NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022), Exams of Nursing

Download NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022) and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022) 1. 1. Question A nurse was instructed by a physician to give clarithromycin (Biaxin) for a child whose BSA is 0.55 m2. The usual adult dose is 500 mg. Biaxin is available in an oral suspension. The 100ml bottle is labeled 50 mg/ml. How many ml would the nurse give per dose? Fill in the blanks. Record your answer using one decimal place. o Answer: (3.2) mL. Correct answer: o 3.2 mL. Formula: BS A Formula: BSA Formula: Rationale: o Use the BSA formula first then the standard formula as shown above. o To get the child’s dose, multiply 0.55m2(child’s BSA) to 500 mg (usual adult dose) to get 275. o Divide 275 with 1.7 m2to get 161.76 mg. o Use the standard formula above. o Divide 161.76 mg (desired pedia dose) with 50 mg (drug on hand) and multiply by 1 ml (vehicle) to get 3.2 ml. Computation:  2. Question A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first? o A. Blood sugar check o B. CT scan o C. Blood cultures o D. Arterial blood gases Correct Answer: A. Blood sugar check With a history of diabetes, the first response should be to check blood sugar levels. o Option B: Performing a CT scan at this stage of assessment is unnecessary. A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross- sectional images (slices) of the bones, blood vessels, and soft tissues inside the body. CT scan images provide more detailed information than plain X-rays do. o Option C: A blood culture test helps the doctor figure out if the client has a kind of infection that is in the bloodstream and can affect the entire body. Doctors call this a systemic infection. The test checks a sample of the blood for bacteria or yeast that might be causing the infection. o Option D: An arterial blood gas (ABG) test measures oxygen and carbon dioxide levels in the blood. It also measures the body’s acid-base (pH) level, which is usually in balance when healthy. o Option B: Never give an IM injection in the gluteal muscles to avoid the risk of sciatica nerve damage. o Option D: The vastus medialis muscle is a part of the quadriceps muscle group, located on the front of the thigh.  6. Question A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do? o A. Contact the provider o B. Ask the child to write their name on paper o C. Ask a coworker about the identification of the child o D. Ask the father who is in the room the child’s name Correct Answer: D. Ask the father who is in the room the child’s name. In this case, you can determine the name of the child by the father’s statement. You should not withhold the medication from the child after identification. o Option A: Contacting the provider is unnecessary and may take time. A pediatric patient must have folks with them inside the room, so asking the child’s folks would be the most appropriate intervention. o Option B: The child may have not yet developed his writing abilities. Some children are able to write their names at age 4, but some typically developing children still aren’t ready until well into age. o Option C: Asking a coworker would be inappropriate and against the patient’s confidentiality.  7. Question A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings? o A. Elevated serum calcium o B. Low serum parathyroid hormone (PTH) o C. Elevated serum vitamin D o D. Low urine calcium Correct Answer: A. Elevated serum calcium The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. The chronic excessive resorption of calcium from bone caused by excessive parathyroid hormone can result in osteopenia. o Option B: Parathyroid hormone levels may be high or normal but not low. The main effects of parathyroid hormone are to increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidney, and increasing renal production of 1,25-dihydroxyvitamin D-3 (calcitriol), which increases intestinal absorption of calcium. o Option C: The body will lower the level of vitamin D in an attempt to lower calcium. Vitamin D levels should be measured in the evaluation of primary hyperparathyroidism. Vitamin D deficiency (a 25- hydroxyvitamin D level of less than 20 ng per milliliter) can cause secondary hyperparathyroidism, and repletion of vitamin D deficiency can help to reduce parathyroid hormone levels. o Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones. In addition, the chronically increased excretion of calcium in the urine can predispose to the formation of renal stones.  8. Question A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended? o A. A diet high in grains o B. A diet with adequate caloric intake o C. A high protein diet o D. A restricted sodium diet Correct Answer: D. A restricted sodium diet A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Patients should eat an unrestricted diet. Those with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt-wasting that occurs if their condition is untreated. Infants with primary adrenal insufficiency often need 2-4 g of sodium chloride per day. o Option A: A well-balanced diet is the best way to keep the body healthy and to regulate sugar levels. Doctors recommend balancing protein, healthy fats, and high-quality, nutrient-dense carbohydrates. o Option B: High-calorie comfort food reduces symptoms of neuroglycopenia in Addison patients, suggesting that Addison’s disease is associated with a deficit in cerebral energy supply that can partly be alleviated by intake of palatable food. o Option C: Healthy fats and high-quality proteins slow the blood sugar rollercoaster and promote stable blood sugar levels throughout the day.  9. Question A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient’s symptoms? o A. Anesthesia reaction o B. Hyperglycemia o C. Hypoglycemia o D. Diabetic ketoacidosis Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. HAV is a single-stranded, positive-sense, linear RNA enterovirus of the Picornaviridae family. In humans, viral replication depends on hepatocyte uptake and synthesis, and assembly occurs exclusively in the liver cells. Virus acquisition results almost exclusively from ingestion (eg, fecal-oral transmission) o Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is commonly transmitted via body fluids such as blood, semen, and vaginal secretions. [1] Consequently, sexual contact, accidental needle sticks or sharing of needles, blood transfusions, and organ transplantation are routes for HBV infection. o Option C: Before widespread screening of the blood supply in 1992, hepatitis C was also spread through blood transfusions and organ transplants. Now, the risk of transmission to recipients of blood or blood products is extremely low. o Option D: Today, most people become infected with hepatitis B, C, or D by sharing needles, syringes, or any other equipment used to prepare and inject drugs.  12. Question A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this? o A. A history of hepatitis C five years previously o B. Cholecystitis requiring cholecystectomy one year previously o C. Asymptomatic diverticulosis o D. Crohn's disease in remission Correct Answer: A. A history of hepatitis C five years previously Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. o Option B: Cholecystitis is the inflammation of the gallbladder. This condition does not transmit through bodily fluids. o Option C: Diverticulosis is when pockets called diverticula form in the wall of the digestive tract. The inner layer of the intestine pushes through weak spots in the outer lining. This pressure makes them bulge out, making little pouches. o Option D: Crohn’s disease is an inflammatory bowel disease. It causes inflammation of the digestive tract. This disease does not transmit through the blood.  13. Question A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient? o A. Naproxen sodium (Naprosyn) o B. Calcium carbonate o C. Clarithromycin (Biaxin) o D. Furosemide (Lasix) Correct Answer: A. Naproxen sodium (Naprosyn) Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Naproxen is used to relieve pain from various conditions such as headache, muscle aches, tendonitis, dental pain, and menstrual cramps. It also reduces pain, swelling, and joint stiffness caused by arthritis, bursitis, and gout attacks. o Option B: Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach. It is available with or without a prescription. o Option C: Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Clarithromycin is used to treat certain bacterial infections, such as pneumonia (a lung infection), bronchitis (infection of the tubes leading to the lungs), and infections of the ears, sinuses, skin, and throat. It also is used to treat and prevent disseminated Mycobacterium avium complex (MAC) infection [a type of lung infection that often affects people with human immunodeficiency virus (HIV)]. It is used in combination with other medications to eliminate H. pylori, a bacterium that causes ulcers. Clarithromycin is in a class of medications called macrolide antibiotics. It works by stopping the growth of bacteria. o Option D: Furosemide is a loop diuretic and is NOT contraindicated in a patient with gastritis. Furosemide is used alone or in combination with other medications to treat high blood pressure. Furosemide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease. Furosemide is in a class of medications called diuretics (‘water pills’). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.  14. Question The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? o A. The patient must maintain a low-calorie diet. o B. The patient must maintain a high protein/low carbohydrate diet. o C. The patient should limit sweets and sugary drinks. o D. The patient should limit fatty foods. patient with significant ventricular symptoms, such as tachycardia resulting in syncope. o Option A: A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. o Option B: A patient recovering well from coronary bypass would not need the device. o Option D: Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.  17. Question A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient? o A. The patient is allergic to shellfish. o B. The patient has a pacemaker. o C. The patient suffers from claustrophobia. o D. The patient takes antipsychotic medication. Correct Answer: B. The patient has a pacemaker The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Patients with cardiac implantable electronic devices or CIED are at risk for inappropriate device therapy, device heating/movement, and arrhythmia during MRI. These patients must be scheduled in a CIED blocked slot or scheduled with electrophysiology nurse or technician support. But nowadays MRI conditional cardiac implantable electronic devices are widely available. o Option A: Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. MRI contrast agents are gadolinium chelates with different stability, viscosity, and osmolality. Gadolinium is a relatively very safe contrast; however, it rarely might cause allergic reactions in patients. o Options C: Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Claustrophobic patients might refuse to complete the MRI scan and need sedation. These patients need to be well informed about the MRI scan procedure. The recommendation is that a physician has a discussion with them about the details in advance. Using Larger and opener MRI systems might be helpful in claustrophobic patients. o Option D: Psychiatric medication is not a contraindication to MRI scanning. MRI helps in high- resolution investigations of soft tissues without the use of ionizing radiation. This safe modality currently becomes the imaging technique of choice for diagnosing musculoskeletal, neurologic, and cardiovascular disease. However, there are restrictions and contraindications caused by MRI magnetic fields, machine structure, and gadolinium contrast agents.  18. Question A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? o A. The patient is somnolent with decreased response to the family. o B. The patient suddenly complains of chest pain and shortness of breath. o C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. o D. The patient has a fever, chills, and loss of appetite. Correct Answer: B. The patient suddenly complains of chest pain and shortness of breath. Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism—must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed. o Option A: The patient may present atypical symptoms based on risk factors, such as delirium or a decreasing level of consciousness. o Option B: The diagnosis of pulmonary embolism should be sought actively in patients with respiratory symptoms UNEXPLAINED by an alternative diagnosis; symptoms may include productive cough and wheezing. o Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of patients; however, a temperature higher than 39.5°C (103.1º) F is not from a pulmonary embolism.  19. Question A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? o A. The patient will be admitted to the medicine unit for observation and medication. o B. The patient will be admitted to the day surgery unit for sclerotherapy. o C. The patient will be admitted to the surgical unit and resection will be scheduled. o D. The patient will be discharged home to follow-up with his cardiologist in 24 hours. Correct Answer: C. The patient will be admitted to the surgical unit and resection will be scheduled. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist. o Option A: Admitting the patient for observation will be a delay and may result in the rupture of the o Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old. Young toddlers have a sleep schedule supplemented by two naps a day. Toddler sleep problems are compounded by separation anxiety and a fear of missing out, which translates to stalling techniques and stubbornness at bedtime. o Option D: The average 4-year-old child cannot read yet, so this too is normal. At 4, many children just aren’t ready to sit still and focus on a book for long. Others may learn the mechanics of reading but aren’t cognitively ready to comprehend the words.  22. Question A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)? o A. Small blue-white spots are visible on the oral mucosa. o B. The rash begins on the trunk and spreads outward. o C. There is low-grade fever. o D. The lesions have a "teardrop-on-a-rose-petal" appearance. Correct Answer: A. Small blue-white spots are visible on the oral mucosa. Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. Near the end of the prodrome, Koplik spots (ie, bluish-gray specks or “grains of sand” on a red base) appear on the buccal mucosa opposite the second molars. The Koplik spots generally are first seen 1-2 days before the appearance of the rash and last until 2 days after the rash appears. This enanthem begins to slough as the rash appears. Although this is the pathognomonic enanthem of measles, its absence does not exclude the diagnosis. o Option B: The body rash typically begins on the face and travels downward. Blanching, erythematous macules and papules begin on the face at the hairline, on the sides of the neck, and behind the ears (see the images below). Within 48 hours, they coalesce into patches and plaques that spread cephalocaudally to the trunk and extremities, including the palms and soles, while beginning to regress cephalocaudally, starting from the head and neck. Lesion density is greatest above the shoulders, where macular lesions may coalesce. The eruption may also be petechial or ecchymotic in nature. o Option C: High fever (may spike to more than 104°F) is often present. The first sign of measles is usually a high fever (often >104o F [40o C]) that typically lasts 4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the classic triad of conjunctivitis (see the image below), cough, and coryza (the “3 Cs”). o Option D: “Teardrop on a rose petal” refers to the lesions found in varicella (chickenpox). The characteristic chickenpox vesicle, surrounded by an erythematous halo, is described as a dewdrop on a rose petal  23. Question A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? o A. Scarlet fever is caused by infection with group A Streptococcus bacteria. o B. "Strawberry tongue" is a characteristic sign. o C. Petechiae occur on the soft palate. o D. The pharynx is red and swollen. Correct Answer: C. Petechiae occur on the soft palate. Petechiae on the soft palate is characteristic of rubella infection. o Option A: Bacteria called group A Streptococcus or group A strep cause scarlet fever. The bacteria sometimes make a poison (toxin), which causes a rash- the “scarlet” of scarlet fever. As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness. The circulating toxin, produced by GABHS and often referred to as erythemogenic or erythrogenic toxin, causes the pathognomonic rash as a consequence of local production of inflammatory mediators and alteration of the cutaneous cytokine milieu. This results in a sparse inflammatory response and dilatation of blood vessels, leading to the characteristic scarlet color of the rash. o Option B: The tongue may have a “strawberry”-like (red and bumpy) appearance, which is a characteristic sign of scarlet fever. On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). Red, edematous, exudative tonsils are typically observed if the infection originates in this area. o Option D: The throat and tonsils may be very red and sore with scarlet fever, and swallowing may be painful. The mucous membranes usually are bright red and scattered petechiae and small red papular lesions on the soft palate are often present.  24. Question A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose? o A. It is the correct dose o B. The dose is too low o C. The dose is too high o D. The dose should be increased or decreased, depending on the symptoms Correct Answer: B. The dose is too low This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore, The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, the residual non-hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis. o Option A: The mass is solid at presentation and usually >10 cm. o Option B: This option describes stage 1, wherein the tumor is limited to the kidney and completely resected. o Option D: In stage IV, hematogenous metastasis has occurred with spread beyond the abdomen.  27. Question A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply. o A. Urine specific gravity of 1.040 o B. Urine output of 350 ml in 24 hours o C. Brown ("tea-colored") urine o D. Generalized edema Correct Answer: A, B, & C Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea-colored” urine caused by large amounts of red blood cells. Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and RBC casts are present. o Option B: Functional changes include proteinuria, hematuria, reduction in GFR (ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The decreased GFR and avid distal nephron salt and water retention result in the expansion of intravascular volume, edema, and, frequently, systemic hypertension. o Option C: This is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients, often manifesting as smoky-, coffee-, or cola-colored urine. o Option D: There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis. Most often, the patient is a boy, aged 2-14 years, who suddenly develop puffiness of the eyelids and facial edema in the setting of a post- streptococcal infection.  28. Question Which of the following conditions most commonly causes acute glomerulonephritis? o A. A congenital condition leading to renal dysfunction. o B. Prior infection with group A Streptococcus within the past 10-14 days. o C. Viral infection of the glomeruli. o D. Nephrotic syndrome. Correct Answer: B. Prior infection with group A Streptococcus within the past 10-14 days. Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine, and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis. o Option A: No congenital condition predisposes to glomerulonephritis. Noninfectious causes of acute GN may be divided into primary renal diseases, systemic diseases, and miscellaneous conditions or agents. o Option C: Viruses may cause acute glomerulonephritis but rarely. Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B virus (HBV), rubella, rickettsiae (as in scrub typhus), parvovirus B19, and mumps virus are accepted as viral causes only if it can be documented that a recent group A beta-hemolytic streptococcal infection did not occur. Acute GN has been documented as a rare complication of hepatitis A. o Option D: Nephrotic syndrome does not cause acute glomerulonephritis. PSGN usually develops 1-3 weeks after acute infection with specific nephritogenic strains of group A beta-hemolytic streptococcus. The incidence of GN is approximately 5-10% in persons with pharyngitis and 25% in those with skin infections.  29. Question An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but the fluid is still visible on illumination. Which of the following actions is the physician likely to recommend? o A. Massaging the groin area twice a day until the fluid is gone. o B. Referral to a surgeon for repair. o C. No treatment is necessary; the fluid is reabsorbing normally. o D. Keeping the infant in a flat, supine position until the fluid is gone. Correct Answer: C. No treatment is necessary; the fluid is reabsorbing normally. A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases, the fluid reabsorbs within the first few months of life and no treatment is necessary. o Option A: A hydrocele can develop before birth. Normally, the testicles descend from the developing baby’s abdominal cavity into the scrotum. A sac accompanies each testicle, allowing fluid to surround the testicles. Usually, each sac closes and the fluid is absorbed. Sometimes, the fluid remains after the sac closes (noncommunicating hydrocele). The fluid is usually absorbed gradually within the first year of life. o Option C: Smoking can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn’t allow enough oxygen to reach the body’s tissues. o Option D: Advancing age increases the risk of atherosclerosis but is not a hereditary factor. As one gets older, the risk for atherosclerosis increases. Genetic or lifestyle factors cause plaque to build up in the arteries as one ages. By the time one is middle- aged or older, enough plaque has built up to cause signs or symptoms. In men, the risk increases after age 45. In women, the risk increases after age 55.  32. Question Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply: o A. It results when oxygen demand is greater than oxygen supply. o B. It is characterized by pain that often occurs during rest. o C. It is a result of tissue hypoxia. o D. It is characterized by cramping and weakness. o E. It always affects the upper extremities. Correct Answer: A, C, & D. Claudication describes the pain experienced by a patient with a peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue becomes hypoxic, causing cramping, weakness, and discomfort. o Option A: Claudication refers to muscle pain due to lack of oxygen that’s triggered by activity and relieved by rest. o Option B: This most often occurs during activity when demand increases in muscle tissue. o Option C: The condition is also called intermittent claudication because the pain usually isn’t constant. It begins during exercise and ends with rest. As claudication worsens, however, the pain may occur during rest. o Option D: Claudication is pain caused by too little blood flow to muscles during exercise. Most often this pain occurs in the legs after walking at a certain pace and for a certain amount of time — depending on the severity of the condition. Option E: Pain in the shoulders, biceps, and forearms may occur, but less often.  33. Question A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in the instructions? o A. Walk barefoot whenever possible. o B. Use a heating pad to keep feet warm. o C. Avoid crossing the legs. o D. Use antibacterial ointment to treat skin lesions at risk of infection. Correct Answer: C. Avoid crossing the legs. Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient. o Option A: Walking barefoot is not advised, as foot protection is important to avoid the trauma that may lead to serious infection. o Option B: Heating pads can cause injury, which can also increase the risk of infection. o Option D: Skin lesions at risk for infection should be examined and treated by a physician.  34. Question A patient who has been diagnosed with the vasospastic disorder (Raynaud’s disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient? o A. An adolescent male o B. An elderly woman o C. A young woman o D. An elderly man Correct Answer: C. young woman. Raynaud’s disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis. Vasospasm of the arteries reduces blood flow to the fingers and toes. In people who have Raynaud’s, the disorder usually affects the fingers. In about 40 percent of people who have Raynaud’s, it affects the toes. Rarely, the disorder affects the nose, ears, nipples, and lips. o Option A: Primary Raynaud’s usually develops before the age of 30. In primary Raynaud’s (also called Raynaud’s disease), the cause isn’t known. Primary Raynaud’s are more common and tend to be less severe than secondary Raynaud’s. o Option B: Secondary Raynaud’s usually develops after the age of 30. Secondary Raynaud’s is caused by an underlying disease, condition, or other factors. This type of Raynaud’s is often called Raynaud’s phenomenon. o Option D: Although anyone can develop the condition, Raynaud’s disease often begins between the ages 15 to 30, but it mostly affects women. If one has primary or secondary Raynaud’s, cold temperatures or stress can trigger “Raynaud’s attacks.” During an attack, little or no blood flows to affected body parts. insult occurs, an immediate local cellular response takes place. Platelets migrate to the area of injury, where they secrete several cellular factors and mediators. These mediators promote clot formation. o Option D: Thrombolytic therapy does not lead to the expansion of the clot, but to resolution, which is the intended effect.  37. Question An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation? o A. Torticollis, with shortening of the sternocleidomastoid muscle. o B. Craniosynostosis, with premature closure of the cranial sutures. o C. Plagiocephaly, with flattening of one side of the head. o D. Hydrocephalus, with increased head size. Correct Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle. In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion of the neck and causing the chin to point to the opposing side. o Option B: In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape. o Option C: Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time. o Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size.  38. Question An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood- Schlatter disease. Which of the following statements about the disease is correct? o A. The condition was caused by the student's competitive swimming schedule. o B. The student will most likely require surgical intervention. o C. The student experiences pain in the inferior aspect of the knee. o D. The student is trying to avoid participation in physical education. Correct Answer: C. The student experiences pain in the inferior aspect of the knee. Osgood-Schlatter disease occurs in adolescents in the rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. o Option A: Swimming is not a likely cause. OSD is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. The pain associated will be localized to the tibial tubercle and occasionally the patellar tendon itself. o Option B: The condition is usually self-limited, responding to ice, rest, and analgesics. OSD is a self- limiting condition. In a study by Krause et al, 90% of patients treated with conservative care were relieved of all of their symptoms approximately 1 year after the onset of symptoms. [3] After skeletal maturity, patients may continue to have problems kneeling. This typically is due to tenderness over an unfused tibial tubercle ossicle or a bursa that may require resection. o Option D: Continued participation will worsen the condition and the symptoms. The onset of OSD is usually gradual, with patients commonly complaining of pain in the tibial tubercle and/or patellar tendon region after repetitive activities. Typically, running or jumping activities that significantly stress the patellar tendon insertion upon the tibial tubercle aggravate the patient’s symptoms.  39. Question The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? o A. Spinal flexibility o B. Leg length disparity o C. Hypostatic blood pressure o D. Scoliosis Correct Answer: D. Scoliosis. A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. o Options A: The ability to move the spine through its full range of motion, both forward and backward, is called spinal flexibility. However, it is not included in routine adolescent exams. o Options B: Leg length discrepancy or disparity is a condition in which the paired lower extremity limbs have a noticeably unequal length. o Option C: Hypostatic or orthostatic blood pressure is a form of low blood pressure that happens when one is sitting or stands up suddenly.  40. Question A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent? protection, and home exercises, can help ensure that patients are as active as possible.  42. Question A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started? o A. The admission orders are written. o B. A blood culture is drawn. o C. A complete blood count with differential is drawn. o D. The parents arrive. Correct Answer: B. A blood culture is drawn. Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. o Option A: Making sure that the physician’s orders for antibiotics are written, instead of admitting orders, should be done. o Option C: The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. o Option D: Parental presence is important for the adjustment of the child but not for the administration of medication.  43. Question A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms? o A. Possible fracture of the tibia. o B. Bruising of the gastrocnemius muscle. o C. Possible fracture of the radius. o D. No anatomic injury, the child wants his mother to carry him. Correct Answer: A. Possible fracture of the tibia. The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture. o Option B: Toddlers will often continue to walk on a muscle that is bruised or strained. o Option C: The radius is found in the lower arm and is not relevant to this question. o Option D: Toddlers rarely feign injury to be carried, and swelling indicates a physical injury.  44. Question A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply. o A. Regular developmental screening is important to avoid secondary developmental delays. o B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. o C. Developmental milestones may be slightly delayed but usually will require no additional intervention. o D. Parent support groups are helpful for sharing strategies and managing health care issues. o E. Therapies and surgical interventions can cure cerebral palsy. Correct Answer: A, B, and D. Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones. o Option A: During a developmental screening, a short test is given to see if the child has specific developmental delays, such as motor or movement delays. If the results of the screening test are cause for concern, then the doctor will make referrals for developmental and medical evaluations. o Option B: Cerebral palsy (CP) is a group of disorders that affect a person’s ability to move and maintain balance and posture. CP is the most common motor disability in childhood. Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles. CP is caused by abnormal brain development or damage to the developing brain that affects a person’s ability to control his or her muscles. o Option C: Delayed developmental milestones definitely need interventions and constant follow ups. Developmental monitoring (also called surveillance) means tracking a child’s growth and development over time. If any concerns about the child’s development are raised during monitoring, then a developmental screening test should be given as soon as possible. o Option D: Both early intervention and school-aged services are available through a special education law —the Individuals with Disabilities Education Act (IDEA). Part C of IDEA deals with early intervention services (birth through 36 months of age), while Part B applies to services for school-aged children (3 through 21 years of age). Even if the child has not been diagnosed with CP, he or she may be eligible for IDEA services. o Option E: Cerebral palsy has no cure, but treatment can improve the lives of those who have the condition. After a CP diagnosis is made, a team of health professionals works with the child and family to develop a plan to help the child reach his or her full potential. Common treatments include medicines; surgery; braces; and physical, occupational, and speech therapy. No single treatment is the best one for all children with CP. Before deciding on a treatment o Option D: PTCA is not a radiographic examination of the heart.  47. Question A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize: o A. They can expect the child will be mentally retarded. o B. Administration of thyroid hormone will prevent problems. o C. This rare problem is always hereditary. o D. Physical growth/development will be delayed. Correct Answer: B. Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement correct this condition. o Option A: Mental retardation can be prevented with early detection and treatment. Neurologic sequelae, characterized by spasticity, tremor, and hyperactive deep tendon reflexes, are found frequently in severe cretinism, but not in mild cretinism or acquired hypothyroidism. The severity of neurologic sequelae parallels mental retardation. Early therapy apparently prevents, in part, these sequelae. o Option C: Congenital hypothyroidism is caused by iodine deficiency and is occasionally exacerbated by naturally occurring goitrogens. In the majority of patients, CH is caused by abnormal development of the thyroid gland (thyroid dysgenesis) which is a sporadic disorder and accounts for 85% of cases, and the remaining 15% of cases are caused by dyshormonogenesis. The clinical features of congenital hypothyroidism are so subtle that many newborn infants remain undiagnosed at birth and delayed diagnosis leads to the most severe outcome of CH, mental retardation, emphasizing the importance of neonatal screening. o Option D: The growth and development of an infant with congenital hypothyroidism can be normal if it is detected and treated early. In overt hypothyroidism, the severe impairment of linear growth leads to dwarfism, which is characterized by limbs that are disproportionately short compared with the  48. Question A priority goal of involuntary hospitalization of the severely mentally ill client is o A. Re-orientation to reality o B. Elimination of symptoms o C. Protection from harm to self or others o D. Return to independent functioning Correct Answer: C. Protection from self-harm and harm to others. Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled. o Option A: Mentally ill clients should be kept safe first before reorienting them back to reality. In keeping with emergent mental health public policy and nursing professional ethics, the articulated aims of deinstitutionalization included returning individuals to home communities to restore freedom and autonomy and reducing or eliminating nursing practices grounded in punishment that was being societally reconceptualized as harmful. o Option B: Gradual elimination of the symptoms is not the primary goal in the hospitalization of a mentally ill client. There are two important concepts of psychological treatment. First, although it is called “psychological” treatment, the ultimate effect of these treatments is to bring some changes in the very delicate change in the structure and function of neurons by changing the way a person habitually thinks and behaves. They also promote the healing of the brain by reducing the stress experienced by the patients in daily life. In psychological treatment, all treatment effects come from the effort to take new behavior and adopt new ways of thinking. o Option D: The client should be kept safe from himself and others first before he can return to independent functioning. The measurement of functional capacity in mental illness is an important recent development. Determination of functional capacity may serve as a surrogate marker for real-world functioning, thereby aiding clinicians in making important treatment determinations.  49. Question A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”? o A. “I don’t remember anything about what happened to me.” o B. “I’d rather not talk about it right now.” o C. “It’s the other entire guy’s fault! He was going too fast.” o D. “My mother is heartbroken about this.” Correct Answer: A. “I don’t remember anything about what happened to me.” Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-esteem. o Option B: Denial is a defense mechanism proposed by Anna Freud which involves a refusal to accept reality, thus blocking external events from awareness. If a situation is just too much to handle, the person may respond by refusing to perceive it or by denying that it exists. o Option C: This statement refers to projection, which is when an individual attributes her negative self-concept onto others. becomes wet, it can hurt the child’s skin. Do not try to dry cast with something warm (i.e., a blow dryer) this may cause burns.  52. Question A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would: o A. Instruct the client to maintain a regular diet the day prior to the examination. o B. Restrict the client’s fluid intake 4 hours prior to the examination. o C. Administer a laxative to the client the evening before the examination. o D. Inform the client that only 1 x-ray of his abdomen is necessary. Correct Answer: C. Administer a laxative to the client the evening before the examination Bowel prep is important because it will allow greater visualization of the bladder and ureters. Intravenous pyelogram (IVP) is an x- ray exam that uses an injection of contrast material to evaluate the kidneys, ureters, and bladder and help diagnose blood in the urine or pain in the side or lower back. An IVP may provide enough information to allow the doctor to treat with medication and avoid surgery. o Option A: Eating and drinking the night before the exam should be avoided. o Option B: Restriction of fluids on the night before the exam should be emphasized. o Option D: An intravenous pyelogram is an x-ray of the kidneys, ureters, and urinary bladder that uses iodinated contrast material injected into veins.  53. Question Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that: o A. AGN is a streptococcal infection that involves the kidney tubules. o B. The disease is easily transmissible in schools and camps. o C. The illness is usually associated with chronic respiratory infections. o D. It is not “caught” but is a response to a previous B-hemolytic strep infection. Correct Answer: D. It is not “caught” but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease. o Option A: Acute glomerulonephritis comprises a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium. o Option B: The disease is most commonly caused by Streptococcus species. Glomerulonephritis may develop a week or two after recovery from a strep throat infection or, rarely, a skin infection (impetigo). To fight the infection, the body produces extra antibodies that can eventually settle in the glomeruli, causing inflammation. o Option C: Acute glomerulonephritis is usually associated with staphylococcal infection. Infections with other types of bacteria, such as staphylococcus and pneumococcus, viral infections, such as chickenpox, and parasitic infections, such as malaria, can also result in acute glomerulonephritis. Acute glomerulonephritis that results from any of these infections is called postinfectious glomerulonephritis.  54. Question The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately? o A. 3 episodes of vomiting in 1 hour. o B. Periodic crying and irritability. o C. Vigorous sucking on a pacifier. o D. No measurable voiding in 4 hours. Correct Answer: D. No measurable voiding in 4 hours. The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. Successful management of acute hyperkalemia involves protecting the heart from arrhythmias with the administration of calcium, shifting potassium (K+) into the cells, and enhancing the elimination of K+ from the body. o Option A: Episodes of vomiting should be reported, but it is not the priority and is currently being managed with intravenous infusions. Once clinically significant dehydration is present, effective and safe strategies for rehydration are required. Additionally, following rehydration there may be a risk of recurrence of dehydration and appropriate fluid management may reduce the likelihood of that event. o Option B: Crying and irritability is a normal reaction of an infant who is unwell. o Option C: Vigorous sucking is a good sign in an infant who has episodes of vomiting.  55. Question While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action? o A. Check vital signs. o B. Administer stool softeners every day as ordered. o C. Administer antidysrhythmics prn as ordered. o D. Maintain the client on strict bed rest. Correct Answer: B. Administer stool softeners every day as ordered. Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the Valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate. o Option A: A bedside commode for a client with acute MI should be provided, but it does not prevent Valsalva maneuver alone. o Option C: Antidysrhythmics do not prevent Valsalva maneuver. Antidysrhythmic agents, which are also known as antiarrhythmic agents, are a broad category of medications that help ameliorate the spectrum of cardiac arrhythmias to maintain normal rhythm and conduction in the heart. o Option D: A client with acute MI can be given bathroom privileges with assistance.  58. Question On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to: o A. Give the client orientation materials and review the unit rules and regulations. o B. Introduce him/her and accompany the client to the client’s room. o C. Take the client to the day room and introduce her to the other clients. o D. Ask the nursing assistant to get the client’s vital signs and complete the admission search. Correct Answer: B. Introduce him/herself and accompany the client to the client’s room. Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. o Option A: The client is still confused and fearful. Orientation should be postponed until he is calm. They can deliver effective, safe care by assessing risk and building a rapport with the patient during the admission process; utilizing crisis prevention strategies, including appropriate medication administration, environmental, psychobiological, counseling, and health teaching interventions; and employing conflict resolution techniques. o Option C: The client should be taken to a calm environment with less stimuli so he could feel safe and become calmer. o Option D: Taking the client’s vital signs while he is still fearful would further aggravate his feelings of insecurity and fear. Utilizing the nursing process, the nurse can provide effective therapeutic interventions to promote safety for both the patient and the nurse.  59. Question During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? o A. “I have constant blurred vision.” o B. “I can’t see on my left side.” o C. “I have to turn my head to see my room.” o D. “I have specks floating in my eyes.” Correct Answer: C. “I have to turn my head to see my room.” Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabecular meshwork. If left untreated or undetected blindness results in the affected eye. o Option A: Central vision is one of the most common signs of glaucoma. The fluid inside the eye, called aqueous humor, usually flows out of the eye through a mesh-like channel. If this channel gets blocked, the liquid builds up. Sometimes, experts don’t know what causes this blockage. But it can be inherited, meaning it’s passed from parents to children. o Option B: The peripheral field of vision is most often lost in a client with glaucoma. The increased pressure in the eye, called intraocular pressure, can damage the optic nerve, which sends images to the brain. If the damage worsens, glaucoma can cause permanent vision loss or even total blindness within a few years. o Option D: Patchy blind spots in the peripheral or central vision of both eyes is a symptom of open-angle glaucoma. It is caused by the drainage channels in the eye becoming gradually clogged over time.  60. Question A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client: o A. Has increased airway obstruction. o B. Has improved airway obstruction. o C. Needs to be suctioned. o D. Exhibits hyperventilation. Correct Answer: A. Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning. o Option C: Aerobic exercise is any type of cardiovascular conditioning and is inappropriate for a client who has a leg cast. o Option D: Isotonic exercise is one method of muscular exercise and it is not recommended for a client who has leg cast.  63. Question A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?A. Counsel the woman to consent to HIV screening. o A. Counsel the woman to consent to HIV screening. o B. Perform tests for sexually transmitted diseases. o C. Discuss her high risk for cervical cancer. o D. Refer the client to a family planning clinic. Correct Answer: A. Counsel the woman to consent to HIV screening The client”s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome. o Option B: Before performing the tests, the client should be informed first and she must give her consent. Separate written consent for HIV testing is not recommended. General informed consent for medical care that notifies the patient that an HIV test will be performed unless the patient declines (opt-out screening) should be considered sufficient to encompass informed consent for HIV testing. o Option C: Discussion about the risks can come after determining if the client is HIV positive or not. Increased HIV vulnerability is often associated with legal and social factors, which increases exposure to risk situations and creates barriers to accessing effective, quality and affordable HIV prevention, testing and treatment services. o Option D: Family planning could come after the HIV screening has results. For women with HIV who want to become pregnant, use of antiretroviral prophylaxis during pregnancy can reduce mother-to-child transmission of HIV. Afterwards, family planning services that promote healthy timing and spacing of pregnancies are important to reduce the risk of adverse pregnancy outcomes such as low birth weight, preterm birth, and infant mortality.  64. Question A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse? o A. Arrange to change client care assignments. o B. Explain that this behavior is expected. o C. Discuss the appropriate use of “time-out”. o D. Explain that the child needs extra attention. Correct Answer: B. Explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool. o Option A: Changing client assignments is unnecessary. The nurse may wait for the child to calm down. o Option C: Time outs are usually not appropriate for a toddler, especially if she is in a new environment. o Option D: The behavior shown by the toddler is normal and she does not need any additional attention.  65. Question While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? o A. Strange bed and surroundings. o B. Separation from parents. o C. Presence of other toddlers. o D. Unfamiliar toys and games. Correct Answer: B. Separation from parents Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. o Option A: Most children, even school-aged children, are fearful of a strange bed and new surroundings. o Option C: The presence of other toddlers might help the client calm down and adjust with the environment. o Option D: Unfamiliar toys and games would least likely affect the toddler’s behavior.  66. Question While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age? o A. They are able to make simple associations of ideas. o B. They are able to think logically in organizing facts. o C. Interpretation of events originates from their own perspective. o D. Conclusions are based on previous experiences. Correct Answer: B. They are able to think logically in organizing facts. o Option C: Dress-up and props are recommended for preschool. When a child plays together with others and has interest in both the activity and other children involved in playing they are participating in cooperative play. o Option D: Chess is recommended for school-age to adolescent stage. During the school-age years, you’ll see a change in your child. He or she will move from playing alone to having multiple friends and social groups.  69. Question A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? o A. High Fowler’s o B. Supine o C. Left lateral o D. Low Fowler’s Correct Answer: A. High Fowler’s Sitting in a chair or resting in a bed in a high Fowler”s position decreases the cardiac workload and facilitates breathing. o Option B: Lying flat or in a supine position would be difficult for the client and may induce increased cardiac workload. o Option C: Left lateral position may increase the client’s cardiac workload. o Option D: Low Fowler’s may not be sufficient enough to support the client’s cardiac workload.  70. Question The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is: o A. Urinary output of 30 ml per hour o B. No complaints of thirst o C. Increased hematocrit o D. Good skin turgor around burn Correct Answer: A. Urinary output of 30 ml per hour For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces. o Option B: Relying on the client’s thirst would not create accurate results. The steady intravascular fluid loss due to these sequences of events requires sustained replacement of intravascular volume in order to prevent end-organ hypoperfusion and ischemia. o Option C: An increase in hematocrit suggests vascular space fluid losses. Reduced cardiac output is a hallmark in this early post-injury phase. The reduction in cardiac output is the combined result of decreased plasma volume, increased afterload and decreased cardiac contractility, induced by circulating mediators. o Option D: A good skin turgor is not an accurate indicator of adequate fluid replacement. The goal of fluid management in major burn injuries is to maintain the tissue perfusion in the early phase of burn shock, in which hypovolemia finally occurs due to steady fluid extravasation from the intravascular compartment.  71. Question What is the priority nursing diagnosis for a patient experiencing a migraine headache? o A. Acute pain related to biologic and chemical factors o B. Anxiety related to change in or threat to health status o C. Hopelessness related to deteriorating physiological condition o D. Risk for Side effects related to medical therapy Correct Answer: A. Acute pain related to biologic and chemical factors The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management. o Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension headaches are common for people that struggle with severe anxiety or anxiety disorders. Tension headaches can be described as a heavy head, migraine, head pressure, or feeling like there is a tight band wrapped around their head. These headaches are due to a tightening of the neck and scalp muscles. o Option C: Hopelessness should be addressed as part of the nursing care plan, but it does not require urgency. Hopelessness can result when someone is going through difficult times or unpleasant experiences. A person may feel overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to multiple stresses and losses. He or she might think that challenges are unconquerable or that there are no solutions to the problems and may not be able to mobilize the energy needed to act on his or her own behalf. o Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization  72. Question You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? Select all that apply. o A. Complete admission assessment o B. Set up oxygen and suction equipment o C. Place a padded tongue blade at the bedside o D. Pad the side rails before the patient arrives Correct Answer: B. Set up oxygen and suction equipment The LPN/LVN can set up the equipment for oxygen and suction. o Option A: The RN should perform the complete initial assessment. o Option C: Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins. o Option D: Padded side rails are controversial in terms of whether they actually provide safety and may embarrass the patient and family.  75. Question A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene? o A. “You should avoid consumption of all forms of alcohol.” o B. “Wear your medical alert bracelet at all times.” o C. “Protect your loved one’s airway during a seizure.” o D. “It’s OK to take over-the-counter medications.” Correct Answer: D. “It’s OK to take over-the-counter medications.” A patient with a seizure disorder should not take over-the-counter medications without consulting with the physician first. o Option A: Alcohol is not allowed for patients with seizures because it increases the risk of another episode. o Option B: A medical alert bracelet bears the message that the wearer has an important medical condition that might require immediate attention. o Option C: One of the priorities during a seizure is to prevent obstruction of the airway by turning the client into a side-lying position to allow drainage to flow.