instructions about making
C. Muscle paralysis in severe cases may lead to appropriate lifestyle changes to a patient who has venous
low blood pressure and the need for vasopressant insufficiency. Which of the following comments, if made by the
agents and volume expanders. The priority of care is patient, would indicate compliance with the instructions?
airway maintenance.
D. A total self-care deficit relates to inability to A. ” I eat fried chicken during the week.”
use muscle to protect oneself and places the patient B. “I put on a girdle in the morning.”
C. “I place a stool under my legs when I sit.”
D. “I drink a beer every night after eating.” treatment, a count every week while on the
medication and count for four weeks after
Key: C Client Need: Physiological Integrity discontinuing the drug is recommended.
B. Elevating the legs decrease edema, B, C and D.
promotes venous return and provides symptomatic None of these time frames is indicated for blood level
relief. The legs should be elevated frequently monitoring in the patient
throughout the day, preferably for at least 30 minutes taking Clozaril.
every two hours.
A and D. 76. Which of the following questions is most important for
Modifications in diet and alcohol intake will not a nurse to ask when gathering information from a patient who
provide relief to patients with venous insufficiency. has a history of peripheral vascular disease?
B. Constricting garments such as girdles or
garters should be avoided. A. “Have you had recent lapses of memory?”
B. “Do you require several pillows to sleep?”
73. A nurse should carefully assess a patient who has C. “Have you noticed weakness in your legs?”
partial occlusion for the carotid arteries for development of D. “Do you have pain in your calves when you walk?”
which of the following conditions?
Key: D Client Need: Health Promotion and Maintenance
A. Rapid eye movements D. A severe cramp-like pain, intermittent
B. Projectile vomiting claudication is experienced in the extremities after
C. Intermittent claudication activity by patients with peripheral arterial
D. Transient ischemic attacks insufficiency. When the patient rests, and thereby
decreases the metabolic needs of the muscles, the
pain subsides. The site of arterial disease can be
Key: D Client Need: Physiological Integrity deduced from the location of the claudication. Calf
D. The nurse of transient inschemic attacks pain may accompany reduced blood flow through the
(TIAs) is a temporary impairment of blood flow to a superficial femoral or popliteal arteries.
specific region of the brain due to a variety of A. Lapse of memory is present in neurological
reasons, including atherosclerosis of the vessels disorders.
supplying the brain, obstruction of the cerebral B. Sleeping on several pillows is seen in the
microcirculation by a small embolus, a decrease in patient who has cardiac failure.
cerebral perfusion pressure or cardiac dysrhythmias. C. Weakness in the legs may be seen in
The most common sites of atherosclerosis in the neurological disorders.
extracranial arteries are at the bifurcation of the
common carotid arteries and at the origin of the 77. A patient who has had a left, above-the-knee
vertebral arteries. amputation asks a nurse why there is a sensation of pain in
A. Rapid eye movements occur in inner ear and the left foot. The nurse should know that this sensation is
neurologic conditions. called
B. Projectile vomiting is present in increased
intracranial pressure. A. intractable pain
C. Intermittent claudication is present in B. radiating pain
peripheral vascular disease. C. phantom pain
D. referred pain
74. A 10-year-old child who has cystic fibrosis is receiving
pancrelipase (Pancrease) as part of the treatment plan. Which Key: C Client Need: Physiological Integrity
of the following responses in the child indicates that the D. Phantom pain is used to describe the normal
medication has been effective? perception of the missing extremity that most
amputees feel. When the leg is amputated, the
A. Increase in appetite patient will feel the presence of the missing limb for
B. Measure weight gain many weeks. This is due to intact peripheral nerves
C. Thinning of respiratory secretions proximal to the amputation site that used to carry
D. Improved pulmonary function messages between the brain and the now amputated
part.
Key: B Client Need: Physiological Integrity A. Intractable pain is that which is not relieved
B. Digestive management of cystic fibrosis by the usual medication regimes comfort measures. It
consists of pancreatic enzyme replacement, diet is often experience by cancer patients.
adjustment and, in some cases, fat-soluble B. Radiating pain is that which spreads out
supplementation to promote growth, adequate from its original source, e.g., pain of cardiac origin
nutrition and normal bowel movements. Measurable spreading to the shoulder, jaw and arm.
weight gain is an indication of effectiveness of D. Referred pain is that which is felt at a site
treatment. distal to the original, e.g., pain in the shoulder caused
A. Nausea is one of the frequent, undesired, by abdominal gas pockets pressing on the diaphragm.
clinical responses to Pancrease.
C. Pancrease does not thin respiratory 78. Which of the following observations would help a
secretions. nurse to establish a nursing diagnosis of potential for violence
D. Pancrease does not affect lung function. for a patient who has a diagnosis of schizophrenia, paranoid
type?
75. When a patient begins clozapine (Clozaril) therapy, a
nurse should instruct the patient to return for blood level the A. Avoidance of staff and other patients
patient to return for blood level monitoring B. Verbal threats to other patients
C. Refusal to other patients
A. weekly D. Continual change of position.
B. every two weeks
C. monthly Key: B Client Need: Psychosocial Integrity
D. every six moths B. Clues to aggressive behavior include
expressing intent to harm others and being
Key: A Client Need: Physiological Integrity threatening to others.
A. Because of the risk of agranulocytosis, a A and C.
baseline white blood cell count before initial
 Avoidance of staff and other patients by a paranoid
schizophrenic patient may indicate fear that others
will harm the patient, or that the patient may be
afraid of harming other, and therefore, chooses to
avoid contact. However, by observing just this
behavior, one cannot assume that the patient is
potentially violent.
D. Continually changing position may show
agitation in the patient, but this behavior alone does
not indicate that the patient is potentially violent.
79. Which of the following findings of a child with cystic
fibrosis would indicate that the pulmonary treatment is
achieving the desired therapeutic effect?
A. Nonproductive cough
B. Decreased tidal volume
C. Fewer mucopurulent secretions
D. Adventitious breath sounds
Key: C Client Need: Physiological Integrity
C. Management of pulmonary problems in
cystic fibrosis (CF) is directed toward prevention and
treatment of pulmonary infection by improving
aeration and removing mucopurulent secretions.
A. Initial pulmonary manifestations of CF are
wheezing and a dry, nonproductive cough that
eventually becomes loose and productive.
B. As thick, tenacious mucus accumulates,
obstruction occurs and the flow of air is impaired.
There is an increase in residual volume and
subsequent decrease in vital capacity.
D. Adventitious sounds are additional
respiratory sounds not normally heard.
80. A nurse Is planning to teach parents in a parenting
education class about ways to reduce the incidence of sudden
infant death syndrome (SIDS). Which of the following
strategies should the nurse teach?
A. Position the infant on the back or side when left
unattended in the crib
B. Put a cool mist humidifier in close proximity to the
sleeping infant
C. Avoid placing large stuffed toys in the infant’s crib
D. Place the infant in an infant seat for two hours after
feedings
Key: A Client Need: Health Promotion and maintenance
A. Parents need to be educated that infants
should be placed on their sides or supine on a firm
sleep surface to help prevent sudden infant death
syndrome (SIDS).
B, C and D.
The infant’s position during sleep is a critical factor in
SIDS. Infants who sleep in a
prone position are at greater risk of during from SIDS
than infants who are positioned
on their backs or sides. The prone position may cause
oropharyngeal obstruction; affect
thermoregulation , causing overheating of the infant;
or affect the arousal state. A cool
mist humidifier, avoiding stuffed animals and placing
the infant in an infant seat after
feeding will not prevent the incidence of SIDS.
81. After administering an injection of haloperidol
decanoate (Haldol) to a patient, the nurse should instruct the
patient to
A. stays recumbent for four hours
B. avoid foods containing tyramine
C. return for the next injection in four weeks
D. decrease salt intake
Key: C Client Need: Physiological Integrity
C. Haldol decanoate is released slowly from
the muscle into which it was injected;
therefore, the effects of the medication last for two to
four weeks.
A. It is not necessary for the patient to stay
recumbent for any length of time after an
injection of Haldol decanoate. Although rare, some
patients experience orthostatic
hypotension. All patients receiving Haldol should be
taught to rise slowly from a
recumbent position and to sit for a few minutes
before standing.
B. Avoidance of tyramine-rich foods is indicated
for patients taking monoamine
oxidase inhibitors, not haloperidol.
D. Taking salt supplements in not indicated
when being treated with haloperidol.
82. A patient’s blood test results reveal a hematocrit of 66
mm/dL. To which of the following nursing diagnoses would a
nurse give priority?
A. Ineffective breathing pattern
B. Activity intolerance
C. Hyperthermia
D. Dysreflexia
Key: B Client Need: Safe Effective Care Environment
B. Hematocrit is an effective indicator of body
fluid. Increased hematocrit levels can
indicate shock due to a large fluid loss and
hemoconcentration. Activity in olerance
would be the priority nursing diagnosis for this
patient.
A,C and D.
Ineffective breathing pattern, hyperthermia and
dysreflexia are not priority nursing
diagnoses for a patient with hemoconcentration or an
elevated hematocrit.
83. The bowel retraining program for a patient who has
had a cerebrovascular accident should include which of these
measures?
A. Checking for impaction daily
B. Increasing the intake of milk products
C. Utilizing incontinent pads until control is achieved
D. Establishing a consistent time for elimination
Key: D Client Need: Physiological Integrity
D. Bowel retraining is established by providing a
consistent time for stool evacuation each day.
A. Checking for impaction daily is not indicated
and can interfere with sphincter control.
B. Fluids should be increased to at least 3000
ml per day, unless contraindicated by cardiac or renal
disease. Dairy products are high in calcium and may
be constipating for the patient.
C. Using incontinent pads does not help in
bowel retraining and may encourage
incontinence.
84. Several patients have reported to the charge nurse
that one of the nurses doesn’t come when called and is very
grouchy and ill-humored. The charge nurse knows that the
nurse is having personal probe s. The charge nurse’s best
initial action would be to
A. ask each of the patients to talk more about the
nurse’s behavior
B. tell the patients that the nurse is going through some
difficult times
C. report these complaints to the nursing supervisor
D. tell the nurse the comments the patients have been
making about her
Key: D Client Need: Safe Effective Care Environment
D. The charge nurse should discuss patient
comments with the nurse and work with the nurse to
develop a plan that promotes change in the behavior.
 A. The charge nurse has enough information to C. Chest pain may indicate an emergency
be3gin exploring the situation with the identified situation (acute chest syndrome) and should be
nurse. Continuing discussion with the patients is not reported to the physician immediately.
appropriate unless a piece of information needs to be A. While there can be renal involvement in
clarified. sickle cell anemia, decreased urinary output is not an
B. The charge nurse should not discuss the emergency.
potential reasons for the nurses behavior with the B. Vomiting and diarrhea can be seen with
patients. This violates the nurse’s right to sickle cell anemia but do not require
confidentiality. emergency management as does chest pain.
C. The charge nurse in the first in the chain of D. A nonproductive cough may be present in
command and should address the issues with the sickle cell anemia but it does not require emergency
nurse. intervention.
88. The nurse should asses a patient who has bipolar
85. A patient tells the nurse, “The therapist doesn’t like disorder, manic episode for which of the following
me.” Which of the following responses, if made by the nurse, manifestations?
would be the most therapeutic?
A. Waxy flexibility
A. “Why do you say that?” B. Flat affect
B. “I wouldn’t take personally.” C. Flight of ideas
C. “Would you like me to talk to the therapist for you?” D. Hypersomnia
D. “You need to discuss that concern with the therapist
Key: C Client Need: Psychosocial Integrity
C. Flight of ideas is a manifestation of mania.
As the patient’s mood state becomes increasingly
Key: D Client Need: Psychosocial Integrity expansive, speech may become full of irrelevancies.
D. The nurse should avoid participating in The manic patient jumps quickly from topic to topic,
criticism of another staff person. The concern needs and rapid thinking proceeds to racing and disjointed
to be resolved between those involved, namely the thinking.
therapist and the patient. With this statement the A. Waxy flexibility, a condition in which the
nurse conveys confidence in the patient’s ability to patient remains in any body position in which he/she
speak for him/herself. is placed, is seen in patients with catatonia.
A. By asking this question the nurse becomes B. Flat affect, the absence of emotional
involved in a situation that does not concern the expression, is seen in depressed or psychotic patient.
nurse and does not teach the patient the appropriate D. Hypersomnia, excessive sleepiness, is seen
process of resolving conflict. Also, the nurse should in depressed patient.
avoid use of the word “why” because it challenges the
person’s position and the response is usually to 89. Following an amniocentesis, the nurse should instruct
defend one’s position rather than address the real a client to immediately report which of the following signs and
issue. symptoms?
B. In this example the nurse gives a A. Flu-like symptoms
stereotypical response, which belittles the patient’s B. Inability to sleep
concern, gives advice and does not direct the patient C. A decrease in uterine contraction
to deal with the concern appropriately. D. An increase in uterine contractions
C. By talking to the therapist on behalf of the
patient, the nurse accepts responsibility for solving Key: D Client Need: Health Promotion and Maintenance
the patient’s problem and misses and opportunity to D. Following an amniocentesis, the patient is at
teach the patient how to communicate effectively to risk for contractions and preterm labor.
resolve conflict. A. Flu-like symptoms are not associated with
amniocentesis.
86. A three-year-old child to receive pyrvinium pamoate B. Inability to sleep is associated with
(Povan) as part of the treatment plan for pinworm infestation advancing pregnancy. It is not related to
.A nurse would instruct the child’s parent to be aware of amniocentesis.
adverse effects, including C. Contractions should not be present at this
time.
A. dry, scaly skin
B. bleeding gums 90. Which making a postpartum home visits, the nurse
C. tea-colored urine observe that the newborn is sleeping comfortably in a prone
D. red –colored stool position. Parent teaching during this visit will appropriately
include
Key: D Client Need: Physiological Integrity
D. Povan stains the stool and vomitus bright A. reinforcing this correct positioning of the infant since
red. the baby is comfortable.
A, B and C. B. teaching the parents that infant should be placed on
Dry scaly skin, bleeding gums and tea-colored urine their backs to sleep
are not side effects of treatment C. teaching the parents to alternate the infant’s sleeping
with Povan. position from front to back.
D. teaching the patents that, although the baby appears
87. A child who has sickle cell anemia has been admitted comfortable, infants sleep best on their backs.
to the hospital. Which of the following signs symptoms must
be reported to the physician immediately? Key: B Client Need: Safe Effective Care Environment
B. The nurse should instruct the parents that
A. Decreased urine output correct positioning to prevent sudden infant death
B. Vomiting and diarrhea syndrome (SIDS) is the supine position or the side-
C. Chest pain lying position.
D. Nonproductive cough A. The prone position is not recommended by
the American Academy of Pediatrics.
Key: C Client Need: Physiological Integrity C. Sleeping on the back or side only is
recommended.
 D. Infants generally sleep in whatever position
they are placed. The major reason for placing the
infant on its back or side is to prevent SIDS.
91. A16-year-old girl who is semiconscious is brought to
the emergency department after ingesting an unknown
quantity of acetaminophen (Tylenol) and alcohol. To which of
the following actions would a nurse give priority?
A. Inserting a nasogastric tube
B. Obtaining a urine toxicology sample
C. Inducing vomiting
D. Staring an intravenous infusion
Key: D Client Need: Physiological Integrity
D. The acronym SIRES is an aid in
remembering the essential care in cases of poisoning:
Stabilize the patient; Identify the toxic substance;
Reverse its effect; Eliminate the substance from the
body; and Support the patient and significant others
both physically and psychologically. Airway, breathing
and circulation must be stabilized. A rapid physical
exam is performed. Intravenous lines are inserted and
appropriate laboratory studies obtained.
A and B.
Neither of these options are a priority for emergency
care of a patient who has ingested an unknown
quantity of Tylenol and alcohol.
C. Vomiting should not be induced in a semi-
conscious patient because it could result in aspiration.
92. A child is being treated for lead poisoning (plumbism).
Prior to the administration of dimercaprol (BAL in Oil), it
essential that a nurse assess the child for an allergy to
A. peanuts
B. eggs
C. erythromycin
D. iodine
Key: A Client Need: Physiological Integrity
A. Children with allergies to peanuts or
penicillin cannot receive dimercaprol (BAL) or D-
penicillamine, respectively.
B, C and D.
Allergies to eggs, erythromycin or iodine should be
noted by the nurse. However, such allergies do not
necessarily contradict the use of BAL in Oil.
93. Which of the following statements by a patient with
schizophrenia indicates a correct understanding of the
antipsychotic medication therapy?
A. “I need to follow the dose schedule and tell my nurse
if I have any problems.”
B. “When I’m feeling better, I can use smaller doses of
my medicine”
C. “If I don’t hear the voice, I don’t need the medicine”
D. “I don’t have to worry about many side effects with
this medicine.”
Key: A Client Need: Psychosocial Integrity
A. When teaching clients about schizophrenia,
the nurse should include the need to take medication
regularly, expected side effects, what to do for the
side effects, signs of problems and who to call if
problems occur.
B and C.
The patient should be taught not to decrease the
medication dosage or to stop the medication unless
instructed to do so by the physician.
D. Side effects of antipsychotic medications
include extrapyramidal effects such as tardive
dyskinesiak akathisia, parkinsonism and dystonia.
Anticholinergic side effects include blurred vision.,
nasal congestion, dry mouth, constipation and urinary
hesitancy.
94. The primary purpose for using the Abnormal
Involuntary Movement Scale (AIMS) for a patient who is taking
a phenothiazine medication is to identify
A. tardive dyskinesia
B. motor in coordination
C. a sluggish papillary response
D. a positive Babinski reflex
Key: A Client Need: Psychosocial Integrity
A. The abnormal involuntary movement scale (AIMS)
is used for the assessment of extrapyramidal side
effects of antipsychotic medications. Tardive
dyskinesia is such a side effect and is characterized
by abnormal, involuntary movements that usually
begin in the face, neck and jaw, lip smacking and
facial grimacing.
B, C and D.
Motor incoordination, sluggish papillary response and
a positive Babinski reflex are not measured by the
AIMS scale.
95. Which of the following lunches would be most
appropriate for a patient with bipolar disorder, manic episode?
A. Cheese sandwich, banana and milk shake
B. Vegetables soup, applesauce and tea
C. Rice and beans, custard and carbonated water
D. Beef stew, peas and milk
Key: A Client Need: Psychosocial Integrity
A. Manic patients demonstrate hyperactive
behavior, as well as poor concentration and attention
span, making it difficult for them to sit long enough or
focus long enough to eat certain types of foods.
Because of these behavior, such patients are at risk
for alteration in nutrition: less than body
requirements. Finger foods that are high in nutritious
calories and easily portable will decrease the risk of
altered nutrition.
B, C and D.
While nutritious, these foods are not portable and
would not be suitable for a patient with bipolar
disorder, manic phase.
96. A pregnant woman who has abruption placentae has
an emergency cesarean section under general anesthesia.
Which of the following measures should be the patient’s care
in the recovery room?
A. Maintaining the patient in left lateral Sim’s position
B. Observing the patient for manifestation of infection
C. Checking the characteristics of the patient’s lochia
D. Assessing the patient for a positive Homans’ sign
Key: C Client Need: Psychosocial Integrity
C. Lochial flow should be assessed for amount,
odor and presence of clots in the early postpartum
period.
A. A fresh postoperative patient should not be
placed in the left lateral Sim’s position because it puts
pressure on the new incision line.
B. An assessment of signs and symptoms of
infection should be completed, but is not part of the
initial postpartum assessment in the recovery room.
D. Homans’ sign generally should be assessed
in the postpartum period; however, this patient had
general anesthesia and will be unable to state
whether or not she has call pain.
97. Which of the following behavior by a patient who has
schizophrenia indicates impaired judgment?
A. Spending money on a new television instead of
paying the electric bill
B. Staying up all night to care for a sick child
C. Going outside in the rain to help a neighbor change a
tire
D. Leaving escaping from a house that has caught on
fire
Key: A Client Need: Psychosocial Integrity
A. Not only is the patient demonstrating poor
judgment by making a socially irresponsible choice
(not paying the electric bill), the patient will not be
able to watch the new television if the electricity is
turned off due to nonpayment of the bill. The patient
shows poor judgment because he/she was not able to
reach a logical decision after analyzing the possible
consequences of the choice.
B, C and D.
These examples show involvement in activities and
relationships that are healthy behavior. The person
shows good judgment by making socially responsible
choices.
98. During an in-service education session for hospital
staff, a nurse provides instruction about methods to prevent
the spread of respiratory syncytial virus (RSV) on the pediatric
unit. The nurse should stress the importance of which of the
following measures as a means of control?
A. Wearing a face entering an infected patient’s room
B. Washing hands carefully before and after patient
contact
C. Using a negative pressure air-flow system in all
patient rooms
D. Obtaining personal viral titer levels to establish
susceptibility
D. Focusing on the problems of others allows
this patient to avoid awareness of his/her own
problems.
100.A seven-year-old child who weighs 60 lb (27.6kg) is
postoperative after an appendectomy and has an order for
intravenous hydration. The child is to receive 1640 ml of
solution in 24 hours. Which using an administration set that
delivers 15 drops pr ml, how many drops per minute should a
nurse administer?
A. 17
B. 45
C. 51
D. 68
Key: A Client Need: Physiological Integrity
A. The nurse would first determine the number of
milliliters to be administered per hour by dividing the
total solution by the number of hours of
administration. To determine the flow rate of the
intravenous, multiply the number of milliliters per
hour by the number of drops per milliliter and divide
by the number of minutes in one hour.

Key: B Client Need: Health Promotion and Maintenance

B. The most important infection control
procedures to be employed when taking care of a
child with respiratory synctial virus (RSV) is consistent
hand-washing and not touching the nasal mucosa or
the conjunctiva.
A. Routine use of gowns and masks has not
been shown to be of additional benefit when caring
for the patient with RSV.
C and D.
Other isolation procedures of potential benefit are
those aimed at diminishing the number of hospital
personnel, visitors and uninfected patients in contact
with the child.

99. Four patients who are in group therapy behave in the

following ways. Which behavior would indicate that the patient
is benefiting from the therapy?

A. A depressed patient verbalizes angry feelings to

another patient.
B. A codependent patient accepts responsibility for
harmony in the group.
C. A narcissistic patient focuses on recovery.
D. A borderline personality patient recognizes the faults
of others.

Key: C Client Need: Psychosocial Integrity

C. The goal of a therapy group is for each
individual to work towards self-understanding and
more satisfactory ways of relating to and handling
stress.
A. Confrontation is used for the purpose of
making the second patient change his/her behavior to
that desired by the first patient. The first patient is
trying to elicit the support of the group to pressure
the second patient into the change. The group would
benefit the first patient by holding to the norm that
the only behavior a person has the power to change
is his/her own.
B. Taking responsibility for maintaining
harmony in the group prevents others from feeling
and dealing with the anxiety in the group. This
behavior by the codependent patient shows
preoccupation with the thoughts and feelings of
others as opposed to dealing with his/her own
behavior.
 PRACTICE TEST 8 PRACTICE TEST 8
1. B 21. D 41. C 61. A 81. C 1. B 21. D 41. C 61. A 81. C
2. A 22. B 42. C 62. D 82. B 2. A 22. B 42. C 62. D 82. B
3. A 23. B 43. B 63. B 83. D 3. A 23. B 43. B 63. B 83. D
4. D 24. B 44. B 64. A 84. D 4. D 24. B 44. B 64. A 84. D
5. C 25. D 45. B 65. C 85. D 5. C 25. D 45. B 65. C 85. D
6. C 26. B 46. D 66. C 86. D 6. C 26. B 46. D 66. C 86. D
7. A 27. A 47. A 67. B 87. C 7. A 27. A 47. A 67. B 87. C
8. D 28. B 48. A 68. A 88. C 8. D 28. B 48. A 68. A 88. C
9. B 29. D 49. C 69. D 89. D 9. B 29. D 49. C 69. D 89. D
10. B 30. B 50. D 70. A 90. B 10. B 30. B 50. D 70. A 90. B
11. A 31. D 51. D 71. D 91. D 11. A 31. D 51. D 71. D 91. D
12. B 32. A 52. C 72. C 92. A 12. B 32. A 52. C 72. C 92. A
13. A 33. B 53. A 73. D 93. A 13. A 33. B 53. A 73. D 93. A
14. D 34. A 54. B 74. B 94. A 14. D 34. A 54. B 74. B 94. A
15. A 35. B 55. C 75. A 95. A 15. A 35. B 55. C 75. A 95. A
16. B 36. A 56. A 76. D 96. C 16. B 36. A 56. A 76. D 96. C
17. A 37. C 57. A 77. C 97. A 17. A 37. C 57. A 77. C 97. A
18. C 38. A 58. B 78. B 98. B 18. C 38. A 58. B 78. B 98. B
19. A 39. C 59. A 79. C 99. C 19. A 39. C 59. A 79. C 99. C
20. A 40. B 60. B 80. A 100. A 20. A 40. B 60. B 80. A 100. A

PRACTICE TEST 8 PRACTICE TEST 8

1. B 21. D 41. C 61. A 81. C 1. B 21. D 41. C 61. A 81. C
2. A 22. B 42. C 62. D 82. B 2. A 22. B 42. C 62. D 82. B
3. A 23. B 43. B 63. B 83. D 3. A 23. B 43. B 63. B 83. D
4. D 24. B 44. B 64. A 84. D 4. D 24. B 44. B 64. A 84. D
5. C 25. D 45. B 65. C 85. D 5. C 25. D 45. B 65. C 85. D
6. C 26. B 46. D 66. C 86. D 6. C 26. B 46. D 66. C 86. D
7. A 27. A 47. A 67. B 87. C 7. A 27. A 47. A 67. B 87. C
8. D 28. B 48. A 68. A 88. C 8. D 28. B 48. A 68. A 88. C
9. B 29. D 49. C 69. D 89. D 9. B 29. D 49. C 69. D 89. D
10. B 30. B 50. D 70. A 90. B 10. B 30. B 50. D 70. A 90. B
11. A 31. D 51. D 71. D 91. D 11. A 31. D 51. D 71. D 91. D
12. B 32. A 52. C 72. C 92. A 12. B 32. A 52. C 72. C 92. A
13. A 33. B 53. A 73. D 93. A 13. A 33. B 53. A 73. D 93. A
14. D 34. A 54. B 74. B 94. A 14. D 34. A 54. B 74. B 94. A
15. A 35. B 55. C 75. A 95. A 15. A 35. B 55. C 75. A 95. A
16. B 36. A 56. A 76. D 96. C 16. B 36. A 56. A 76. D 96. C
17. A 37. C 57. A 77. C 97. A 17. A 37. C 57. A 77. C 97. A
18. C 38. A 58. B 78. B 98. B 18. C 38. A 58. B 78. B 98. B
19. A 39. C 59. A 79. C 99. C 19. A 39. C 59. A 79. C 99. C
20. A 40. B 60. B 80. A 100. A 20. A 40. B 60. B 80. A 100. A

PRACTICE TEST 8 PRACTICE TEST 8

1. B 21. D 41. C 61. A 81. C 1. B 21. D 41. C 61. A 81. C
2. A 22. B 42. C 62. D 82. B 2. A 22. B 42. C 62. D 82. B
3. A 23. B 43. B 63. B 83. D 3. A 23. B 43. B 63. B 83. D
4. D 24. B 44. B 64. A 84. D 4. D 24. B 44. B 64. A 84. D
5. C 25. D 45. B 65. C 85. D 5. C 25. D 45. B 65. C 85. D
6. C 26. B 46. D 66. C 86. D 6. C 26. B 46. D 66. C 86. D
7. A 27. A 47. A 67. B 87. C 7. A 27. A 47. A 67. B 87. C
8. D 28. B 48. A 68. A 88. C 8. D 28. B 48. A 68. A 88. C
9. B 29. D 49. C 69. D 89. D 9. B 29. D 49. C 69. D 89. D
10. B 30. B 50. D 70. A 90. B 10. B 30. B 50. D 70. A 90. B
11. A 31. D 51. D 71. D 91. D 11. A 31. D 51. D 71. D 91. D
12. B 32. A 52. C 72. C 92. A 12. B 32. A 52. C 72. C 92. A
13. A 33. B 53. A 73. D 93. A 13. A 33. B 53. A 73. D 93. A
14. D 34. A 54. B 74. B 94. A 14. D 34. A 54. B 74. B 94. A
15. A 35. B 55. C 75. A 95. A 15. A 35. B 55. C 75. A 95. A
16. B 36. A 56. A 76. D 96. C 16. B 36. A 56. A 76. D 96. C
17. A 37. C 57. A 77. C 97. A 17. A 37. C 57. A 77. C 97. A
18. C 38. A 58. B 78. B 98. B 18. C 38. A 58. B 78. B 98. B
19. A 39. C 59. A 79. C 99. C 19. A 39. C 59. A 79. C 99. C
20. A 40. B 60. B 80. A 100. A 20. A 40. B 60. B 80. A 100. A