Practice Examination One

Part OneYou will have two hours and 30 minutes to complete Part

One.1. The nurse is instructing an unlicensed assistant on how to

collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions?

A. "I will empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag. "

B. "I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container. "

C. "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container. "

D. "I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container. "

2. Linda is a 19-year-old primipara who delivered a viable male neonate 2 hours ago. She has decided to breast-feed. Her 22-year-old husband supports her decision. She tells the nurse, "My mother breast-fed all of her children, but I'm going to need lots of help with breastfeeding. I'm worried that I won't be able to do this. " Which of the following should the nurse include when assessing the client?

A. Determine the client's level of motivation to breast-feed.B. Perform a complete physical examination to determine her

need for help.C. Assess her body-to-fat ratio and nutritional status before

beginning breast-feeding.D. Ask the client if she has read any literature about breast-

feeding.3. Mrs. Cray, an African American, is admitted to the hospital

after sustaining a hip fracture. She is 5 ft. , 4 inches tall and weighs 96 lbs. She has five children and has used estrogen replacement therapies for 10 years. She told the nurse that she "just stepped forward and fell. " The results of her bone density tests indicate she has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman?

A. Her long-term use of estrogen.B. Her weight.C. Her family.D. Her race.4. The physician has ordered Oxtriphyllin (Choledyl SA) 0.2 g.

Available tablets of the medicine are 100 mg. How many tablets should be given?

A. 0.5 tablets.B. 2.0 tablets.C. 2.5 tablets.

D. 5.0 tablets.5. The nurse is instructing a client with angina about sublingual

nitroglycerin. Which of the following points should be included?A. The shelf life of nitroglycerin is long, it keeps for up to 2

years.B. Store the tablets in a tight, light-resistant container.C. Use the tablets only when the pain is severe.D. The drug will cause increased urine output.6. An agitated client demands to see his chart so that he can

read what has been written about him. Which of the following statements is the nurse's best response in this situation?

A. "I'm sorry the chart is the property of the facility. We don't permit clients to read them. "

B. "You have the right to see your chart. Please discuss this with your primary care provider. "

C. "You may see your chart after you're discharged. "D. "Please discuss this matter with your attorney. "7. Which part on the wave deflection corresponds to ventricular

muscle repolarization in the following ECG graph?

A. AB. BC. CD. D8. Nursing measures for the client who has had an MI include

helping the client to avoid activity that results in Valsalva's maneuver. Valsalva's maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure, and thrombi dislodgment. Which of the following actions would help prevent Valsalva's maneuver?

A. Have the client drink fluids through a straw.B. Have the client avoid holding her breath during activity.C. Have the client assume a side-lying position.D. Have the client clench her teeth while moving in bed.9. The parents of a 3-year-old boy call the clinic to report

chickenpox. When teaching the parents about how to care for the lesions, the nurse would advise which of the following?

A. Soak in a hot tub for 30 minutes three times a day.B. Take an antihistamine and use calamine lotion on the lesions.C. Take acetaminophen and use an antibiotic ointment on the

lesions.D. Remove lesions crusts as they form.

10. Which of the following goals would be appropriate for the client with hepatitis B?

A. The client will verbalize the importance of using sedatives to provide adequate rest.

B. The client will avoid social activities with friends after discharge from the hospital.

C. The client will adhere to measures to prevent the spread of infection to others.

D. The client will adhere to a low sodium, low protein diet.11. The nurse has assisted a multigravida with a precipitous

delivery of a viable neonate in a local grocery store. Because a precipitous delivery can lead to decreased uterine tone, which of the following nursing actions would help to prevent this complication?

A. Place the neonate on the client's fundus.B. Place the mother in a supine position.C. Encourage the mother to breast-feed the infant.D. Massage the client's fundus continuously.12. A client is prescribed 1000 mL of an antibiotic solution to be

given over 6 hours. What would be the flow rate? The infusion set administers 15 gtts/mL.

A. 28 gtts/min.B. 35 gtts/min.C. 42 gtts/min.D. 45 gtts/min.13. A primipara is under nursing care during the first hour after

a vaginal delivery of a viable neonate under lumbar epidural anesthesia and intravenous fluids. The client has a pulse rate of 65 bpm, temperature of 99.9°F (37.7℃), fundus firm at one finger breath above the midline, and a slow trickle of dark red vaginal bleeding on the perineal pad. The client's legs are still somewhat numb. What should the nurse do?

A. Discontinue the client's intravenous fluids if the client is drinking fluids.

B. Notify the anesthesiologist who performed the lumbar epidural anesthesia.

C. Massage the fundus and contact the client's physician immediately.

D. Continue to monitor the client's temperature on an hourly basis.

14. The nurse is caring for a child with leukemia. Which of the following should the nurse priority pay more attention to?

A. Preventing injury.B. Monitoring the child's platelet count.C. Monitoring the child's temperature.D. Encouraging increased fluid intake.15. During the evening shift on the day of the client's surgery,

the nurse notices that the nasogastric tube drains 500 mL of green-brown fluid. What should the nurse do?

A. Record the amount of drainage on the client's chart.

B. Irrigate the tube with normal saline solution.C. Call the physician immediately.D. Increase the intravenous infusion rate.16. The nurse is caring for a client who has generalized anxiety

disorder. Which statement is true about this client?A. The client has regular obsessions.B. Relaxation techniques and psychotherapy are necessary for

cure.C. Nightmares and flashbacks are common in individuals who

suffer from generalized anxiety disorder.D. Generalized anxiety disorder is characterized by anxiety that

lasts longer than 6 months.17. The client is taking carbamazepine (Tegretol) to treat his

trigeminal neuralgia. While preparing the client's teaching plan, which of the following instructions should the nurse include?

A. Limit physical activity while taking the drug.B. Eliminate caffeine from the diet while taking drug.C. Arrange to have a CBC drawn weekly.D. Take the drug on an empty stomach.18. A 14-month-old child returns from surgery for undescended

testicle, and his postanesthesia recovery period is uneventful. When planning for the child's discharge, which of the following goals would the nurse expect to emphasize to the parents?

A. Absence of redness or swelling at the incision site.B. Intake clear liquids well within 24 hours.C. Passage of normal bowel movement within 24 hours.D. Ability to ambulate after 48 hours.19. The nurse is preparing a gastric lavage for a comatose

victim of the car accident. Which of the following positions would be most appropriate for the client during this procedure?

A. Trendelenburg's.B. Lithotomy.C. Lateral.D. Supine.20. A 34-year-old multigravida is admitted in 36 weeks gestation

in active labor with diagnosis of Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. Which of the following can explain the yellowish fluid?

A. Amniotic fluid embolism.B. Oligohydramnios.C. Rh sensitization.D. Abnormal presentation.21. Trimethobenzamide (Tigan) 150 mg IM has been ordered to

treat a client's nausea and vomiting. The nurse has an ampule of Tigan labeled 200 mg/mL. How many mL should the nurse prepare to give the client?

A. 0.50 mL.B. 0.75 mL.

C. 1.0 mL.D. 1.5 mL.22. A client with ulcerative colitis is chatting with the nurse.

Which of the following statements indicates the client understands the lifestyle modifications he needs to make?

A. "I will have to stop smoking. "B. "I can eat popcorn for an evening snack. "C. "I may have coffee with my meals. "D. "I am allowed to have alcohol as long as I only drink wine. "23. A client is having autonomic dysreflexia. What should the

nurse do first?A. Place the client in Fowler's position.B. Send a urine sample for culture.C. Administer nitroprusside sodium (Nipride) intravenously.D. Call the physician.24. The nurse uses 30 mL of solution to irrigate a nasogastric

tube and notes that 20 mL returns promptly into the drainage container. When the nurse records the results of the irrigation, how much solution should be recorded as intake?

A. 10mL.B. 20mL.C. 30mL.D. 50mL.25. The physician prescribes clomiphene citrate (Clomid) for a

woman who has been having difficulty getting pregnant. When preparing the teaching plan for the client about this drug's potential side effects, which of the following would the nurse include in the teaching plan?

A. Increase in fibrocystic breast disease.B. Increase in congenital anomalies.C. Multiple pregnancies.D. Increase in spontaneous abortions.26. Which of the following findings is suggestive of myocardial

infarction (MI)?A. Below-normal erythrocyte sedimentation rate.B. Elevated white blood cell count.C. Elevated serum cholesterol value.D. Elevated creatine phosphokinase (CPK) value.27. A voluntary client in a health care facility decides to leave

the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?

A. False imprisonment.B. Violation of confidentiality.C. Limit setting.D. Slander.28. A client with diabetes is explaining to the nurse how he

cares for his feet at home. The nurse could judge from which of the

following statements that the client needs further instruction on how to care for his feet properly?

A. "I inspect my feet once a week for cuts and redness. "B. "I am not allowed to use a heating pad on my feet. "C. "It is important to dry my feet carefully after my bath. "D. "I should not go barefoot, even in my home. "29. A mother is discussing with the nurse her 4-year-old boy's

strange eating habits including not finishing meals and eating the same food for several days in a row. She would like to develop a plan to correct this situation. When developing such a plan, which of the following should the nurse and mother consider?

A. Deciding on a good reward for finishing the meal.B. Allowing him to make some decisions about the foods he

eats.C. Restricting the availability of foods to those served at meal

times.D. Not allowing him to leave the table until he has eaten the

food.30. As the nurse helps the client prepare for discharge, the

client says, "You know, I've been in lots of hospitals and I know when I'm sick enough to be there. I'm not that sick now. You don't need to worry about me. " Which of the following would be the most therapeutic response by the nurse?

A. "We're concerned about you. How can we help you before you leave?"

B. "We could have helped you more if you had told us more. "C. "Is there any information you need before you leave the

hospital?"D. "Okay, you know best. "31. Mr. Smith has had a cast applied to his arm as an outpatient

in the emergency room. Which of the following home care instructions should the nurse advice for his cast care?

A. Use a ruler to reach inside and scratch under the cast.B. Apply a heating pad to the arm for 24 hours after the injury.C. Use powder on the skin around the cast.D. Smell the cast for foul odors.32. Which of the following laboratory tests should be monitored

closely by the nurse while the client is receiving heparin therapy?A. International normalized ratio (INR).B. Activated partial thromboplastin time (APTT).C. Prothrombin time (PT).D. Thrombin time.33. A client asks the nurse to help her make out her will. In this

situation, what should be the nurse's best response?A. "I don't believe in getting involved in legal matters, but

maybe I can find another nurse who'll help you. "B. "You need to consult an attorney because I'm not trained in

such matters. Is there a family lawyer I can call for you?"C. "I'm not a lawyer, but I'll do what I can for you. "

D. "You have a long way to go before you'll need to do that. Let's wait on it a while, shall we?"

34. The nurse is assessing a client with an ileal conduit. She notes that the client's urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data?

A. These findings are normal for the client.B. There is irritation of the stoma.C. The client is developing an infection of the urinary tract.D. The mucus is caused by elevated levels of glucose in the

urine.35. A multigravid client in active labor is about to deliver. The

nurse has no help immediately available. What should the nurse do first?

A. Prepare a clean area on which to deliver the neonate.B. Lower the head of the bed to a flat position.C. Have the client push with a contraction.D. Ask the client to take a deep breath and hold it.36. Which of the following denotes the primary reason that the

nurse inserts an indwelling urinary (Foley) catheter in a child with severe burns?

A. Monitoring for a urinary tract infection.B. Measuring urine output accurately.C. Preventing urinary retention.D. Assessing urine specific gravity.37. Which one of the following nursing interventions should be

included in a plan of care for a client with a T tube?A. Maintain client in a supine position while T tube is in place.B. Keep T tube clamped except for during mealtimes.C. Inspect skin around the T tube daily for irritation.D. Irrigate the T tube every 4 hours to maintain patency.38. When preparing to give a neonate the first feeding by

nipple, the nurse uses a 5 mL feeding of sterile water first. Which of the following is the reason for doing so?

A. Ensure that the neonate has the energy to take oral feedings.B. Ensure that the mother will be able to feed the neonate.C. Ascertain the patency of the neonate's esophagus.D. Determine if the neonate can retain the feeding.39. The community health nurse develops a health education

program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the community residents identify which of the following activities to be high risk for acquiring hepatitis B?

A. Sharing needles for drug use.B. Ingestion of contaminated seafood.C. Frequent use of marijuana.D. Ingestion of large amounts of acetaminophen (Tylenol).40. A woman seeking help at a community mental health center

complains of fatigue, sensitivity to criticism, decreased libido, and

feeling self-conscious. She also has aches and pains. Which of the following might be a nursing diagnosis for this client?

A. Delayed growth and development.B. Ineffective role performance.C. Posttrauma syndrome.D. Chronic low self-esteem.41. Which of the following would be an appropriate expected

outcome of nursing care for the client with ulcerative colitis?A. The client experiences decreased frequency of constipation.B. The client accepts that an ileostomy will be necessary.C. The client maintains an ideal body weight.D. The client verbalizes the importance of restricting fluids.42. The nurse plans to administer an injection of heparin to a

client. Which of the following techniques for heparin administration is appropriate?

A. Selects a 1.5-inch, 21-gauge needle for the injection.B. Makes the injection into the deltoid muscle.C. Applies gentle pressure to the site for 5 to 10 seconds after

the injection.D. Aspirates with the plunger to check for entry into the blood

vessel before injecting the heparin.43. While caring for the client with a burn injury, the nurse

should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid?

A. Paralytic ileus.B. Gastric distention.C. Hiatal hernia.D. Gastrointestinal ulceration.44. When instructing the client with severe burns about proper

nutrition, the nurse would encourage him to eat which of the following meals?

A. Chicken breast, salad, iced tea.B. Roast beef sandwich, milkshake, cottage cheese.C. Hamburger, orange, coffee.D. Pasta salad, carrots, iced tea.45. Which of the following serum electrolyte levels would the

nurse expect to find in an infant with persistent vomiting?A. K+, 3.2 mEq/L; Cl-, 92 mEq/L; Na+, 120 mEq/L.B. K+, 3.4 mEq/L; Cl-, 120 mEq/L; Na+, 140 mEq/L.C. K+, 3.5 mEq/L; Cl-, 90 mEq/L; Na+, 145 mEq/L.D. K+, 5.5 mEq/L; Cl-, 110 mEq/L; Na+, 130 mEq/L.46. When helping the client who has had a cerebrovascular

accident (CVA) learn self-care skills, the nurse should use which of the following interventions to help him learn to dress himself?

A. Encourage the client to wear clothing designed especially for people who have had a CVA.

B. Dress the client, explaining each step of the process as it is completed.

C. Teach the client to put on clothing on the affected side first.

D. Encourage the client to ask his wife for help when dressing.47. A client with heart failure loses 3.2 kg while hospitalized.

Approximately how many pounds has the client lost?A. 1 pound.B. 3 pounds.C. 5 pounds.D. 7 pounds.48. The client delivers a viable male neonate who is given a

score of 9 at 5 minutes on the Apgar rating system. The client asks the nurse what it means. The nurse interprets this finding as indicating that the neonate's physical condition is which of the following?

A. Good.B. Fair.C. Poor.D. Critical.49. In providing discharge teaching for the client after a

modified radical mastectomy, the nurse should instruct the client that she might need to modify or avoid which of the following activities?

A. Shampooing her dog.B. Caring for her tropical fish.C. Working in her rose garden.D. Taking a late-evening swim.50. A priority nursing diagnosis during the first 24 hours

following an MI isA. Ineffective cardiac tissue perfusion.B. Risk for infection.C. Deficient fluid volume.D. Constipation.51. The client exhibits signs of sleep disturbance. Which

intervention should the nurse try first?A. Administer sleeping medication before bedtime.B. Provide the client with normal sleep aids, such as pillows,

back rubs, and snacks.C. Ask the client each morning to describe the quality of sleep

during the previous night.D. Teach the client relaxation techniques, such as guided

imagery, meditation, and progressive muscle relaxation.52. Which of the following health-promoting activities should the

nurse teach the client with a new laryngectomy?A. Cleanse the mouth three times a day.B. Avoid taking tub baths.C. Develop an aggressive program of exercise to increase

airway functioning.D. Dehumidify the air for comfort.53. A primigravida at 28 weeks' gestation is admitted with a

diagnosis of preterm labor. The client's contractions are occurring

every 15 to 20 minutes, lasting 25 seconds. The membranes are intact. What should the nurse do?

A. Request assistance from the neonatal resuscitation team.B. Place the client on bed rest on her left side.C. Obtain equipment for an amniotomy.D. Prepare terbutaline in an intravenous solution of normal

saline.54. A client has been placed on levodopa to treat his Parkinson's

disease. Which of the following is a common side effect of levodopa that the nurse should include in the client's teaching plan?

A. Pancytopenia.B. Peptic ulcer.C. Orthostatic hypotension.D. Weight loss.55. The head nurse is observing a new graduate nurse instill eye

drops into a client's eyes. The head nurse evaluates that the new graduate is using appropriate technique when which of the following steps is incorporated into the procedure?

A. The client is instructed to apply pressure to the eyes after instillation of the eye drops.

B. The nurse's hand is stabilized on the client's forehead while instilling the drops.

C. The medication is placed onto the client's sclera.D. The client is instructed to look at the nurse while the drops

are being instilled.56. One-year-old Susan, the second child to have sickle cell

disease in a family of five children, is admitted to the hospital with sickle cell crisis. When preparing the plan of care for her, which of the following treatments would the nurse most likely expect to include in the plan?

A. Intravenous fluid therapy.B. Fast-acting anticoagulant therapy.C. Parenteral iron therapy.D. Exchange transfusion.57. The correct procedure for auscultating the client's abdomen

for bowel sounds would includeA. palpating the abdomen first to determine correct stethoscope

placement.B. encouraging the client to cough to stimulate movement of

fluid and air through the abdomen.C. placing the client on the left side to aid auscultation.D. listening for 5 minutes in all four quadrants to confirm

absence of bowel sounds.58. Assertive behavior involves which of the following elements?A. Expressing an air of superiority.B. Saying what is on your mind at the expense of others.C. Avoiding unpleasant situations and circumstances.D. Standing up for your rights while respecting the rights of

others.

59. While suctioning a client's laryngectomy tube, the nurse should insert the catheter

A. about 1 to 2 inches.B. as the client exhales.C. until resistance is met, then withdraw it 1 to 2 cm.D. until the client begins coughing.60. David, a hyperkinetic 5-year-old, exhibits signs of extreme

restlessness, short attention span, and impulsiveness. In order to alter the child's milieu that would likely be most therapeutic for him, what could the nurse do?

A. Define behaviors of the child that will be acceptable and those that will be unacceptable.

B. Allow the child freedom to choose activities in which to participate and other children with whom to associate.

C. Increase the child's sensory stimulation and activity.D. Limit the child's opportunities to display anger and

frustration.61. The most significant sign of acute renal failure isA. elevated body temperature.B. increased blood pressure.C. decreased urine output.D. increased urine specific gravity.62. An adolescent is admitted to the hospital for headaches. She

approaches the nurse and confides that she is being sexually abused by a family friend. Which of the following would be the nurse's best initial response?

A. "Can you tell me what happened?"B. "I believe you; you were right to tell me. "C. "Have you told your mother and father about this?"D. "Who else have you told about this?"63. The client is taking medication to control his cancer pain.

Which of the following statements indicates that the client needs further instruction?

A. "I should take my medication around-the-clock to control my pain. "

B. "I should skip doses periodically so I don't get hooked on my drugs. "

C. "It is okay to take my pain medication even if I am not having any pain. "

D. "I should contact the oncology nurse if my pain is not effectively controlled. "

64. Which of the following interventions will assist the client in taking phenytoin as prescribed?

A. Calling him daily for the first week after hospital discharge.B. Having a family member monitor him to ensure compliance.C. Providing him with written and verbal instructions about the

medicine.D. Emphasizing that embarrassing seizures may occur again if

he does not take the medicine.

65. A client is taking chlorpropamide (Diabenese). Which of the following side effects should be nurse expect from the medication?

A. Hypoglycemia.B. Oral candidiasis.C. Dumping syndrome.D. Extrapyramidal symptoms.66. A pregnant client with premature rupture of the membranes

has had contractions every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring. The nurse discusses with the client about preterm labor symptoms. Which of the following statements made by the client indicates that she needs further instruction?

A. "I should report contractions that occur every 10 minutes in 1 hour. "

B. "I should lie in bed on my left side if contractions begin. "C. "I should call the doctor if my contractions occur every hour

for 6 hours. "D. "If I start having contractions, I should empty my bladder. "67. A client with a seizure disorder has been prescribed

phenytoin (Dilantin). Which of the following should the nurse include in the teaching plan?

A. It will be necessary for the client to take potassium supplements to prevent hypokalemia.

B. The client should use a soft toothbrush and floss teeth daily.C. The use of phenytoin can lead to the development of

diabetes.D. It is appropriate to substitute various brands of phenytoin as

long as the dosage is the same.68. During the assessment stage, a client with schizophrenia

leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his action?

A. Somatic delusions.B. Waxy flexibility.C. Neologisms.D. Nihilistic delusions.69. An unconscious client has been admitted with a head injury.

Which of the following nursing diagnoses would receive the greatest priority in the plan of care?

A. Disturbed sensory perception related to decreased level of consciousness.

B. Ineffective airway clearance related to inability to remove respiratory secretions.

C. Impaired gas exchange related to shallow irregular breathing.D. Risk for injury related to disorientation and decreased level of

consciousness.70. Antipsyehotie medications may cause which of the following

adverse effects?A. Increased production of insulin.B. Lower seizure threshold.

C. Increased coagulation time.D. Increased risk of heart failure.71. The nurse would evaluate that the client understands his

home care instructions after scleral buckling for a detached retina if the client says which of the following statements?

A. "I should avoid abrupt movements of the head. "B. "I should exercise the eye muscles each day. "C. "I should turn the entire head rather than just the eyes for

sight. "D. "I should avoid activities requiring good depth perception. "72. A 10-month-old girl with bronchitis is taken out of the 30%

oxygen tent for breakfast because she refuses to eat unless in a high chair. During the feeding, the nurse notes that the child's respiratory rate has increased, she is becoming more irritable, and she is using accessory muscles to breathe. Which of the following should be the nurse's first action?

A. Perform postural drainage then complete the feeding.B. Suction the child's nose with a bulb syringe.C. Discontinue the feeding and place the child back in the tent.D. Assess the pulse rate and respirations and notify the

physician.73. A client is at risk for developing a pressure ulcer. The first

warning of an impending pressure ulcer is when pressure applied to skin it turns

A. whitish.B. yellowish.C. bluish.D. reddish.74. The nurse is caring for a client in an acute manic state.

What's the most effective nursing action for this client?A. Assigning him to group activities.B. Reducing his stimulation.C. Assisting him with self-care.D. Helping him express his feelings.75. During a home visit 4 days after delivery, the breast-feeding

client tells the nurse that her breasts are hard and tender. The nurse suspects breast engorgement. Which of the following action should the nurse instruct the client to do?

A. Take a moderately strong analgesic after the infant breast-feeds on both sides.

B. Use her hand or a pump to express a small amount of breast milk before breast-feeding.

C. Discontinue breast-feeding immediately and replace it with bottle-feeding during the night.

D. Apply ice packs to the breasts for 20 minutes just before breast-feeding the newborn.

76. Which of the following symptoms would indicate that a client is at risk for autonomic dysreflexia?

A. Sudden, severe hypertension.

B. Hot, dry skin.C. Paralytic ileus.D. Bradycardia.77. Which of the following signs or symptoms would the nurse

expect to see in a client with pancreatitis?A. Bradycardia.B. Hypertension.C. Decreased white blood cell count.D. Left upper quadrant abdominal pain.78. A 24-year-old primipara decides to breast-feed her baby but

says, "I'm worried that I won't be able to breast-feed my baby because my breasts are so small. " Which of the following is appropriate response by the nurse?

A. Because her breasts are small, she will have to feed the baby more often.

B. Breast size poses no influence on a woman's ability to breast-feed a baby.

C. Breast milk can be enhanced by occasional formula feeding.D. The woman's motivation to breast-feed is less important than

breast size.79. A client has had a total gastrectomy for gastric cancer.

Which one of the following is the most appropriate expected outcomes about nutrition?

A. The client will learn to self-administer enteral feedings every 4 hours.

B. The client will maintain adequate nutrition through oral or parenteral feedings.

C. The client will regain any weight lost within 4 weeks of the surgical procedure.

D. The client will eat three full meals a day without experiencing gastric complications.

80. The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of the following?

A. The client is responding to the antipsychotic.B. The client may be experiencing increased energy and is at an

increased risk for suicide.C. The client is ready to be discharged from treatment.D. The client is experiencing a split personality.81. The development of laryngeal cancer is most clearly linked

to which of the following factors?A. High-fat, low-fiber diet.B. Alcohol and tobacco use.C. Low socioeconomic status.D. Overuse of artificial sweeteners.82. A preschool-aged child who is hospitalized with

gastroenteritis has been NPO. The physician has written an order to advance the diet as tolerated. Which of the following food is the

most appropriate for the first feeding the nurse should offer the child?

A. Clear lemon carbonated beverage.B. Toast.C. Cooked cereal.D. Ice cream shake.83. Mrs. S with preterm labor will be under Terbutaline

(Brethine) therapy. Before beginning the therapy, which of the following assessments would be most important?

A. Estimated fetal size.B. Maternal heart rate.C. Contraction intensity.D. Deep tendon reflexes.84. The nurse is evaluating a client's lung sounds. Which of the

following breath sounds indicate adequate ventilation when auscultated over the lung fields?

A. Vesicular.B. Bronchial.C. Bronchovesicular.D. Adventitious.85. The client experiences a wound evisceration on day 2 after

the abdominal hysterectomy. What should the nurse immediately do?

A. Approximate the wound edges by applying strips of adhesive over the wound.

B. Cover the exposed tissues with sterile dressings moistened with normal saline solution.

C. Replace the abdominal contents into the wound carefully while wearing gloves.

D. Apply a loose-fitting sterile abdominal binder over the wound.86. A client with iron-deficiency anemia is prescribed liquid iron

supplements. The nurse teaches the client's about how to take this drug. Which of the following statements by the client indicates that the education is effective?

A. "I will report any black stools to the physician. "B. "I will dilute the medication and drink it with a straw. "C. "I will check my gums for any bleeding. "D. "I can use antidiarrheal drugs if I develop diarrhea. "87. Three weeks after the application of the spica cast following

surgery for an infant, the mother told the nurse that the infant's toes are swollen and cool to the touch. Which of the following would the nurses suspect?

A. Cotton wadding lining of the cast has shrunk.B. An infection has developed under the cast.C. Child's feet were in a dependent position.D. Child has outgrown the spica cast.88. The nurse is developing a discharge plan for a client who

had cataract removal. Which of the following should be included in the discharge plan?

A. Wear cataract glasses that correct vision by magnifying objects.

B. Wear corrective glasses or contact lenses.C. Wear glasses only until the eye heals.D. Relearn to judge distances accurately.89. A client has a diagnosis of borderline personality disorder.

She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?

A. Provide an unstructured environment for the client.B. Rotate the nurses who are assigned to the client.C. Ignore the client's behaviors.D. Bend unit rules to meet the client's needs.90. Mrs. Wilson, a primigravida, was admitted to the hospital at

12 weeks' gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse determines that the client is most likely experiencing which of the following types of abortion?

A. Complete.B. Threatened.C. Inevitable.D. Missed.91. The nurse is assessing a 15-year-old female who is being

admitted for treatment of anorexia nervosa. Which of the following clinical manifestation is the nurse most likely to find from the client?

A. Tachycardia.B. Coarse hair growth.C. Parotid gland tenderness.D. Warm, flushed extremities.92. The nurse evaluates the client's understanding of

myasthenia gravis. The nurse would judge that the client has formed a realistic concept of her condition when she says

A. "By taking medication and pacing activities, I will live longer, but ultimately the disease will cause my death. "

B. "By taking medication and pacing activities, my fatigue will be relieved, but I should expect occasional periods of muscle weakness. "

C. "By taking medication and pacing activities, my symptoms will be controlled and eventually the disease will be cured. "

D. "By taking medication and pacing activities, I should be able to control the disease and enjoy a healthy lifestyle. "

93. Which of the following interventions would likely be most effective for the client to use at home when managing the discomfort of rhinoplasty the initial 2 days after surgery?

A. Applying ice compresses.B. Applying warm, moist compresses.

C. Lying in a prone position.D. Blowing the nose gently.94. A community nurse is performing a physical assessment on

an 18-month-old child. Which of the following would be best?A. Carry out the assessment from head to toe.B. Assess motor function by having the child run and walk.C. Have the mother hold the toddler on her lap.D. Assess the respiratory and cardiac systems first.95. After abdominal surgery, a client is reluctant to turn in bed.

Which of the following interventions would be most appropriate?A. Remind her that she must follow her doctor's orders.B. Tell her family to encourage her to turn.C. Allow the client to turn when she wants.D. Explain the importance of turning to the client.96. Which of the following is the single most reliable indicator of

the existence and intensity of acute pain?A. The client's vital signs.B. The client's self-report of pain.C. The nurse's assessment of the client.D. The severity of the condition causing the pain.97. When developing a teaching plan for the mother of a child

diagnosed with spastic cerebral palsy, which of the following descriptions would the nurse include?

A. Wide-based gait and poor muscle coordination.B. Tremors and lack of active movement.C. Increased muscle tone and stretch reflexes.D. Slow, wormlike writhing movements.98. The nurse is caring for a client with late-stage Alzheimer's

disease. The client's wife tells the nurse that the client has become very dependent. The client's wife feels guilty if she takes any time for herself because the client cries out for her. The nurse should develop which outcome to assist the client's wife?

A. The caregiver learns to explain to the client why she needs time for herself.

B. The caregiver distinguishes obligations she must fulfill from those that can be controlled or limited.

C. The caregiver leaves the client at home alone for short periods of time to encourage independence.

D. The caregiver avoids asking other family members to help for fear of imposing on them.

99. Which of the following is an early sign of laryngeal cancer?A. Difficulty swallowing.B. Chronic foul breath.C. Persistent mild hoarseness.D. Nagging unproductive cough.100. The most common symptom associated with bladder

cancer isA. burning on urination.B. frequent infections.

C. painless hematuria.D. decreasing urine output.101. The nurse is caring for several clients who have eating

disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients?

A. By their teeth.B. By body size and weight.C. By looking for Mallory-Weiss tears.D. The clients are indistinguishable upon physical examination.102. Which of the following nursing diagnoses would be most

appropriate when teaching the mother of a toddler?A. Activity intolerance.B. Risk for injury.C. Delayed growth and development.D. Impaired mobility.103. Which of the following interventions would be most helpful

in preventing pressure ulcer formation in at-risk client?A. Massaging reddened areas on the sacrum.B. Ensuring a generous fluid intake.C. Repositioning every hour.D. Providing a low protein diet.104. The nurse is planning a genetic counseling with the parents

of a child with Down syndrome, which of the following would the nurse include as the primary role of the genetic team when working with a family?

A. Preparing the parents psychologically for the birth of a defective child.

B. Prescribing birth control or abortion measures for the parents as needed.

C. Providing parents with information about the risks of birth defects.

D. Reporting the findings of chromosome analysis of the amniotic cells.

105. A client has had a cerebrovascular accident (CVA). Because the CVA affected the left side of the client's brain, the nurse should anticipate that the client would most likely experience

A. dyslexia.B. apraxia.C. agnosia.D. expressive aphasia.106. The client with a lumbar laminectomy asks to be turned

onto his side. What should the nurse do?A. Inform the client that because of his laminectomy, he may

only lie supine.B. Ask the client to help by using an overhead trapeze to turn

himself.C. Turn the client's shoulders first, followed by his hips and legs.D. Get another nurse to help log roll the client into position.

107. While managing the separation anxiety during hospitalization for a two-year-old boy, which of the following suggestions would be most helpful to the parents?

A. Tell the child the time they are leaving and returning.B. Bring the child's favorite toys from home.C. Leave while the child is sleeping.D. Keep the visit time short.108. Which of the following is of the nurse's the primary concern

for a client after cataract removal surgery?A. The client states her vision is clear.B. The client states her infection is under control.C. The client states she is able to administer parenteral pain

medication.D. The client describes methods to prevent an increase in

intraocular pressure.109. The mother of a child with flat feet asks the nurse why her

child needs to wear corrective shoes. Which of the following is the most appropriate reason that the child needs to wear corrective shoes?

A. Preventing the development of internal tibial torsion.B. Strengthening the arches of the feet.C. Keeping the legs in proper alignment.D. Delaying the development of femoral anteversion.110. The nurse administers a preoperative intramuscular

medication at the ventrogluteal site. The nurse will inject the medication into which muscle?

A. Rectus femoris.B. Gluteus maximus.C. Gluteus minimus.D. Vastus lateralis.111. The nurse would plan to use an abduction pillow (or splint)

after a total hip replacement. What is the purpose for this activity?A. To prevent hip flexion.B. To prevent dislocation of the prosthesis.C. To increase peripheral circulation.D. To decrease formation of sacral pressure ulcers.112. When caring for an adolescent client diagnosed with

depression, the nurse should remember that depression manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include which of the following?

A. Helplessness, hopelessness, hypersomnolence, and anorexia.B. Truancy, a change of friends, social withdrawal, and

oppositional behavior.C. Curfew breaking, stealing from family members, truancy, and

oppositional behavior.D. Hypersomnolence, obsession with body image, and valuing of

peers' opinions.

113. Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?

A. Monitoring intake and output.B. Allowing the infant to rest undisturbed.C. Providing age-appropriate diversionary activities.D. Initiating oral feedings.114. Susan is an adolescent client with pregnancy-induced

hypertension (PIH). The physician orders 5% dextrose in Ringer's solution and magnesium sulfate intravenously for her. Before the magnesium sulfate is administered, which of the following assessments would be the priority?

A. Maternal urinary output.B. Fetal position.C. Fetal heart rate variability.D. Maternal respiratory rate.115. To encourage adequate nutritional intake for a client with

Alzheimer's disease, what should the nurse do?A. Stay with the client and encourage him to eat.B. Help the client fill out his menu.C. Give the client privacy during meals.D. Fill out the menu for the client.116. The nurse is evaluating the effectiveness of airway

suctioning. Which of the following outcome criteria is most appropriate?

A. Respirations unlabored.B. Decreased mucus production.C. Hollow sound on chest percussion.D. Breath sounds clear on auscultation.117. A client with rheumatoid arthritis has been taking large

doses of aspirin to relieve her joint pain. The nurse should assess the client for which important symptom of aspirin toxicity?

A. Chest pain.B. Drowsiness.C. Dysuria.D. Tinnitus.118. The nurse plans to teach a client who is receiving radiation

therapy how to care for his skin at home. Which of the following should be included in the nurse's instructions?

A. "Apply a heating pad to the area to relieve pain. "B. "Keep the area covered when you go outdoors. "C. "You may use deodorant soap if you wish to cleanse the area.

"D. "Put baby oil on the area after each treatment to keep it from

getting dry. "119. Lily, a 23-month-old, pulled a pan of hot water off the stove

and spilled it onto her chest and arms. Her mother was right there when it happened. Which of the following is the most appropriate that the mother should have done immediately?

A. Call the neighbor to come over and help her.B. Place the child in the bathtub of cool water.C. Apply antibiotic ointment to the burned areas.D. Apply ice directly to the burned areas.120. A client with diverticulitis is treated as an outpatient with

drug therapy. Which of the following medication would most probably be included in the drug therapy?

A. Broad-spectrum antibiotics.B. Opioid analgesics.C. Tranquilizers.D. Laxatives.121. Emergency restraints or seclusion may be implemented

without a physician's order under which of the following conditions?A. When a written order will be obtained from the primary

physician within 1 hour.B. If a voluntary client wants to leave against medical advice.C. When a minor child is out of control.D. Never.122. The nurse noticed that an 8-month-old child's posterior

fontanel is slightly open. Which of the following should the nurse do next?

A. Check the child's head circumference.B. Question the mother about the child's delivery.C. Schedule an X-ray of the child's head.D. Document this as a normal finding.123. The client is advised by the physician to have

mammography screening annually. Which of the following is the best measure to improve adherence with mammography screening?

A. Making sure that the individual barriers to screening are minimized.

B. Emphasizing that mammography screening can prevent breast cancer.

C. Emphasizing that mammography screening is a low-cost approach to cancer prevention.

D. Informing the client that she is at high risk for breast cancer and needs to follow the physician's recommendation.

124. Which of the following symptoms would the nurse most likely observe in a client with cholecystitis from cholelithiasis?

A. Black stools.B. Decreased white blood cell count.C. Nausea after ingestion of high-fat foods.D. Elevated temperature of 103°F(39.4℃).125. Mrs. Brown, who is breast-feeding, asks the nurse if she

should supplement breast- feeding with formula feeding. The nurse bases the response on which of the following?

A. Formula feeding should be avoided to prevent interfering with the breast milk supply.

B. Primarily, water supplements should be used to prevent jaundice.

C. Formula supplements can provide nutrients not found in breast milk.

D. More vigorous sucking is needed for a bottle-feeding, so supplements should be avoided.

126. Discharge instructions for clients receiving tricyclic antidepressants include which of the following information?

A. Don't consume alcohol.B. Restrict fluid and sodium intake.C. It's safe to continue taking during pregnancy.D. Discontinue if dry mouth and blurred vision occur.127. A pregnant client is admitted to the hospital at 34 weeks

gestation and is receiving intravenous tocolytic therapy for preterm labor. The physician orders betamethasone (Celestone) intramuscularly for her. After administering the drug, the nurse would assess the client for which of the following as a possible side effect?

A. Decreased skin turgor.B. Infection.C. Urinary frequency.D. Hypoglycemia.128. Which of the following techniques is appropriate for

irrigating an adult client's ear to move cerumen?A. After instilling the solution, pack the ear canal tightly with

cotton pledgets.B. Allow the irrigating solution to run down the wall of the ear

canal.C. The irrigating solution should be cool.D. Use sterile solution and equipment.129. Pancrelipase (Viokase), an enzyme replacement, has been

prescribed for a client with chronic pancreatitis. The nurse evaluates the client's understanding of how to take this drug. Which of the following statements indicates the client has adequate knowledge?

A. "The enzyme mixture should be taken after each meal. "B. "The enzyme mixture should be stored in the refrigerator to

keep it fresh. "C. "I should be careful not to inhale the powder when mixing it

with food. "D. "I should chew the capsule thoroughly. "130. A client is suffering from short-term memory loss after a

head injury. Which of the following nursing actions would be appropriate to help him cope with his memory loss?

A. Instruct family members to ignore his behavior.B. Place a single-date calendar where he can view it.C. Explain that he will have to try harder to remember things.D. Tell him every morning what activities he will be expected to

perform that day.131. The mother of a new-born asks the nurse how often she

should breastfeed her baby. Which of the following responses by the nurse would be best?

A. "Newborns should breastfed at least every 3 hours during the day. "

B. "Newborns should be fed when they cry. "C. "As long as the baby feeds four times a day, he will get

enough. "D. "Newborns may breastfeed continuously until they stabilize. "132. At an outpatient clinic, a client asks the nurse how she can

prepare for pregnancy. Which of the following responses by the nurse would be best?

A. "Begin an iron supplement of 100 mg daily. "B. "Supplement your diet with 400 meg of folio acid. "C. "Avoid raw eggs and cats until conception. "D. "Receive immunization against toxoplasmosis. "133. A 9-year-old child is in diabetes. The nurse offers to meet

with the mother and the child's teacher before school to discuss the teacher's responsibilities in relation to the child's diabetes. Which of the following would the nurse expect to discuss in this meeting?

A. How to perform a glucometer test.B. How to give an insulin injection.C. Signs and symptoms of hypoglycemia.D. The American Diabetic Association (ADA) diet.134. The nurse is caring for a client in the first 4 weeks of

pregnancy. The nurse should expect to collect which assessment findings?

A. Presence of menses.B. Uterine enlargement.C. Breast sensitivity.D. Fetal heart tones.135. A client is prescribed Gentamycin (Garamycin) IV to treat

infection. It is important to monitor the client for the development of which of the following side effects from the medication?

A. Ascites.B. Confusion.C. Ototoxicity.D. Cardiac dysrhythmias.136. A client with a retinal detachment does not understand

what happened to his eye and asks the nurse's explanation. Which of the following would be the nurse's best response to describe the pathology of retinal detachment?

A. "The optic nerve is damaged when it is exposed to vitreous humor. "

B. "A tear in the retina permits the escape of vitreous humor from the eye. "

C. "The two layers of the retina separate, allowing fluid to enter between them. "

D. "Retinal injury produces inflammation and edema that increase intraoeular pressure. "

137. A young man is remanded by the courts for psychiatric treatment. From his police record the nurse notices that the client

has records of delinquency, running away, auto theft, and vandalism in his early teenage years. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping. Which of the following problems is most associated with maladaptive coping?

A. Antisocial personality disorder.B. Borderline personality disorder.C. Obsessive-compulsive personality disorder.D. Narcissistic personality disorder.138. A client is admitted to the labor and delivery department in

preterm labor. To help manage preterm labor the nurse would expect to administer which of the following medication?

A. Ritodrine (Yutopar).B. Bromocriptine (Parlodel).C. Betamethasone (Celestone).D. Magnesium sulfate.139. The mother of a 3-year-old calls the emergency room nurse

at 3.00 AM and reports her child has a temperature of 101.1°F (38.4℃), a runny nose, and a barky cough that "gets going and won't stop. " The mother states that she just gave the child acetaminophen (Tylenol). Which of the following should the nurse recommend next?

A. Giving the child an over-the-counter decongestant.B. Administering aspirin in 2 hours.C. Sitting with the child in a steamy warm bathroom.D. Running a steam vaporizer near the child's bedside.140. A pregnant client who is diabetic is at risk for having a

large-for-gestational-age infant because of which of the following?A. Excess sugar causing reduced placental functioning.B. Insulin acting as a growth hormone on the fetus.C. Maternal dietary intake of high calories.D. Excess insulin reducing placental functioning.141. The nurse at a substance abuse center answers the phone.

A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here. " Which of the following statements best describes the nurse's response?

A. Correct because she didn't give out information about the client.

B. A breech of the principle of veracity because the nurse is misleading the officer.

C. Illegal because she's withholding information from law enforcement agents.

D. A violation of confidentiality because she informed the officer that the client wasn't there.

142. A mother of an ill child tells the nurse that her child "isn't eating well. " Which of the following strategies devised by the mother to help increase the child's intake is not appropriate?

A. Asking the child to say why he is not eating.B. Telling the child he must eat or else he will not get better.

C. Allowing the child to choose his meals from an acceptable list of foods.

D. Letting the child to substitute items on his tray for other nutritious foods.

143. An infant is admitted to the hospital because of having frequent diarrheal stools with acute rotaviral infection. The nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor, and the mucous membranes are dry. The nurse would make a nursing diagnosis of Deficient fluid volume related to

A. insufficient antidiuretic hormone.B. inability to metabolize nutrients.C. decreased gastric emptying.D. increased gastrointestinal motility.144. The client with a head injury receives mannitol (Osmitrol)

during surgery to help decrease intracranial pressure. Which of the following nursing observations would most likely indicate that the drug is having the desired effect?

A. Urine output increases.B. Pulse rate decreases.C. Blood pressure decreases.D. Muscular relaxation increases.145. The nurse instructs the female client concerning hormone

replacement therapy for menopausal symptoms. Which of the following points should the nurse include in the client's teaching plan?

A. Estrogen therapy eliminates the need for supplemental calcium intake.

B. Estrogen therapy can reduce the risk of menopausal bone loss.

C. The risk of uterine cancer is decreased after menopause.D. Smoking is associated with a later onset of menopause.146. While a client with hypertension is being assessed, he says

to the nurse, "I really don't know why I'm here. I feel fine and haven't had any symptoms. " Which of the following would be the nurse's best response?

A. "Symptoms of hypertension are often not present. "B. "Symptoms of hypertension signify a high risk of stroke. "C. "Symptoms of hypertension occur only with malignant

hypertension. "D. "Symptoms of hypertension appear after irreversible kidney

damage has occurred. "147. Which of the following fluid and electrolyte imbalances

would the nurse anticipate that the client would be particularly susceptible to in the emergent phase of burn care?

A. Metabolic alkalosis.B. Hemodilution.C. Hypernatremia.D. Hyperkalemia.

148. A client who has stress incontinence has been given a pamphlet that describes Kegel exercises. Which of the following statements indicates that the client has understood the instructions in the pamphlet?

A. "It will probably take a year before the exercises are effective. "

B. "I should perform these exercises every evening. "C. "I can do these exercises sitting up, lying down, or standing. "D. "I need to tighten my abdominal muscles to do these

exercises correctly. "149. Positive symptoms of schizophrenia include which of the

following?A. Waxy flexibility, alogia, and apathy.B. Flat affect, avolition, and anhedonia.C. Hallucinations, delusions, and disorganized thinking.D. Somatic delusions, echolalia, and a flat affect.150. A multigravida at 37 weeks' gestation tells the nurse that

she has frequent heartburn. The nurse teaches the client with suggestions for obtaining relief from the heartburn. Which of the following statements by the patient indicates that she has understood the nurse's instructions?

A. "I can take a teaspoon of baking soda in water occasionally. "B. "I should eat only three large meals and drink plenty of fluids.

"C. "It's all right for me to have a fried hamburger and fries. "D. "I should eat smaller, more frequent meals with fluids. "Part TwoYou will have one hour and 50 minutes to complete Part

Two.151. Which of the following is the nurse's goal in crisis

intervention?A. To provide medication to sedate the client.B. To provide nondirective techniques such as free association.C. To provide problem-solving techniques and structured

activities.D. To provide an insight-oriented analytic approach.152. The client with benign prostatic hypertrophy is prepared for

admission to the hospital Which of the following information reported by the emergency room nurse would be most helpful to the nurse responsible for admitting the client?

A. "A urine specimen was obtained from the client and sent to the laboratory for analysis. "

B. "The client was catheterized, and 1100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory. "

C. "The client is very cooperative. He is comfortable now that his bladder has been emptied. He had no ill effects from catheterization. "

D. "The client was in the emergency room for 3 hours because of bladder distention. He is fine now but is being admitted as a possible candidate for surgery. "

153. Nitroglycerin is also available in ointment or paste form. Before applying nitroglycerin ointment, what should the nurse do first?

A. Cleanse the skin with alcohol where the ointment will be placed.

B. Obtain the client's pulse rate and rhythm.C. Remove the ointment previously applied."D. Instruct the client to expect pain relief in the next 15

minutes.154. The nurse is making a plan of care for the child with

juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising. Which of the following interventions would be included in the plan?

A. Awakening the child once nightly to exercise the joints.B. Having the child sleep in a sleeping bag.C. Having the child sleep with the joints flexed.D. Increasing pain medication at bedtime.155. A client has just expelled a hydatidiform mole. She's visibly

upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response?

A. "I can see you're upset. Why don't we discuss this with you at a later time when you're feeling better. "

B. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again. "

C. "Let me check with your physician and get you something that will help you relax. "

D. "Pregnancy should be avoided until all of your testing is normal. "

156. The nurse is caring for a client after a closed renal biopsy. Which of the following nursing measures should be included in the plan of care?

A. Maintaining the client on strict bed rest in a supine position for 6 hours.

B. Administering intravenous narcotic medications to promote comfort.

C. Inserting an indwelling catheter to monitor urine output.D. Applying a sandbag to the biopsy site to prevent bleeding.157. In caring for the client with hepatitis B, which of the

following situations would most likely expose the nurse to the virus?A. Contact with fecal material.B. A blood splash into the nurse's eyes.C. Disposing of syringes and needles without recapping.D. Touching the client's arm with ungloved hands while taking

blood pressure.

158. During a conversation with the client, the nurse observes the client shaking his leg and tapping his fingers on the table next to him. The nurse's best statement is.

A. "I'll get you something to help you feel less anxious. "B. "I know that you feel anxious. Let's discuss something more

pleasant. "C. "I see that you're anxious. I'll be back later when you're

calmer. "D. "I noticed that your leg is shaking and you're tapping your

fingers on the table. How are you feeling now?"159. A client with cirrhosis should be encouraged to follow which

of the following diet regime?A. High-calorie, restricted protein, low-sodium diet.B. Bland, low-protein, low-sodium diet.C. Well-balanced normal nutrients, low-sodium diet.D. High-protein, high-calorie, high-potassium diet.160. A client receiving morphine for long-term pain

management develops tolerance. When the client asks the nurse what it means, which of the following should the nurse response?

A. "Tolerance is an allergic reaction to a medication. "B. "Tolerance is an ability to take the same drug for extended

periods of time. "C. "Tolerance is an increased response to a medication. "D. "Tolerance is a diminished response to a drug so that more is

required to reach the same effect. "161. Which of the following signs and symptoms is classic for a

patient with rheumatoid arthritis?A. Joint swelling, joint stiffness in the morning, and bilateral joint

involvement.B. Crepitus, development of Heberden's nodes, and anemia.C. Pain on weight-bearing, rash, and low-grade fever.D. Fatigue, leukopenia, and joint pain.162. Which nursing diagnosis would the nurse anticipate as

having the highest priority for the client with gestational diabetes in labor?

A. Risk for infection related to invasive procedures during labor.B. Risk for injury to fetus related to the effects of diabetes on

uteroplacental functioning.C. Deficient knowledge related to lack of information about care

during labor.D. Interrupted family processes related to diabetes increasing

the client's risk of complications.163. A client diagnosed with schizoaffective disorder is suffering

from schizophrenia with elements of which of the following disorders?

A. Thought disorder.B. Amnestic disorder.C. Personality disorder.D. Mood disorder.

164. The parents of a neonate with a cleft lip are shocked when they see their child for the first time. In order to help the parents accept their infant's anomaly, which of the following should be included in the neonate's plan of care?

A. Reassuring them that surgery will correct the defect.B. Encouraging the parents to visit more frequently.C. Showing them pictures of babies before and after corrective

surgery.D. Allowing them to complete their grieving process before

seeing the infant again.165. A woman seeking help at a community mental health

center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. She also has aches and pains. A nursing diagnosis for this client might include

A. Delayed growth and development.B. Ineffective role performance.C. Posttrauma syndrome.D. Chronic low self-esteem.166. To obtain a good monitor tracing on a client in labor, the

mother lies on her back. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which of the following should be the nurse's first action?

A. Reposition the client to her left side.B. Immediately take the client's blood pressure and call the

physician.C. Start oxygen at 6 L via nasal cannula.D. Increase the IV fluids to correct the client's dehydration.167. A client diagnosed with tuberculosis is taking the

prescribed chemotherapy of isoniazid, rifampin, and pyrazinamide. The nurse should evaluate the client for signs of which of the following commonly occurring toxicities?

A. Ototoxicity.B. Nephrotoxicity.C. Optic neuritis.D. Hepatotoxieity.168. A client with recurred cancer is planned to take internal

radiation treatment with a radium implant. The client tells the nurse that she is concerned about being radioactive and has been having nightmares about the treatment. What would be a reasonable explanation for the nurse to give to the client?

A. "Careful shielding prevents the area above your waist from radioactivity. "

B. "These nightmares indicate that you're in the denial phase of accepting the diagnosis. "

C. "The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain. "

D. "The radioactivity will gradually decrease, and you will be discharged when the radioactive material reaches its half-life. "

169. Mr. W is with bipolar disorder, manic phase, with a nursing diagnosis of Imbalanced nutrition: less than body requirements. In order to help the client meet recommended daily allowances of nutrients, which of the following nursing interventions should be included in the plan of care?

A. Tell the client to sit alone at mealtime so that he won't be distracted by others.

B. Teach the client about proper nutrition.C. Give the client half of a meat and cheese sandwich between

meals.D. Inform the client that snacks are available only if he eats

properly at mealtime.170. In developing a plan of care for a client with rheumatoid

arthritis, the nurse should consider that clients with rheumatoid arthritis should be positioned so as to

A. prevent flexion deformities of the joints.B. decrease edema around the joints.C. promote maximum comfort.D. prevent venous stasis.171. One nurse strongly believes that all psychiatric medication

is a form of chemical mind control. When the client's wife asks about the efficacy of antidepressant medications, which of the following courses of action would be best for this nurse to take?

A. Give an honest opinion of the treatment.B. Explain that there are not enough current statistics about the

efficacy of the treatment.C. Provide a package insert for the wife to read.D. Refer the client's wife to another knowledgeable person for

information about the treatment.172. The nurse is preparing an elderly client to get out of bed on

the first postoperative day after a total hip replacement. Which of the following activities would be most helpful to the client?

A. Demonstrate the use of a walker with partial weight bearing.B. Explain to the client that she will be lifted out of bed to a

chair.C. Reassure the client that she will be assisted to walk to the

hall.D. Demonstrate the swing-through crutch-walking gait with

limited weight hearing.173. A breast-feeding neonate will turn his head toward the

mother's breast in a natural instinct to find food. What is the name of this reflex?

A. Tonic neck reflex.B. Moro's reflex.C. Grasp reflex.D. Rooting reflex.174. Which one of the following observation would the nurse

evaluate as an expected outcome for a client who has undergone surgical repair of an inguinal hernia?

A. The client will remain on a soft diet until the wound is healed.B. The client's voiding patterns will return to normal within 6

months after surgery.C. The client will use a cane for assistance with ambulation for 2

to 6 weeks after surgery.D. The client will verbalize understanding of instructions to avoid

lifting for 2 to 6 weeks175. After the nurse has taught the parents of a 5-year-old boy

who has leukemia how to talk with their child about death and dying, which of the following would indicate that the parents have age-appropriate expectations about their child's reaction to his impending death?

A. "He is too young to understand what is happening to him. "B. "He might think he can cause his death because he has

misbehaved. "C. "He will accept his death as caused by his disease. "D. "He will understand how much his siblings will miss him. "176. A client exhibits confusion and severe memory loss. At

11:30 AM, he tells the nurse that he is going to work and proceeds to walk toward the door. Which of the following actions should be the nurse take?

A. Remind him that he retired from his job 10 years ago.B. Tell him that she'll accompany him for a short walk outdoors.C. Divert his attention toward the dining room where lunch is

being served.D. Tell him that he does not have to go to work today.177. The parents report that the child has a runny nose, fever,

cough, and is irritable and constantly rubbing his ears. Which findings of the tympanic membrane would the nurse would expect to see?

A. Bulging and red.B. Clear and inverted.C. Pearly gray.D. Scarred.178. Cindy is a newborn who has undergone corrective surgery

for a tracheoesophageal fistula (TEF). When preparing for her discharge plan, the nurse teaches the parents about the need for long-term health care because Cindy would have a high probability of developing which of the following?

A. Gastric ulcers.B. Esophageal stricture.C. Speech problems.D. Recurrent mild diarrhea with dehydration.179. Of the following signs and symptoms of bowel obstruction,

which is related primarily to small bowel obstruction rather than large bowel obstruction?

A. Profuse vomiting.B. Cramping abdominal pain.C. Abdominal distention.

D. High-pitched bowel sounds above the obstruction.180. Immediately after a spontaneous rupture of the

membranes, the nurse observes a loop of umbilical cord protruding from the vagina. What should the nurse do first?

A. Administer oxygen.B. Notify the physician.C. Document the deceleration.D. Elevate the hips on two pillows.181. A client has a perforated nasal septum. The nurse correctly

judges the client to be a user of which of the following substances?A. Heroin.B. Cocaine.C. LSD.D. Marijuana.182. The nurse teaches a client about the relationship between

body position and gastroesophageal reflux. Which of the following statements by the client would indicate that he understands measures to avoid problems with reflux while sleeping?

A. "I can elevate the head of the bed 4 to 6 inches. "B. "I can elevate the foot of the bed 4 to 6 inches. "C. "I can sleep on my back without a pillow under my head. "D. "I can sleep on my stomach with my head turned to the left. "183. To prevent external rotation of the client's hips while he is

lying on his back, it would be best for the nurse to placeA. firm pillows under the length of his legs.B. sandbags alongside his legs from knees to ankles.C. troehanter rolls alongside his legs from ilium to midthigh.D. a footboard that supports his feet in the normal anatomic

position.184. The nurse is teaching a student nurse in a mental health

unit about how to establish a therapeutic nurse-client relationship. Which of the following is of prior importance in the therapeutic nurse-client relationship?

A. Nurse's self-awareness and understanding.B. Nurse's sound knowledge of psychiatric nursing.C. Nurse's sincere desire to help others.D. Nurse's acceptance of others.185. The client complains a continuous bladder irrigation after a

transurethral resection. Which of the following is the major goal of nursing interventions related to the irrigation?

A. Recognize signs of prostate cancer.B. Perform activities of daily living.C. Maintain catheter patency.D. Reduce incisional bleeding.186. On initial assessment of a 7-year-old with rheumatic fever,

which of the following would require the nurse to contact the physician immediately?

A. Heart rate of 150 bpm.B. Twitching in the extremities.

C. Red rash on the trunk.D. Swollen and painful knee joints.187. A client receiving haloperidol (Haldol) complains of a stiff

jaw and difficulty swallowing. Which of the following should be the nurse's first action?

A. Reassure the client and administer as-needed lorazepam (Ativan) IM.

B. Administer as-needed dose of benztropine (Cogentin) by mouth as ordered.

C. Administer as-needed dose of benztropine (Cogentin) IM as ordered.

D. Administer as-needed dose of haloperidol (Haldol) by mouth.188. Which of the following is not a contributory factor to

thermoregulation in the preterm neonate?A. Immature central nervous system (CNS).B. Large skin surface area.C. Lack of subcutaneous (S. C. ) and brown fat.D. Tendency toward capillary fragility.189. The nurse in the substance abuse unit is trying to

encourage a client to attend Alcoholics Anonymous (AA) meetings. When the client asks the nurse what he must do to become a member, which of the following the best response from the nurse?

A. "Admit you're powerless over alcohol and that you need help. "

B. "You must bring along a friend who will support you. "C. "You must first stop drinking. "D. "Your physician must refer you to this program. "190. When developing the postoperative plan of care for a child

who is scheduled to have a tympanostomy tubes inserted into the right ear, which of the following interventions would the nurse identify to accomplish the goal of facilitating drainage?

A. Applying warm compresses to the right ear.B. Applying a gauze dressing to the left ear.C. Applying an ice pack to the left ear.D. Positioning the child to lie on the right side.191. While caring for pregnant adolescents, the nurse should

develop a plan of care that incorporates which health concern?A. Age of menarche.B. Family and home life.C. Healthy eating habits.D. Level of emotional maturity.192. Which of the following nursing measures would the nurse

institute to help reduce eyelid edema in a child with nephrotic syndrome?

A. Instill eye drops every 8 hours.B. Limit the child's television watching.C. Apply cool compresses to the child's eyes.D. Elevate the head of the child's bed.

193. Which of the following findings would indicate that the goals for total parenteral nutrition (TPN) are being achieved for the client?

A. Serum glucose level of 96.B. Weight gain of 0.5 pounds/day.C. Urine negative for glucose.D. Serum potassium level of 4 mEq/L.194. An 20-month-old with acquired immunodeficiency

syndrome (AIDS) is seen in the clinic for health maintenance. Which of the following vaccines would the nurse anticipate administering to this toddler?

A. Diphtheria-tetanus-acellular pertussis.B. Varicella.C. Measles, mumps, and rubella.D. Hemophilus influenza.195. Mr. Smith is admitted to the psychiatric hospital for

evaluation after numerous incidents of threatening, angry outbursts and two episodes of hitting a coworker at the grocery store where he works. He is very anxious and tells the nurse, "I didn't mean to hit him. He made me so mad that I just couldn't help it. I hope I don't hit anyone here. " Which of the following is the nurse's best response?

A. "It sounds like you were angry. When you feel angry here, talk to the staff about it instead of hitting. "

B. "I'm sure you didn't mean to hit him and that it won't happen here. "

C. "You'd better not hit anyone here, even if you do get mad. "D. "Tell me more about what happened. "196. The mother of a 4-year-old asks about dental care for her

child. "I help brush her teeth every day and her teeth look healthy. When should I take her to see a dentist?" Which of the following responses would be most appropriate?

A. "Because you help brush her teeth, there's no need to see a dentist right now. "

B. "Ideally she should have seen a dentist already, but it's still not too late. "

C. "Your child doesn't need to see the dentist until she starts school. "

D. "A dental checkup is a good idea even if no problems are noticeable. "

197. A client with heart failure asks the nurse about the reason for taking enalapril maleate. The nurse would explain that the medication is prescribed for which of the following reason?

A. Lower the blood pressure by increasing peripheral vasoconstriction.

B. Lower the heart rate by slowing the conduetion system.C. Block the conversion of angiotensin Ⅰ to angiotensin Ⅱ.D. Increase myocardial contractility, thereby improving cardiac

output.

198. A mother asks the nurse about how to manage her child's morning hyperglycemia. Which of the following would be most appropriate response by the nurse?

A. Question the mother if her child has been avoiding sweets.B. Tell the mother that this is normal and to continue with the

ordered doses.C. Ask the mother what her child's blood glucose levels have

been for the last few days.D. Inform the mother that this is unusual and the child needs to

be seen in the emergency room now.199. A woman tells the nurse that her 6-year-old daughter has

severe nosebleeds. Which of the following instructions should the nurse give this woman to manage nosebleeds?

A. Help the child assume a comfortable position with her head tilted backward.

B. Tilt the child's head backward and place firm pressure on the nose.

C. Help the child lie on her stomach and collect the blood on a clean towel.

D. Place the child in a sitting position with her neck bent forward and apply firm pressure on the nasal septum.

200. A hospitalized client craves a drink while withdrawing from alcohol. Which of the following measures is the best way to help the client resist the urge to drink?

A. A routine search of visitors.B. A locked-door policy.C. One-to-one supervision by the staff.D. Support from other alcoholic clients.201. The nursing care plan for a client after gynecologic surgery

includes nursing orders intended to help reduce the risk of thrombophlebitis. Which is not appropriate among the following nursing interventions?

A. Ambulate the client.B. Massage the client's legs.C. Have the client wear elasticized stockings.D. Have the client perform range-of-motion exercises in bed.202. The nurse is interviewing a client who is currently under

the influence of a controlled substance and shows signs of becoming agitated. Which measure should the nurse take first when caring for this client?

A. Be aware of hospital security.B. Communicate a scolding attitude to intimidate the client.C. Use confrontation.D. Express disgust with the client's behavior.203. After staying several hours with her 10-year-old daughter

who is admitted to the hospital with an asthmatic attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following

findings would lead the nurse to make a nursing diagnosis of Anxiety related to respiratory distress?

A. Complaints of an inability to get comfortable.B. Frequently requests for someone to stay in the room.C. Inability to remember his exact address.D. Verbalization of a feeling of tightness in his chest.204. When caring for a client during the second stage of labor,

which action would be least appropriate?A. Assisting the client with pushing.B. Ensuring the client's legs are positioned appropriately.C. Allowing the client clear liquids.D. Monitoring the fetal heart rate.205. The immobile adolescent with a recent fractured femur

suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect?

A. Atelectasis.B. Pneumonia.C. Pulmonary edema.D. Pulmonary emboli.206. A 28-year-old client delivered a full-term male neonate one

hour ago. Which finding should the nurse expect when palpating the client's fundus?

A. Soft, at the level of the umbilicus.B. Firm, 2 cm below the umbilicus.C. Firm, at the level of the umbilicus.D. Boggy, midway between the umbilicus and symphysis pubis.207. Sedative-hypnotic drugs are used to treat which of the

following problems?A. Hallucinations and delusions.B. Anxiety and insomnia.C. Obsessive-compulsive disorder (OCD).D. Attention deficit hyperactivity disorder (ADHD).208. After a gastrectomy, the client will have a nasogastric tube

in place for several days postoperatively. The nurse explains to the client that the nasogastric tube is for which of the following reasons?

A. Prevent excessive pressure on suture lines.B. Prevent the development of ascites.C. Provide enteral feedings in the immediate postoperative

period.D. Enable administration of antacids to promote healing of the

anastomosis.209. The nurse is caring for a 35-year-old multipara who

delivered a full-term infant by cesarean delivery because of a breech presentation. The nurse recognizes that which of the following events would be the most important contribution to preventing thromboembolism?

A. Increasing oral fluid intake.B. Providing oxygen therapy.

C. Encouraging frequent ambulation.D. Administering pain medications as needed.210. The nurse observes that a depressed client has bathed, is

wearing a clean blouse and slacks, and has combed her hair. Which statement by the nurse would be most helpful for the client?

A. "I like your blouse and slacks. "B. "You look good today. "C. "I'm glad you're feeling better today. "D. "I'm glad you combed your hair today. "211. A 30-year-old primigravida tells the nurse that her

hemorrhoids have become itchy and painful. The nurse instructs the client about relief measures. From which of the following statements by the client would the nurse suspect that the client needs further instructions?

A. "I should sit in a warm sitz bath daily. "B. "I can use a topical ointment for relief. "C. "I should apply an ice pack at night. "D. "I should decrease my fluid intake. "212. A client takes prednisone for an acute exacerbation of her

rheumatoid arthritis. The nurse teaches the client about how to take this drug. Which of the following statements by the client indicates that the education is effective?

A. "I can stop taking the prednisone as soon as my joints feel better. "

B. "It is important for me to increase my sodium intake while I am taking this medication. "

C. "I should not be concerned if I lose a little weight while I take the prednisone. "

D. "It is best if I take this medication with some food. "213. The parents of a child being discharged from the day

surgery center after insertion of tympanostomy tubes ask the nurse. "What will happen to the tubes in my child's ears?" Which of the following would be the nurse's best response?

A. "The tubes usually dissolve on their own in about 1 year. "B. "The tubes must remain permanently in place. "C. "You'll probably see them fall out in about 6 months. "D. "Call for an appointment to have them removed in about 6

months. "214. A multigravida at 36 weeks' gestation visits the emergency

department because her boyfriend has beaten her severely. What should the nurse do first?

A. Contact the authorities.B. Ensure the client's safety.C. Identify a support person.D. Photograph the client's injuries.215. A parent group is discussing different types of punishment.

The parents ask the nurse to discuss corporeal punishment. What would be the nurse's response?

A. "Corporeal punishment does not physically harm the child. "

B. "Corporeal punishment can result in children becoming accustomed to spanking. "

C. "Corporeal punishment can be beneficial in teaching children what they should do. "

D. "Corporeal punishment reinforces the idea that violence is not acceptable. "

216. The infant's skin is inelastic and the upper abdomen is distended. To palpate the olive like mass most easily, the nurse palpates the epigastrium just to the right of the umbilicus at which of the following times?

A. Just before the infant vomits.B. While the infant is eating.C. When infant is lying on the left side.D. When the stomach is empty.217. A community nurse visits a family living in a rural area

where the drinking water is not fluoridated. Which of the following would the nurse suggest to the family as the most appropriate means for obtaining a significant amount of fluoride?

A. Tea.B. Yogurt.C. Citrus juices.D. Natural cheeses.218. The nurse is caring for a client hospitalized on numerous

occasions for complaints of chest pain and fainting spells, which she attributes to her deteriorating heart condition. No relatives or friends report ever actually seeing a fainting spell. After undergoing an extensive cardiac, pulmonary, GI, and neurologic workup, she's told that all test results are completely negative. The client remains persistent in her belief that she has a serious illness. What diagnosis is appropriate for this client?

A. Exhibitionism.B. Somatoform disorder.C. Degenerative dementia.D. Echolalia.219. A client calls the physician's office 2 days after a

herniorrhaphy to report that his scrotum is swollen and painful. Which of the following instruction by the nurse could promote comfort for the client?

A. Apply a snug binder on his abdomen.B. Have him wear a truss to support the scrotum.C. Have him lie on his side and place a pillow between his legs.D. Elevate the scrotum and place ice bags on the area

intermittently.220. A primigravida at 34 weeks' gestation is diagnosed with

hydramnios. After delivery of the neonate, a priority for the nurse is to assess the neonate for which problem?

A. Kidney disorders.B. Cardiac defects.C. Diabetes mellitus.

D. Esophageal atresia.221. The nurse teaches the parents of a child being treated with

antibiotics for an ear infection for a follow-up visit after the child completes the course of therapy. Which of the following statements by the parents indicates that they understand the reason for the follow-up visit?

A. "Her hearing needs to be checked to see if the infection has done any damage. "

B. "The doctor wants to make certain she has taken all the antibiotics. "

C. "We need to make sure that her ear infection has completely cleared. "

D. "She needs to get another prescription for second course of antibiotics. "

222. A 34-year-old client is 34 weeks pregnant and is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which of the following nursing interventions should be of priority?

A. Monitor the amount of vaginal blood loss.B. Allow the client to ambulate with assistance.C. Perform a vaginal examination to cheek for cervical dilation.D. Notify the physician for a fetal heart rate of 130

beats/minute.223. A client is admitted to the psychiatric unit with a diagnosis

of anorexia nervosa. Although she is 5'7" and weighs only 100 lb, she keeps on telling the nurse about how fat she is. What should the nurse do first?

A. Discuss cultural stereotypes regarding thinness and attractiveness.

B. Explore the reasons why the client doesn't eat.C. Teach the client about nutrition, calories, and a balanced diet.D. Establish a trusting relationship with the client.224. The neonate's big toe dorsiflexes and the other toes fan

when the nurse gently strokes the sole of the foot. The nurse should interpret this positive finding as which of the following?

A. Stepping reflex.B. Plantar grasp.C. Galant reflex.D. Babinski sign.225. A patient who is admitted for treatment of an eating

disorder displays controlling behaviors, takes responsibility for others' actions, and has difficulty identifying feelings. These manifestations suggest

A. dependency.B. manipulation.C. learned helplessness.D. codependency.226. Which of the following situations is more likely to

predispose a client to postpartum hemorrhage?

A. Birth of a 7 lb (3,175g) infant.B. Prolonged first stage of labor.C. Pregnancy-induced hypertension (PIH).D. Birth of twins.227. The second morning after surgery for a below-the-knee

amputation of the left leg, the client says, "This sounds weird, but I feel pain on my left feet. " The nurse knows the client is experiencing a

A. denial reaction.B. hallucination.C. phantom-limb sensation.D. body image disturbance.228. A client who was found huddled in her apartment by the

police is admitted to the clinic. The client stares toward one corner of the room and seems to be responding to something not visible to others. She appears hyperalert and scared. Which of the following conclusion by the nurse is most appropriate according to the situation?

A. Nothing is wrong because the client isn't a threat to society.B. The client is malingering.C. The client may be hallucinating.D. The client is suicidal.229. Which of the following is the most important aspect of

nursing care in the postpartum period?A. Supporting the mother's ability to successfully feed and care

for her neonate.B. Providing group discussions on infant care.C. Monitoring the normal progression of lochia.D. Involving the family in the teaching.230. By age 7 months, an infant most likely will develop which

of the following motor skill?A. Walk with one hand held.B. Eat successfully with a spoon.C. Stand while holding onto furniture.D. Sit alone using the hands for support.231. The nurse is teaching a client who is 28 weeks pregnant

and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling this client's blood glucose levels, so she has started insulin therapy. Which of the following statements indicates the client has adequate knowledge?

A. "I won't use insulin if I'm sick. "B. "I need to use insulin each day. "C. "If I give myself an insulin injection, I don't need to watch

what I eat.D. "I'll monitor my blood glucose levels twice a week. "232. A client with a history of alcoholism returns to the hospital

3 hours later than he supposed to be. His breath smells of alcohol

and his gait is unsteady. Which of the following would be the best response by the nurse?

A. "I'm disappointed that you weren't responsible with your day pass. "

B. "Please go to bed now. We'll talk in the morning. "C. "Why are you 3 hours late?"D. "How much did you drink tonight? Drinking is against the

rules. "233. The nurse is caring for a client with acute osteomyelitis in

the right tibia. Which of the following measures is most appropriate when repositioning the client's leg?

A. Hold the leg by the ankle when repositioning to avoid touching the tibia.

B. Support the leg above and below the affected area when positioning.

C. Have the client move the leg by himself to decrease pain.D. Apply warm moist compresses to the leg before repositioning.234. Which of the following signs or symptoms would be of least

importance when the nurse evaluates the client for postoperative peripheral nerve damage?

A. Pain.B. Bleeding.C. Altered sensation.D. Pulselessness.235. Which pregnancy-related physiologic change would place

the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems?

A. Decreased heart rate.B. Decreased cardiac output.C. Increased plasma volume.D. Increased blood pressure.236. The nurse is teaching a new mental health aide. For which

of the following clients is setting limits most important?A. A depressed client.B. A manic client.C. A suicidal client.D. An anxious client.237. After determining that a pregnant client is Rh-negative, the

physician orders an indirect Coombs'test. What's the purpose of performing this test on a pregnant client?

A. To determine the fetal blood Rh factor.B. To determine the maternal blood Rh factor.C. To detect maternal antibodies against fetal Rh-positive factor.D. To detect maternal antibodies against fetal Rh-negative

factor.238. Which of the following is an appropriate health promotion

activity to reduce the incidence of osteoporosis?A. Teaching women to maintain adequate calcium intake.B. Teaching women how to administer pain medication safely.

C. Avoiding estrogen replacement therapy when postmenopausal.

D. Teaching women to increase caffeine intake as a preventive measure.

239. When magnesium sulfate is administered to a client in labor, its action occurs at which of the following sites?

A. Neural-muscular junctions.B. Distal renal tubules.C. Central nervous system (CNS).D. Myocardial fibers.240. Which of the following measures would the nurse take into

consider to help minimize joint pain in a child with rheumatic fever?A. Massaging the affected joints.B. Applying ice to the affected joints.C. Limiting movement of the affected joints.D. Encouraging progressive weight bearing.241. When caring for a client who has had a cesarean birth,

which of the following nursing interventions is least appropriate?A. Removing the initial dressing for incision inspection.B. Monitoring pain status and providing necessary relief.C. Supporting self-esteem concerns about delivery.D. Assisting with parental neonate bonding.242. Which abnormal laboratory value is most indicative of

aplastic anemia?A. A decreased hemoglobin.B. An elevated white blood cell count.C. An elevated red blood cell count.D. A decreased erythrocyte sedimentation rate.243. A child with leukemia presents with peteehiae; gums, lips,

and nose that bleed easily; and bruising on various parts of her body. Which of the following laboratory test results would the nurse correlate with these findings?

A. Platelet count of 80×103/mm3.B. Serum calcium level of 5 mg/dL.C. Fibrinogen level of 75 mg/dL.D. Partial thromboplastin time (PTT) of 38 seconds.244. A 15-year-old girl with anorexia refuses to eat in a mental

health unit. Which of the following statements is the best response from the nurse?

A. "Why do you think you're fat? You're underweight. Here--look in the mirror. "

B. "You really look terrible at this weight. I hope you'll eat. "C. "You don't have to eat. It's your choice. "D. "I hope you'll eat your food by mouth. Tube feedings and IV

lines can be uncomfortable. "245. A mother brings her 2-year-old adopted Korean child to the

clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area

of deep blue pigment on the child's buttocks extending into the sacral area. What should the nurse do?

A. Ask the mother in private how the bruise occurred.B. Notify social services of a case of possible child abuse.C. Question the mother about the family's discipline style.D. Do nothing concerning this finding.246. If none of the following bed positions is contraindicated,

which position would be preferred for the client with hypovolemic shock?

A. Supine.B. Semi-Fowler's.C. Trendelenburg's.D. Supine with the legs elevated 15 degrees.247. Which of the following findings in a client's history would

be most likely to predispose her to renal calculi?A. The client takes large doses of vitamin E.B. The client drinks one to two glasses of fluid daily.C. The client had a urinary tract infection within the last 6

months.D. The client eats a diet that meets the daily requirements for

calcium.248. Assessment of a client in active labor reveals meconium-

stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?

A. Breech position.B. Late decelerations.C. Entrance into the second stage of labor.D. Multiple gestation.249. A client who recently developed paralysis of the arms is

diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. When preparing the plan of care for the client, which of the following interventions should be included in the plan?

A. Teaching the client how to use nonpharmacologic pain-control methods.

B. Exercising the client's arms regularly.C. Insisting that the client eat without assistance.D. Working with the client rather than the family.250. Which of the following functions would the nurse expect to

be unrelated to the placenta?A. Production of estrogen and progesterone.B. Detoxification of some drugs and chemicals.C. Exchange site for food, gases, and waste.D. Production of maternal antibodies.251. To assess the client's dorsalis pedis pulse, the nurse should

palpate theA. medial surface of the ankle.B. lateral surface of the ankle.

C. ventral aspect of the top of the foot.D. medial aspect of the dorsum of the foot.252. The nurse is assessing an elderly client for dementia.

Which of the following is a primary symptom of dementia?A. Neurosis.B. Loss of impulse control.C. Psychosis.D. Memory loss.253. During the first 48 to 72 hours of fluid resuscitation therapy

after a major burn injury, the intravenous infusion rate will be adjusted by evaluating which of the following observation?

A. Daily body weight.B. Hourly urine output.C. Hourly urine specific gravity.D. Hourly body temperature.254. Which assessment would the nurse perform to validate that

the membranes are ruptured?A. Observe for a pink, mucus vaginal discharge.B. Test the leaking fluid with nitrazine paper.C. Assess the client's temperature, pulse, and blood pressure.D. Send a urine specimen from the client to be cultured.255. The clinic nurse is instructing a group of parents about

emergency treatment for accidental poisoning and injury. Which of the following statements by one of the mothers indicates that she needs further instruction?

A. "I should flush my child's eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it. "

B. "I should save the emesis if my child vomits. "C. "I should call the poison control center if there are any

symptoms. "D. "I should give 2 to 5 teaspoons of clear fluids after

administering ipecac. "256. The nurse is caring a client in an acute care mental health

program. The client refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. What should the nurse do?

A. Crushing the medication and putting it in his food.B. Consulting with the physician about a plan of care.C. Administering the medication by injection.D. Omitting the dose and trying again the next day.257. A nurse in a prenatal clinic is assessing a 28-year-old

woman who is 24 weeks pregnant. Which of the following findings would lead this nurse to suspect that the client has mild preeclampsia?

A. Hypertension, edema, proteinuria.B. Glycosuria, hypertension, seizures.C. Hematuria, blurry vision, reduced urine output.D. Burning on urination, hypotension, abdominal pain.

258. Which of the following signs and symptoms would be an early indication that the client's serum potassium level is below normal?

A. Diarrhea.B. Tingling in the fingers.C. Sticky mucous membranes.D. Muscle weakness in the legs.259. The nurse is teaching the client how to use a cane. Which

of the following statements is most inaccurate?A. The client should hold the cane on the involved side.B. The client should hold the cane close to his body.C. The stride length and the timing of each step should be

equal.D. The nurse should stand behind the client to prevent falls.Multiple-correct answer itemDirections: The question below is followed by six choices

numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.

The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion?

260. (Select A or B. ) Right to select health care team members.261. (Select A or B. ) Right to refuse treatment.262. (Select A or B. ) Right to a written treatment plan.263. (Select A or B. ) Right to obtain disability.264. (Select A or B. ) Right to confidentiality.265. (Select A or B. ) Right to personal mail.

Answers and Rationales

1. B When obtaining a urine specimen from an indwelling catheter, a sterile syringe and needle should be used to access the catheter port that allows removal of urine from the closed system. This technique preserves sterility of the system and the urine specimen.

2. A Successful breast-feeding depends on the client's willingness and motivation to breast-feed. Women who have a strong desire to breast-feed tend to continue breast-feeding longer and are often more tolerant of the discomforts of breast-feeding and more accepting of the need for frequent feedings.

3. B Heavier body weights and some body fat stress bones and promote their maintenance. Osteoporosis is most often associated with being underweight. Women who are thin throughout their lives are twice as likely to develop hip fractures.

4. B Convert grams to milligrams. 0.2g=200mg. 200mg/x tablets=100mg/tablet, x= 2 tablets.

5. B Clients should be instructed to keep nitroglycerin in a tightly closed, dark container and to replenish it frequently because it deteriorates rather rapidly.

6. B The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might be detrimental to the client, the primary care provider should be informed of the client's request. The client doesn't need an attorney to view his chart. He also doesn't need to wait until after discharge to view it.

7. C The T wave represents ventricular muscle repolarization as shown in the accompanying figure.

8. B Valsalva's maneuver, or bearing down against a closed glottis, can best be prevented by instructing the client to exhale during activities such as having a bowel movement or moving around in bed.

9. B Use of an antihistamine and calamine lotion are recommended to help decrease the itching.

10. C The client should be taught how to prevent the spread of hepatitis B to others.

11. C The nurse should encourage the mother to breast-feed the infant. Neonatal sucking will induce the release of natural oxytocin which will help contract the uterus and control uterine bleeding.

12. C The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. Flow Rate = (Volume×Calibration) /Time (minutes). In this case, the Rate=15gtts/mL×1000mL/360min=42gtts/min.

13. C A slow, dark-red trickle of blood after a delivery is a symptom of postpartum hemorrhage; it should be reported and treated immediately. If the cause is due to uterine atony, the nurse should gently massage the fundus, call for assistance, and prepare to administer oxytocic drugs. If the cause is due to massive blood clots in the uterus, the client may need to have the clots manually extracted.

14. C The most common cause of death in children with leukemia is infection. The child should be monitored for any signs of infection, including temperature.

15. A Because peristalsis has not been reestablished, this amount of gastric drainage would be expected. The green-brown color would also be expected. The appropriate nursing action is to chart the amount and color of output and continue monitoring the client.

16. D Constant patterns of anxiety that affect the client for more than 6 months and interfere with normal activities are characteristic of generalized anxiety disorder. Frequently, pharmaceutical therapy with benzodiazepines can help. Clients having regular obsessions are probably suffering from obsessive-compulsive disorder. Nightmares and flashbacks are typical symptoms of posttraumatic stress disorder.

17. C Carbamazepine (Tegretol) can cause potentially fatal hematological disorders. To detect pancytopenia, it is important that the client have weekly CBC checks during the first few months of therapy. The client should be told to report any indications of bone marrow depression such as bleeding, easy bruising, sore throat, fever, or mouth ulcers.

18. A As with any surgery or invasive procedure, a priority goal at this time would be to prevent infection at the operative site.

19. C An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration.

20. C Amniotic fluid is normally clear. Yellowish fluid indicates Rh sensitization. The yellowish color is related to fetal anemia and bilirubin in the amniotic fluid.

21. B 150mg/x mL=200mg/mL; x=0.75mL.22. A Tobacco is a gastrointestinal stimulant and should be

avoided by clients with ulcerative colitis.23. A Autonomic dysreflexia is a medical emergency. The rising

blood pressure can cause cerebrovascular accident, blindness, or even death. Placing the client in Fowler's position lowers blood pressure.

24. C The nurse records the total amount of solution used to irrigate a gastric tube as intake and the total amount of return in the drainage container as output.

25. C Clomiphene citrate (Clomid) is a fertility drug that induces ovulation in women desiring pregnancy. One of the drug's most common side effects is multiple gestation (twins, triplets, or more).

26. D Common laboratory findings in the client who has suffered a MI include elevated CPK level. CPK is also released during muscle injury and brain injury. The CPK isoenzyme CPK-MB elevates only in response to myocardial damage.

27. A Confining a voluntary client against his will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.

28. A Clients with diabetes should be taught to visually inspect their feet on a daily basis.

29. B Allowing a child to make some decisions about the foods he eats and not insisting that he finish meals can avoid power struggles. Refusing to finish meals and to eat certain foods is normal behavior for a preschool-aged child. It is important to avoid tension at mealtime and to avoid confrontation about food.

30. A It is most therapeutic to let the client know of the staff's continued concern and to ask her what might be useful to her.

31. D The client should be instructed to smell the cast to note foul odors, a sign of potential infection.

32. B Activated partial thromboplastin time (APTT) is used to measure the clotting status when the client is receiving heparin.

33. B A will is an important legal document. It is best to have one prepared with the help of an attorney.

34. A A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane.

35. A Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for delivery. Most agency labor units have emergency delivery packs with sterile towels, a bulb syringe, and a cord clamp.

36. B Accurate determination of urine output is a crucial factor in the care of a burn victim. The benefits of using an indwelling catheter to measure urine output to the nearest milliliter outweigh the risk of infection and other problems associated with use.

37. C Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the T tube be kept clean and dry.

38. C Small amounts of sterile water are given to a neonate first to ascertain if the esophagus is patent and to prevent the aspiration of formula if it is not.

39. A Sharing needles is associated with increased incidence of blood-borne diseases such as hepatitis.

40. D All symptoms define chronic low self-esteem. There isn't enough information to determine delayed growth and development. The question doesn't describe the client's ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data in the question.

41. C An appropriate expected outcome for a client with ulcerative colitis is maintaining an ideal body weight.

42. C Gentle pressure should be applied after the injection, but the area must not be massaged.

43. D Gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hypersecretion of gastric acid and compromised gastrointestinal perfusion.

44. B A roast beef sandwich, milkshake, and cottage cheese would provide the burn victim with the extra protein and calories needed for healing.

45. A The serum electrolyte values in an infant with persistent vomiting reflect hypokalemia (K+ level of 3.2mEq/L), hypochloremia (Cl- level of 92mEq/L), and hyponatremia (Na+ level of 120mEq/L). Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid.

46. C When dressing, the client should put clothing on the affected side first.

47. D 1kg=2.2 pounds; therefore, 3.2×2.2=7.04 pounds.

48. A The Apgar rating system evaluates the neonate on the basis of heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1- and 5-minute intervals after birth. The neonate receives a score between 0 and 10. The higher the score, the better the neonate's condition. An Apgar score of 9 out of a possible score of 10 means that the neonate is in good condition.

49. C After a mastectomy, every effort should be made to avoid cuts, bruises, and burns on the affected arm because normal circulation has been impaired. Working in a rose or cactus garden is a risk because of the danger of skin pricks. The client should be advised to wear protective clothing to prevent cuts, bruises, and burns.

50. A Ineffective Cardiac Tissue Perfusion related to myocardial damage and inadequate cardiac output is a major problem immediately after a heart attack. Therapy is directed toward improving cardiac output and decreasing myocardial workload.

51. B The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill, such as relaxation techniques. At some point, the nurse should do a thorough sleep assessment, especially if common-sense interventions fail.

52. A Oral hygiene is an important aspect of self-care for the laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection.

53. B This client is experiencing early signs of preterm labor. The nurse should plan to place the client on bed rest on her left side which promotes uterine placental perfusion and increased oxygen supply to the fetus.

54. C Orthostatic hypotension resulting in lightheadedness, dizziness, and fainting is a common side effect of levodopa. Clients should be taught to change positions slowly.

55. B Correct technique for instilling eye drops includes the nurse bracing his or her hand on the client's forehead while instilling the medication.

56. A During a sickle cell crisis, increasing the transport and availability of oxygen to the body's tissues is paramount. Administering a high volume of intravenous fluid and electrolytes to help compensate for the acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. Fluid administration also helps overcome dehydration, a possible predisposing factor common in clients with sickle cell crisis.

57. D Because of the irregularity of bowel sounds, the nurse should listen for 5 minutes in each quadrant to confirm the absence of bowel sounds.

58. D The basic element of assertive behavior includes the ability to express your feelings and thoughts while respecting the rights of others. Options A and B describe aggressive behavior, and option C describes passive behavior.

59. C The proper suctioning technique is to insert the suction catheter until resistance is met, withdraw the catheter 1 to 2 cm, then begin applying intermittent suction while withdrawing the catheter.

60. A Children need to know what behaviors are acceptable and what behaviors are unacceptable. They feel more secure when boundaries are clear and when policies concerning their behavior are consistently enforced.

61. C A sudden change in urine output is typical of acute renal failure. Most commonly, the initial change is greatly decreased urine output. Later in the course of acute renal failure, the client may have marked diuresis (nonoliguric failure).

62. B Regardless of the child's age, a child who reports abuse must be believed because confiding this information is frightening and takes courage. Establishing trust is essential.

63. B The client should not skip his dosages of pain medication to prevent addiction. Clients with cancer pain do not become psychologically dependent on the medication and should not fear becoming addicted. The nurse should allow the client and family members to verbalize their concerns about drug addiction.

64. C Providing the client with written and verbal instructions will increase understanding of the medication regimen

65. A Chlorpropamide is an antidiabetic agent. Clients should be observed for signs and symptoms of hypoglycemia. Other common side effects include anorexia, nausea, vomiting and heartburn.

66. C It is not necessary for the client to call the health care provider if she experiences contractions every hour for 6 hours, but she should continue to monitor the contraction pattern to determine if the contractions are increasing in frequency.

67. B With long- term use phenytoin can cause gingival hyperplasia, so it is essential that the client understand how to provide proper oral hygiene.

68. B The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.

69. B A major goal of nursing care of the unconscious client with a head injury is to establish and maintain an open airway. An obstructed airway can lead to hypoxia and carbon dioxide retention which will further increase intracranial pressure.

70. B Antipsychotic medications exert an effect on brain neurotransmitters that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect of antipsychotic agents.

71. A During recovery, the client should be instructed to avoid abrupt or jarring head movements. Activities such as shampooing or brushing hair may be restricted.

72. C The child who has increasing respiratory difficulty after being removed from an increased oxygen environment should be placed back in the environment. The child's pulse rate will most likely be increased.

73. D When pressure is applied to the skin, the area first becomes blanched, or whitish. When pressure is relieved, the circulation tends to carry excess blood to the area to make up for the temporary decrease in blood supply. This effect, called reactive hyperemia, causes the skin to redden. Such a reddened area is a precursor of a pressure sore.

74. B Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients can't express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control.

75. B The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breast-feed. Frequent feedings with complete emptying of the breasts should alleviate engorgement.

76. A With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating.

77. D The most common symptom of pancreatitis is intense abdominal pain in the mid-epigastric area or the left upper quadrant. The pain may radiate to the back.

78. B Breast size is not important as long as there is glandular tissue to secrete the milk, although various factors can influence milk supply, such as suckling, emptying of the breasts, diet, exercise, rest, level of contentment, and stress. The fat in breast tissue plays no role in milk production.

79. B An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently.

80. B As antidepressants take effect, individuals suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Option A is incorrect because Elavil is an antidepressant, not an antipsychotic. Option C is incorrect because the client shouldn't be discharged until the risk of suicide has diminished. Option D indicates a response to the antidepressant, not a split personality.

81. B Predisposing factors for laryngeal cancer include chronic irritants such as alcohol, tobacco, and exposure to noxious fumes. About 75% of people who develop laryngeal cancer are smokers. The combination of smoking and heavy alcohol intake is even more strongly implicated as a causative agent in the laryngeal cancer.

82. C A child with gastroenteritis should start to receive soft foods first after resting the bowel and rehydration. Cooked cereals, vegetables, and meats are recommended.

83. B Terbutaline, a beta-2 selective adrenergic agonist, is used to suppress labor by relaxing the pregnant uterus. In some cases, its beta-2 selectivity is lost, causing cardiac overstimulation. Generally, the drug is contraindicated for a client with a heart rate greater than 130 beats/minute or any cardiac arrhythmias. Therefore, the nurse would need to assess the client's heart rate.

84. A Vesicular breath sounds are normal breath sounds heard over all lung fields except the main bronchi.

85. B If the wound opens and tissues are exposed (wound evisceration), the nurse should cover the exposed tissues with sterile dressings moistened with sterile normal saline solutions. The nurse should also cover an eviscerated wound with sterile dressings moistened with sterile normal saline solution. The physician should be notified immediately when a wound dehisces or eviscerates.

86. B Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth.

87. D Infants grow rapidly. A cast adequate for a infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch.

88. D Even with glasses, the client who has had cataract surgery may have changes in depth perception. The client may need to relearn to judge distances accurately to walk safely.

89. B Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.

90. B In a threatened abortion, vaginal bleeding or spotting occurs and abdominal cramping may occur. However, the cervix is not dilated. Termination of the pregnancy may or may not be prevented.

91. C Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.

92. D With a well-managed regimen, a client with myasthenia gravis should be able to control symptoms, maintain a normal lifestyle, and achieve a normal life expectancy.

93. A The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective.

94. C The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler.

95. D The most appropriate intervention for the nurse is to reinforce for the client that turning in bed will decrease the likelihood for developing postoperative complications.

96. B The client's self-report of pain is the single most reliable indicator of the amount of pain the client is experiencing. Pain tolerance and the expression of pain can vary a great deal among clients.

97. C Spastic cerebral palsy, the most common clinical type, represents an upper motor neuron muscular impairment resulting in increased muscle tone and stretch reflexes, persistent reflexes, and a lack or delay of postural control.

98. B The caregiver must learn to distinguish obligations that she must fulfill and limit those that aren't necessary. The caregiver can tell the client when she leaves but she shouldn't expect that the client will remember or won't become angry with her for leaving. The caregiver shouldn't leave the client home alone for any length of time because it may compromise the client's safety. The nurse can provide support to the primary caregiver if she needs to ask other family members for assistance.

99. C Hoarseness occurs early in the course of most laryngeal cancers because the tumor prevents accurate approximation of the vocal cords during phonation.

100. C Painless hematuria is the most common symptom associated with bladder cancer. Bleeding from the lesions occurs fairly early in the disease process, but bladder cancer is basically asymptomatic in early stages.

101. B Behaviors of the anorectic client and the bulimic client are commonly similar, especially because both implement rituals to lose weight; however, the bulimic client tends to eat much more, due to the binge episodes, and therefore can be near-normal weight. Not all persons with the purge disorder have loss of enamel on teeth, especially if the disorder has developed recently. Mallory-Weiss tears are small tears in the esophageal mucosa caused by forceful vomiting, but they aren't always present in bulimic clients.

102. B The most appropriate nursing diagnosis would be Risk for injury because a toddler is typically engaged in exploring the environment while becoming increasing mobile. Safety issues are an important part of anticipatory guidance with parents of toddlers.

103. C Because pressure ulcers (decubitus ulcers) are caused by pressure to the tissues, the most important measure in preventing them is to relieve the pressure by repositioning the client every 1 to 2 hours.

104. C The primary aim of genetic counseling is to inform clients of birth defect risks and the disorder to help the family understand and adjust to the disorder.

105. D Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia.

106. D After a laminectomy, the client's spine must be maintained in proper alignment. The client who had a laminectomy may be turned to his side by logrolling him in one unit while keeping his back straight. It takes at least two people to perform this procedure correctly.

107. B Bringing a child's favorite toys, security blanket, or familiar objects from home can make the transition from home to hospital less stressful. The child receives comfort and reassurance from these items.

108. D Preventing an increase in intraocular pressure is the primary concern after cataract removal.

109. C Although there is no treatment for flat feet, corrective shoes are often prescribed to keep the legs in proper alignment.

110. C When using the ventrogluteal site, the nurse injects the medication into the gluteus minimus muscle.

111. B After a total hip replacement, it is important to maintain the hip in a state of abduction to prevent dislocation of the prosthesis.

112. B In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, it usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. It's normal for adolescents to display hypersomnolence, an obsession with body image, and valuing of peers' opinions.

113. A In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.

114. D Magnesium sulfate is a central nervous system depressant used as an anticonvulsant for severe PIH. It may depress respirations to a dangerously low and even life-threatening level. Therefore, the nurse must assess the client's respiratory rate before administering the drug. If the client's respiratory rate is below 12 to 14 breaths/ minute, the physician should be notified and the drug should be withheld.

115. A Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.

116. D Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning.

Auscultation should also be done to determine whether or not the client needs suctioning.

117. D Tinnitus (ringing in the ears) is a common symptom of aspirin toxicity.

118. B Radiated skin is sensitive to the sun and cold temperatures so it should be protected.

119. B The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water.

120. A Clients with diverticulitis are usually treated with broad-spectrum antibiotics. Mild analgesics and anticholinergics may also be administered.

121. A The primary physician in charge of a client's care must write an order for the restraint within 1 hour. In an emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints.

122. A The posterior fontanel usually closes by age 2 to 3 months. Therefore, the nurse should measure the head circumference to determine if the child's head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures.

123. A Reducing barriers to mammography is the best way to improve adherence with screening.

124. C A client with cholecystitis from cholelithiasis may experience nausea, vomiting, abdominal discomfort, and other gastrointestinal symptoms after eating high-fat foods. This is due to decreased fat absorption related to lack of normal bile flow from the gallbladder.

125. A Bottle supplements tend to cause a decrease in the breast milk supply and demand for breast-feeding and should be avoided. Once in a while if the client is tired, a bottle supplement may be given to the neonate by another caregiver.

126. A Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. Fluid and sodium intake must be monitored during lithium (Lithobid) treatment. Safe use during pregnancy and lactation hasn't been established.

127. B Maternal side effects of betamethasone (Celestone, Soluspan) include increased risk of infection, initiation of lactation, gastrointestinal bleeding, weight gain, edema, and pulmonary edema when used concurrently with tocolytic agents.

128. B The irrigating solution should not be allowed to drop directly on the tympanic membrane because this may cause discomfort or damage.

129. C When mixing the enzyme (lipase, protease, amylase) powder into food, the client should be careful not to inhale it as the powder may trigger an asthma attack.

130. B It is not unusual for a client to be disoriented and suffer short-term memory loss after a head injury. Clocks, single-date calendars, and other items to help orient the client should be provided. Frequent reassurance and orientation by the nurse and family members will help the client understand the reason for his hospitalization and recognize that he is in a safe environment.

131. A Newborns should breastfed at least every 3 hours during the day.

132. B Folic acid is very important to pregnancy.133. C Because an insulin reaction can be life threatening and

may occur while the child is in school, the nurse and mother should discuss hypoglycemia's seriousness and evaluation in the child with the child's teachers. The teachers also need to know what measures to take if an insulin reaction occurs.

134. C Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.

135. C Ototoxicity is a serious side effect of gentamycin. Tinnitus and dizziness are common; irreversible deafness can develop if the onset of ototoxicity is not detected early. Gentamycin is also known to be nephrotoxic and hepatoxic.

136. C In retinal detachment, the two layers of the retina separate as a result of a small hole or tear, trauma, or degeneration. Vitreous humor seeps into the tear and separates the retinal layers.

137. A The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client can't control, even though he realizes they're senseless. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.

138. A Ritodrine reduces frequency and intensity of uterine contractions by stimulating vitamin B12 receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia--a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).

139. C Based on the mother's description, the child most likely is exhibiting signs and symptoms of laryngotracheal bronchitis. The mother should try to decrease the inflammation in the upper airway

by exposing her child to a warm, steamy environment. The safest method is to steam up the bathroom and stay with the child.

140. B Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.

141. D The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.

142. B Although nutrition plays a large part in the healing process, it is not advisable to tell a child that he will not get better if he does or does not do a particular activity. Not only is this dishonest, it also makes the child believe that his own actions are causing the illness.

143. D Rotavirus is a type of viral infection that affects the gastrointestinal tract. It causes diarrhea which results in fluid loss. This type of infection can be very serious in infants who, because of their immature kidneys, cannot adjust to fluid loss as readily as adults.

144. A Mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases.

145. B Research studies have demonstrated that estrogen has been effective in decreasing bone loss.

146. A Most people with hypertension, even those with dangerous elevations in blood pressure, have no symptoms. Therefore, the presence or absence of symptoms is not an accurate reflection of a person's status.

147. D Owing to the massive cellular destruction that occurs in burns, potassium is released into the extracellular fluid which leads to hyperkalemia.

148. C The client can perform the Kegel exercises anytime in any position listed.

149. C The positive symptoms of schizophrenia are distortions of normal functioning, including hallucinations, delusions, disorganized thinking, somatic delusions, echolalia, and waxy flexibility. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms list the diminution or loss of normal function.

150. D The client who complains of heartburn should eat smaller, more frequent meals with fluids. Baking soda in water should be avoided because of the sodium in baking soda. Large meals and fried foods should also be avoided.

151. C Individuals in a crisis need immediate assistance. They're unable to solve problems and need structure and assistance in

accessing resources. Clients in a crisis don't need lengthy explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction can be most helpful.

152. B A report about the client's condition should be as clear, pertinent, and concise as possible. It should be free of subjective information that could be interpreted differently by different caregivers.

153. C When applying nitroglycerin ointment to a client's skin, the nurse should first remove the ointment applied during previous administration. Otherwise the client will be receiving too much medication.

154. B Sleeping in a sleeping bag keeps the joints warm, therefore more flexible. Thus, joint pain in the morning would be lessened.

155. B Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 12 months by an experienced health care provider. Discussing this situation at a later time and checking with the physician to give the client something to relax ignore the client's immediate concerns. Saying to wait until all tests are normal is vague and provides the client with little information.

156. A After a renal biopsy, the client is maintained on strict bed rest in a supine position for at least 6 hours to prevent bleeding. If no bleeding occurs, the client typically resumes general activity after 24 hours.

157. B Hepatitis B virus is spread through contact with blood, body fluids contaminated with blood, and such body fluids as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions.

158. D The nurse helps the client to recognize that he is feeling anxious by pointing out his behaviors to him The nurse then attempts to help the client recognize his anxiety and describe his feelings to help him connect behaviors with feelings.

159. C Cirrhosis is a slowly progressive disease. Inadequate nutrition is the primary ongoing problem. Clients are encouraged to eat normal, well-balanced diets and to restrict sodium to prevent fluid retention.

160. D Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.

161. A Classic signs and symptoms of rheumatoid arthritis include joint pain, swelling, and warmth. Symptoms are typically bilaterally symmetric. Joint stiffness in the morning lasting longer than 30 minutes is another classic symptom. Rheumatoid arthritis is

a systemic disease. Other symptoms can include fatigue, low-grade fever, anemia, and weight loss.

162. B The priority for care would be to monitor the fetal response to the contractions because pregnancy may have accelerated the progress of vascular disease. The gestational diabetic is at higher risk for the development of preeclampsia, therefore increasing the risk of uteroplacental insufficiency. All of the remaining nursing diagnoses are appropriate for the gestational diabetic during labor, but the priority remains close observation of the client's glucose level and the fetal response to labor contractions.

163. D According to the DSM-IV, schizoaffective disorder refers to clients suffering from schizophrenia with elements of a mood disorder, either mania or depression. The prognosis is generally better than for the other types of schizophrenia, but it's worse than the prognosis for a mood disorder alone. Option C is incorrect because personality disorders and psychotic illness aren't listed together on the same axis. Option A is incorrect because schizophrenia is a major thought disorder and the question asks for elements of another disorder. Option B is incorrect because clients with schizoaffective disorder aren't suffering from schizophrenia and an amnestic disorder.

164. C Preoperative and postoperative pictures of babies with cleft palates and lips provide clear and concrete images of what to expect after corrective surgery. Providing these pictures is specific to the parents' behavior because the parents reflect societal values that emphasize an infant's facial appearance and responsive expressiveness.

165. D All symptoms define chronic low self-esteem. There isn't enough information to determine delayed growth and development. The question doesn't describe the client's ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data in the question.

166. A This client is hypotensive because of decreased blood flow through the aorta. By turning the client to her left side, the nurse removes the weight of the uterus from the aorta and increases the maternal blood flow. Taking blood pressure, summoning the physician, starting oxygen, and increasing IV fluids aren't necessary unless repositioning doesn't relieve the symptoms.

167. D The major side effect of these three drugs is hepatitis. While the client is undergoing chemotherapy for TB, the nurse should carefully monitor the client's liver function tests.

168. C The radioactivity comes from a radioactive material such as radium or cesium. Radioactivity affects tissues but does not make them radioactive. Once the radioactive source is removed, no radioactivity remains. Accurate information can help alleviate ungrounded fears.

169. C The best nursing intervention is giving the client finger-foods high in protein and calories that he can eat while he paces or walks.

170. A Proper positioning to prevent flexion deformities of the joints is an ongoing need for clients with rheumatoid arthritis and should be included in the care plan.

171. D When strongly opposed to a type of therapy, the nurse should refer people who ask about the therapy to another knowledgeable person.

172. A It would be most helpful to demonstrate the use of a walker with partial weight bearing. Partial weight bearing will be required while the hip is healing.

173. D The rooting reflex is a neonate's response to having his cheek stroked. The neonate will turn his head to the side of the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The tonic neck reflex is elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side extend and those on the other side flex. Moro's reflex is the startle reflex. For example, when the neonate's crib is jolted, the neonate abducts his arms and extends them. The grasp reflex occurs when the neonate curls his fingers around another person's fingers.

174. D The client should be instructed to avoid straining and lifting for 2 to 6 weeks after surgery.

175. B A 5-year-old child is in the preoperational stage of cognitive development and thinks of death as temporary. Also, for a child of this age, thinking about behavior often is believed to be magical; thus, the child may think that his behavior can cause death.

176. C The client who is a fantasy or reminiscent wanderer can be helped most by diverting his attention toward an activity to relieve boredom or tension.

177. A Based on the report of the child's signs and symptoms, the nurse would suspect otitis media. On assessment, the tympanic membrane would appear bulging and bright red (because of increased middle ear pressure), typically indicative of otitis media. Other characteristic findings include rhinorrhea, fever, cough, irritability, pulling at the ears, earache, vomiting, and diarrhea. A reddened, nonbulging tympanic membrane may indicate otitis media if the membrane has ruptured.

178. B After corrective surgery for repair of TEF, the risk for esophageal stricture is high because scar tissue forms at the site of the esophageal anastomosis, often requiring dilation at the anastomosis site during the first years of childhood in about half the children.

179. A Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction.

180. D The first nursing action would be to elevate the hips on two pillows. The primary goal with prolapse of the umbilical cord is

to remove the pressure from the cord. Changing the maternal position is the first intervention. Acceptable positions include knee-chest, side-lying, and elevation of the hips. The nurse may also perform a vaginal examination and attempt to push the presenting part of the cord while being careful not to add any pressure to the cord.

181. B Nasal septal perforation is associated with cocaine uses. When the cocaine is inhaled into the nares, it causes vasoconstriction and impairs the blood supply to the septurn. With frequent repeated use, this leads to tissue necrosis.

182. A Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus.

183. C Trochanter rolls placed alongside the client's legs from the ilium to midthigh are recommended to prevent external rotation of the hips.

184. A Although all of the choices are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior is a prerequisite for understanding and helping clients.

185. C Maintaining catheter patency during the immediate postoperative period after a transurethral resection is a priority because postoperative bleeding can occlude the catheter. Catheter occlusion can lead to urinary retention, pain, bladder spasm, and the need to replace the catheter.

186. A A heart rate of 150 bpm is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 bpm.

187. C The client is most likely suffering from muscle rigidity due to haloperidol. I.M. Benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.

188. D Tendency toward capillary fragility has nothing to do with thermoregulation. The hypothalamus is the site of temperature regulation. In preterm neonates, the CNS is poorly developed, so these neonates may be more prone to temperature instability. The large skin surface area provides the perfect medium for heat loss through evaporation and convection. Lack of S. C. and brown fat are also contributors to temperature instability. Without S. C. fat, there is nothing to insulate the infant from heat loss. Brown fat provides calories that help with heat production.

189. A The first of the 12 steps of AA is for an individual to admit that he's powerless over alcohol and that life has become unmanageable. Although AA promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a sponsor who may be called upon when the client has the urge to drink.

190. D Positioning the child on the affected side, in this case the right side, will promote drainage from the middle ear by gravity.

191. D When assessing an adolescent initially, the nurse should try to determine the client's level of emotional maturity. This forms the basis for the nursing plan of care. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the client.

192. D Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body and away from the face.

193. B Steady and progressive weight gain is the best indication that the client's nutritional goals are being met by TPN.

194. A Diphtheria, acellular pertussis, and tetanus are killed vaccines and may be given to this toddler. Live virus vaccines are not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness.

195. A Describing acceptable behavior to the client focuses on the immediate problem.

196. D Routine dental examinations should begin when a child is young, usually after the age of 2 years, before any obvious problems develop.

197. C Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor that prevents conversion of angiotensin Ⅰ to angiotensin Ⅱ. Angiotensin Ⅱ is a potent vasoconstrictor and also contributes to aldosterone secretion. Thus, enalapril decreases blood pressure through systemic vasodilation.

198. C Management of children with early morning hyperglycemia depends on whether the hyperglycemia is due to insulin-waning, a progressive rise in blood glucose throughout the day, or rebound hyperglycemia (Somogyi effect; an increase in blood sugar glucose at bedtime, a drop at about 2. 00 AM, then a rebound rise early in the morning). Information about the child's blood glucose levels would provide clues to determine which event is occurring.

199. D For the initial management of nosebleed, the client should sit up and lean forward with the head tipped downward. The soft tissues of the nose should be compressed against the septum with the fingers. The traditional head-back position allows blood to flow down the throat and can trigger vomiting.

200. D Group support has proved more successful than individual attention from the staff in influencing positive behavior in alcoholics.

201. B Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems.

202. A The nurse, for her own protection, should be aware of hospital security and other assisting personnel. The other options may cause a relatively docile client to become belligerent.

203. B A 10-year-old should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress at this age suggesting Anxiety.

204. C During this time, the client is usually offered ice chips rather than clear liquids. Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate.

205. D Chest pain and dyspnea in an immobilized adolescent with a large bone fracture suggest a fat embolus. With this condition, fat droplets, rather than a thrombus, are transferred from the marrow into the general blood stream by the venous-arterial route, possibly reaching the lung or brain.

206. C Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well because of such factors as a full bladder or retained pieces of placenta, and places the postpartum client at risk for hemorrhage.

207. B Sedative-hypnotic drugs aren't linked to the treatment of a specific disorder. They're used to treat anxiety and insomnia, which can occur in a range of psychiatric disorders. Antidepressants are used to treat OCD. Psychostimulants are used to treat ADHD. Hallucinations and delusions are treated with antipsychotics.

208. A Nasogastric suctioning is ordered to remove accumulated gas or fluid (secretions). Excessive fluid can cause pressure on suture lines, resulting in injury, rupture, or dislodgment. The gastrointestinal tract should remain empty (no food or fluids) until peristalsis returns and suture lines have healed adequately, at which time the nasogastric tube is removed.

209. C Encouraging frequent ambulation would be the most important contribution to the prevention of thromboembolism. Clotting factors and fibrinogen are increased in the immediate postpartum period. When the client is in this hypercoagulable state, the vessel damage that occurs with birth and immobility predisposes her to developing thromboembolism. Although increasing oral fluid intake also is important, encouraging frequent ambulation is most important. Providing oxygen therapy and administering pain medications don't prevent thromboembolism formation.

210. D Relating to the client that she combed her hair points out a visible accomplishment and reinforces positive self-care behavior.

211. D The client needs further instructions when she says she should decrease her fluid intake. Constipation further aggravates hemorrhoid pain and should be avoided through increased fluid and fiber intake. Warm sitz baths, topical ointments, and ice packs all can be helpful measures to reduce the pain, swelling, and itchiness.

212. D Prednisone is a gastrointestinal irritant that is best taken with food.

213. C The tympanostomy tubes, made of a polyurethane material that does not change in structure or composition while in the ear, usually remain in place for about 6 months then are spontaneously ejected from the ear. Parents should be told about the tubes appearance so they can observe them if they fall out.

214. B The first nursing intervention is to ensure the client's safety because these clients are terrified that the abuser will arrive and continue the cycle of violence. After this has been done, the nurse can contact the authorities, identify a support person, and ensure confidentiality. Photographing the client's injuries requires the client's consent.

215. B Corporeal punishment is an aversion technique that teaches children what not to do. Children can often become accustomed to physical punishment, so the punishment must be more severe to get the same results.

216. B The pyloric olive-like mass is most easily palpated when the abdominal muscles are relaxed, the stomach is empty, and the infant is quiet. During eating, the stomach still is empty and the infant is relaxed and comfortable.

217. A Most foods contain limited amounts of fluoride. However, tea contains a significant amount of fluoride and would be the most appropriate suggestion.

218. B Somatoform disorders are characterized by recurrent and multiple physical symptoms that have no organic or physiologic base. Exhibitionism involves public exposure of genitals. Degenerative dementia is characterized by deterioration of mental capacities. Echolalia is a repetition of words or phrases.

219. C A swollen, painful scrotum after herniorrhaphy is relatively common. Elevating the scrotum, as on a rolled towel, and intermittently placing ice bags on the area are helpful.

220. D Esophageal fistula and anencephaly are associated with hydramnios, which is an excess of amniotic fluid. Oligohydramnios, or a decreased amount of amniotic fluid, is associated with renal defects. Diabetes mellitus and cardiac defects aren't associated with either oligohydramnios or hydramnios.

221. C Because ear infections are sometimes difficult to treat, determining if the antibiotic has resolved the infection is essential. If the client is not rechecked, it will be difficult to determine if another infection is a continuation of a previous infection or a separate new infection.

222. A Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage.

223. D A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client's feelings and thoughts. The anorexic client may spend many hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't reinforce her preoccupation with food. Although cultural stereotypes may play a prominent role in anorexia nervosa, discussing these factors isn't the first action the nurse should take. Exploring the reasons why the client doesn't eat would increase her emotional investment in food and eating.

224. D A positive Babinski sign involves dorsiflexion of the big toe and fanning of the other toes. Although normal in infants, this response is abnormal after about age 1 year or when walking begins.

225. D Co-dependents are individuals who allow another's behavior to affect them while being obsessed with controlling the other person's behavior. Co-dependents try to control events and people around them because they feel that everything around them and inside them is out of control.

226. D Multiple gestation causes overdistention of the abdomen, which can lead to uterine atony and, thus, uterine hemorrhage. A weight of 3,175 g (7 lb) is classified as normal for an infant. A

macrocosmic infant [-4,000g (8 lb, oz)] could cause uterine atony. Neither long labor nor PIH causes postpartum hemorrhage.

227. C Descriptions of sensations, painful and otherwise, in the amputated part are common and are known as phantom-limb sensations. The client should be reassured that these sensations are normal and are not a sign of a mental problem.

228. C The scenario is typical of a client who is hallucinating. Not enough information is available to suggest that she's a threat to herself or to society. Malingering refers to a medically unproven symptom that is consciously motivated.

229. A Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on infant care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her infant takes priority.

230. D By age 6 months, an infant can sit alone, leaning forward on the hands for support. The ability to sit follows progressive head control and straightening of the back.

231. B When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting,

postprandial, and bedtime blood glucose levels need to be checked daily.

232. B The client can best discuss his behavior when he's no longer under the influence of alcohol. Option c encourages the client to invent excuses. Option A is judgmental and discourages open communication, and option D is also judgmental.

233. B The most appropriate action when moving an extremity with acute osteomyelitis is to ensure that the extremity is carefully supported above and below the affected area. A splint may be useful to decrease discomfort. Acute osteomyelitis can be very painful. Therefore, the extremity must be handled carefully and moved slowly.

234. B Neurovascular damage may be indicated by the presence of any of the "five Ps" pain, pallor, pulselessness, paresthesia, and paralysis. Bleeding does not indicate neurovascular damage. Neurovascular damage can occur after almost any orthopedic surgery.

235. C Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels.

236. B Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, suicidal, or anxious clients don't physically or mentally test the limits of the caregiver.

237. C The indirect Coombs'test measures the level of antibodies against fetal Rh- positive factor in maternal blood. Although this test may determine the fetal blood Rh factor, the physician doesn't order it primarily for this purpose. The maternal blood Rh factor is determined be{ore the indirect Coombs’test is done. No maternal antibodies against fetal Rh-negative factor exist.

238. A To reduce the risk of osteoporosis, women should have an intake of 1000 to 1500 mg of calcium per day.

239. A Because magnesium has chemical properties similar to those of calcium, it will assume the role of calcium at the neural muscular junction. It doesn't act on the distal renal tubules, CNS, or myocardial fibers.

240. C In rheumatic fever, the joints--especially the knees, ankles, elbows, and wrists--are painful, swollen, red, and hot to the touch. Limiting movement of the affected joints typically minimizes pain.

241. A Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.

242. A A decreased hemoglobin is indicative of aplastic anemia. In addition to a decreased hemoglobin and red blood cell count, the

client will also have a decreased white blood cell count and decreased platelets.

243. A In leukemia, megakaryocytes, from which platelets are derived, are decreased. Normal platelet counts range from 150 to 300×103/mm3. A platelet count of 80×103/ mm3 is low, predisposing the child to bruising and bleeding easily.

244. D Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and IV infusions are ordered to prevent such damage. The nurse is informing her of her treatment options. Option C doesn't tell the client about the consequences of choosing not to eat. Because a client with an eating disorder usually has a distorted self- concept and low self-esteem, options A and B are incorrect because they won't change the client's self-image.

245. D This lesion is a mongolian spot, which is common in children of Asian or African American heritage.

246. D A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation.

247. B Low fluid intake can predispose an individual to stone formation due to the increased urine concentration. Other causes include repeated urinary tract infections, high doses of vitamin C or D, immobility, and large doses of calcium.

248. A Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

249. B To maintain the integrity of the affected areas and prevent muscle wasting and contractures, the nurse should perform regular passive range-of-motion exercises to the client's arms. The nurse shouldn't insist that he eat without assistance because he can't consciously control symptoms and move his arms; furthermore, such insistence may anger the client and endanger the therapeutic relationship. The nurse should include family members because they may be contributing to his stress or conflict, and they're essential in helping the client regain function of his arms. Because the client isn't experiencing pain, he doesn't need education about pain management.

250. D Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.

251. D The dorsalis pedis pulse is found on the medial aspect of the dorsal surface of the foot in line with the big toe.

252. D Memory loss is the primary symptom of dementia. Loss of short-term memory (retaining new information) is more prominent, but tong-term memory (recollection of events that occurred in the past) may also be affected. Psychosis, neurosis, and loss of impulse control aren't symptoms of dementia.

253. B During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also assessed by monitoring mental status, vital signs, peripheral perfusion, and body weight. Pulmonary artery end-diastolic pressure (PAEDP) and even central venous pressure (CVP) are preferred guides to fluid administration, but urine output is best when PAEDP or CVP are not used. After the first 48 to 72 hours, urine output is a less-reliable guide to fluid needs. The victim enters the diuretic phase as edema reabsorption occurs, and urine output increases dramatically.

254. B The nitrazine test determines whether the client's membranes have ruptured. The nurse performs a sterile vaginal examination, inserts the nitrazine test tape, then assesses the tape for a color change. If the membranes are ruptured, the tape becomes bluish, which indicates that the vaginal environment is alkaline. If the test tape remains yellow or green, the vaginal environment is acidic, indicating that the membranes aren't ruptured.

255. C Many poisons require immediate attention but do not cause immediate symptoms.

256. B To determine plans of care for clients who are noneompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, medications can't be forced on a client. A dose shouldn't be omitted without first checking with the physician. Intentionally deceiving or misleading a client violates the therapeutic relationship.

257. A The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Seizures are a sign of eclampsia. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. The other findings aren't typically found in women with preeelampsia.

258. D An early indication of hypokalemia is muscle weakness in the legs. Potassium is essential for proper neuromuscular impulse transmission. When neuromuscular impulse transmission is impaired, as in hypokalemia, leg muscles become weak and flabby. If hypokalemia progresses, respiratory muscles become involved and the client becomes apneic. Hypokalemia also causes electrocardiogram changes.

959. A The client is instructed to hold the cane on the uninvolved side, 94" to 26" (61 to 66 era) from the base of the little toe. This is done to promote a reciprocal gait pattern. The nurse should instruct the client to hold the cane close to his body to prevent leaning. The stride length and timing of each step should be

equal. To prevent fails, the nurse stands behind the client as he's learning to use the cane.

260. B261. A262. A263. B264. A265. A An inpatient client usually receives a copy of the Bill of

Rights for psychiatric patients, which includes right to refuse treatment, right to a written treatment plan, right to confidentiality and right to personal mail. However, a client in an inpatient setting cannot select health team members. A client may apply for disability as a result of a chronic, incapacitating illness; however, disability is not a patient right, and members of a psychiatric institution do not decide who should receive it.