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100 Item Comprehensive Exam With Answers and Rationale

100 Item Comprehensive Exam With Answers and Rationale

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Published by mervilyn
Godbless. 10% work and 90% prayer. :)
Godbless. 10% work and 90% prayer. :)

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Published by: mervilyn on Aug 17, 2010
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100 item Comprehensive Exam with Answers and Rationale
1. The nurse enters the room as a 3 year-old is having a generalized seizure. Whichintervention should the nurse do first?A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the childD) Give the prescribed anticonvulsantThe correct answer is B: Place the child on the sideProtecting the airway is the top priority in a seizure. If a child is actively convulsing, apatent airway and oxygenation must be assured.2. A client has just returned to the medical-surgical unit following a segmental lungresection. After assessing the client, the first nursing action would be toA) Administer pain medication
B) Suction excessive tracheobronchial secretions
 C) Assist client to turn, deep breathe and coughtD) Monitor oxygen saturationThe correct answer is B: Suction excessive tracheobronchial secretionsSuctioning the copious tracheobronchial secretions present in post-thoracic surgery clientsmaintains an open airway which is always the priority nursing intervention.3. A nurse from the surgical department is reassigned to the pediatric unit. The chargenurse should recognize that the child at highest risk for cardiac arrest and is the least likelyto be assiged to this nurse is which child?A) Congenital cardiac defectsB) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple traumaThe correct answer is C: Prolonged hypoxemiaMost often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia.Children usually have both cardiac and respiratory arrest.4. Which of the following would be the best strategy for the nurse to use when teachinginsulin injection techniques to a newly diagnosed client with diabetes?A) Give written pre and post testsB) Ask questions during practiceC) Allow another diabetic to assist
D) Observe a return demonstration
 The correct answer is D: Observe a return demonstrationSince this is a psychomotor skill, this is the best way to know if the client has learned theproper technique.5. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heartdisease. Which of these is most likely to be seen with this diagnosis?A) Several otitis media episodes in the last yearB) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikesThe correct answer is C: Takes frequent rest periods while playingChildren with heart disease tend to have exercise intolerance. The child self-limits activity,which is consistent with manifestations of congenital heart disease in children.6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which
of these cases of childhood poisoning would the nurse suggest that parents have the childdrink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
 B) A 14 month-old who chewed 2 leaves of a philodendron plantC) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluidThe correct answer is A: An 18 month-old who ate an undetermined amount of crystal draincleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralizethis substance.7. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nursethat she has everything ready for the baby and has made plans for the first weeks togetherat home. Which normal emotional reaction does the nurse recognize?A) Acceptance of the pregnancyB) Focus on fetal development
C) Anticipation of the birth
 D) Ambivalence about pregnancyThe correct answer is C: Anticipation of the birthDirecting activities toward preparation for the newborn''s needs and personal adjustmentare indicators of appropriate emotional response in the third trimester.8. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth havechalky white-to-yellowish staining with pitting of the enamel. Which of the followingconditions would most likely explain these findings?A) Ingestion of tetracycline
B) Excessive fluoride intake
 C) Oral iron therapyD) Poor dental hygieneThe correct answer is B: Excessive fluoride intakeThe described findings are indicative of fluorosis, a condition characterized by an increase inthe extent and degree of the enamel''s porosity. This problem can be associated withrepeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.9. Which of the following should the nurse teach the client to avoid when takingchlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramineC) Foods fermented with yeastD) Canned citrus fruit drinksThe correct answer is A: Avoid direct sunlightPhenothiazine increases sensitivity to the sun, making clients especially susceptible tosunburn.10. The nurse is discussing dietary intake with an adolescent who has acne. The mostappropriate statement for the nurse is
A) "Eat a balanced diet for your age."
 B) "Increase your intake of protein and Vitamin A."C) "Decrease fatty foods from your diet."D) "Do not use caffeine in any form, including chocolate."The correct answer is A: "Eat a balanced diet for your age."A diet for a teenager with acne should be a well balanced diet for their age. There are norecommended additions and subtractions from the diet.
 11. The nurse is caring for a child who has just returned from surgery following atonsillectomy and adenoidectomy. Which action by the nurse is appropriate?A) Offer ice cream every 2 hoursB) Place the child in a supine positionC) Allow the child to drink through a straw
D) Observe swallowing patterns
 The correct answer is D: Observe swallowing patternsThe nurse should observe for increased swallowing frequency to check for hemorrhage.12. The nurse is caring for a client with acute pancreatitis. After pain management, whichintervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolationC) Provide a diet high in proteinD) Institute seizure precautionsThe correct answer is A: Cough and deep breathe every 2 hoursRespiratory infections are common because of fluid in the retro peritoneum pushing upagainst the diaphragm causing shallow respirations. Encouraging the client to cough anddeep breathe every 2 hours will diminish the occurrence of this complication.13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist theclient with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
 B) Assist the client to sit in a chair for mealsC) Provide additional servings of fruits and raw vegetablesD) Encourage the client to eat fish, liver and chickenThe correct answer is A: Offer small meals of high calorie soft foodIf the client is losing weight because of poor appetite due to the pain, assist in selectingfoods that are high in calories and nutrients, to provide more nourishment with lesschewing. Suggest that frequent, small meals be eaten instead of three large ones. Tominimize jaw movements when eating, suggest that foods be pureed.14. A client treated for depression tells the nurse at the mental health clinic that he recentlypurchased a handgun because he is thinking about suicide. The first nursing action shouldbe to
A) Notify the health care provider immediately
 B) Suggest in-patient psychiatric careC) Respect the client's confidential disclosureD) Phone the family to warn them of the riskThe correct answer is A: Notify the health care provider immediatelyThe health care provider must be contacted immediately as the client is a danger to self andothers. Hospitalization is indicated.15. The initial response by the nurse to a delusional client who refuses to eat because of abelief that the food is poisoned is
A) "You think that someone wants to poison you?"
 B) "Why do you think the food is poisoned?"C) "These feelings are a symptom of your illness."D) "You’re safe here. I won’t let anyone poison you."The correct answer is A: "You think that someone wants to poison you?"This response acknowledges perception through a reflective question which presentsopportunity for discussion, clarification of meaning, and expressing doubt.

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