Q&A Random Selection #14

1. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be
included in the plan of care?
A) Monitor for hyperkalemia
B) Place in protective isolation
C) Precautions with position changes
D) Administer diuretics as ordered

2. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major
concern now, and what will we have to deal with in the future?" Which of the following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that the family can attend."

3. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be
most effective in meeting the growth and development needs for persons in this age group?
A) Aerobic exercise classes
B) Transportation for shopping trips
C) Reminiscence groups
D) Regularly scheduled social activities

4. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse
to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball

5. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common
nutritional disorder in this age group?
A) Bulimia
B) Anorexia
C) Obesity
D) Malnutrition

6. A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for
premature infants because it
A) contains less lactose
B) is higher in calories/ounce
C) provides antibodies
D) has less fatty acid

7. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the
expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than
before. What is the best advice by the nurse?
A) Change the baby to whole milk
B) Add chocolate syrup to the bottle
C) Continue with the present formula
D) Offer fruit juice frequently

8. Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects?
A) Red reflex test
B) Visual acuity
C) Pupil response to light
D) Cover test

9. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third
admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the
time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway
inflammation?
A) The alveoli will degenerate
B) Chronic bronchoconstriction of the large airways will occur
C) Lung remodeling and permanent changes in lung function will result
D) The client will experience frequent bouts of pneumonia
10. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute
glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure

11. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural
belief system, the nurse would explain that illness is attributed to the
A) Yang, the positive force that represents light, warmth, and fullness
B) Yin, the negative force that represents darkness, cold, and emptiness
C) use of improper hot foods, herbs and plants
D) a failure to keep life in balance with nature and others

12. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client
refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is
to
A) ask the client about the refusal of certain pain medications
B) talk with the client's family about the situation
C) report the situation to the primary care provider
D) document the situation in the notes

13. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the
hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room.
What
would be the best response by the nurse demonstrating emotional support for the client?
A) "No, it would be best if you brought the client some reading material that she could read at night."
B) "No, your presence may cause the client to become more anxious."
C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
D) "Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?"

14. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse
would be appropriate?
A) Schedule the therapy thirty minutes after meals
B) Teach the child not to cough during the treatment
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy

15. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the
wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is
most appropriate for this wound?
A) transparent dressing
B) dry sterile dressing with antibiotic ointment
C) wet to dry dressing
D) occlusive moist dressing

16. A mother asks the nurse if she should be concerned about her child’s tendency to stutter. What assessment data
will be most useful in counseling the parent?
A) Age of the child
B) Sibling position in family
C) Stressful family events
D) Parental discipline strategies

17. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells
the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to
catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this
assessment?
A) Activity intolerance caused by fatigue related to chronic tissue hypoxia
B) Impaired mobility related to chronic obstructive pulmonary disease
C) Self care deficit caused by fatigue related to dyspnea
D) Ineffective airway clearance related to increased bronchial secretions

18. At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the
activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication
to control her mind. The client's behavior most likely indicates
A) Feelings of increasing anxiety related to paranoia
B) Social isolation related to altered thought processes
C) Sensory perceptual alteration related to withdrawal from environment
D) Impaired verbal communication related to impaired judgment
19. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
A) Maintaining and preserving function
B) Anticipating side effects of therapy
C) Supporting coping with limitations
D) Ensuring compliance with medications

20. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most
concerned about which statement by the mother?
A) "My child has lost 3 pounds in the last month."
B) "Urinary output seemed to be less over the past 2 days."
C) "All the pants have become tight around the waist."
D) "The child prefers some salty foods more than others."

21. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
D) Bradycardia

22. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for
me." The nurse should
A) Inform the client that she must wait until the program ends at 5:00 pm to leave
B) Give the client simple information about what she will be doing
C) Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
D) Firmly direct the client to her assigned group activity

23. The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His
symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first
assessment?
A) Stressors in the home
B) Medication compliance
C) Exposure to hot temperatures
D) Alcohol use

24. Which type of accidental poisoning would the nurse expect to occur in children under age 6?
A) Oral ingestion
B) Topical contact
C) Inhalation
D) Eye splashes

25. The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child
has iron deficiency anemia. The nurse's best response is
A) "Although the results are here, your doctor will explain them later."
B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."

26. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental
achievements would the nurse anticipate that the child would be able to perform?
A) Say 2 words
B) Pull up to stand
C) Sit without support
D) Drink from a cup

27. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which
action confirms this finding?
A) Stand on 1 foot
B) Catch a ball
C) Skip on alternate feet
D) Ride a bicycle

28. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling
sad and hopeless, the nurse would assess for
A) Anxiety, unconscious anger, and hostility
B) Guilt, indecisiveness, poor self-concept
C) Psychomotor retardation or agitation
D) Meticulous attention to grooming and hygiene
29. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take
priority in planning care?
A) Increase fluid intake to prevent dehydration
B) Place client on a pressure reducing support surface
C) Use skin care products designed for use with incontinence
D) Increase caloric intake to aid healing

30. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the
highest risk for poisoning?
A) 9 month-old who stays with a sitter 5 days a week
B) 20 month-old who has just learned to climb stairs
C) 10 year-old who occasionally stays at home unattended
D) 15 year-old who likes to repair bicycles

31. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating
regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the
client’s behaviors are warning signs to indicate that the client may be
A) headed for relapse
B) feeling hopeless
C) approaching recovery
D) in need of increased socialization

32. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse
make an exception to this practice?
A) When a family member offers information about their loved one
B) When the client threatens self-harm and harm to others
C) When the provider decides the family has a right to know the client's diagnosis
D) When a visitor insists that the visitor has been given permission by the client

33. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood
pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position

34. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this
client?
A) Hyperextension of the neck with passive shoulder flexion
B) Flexion of the hip and knees with passive flexion of the neck
C) Flexion of the legs with rebound tenderness
D) Hyperflexion of the neck with rebound flexion of the legs

35. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to
be, I know things would be different." Which would be the best response by the nurse?
A) "The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change."
B) "Perhaps, if you understood the need to abuse, you could stop the violence."
C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"
D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not
do."

36. In a child with suspected coarctation of the aorta, the nurse would expect to find
A) strong pedal pulses
B) diminishing carotid pulses
C) normal femoral pulses
D) bounding pulses in the arms

37. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned
about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest
expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in
length. What is the correct analysis of these findings?
A) The pediatrician must examine the baby
B) Emergency equipment should be available
C) This breathing pattern is normal
D) A future referral may be indicated
38. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly “bothers” other
clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from
the staff. Which activity would be best for the client?
A) Reading
B) Checkers
C) Cards
D) Ping-pong

39. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the
most common infection?
A) Gonorrhea
B) Chlamydia
C) Herpes
D) HIV

40. Post-procedure nursing interventions for electroconvulsive therapy include