Professional Documents
Culture Documents
All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.
1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
C) Dehydration.
D) Skin breakdown.
Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of
discomfort with distention, and overflow with a large residual. This leads to urinary stasis
and infection. High fluid intake limits urinary stasis and infection by diluting the urine
and increasing urinary output.
2. The client is transferred from the operating room to recovery room after an open-heart
surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the
physician when the temperature of the client rises to 38.8 C or 102 F because elevated
temperatures:
A) Hematuria
B) Dysuria
C) Polyuria
D) Dribbling
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following
will the client most likely experience?
A) Visual hallucinations.
B) Receptive aphasia.
C) Hemiparesis.
D) Personality changes.
A) Androgens
B) Glucocorticoids
C) Mineralocorticoids
D) Estrogen
Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus
causes hypotension.
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The
nurse would base the teaching on the understanding that:
A) Inspired air will move from the lung into the pleural space.
As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.
7. During an assessment, the nurse recognizes that the client has an increased risk for
developing cancer of the tongue. Which of the following health history will be a
concern?
C) Nail biting.
A) Compact bone is stronger than cancellous bone because of its greater size.
B) Compact bone is stronger than cancellous bone because of its greater weight.
C) Compact bone is stronger than cancellous bone because of its greater volume.
D) Compact bone is stronger than cancellous bone because of its greater density.
The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are
reduced to haversian canals.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of
the RBC count, the nurse understands that the higher the red blood cell count, the :
10. The physician advised the client with Hemiparesis to use a cane. The client asks the
nurse why cane will be needed. The nurse explains to the client that cane is advised
specifically to:
Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.
11. The nurse is conducting a discharge teaching regarding the prevention of further
problems to a client who undergone surgery for carpal tunnel syndrome of the right
hand. Which of the following instruction will the nurse includes?
Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.
12. A female client is admitted because of recurrent urinary tract infections. The client
asks the nurse why she is prone to this disease. The nurse states that the client is most
susceptible because of:
The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the
anus in females also increases this incidence.
13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and
shoulders that occurs at rest, with high body temperature, weak with generalized sweating
and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse
knows that the most accurate explanation for one of these presenting adaptations is:
Temperature may increase within the first 24 hours and persist as long as a week.
14. Following an amputation of a lower limb to a male client, the nurse provides an
instruction on how to prevent a hip flexion contracture. The nurse should instruct the
client to:.
The hips are in extension when the client is prone; this keeps the hips from flexing.
15. The physician scheduled the client with rheumatoid arthritis for the injection of
hydrocortisone into the knee joint. The client asks the nurse why there is a need for this
injection. The nurse explains that the most important reason for doing this is to:
C) Reduce inflammation.
D) Provide physiotherapy.
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
16. The nurse is assigned to care for a 57-year-old female client who had a cataract
surgery an hour ago. The nurse should:
A) Advise the client to refrain from vigorous brushing of teeth and hair.
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency
department. The clients arterial blood gases is drawn and the result is PaO2 80mmHg.
then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65
mmHg. The nurse should;
A) You sound concerned; Youll probably remember more as you wake up.
This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.
B) Denial of illness.
Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.
20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal
cancer for discharge instruction about resuming activities. The nurse should plan to help
the client understands that:
B) Most sports activities, except for swimming, can be resumed based on the
clients overall physical condition.
There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of
the following statement would alert the nurse that further teaching to the client is
necessary?
A) I will be limiting my intake to 600 to 800 calories a day once I start eating
again.
D) I will be going to be out of bed and sitting in a chair the first day after
surgery..
clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after
weight stabilizes, which may require a panniculectomy. Body image disturbance often
occurs in response to incorrectly estimating ones size; it is not uncommon for the client
to still feel fat no matter how much weight is lost.
22. The client who had transverse colostomy asks the nurse about the possible effect of
the surgery on future sexual relationship. What would be the best nursing response?
C) The partner should be told about the surgery before any sexual activity.
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance.
However, the nurse should encourage verbalization.
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what
chances he had of getting also osteoporosis like his wife. Which of the following is the
correct response of the nurse?
Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture
and the risk in men is estimated between 13% and 25%; a bone mineral density
measurement assesses the mass of bone per unit volume or how tightly the bone is
packed.
24. An older adult client with acute pain is admitted in the hospital. The nurse
understands that in managing acute pain of the client during the first 24 hours, the nurse
should ensure that:
Generally, female voices have a higher pitch than male voices; older adults with
presbycusis (hearing loss caused by the aging process) have more difficulty hearing
higher-pitched sounds.
26. The nurse is reviewing the clients chart about the ordered medication. The nurse
must observe for signs of hyperkalemia when administering:
A) Furosemide (Lasix)
B) Hydrochlorothiazide (HydroDIURIL)
C) Metolazone (Zaroxolyn)
D) Spironolactone (Aldactone)
A) Palpitation
B) Visual disturbance
D) Lethargy
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is
effective when there is decrease in:
A) The triglycerides
B) The INR
C) Chest pain
D) Blood pressure
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32. The client with an acute myocardial infarction is hospitalized for almost one week.
The client experiences nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.
33. A client with a partial occlusion of the left common carotid artery is scheduled for
discharge. The client is still receiving Coumadin. The nurse provided a discharge
instruction to the client regarding adverse effects of Coumadin. The nurse should tell the
client to consult with the physician if:
Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported,
because it may indicate toxic levels of the drug.
34. Levodopa is ordered for a client with Parkinsons disease. Before starting the
medication, the nurse should know that:
A) Muscle strength
B) Symptoms
C) Blood pressure
D) Consciousness
A) Seizure activity
B) Liver function
C) Cardiac output
D) Pain relief
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.
38. A client with Addisons disease is scheduled for discharge. Before the discharge, the
physician prescribes hydrocortisone and fludrocortisone. The nurse expects the
hydrocortisone to:
A) Arterial blood pH
B) Pulse rate
C) Serum glucose
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of
normal urine output and thirst.
40. A client with recurrent urinary tract infections is to be discharged. The client will be
taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides
discharge instructions to the client. Which of the following instructions will be correct?
To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders
antibiotic therapy for the client. The nurse understands that chemotherapy destroys
rapidly growing leukocytes in the:
A) Bone marrow
B) Liver
C) Lymph nodes
D) Blood
Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help
counter infections that the body can no longer handle easily.
42. The physician reduced the clients Dexamethasone (Decadron) dosage gradually and
to continue a lower maintenance dosage. The client asks the nurse about the change of
dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to
allow:
Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is
expected. The nurse is aware that fluid deficit can most accurately be assessed by:
A) Potassium
B) Sodium
C) Chloride
D) Calcium
The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cells ability to function.
45. Which of the following client has a high risk for developing hyperkalemia?
A) Crohns disease
C) Cushings syndrome
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.
46. The nurse is reviewing the laboratory result of the client. The clients serum
potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client
in a diabetic ketoacidosis. The primary reason for administering this drug is:
B) Treatment of hyperpnea
Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is
generally supplied.
48. A female client is brought to the emergency unit. The client is complaining of
abdominal cramps. On assessment, client is experiencing anorexia and weight is
reduced. The physicians diagnosis is colitis. Which of the following symptoms of fluid
and electrolyte imbalance should the nurse report immediately?
Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.
49. The client is to receive an IV piggyback medication. When preparing the medication
the nurse should be aware that it is very important to:
Because IV solutions enter the bodys internal environment, all solutions and medications
utilizing this route must be sterile to prevent the introduction of microbes.
50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report
indicates the clients pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results
are consistent with:
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
TEST V
All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.
1. A 17-year-old client has a record of being absent in the class without permission, and
borrowing other peoples things without asking permission. The client denies stealing;
rationalizing instead that as long as no one was using the items, there is no problem to use
it by other people. It is important for the nurse to understand that psychodynamically, the
behavior of the client may be largely attributed to a development defect related to the:
A) Oedipal complex
B) Superego
C) Id
D) Ego
C) You seem upset. I am going to be here with you; perhaps you will want to talk
about it
The client needs to have his or her feelings acknowledged, with encouragement to discuss
feelings, and be reassured about the nurses presence.
3. In crisis intervention therapy, which of the following principle that the nurse will use to
plan her/his goals?
The client is most likely confused, rather than exhibiting acting-out, hostile behavior.
Frequent toileting will allow urination in an appropriate place.
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric
unit. In the past two months, the client has poor appetite, experienced difficulty in
sleeping, was mute for long periods of time, just stayed in her room, grinning and
pointing at things. What would be the initial nursing action on admitting the client to the
unit?
The client needs basic, simple orientation that directly relates to the here-and-now, and
does not require verbal interaction.
6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of
the nurse?
Although all options may appear correct. A is the best because it focuses on a range of
possible positive reinforcers, a basis for an effective behavior modification program. It
can lead to concrete, specific nursing interventions right away and provides a
therapeutic use of control for the 16-year-old.
7. On an adolescent unit, a nurse caring to a client was informed that her clients closest
roommate dies at night. What would be the most appropriate nursing action?
The nurse needs to wait and see: do not jump the gun; do not assume that the client
wants to know now.
8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse
should expect the womans initial reactions to include:
A) Depression
B) Withdrawal
C) Apathy
D) Anger
The woman is experiencing an actual loss and will probably exhibit many of the same
symptoms as a person who has lost someone to death.
9. A client in the psychiatric unit is shouting out loud and tells the nurse, Please, help
me. They are coming to get me. What would be the appropriate nursing response?
10. A client who is severely obese tells the nurse, My therapist told me that I eat a lot
because I didnt get any attention and love from my mother. What does the therapist
mean? What is the best nursing response?
A) What do you think is the connection between your not getting enough love
and overeating?
D) We are here to deal with your diet, not with your psychological problems.
This response asks information that the nurse can use. If the client understands the
statement, the nurse can support the therapist when focusing on connection between food,
love, and mother. If the client does not understand the statement, the nurse can help get
clarification from the therapist.
11. After the discussion about the procedure the physician scheduled the client for
mastectomy. The client tells the nurse, If my breasts will be removed, Im afraid my
husband will not love me anymore and maybe he will never touch me. What should the
nurses response?
D) Ask the husband, in front of the wife, how he feels about this.
B) Flat affect.
C) Expressions of guilt.
13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the
morning shift, the nurse is talking with the client who is now exhibiting a manic episode
with flight of ideas. The nurse primarily needs to:
B) Speak loudly and rapidly to keep the clients attention, because the client is
easily distracted.
Often the verbalized ideas are jumbled, but the underlying feelings are discernible and
must be acknowledged.
14. The nurse is caring to an autistic child. Which of the following play behavior would
the nurse expect to see in a child?
A) competitive play
B) nonverbal play
C) cooperative play
D) solitary play
Autistic children do best with solitary play because they typically do not interact with
others in a socially comprehensible and acceptable way.
15. The client is telling the nurse in the psychiatric ward, I hate them. Which of the
following is the most appropriate nursing response to the client?
The nurse is asking the client to clarify and further discuss feelings.
16. The mother visits her son with major depression in the psychiatric unit. After the
conversation of the client and the mother, the nurse asks the mother how it is talking to
her son. The mother tells the nurse that it was a stressful time. During an interview with
the client, the client says, we had a marvelous visit. Which of the following coping
mechanism can be described to the statement of the client?
A) Identification.
B) Rationalization.
C) Denial.
D) Compensation.
A) Indifference
B) Denial
C) Resignation
D) Anger
Reactions when told of a life-threatening illness stem from Kbler-Ross ideas on death
and dying. Denial is a typical grief response, and usually is a first reaction.
18. A nurse is caring to a female client with five young children. The family member told
the client that her ex-husband has died 2 days ago. The reaction of the client is stunned
silence, followed by anger that the ex-husband left no insurance money for their young
children. The nurse should understand that:
A) The children and the injustice done to them by their fathers death are the
womans main concern.
B) To explain the womans reaction, the nurse needs more information about the
relationship and breakup.
19. A client who is manic comes to the outpatient department. The nurse is assigning an
activity for the client. What activity is best for the nurse to encourage for a client in a
manic phase?
This option avoids external stimuli, yet channels the excess motor activity that is often
part of the manic phase.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client
says, Why should I take this? The doctor started me on this 10days ago; it didnt help
me at all. Which of the following is the best nursing response:
A) Isocarboxazid (Marplan)
Persons with dementia needs sameness, consistency, structure, routine, and predictability.
23. A client tells the nurse, I dont want to eat any meals offered in this hospital because
the food is poisoned. The nurse is aware that the client is expressing an example of:
A) Delusion.
B) Hallucination.
C) Negativism.
D) Illusion.
A) Ignore the client as long as he or she is talking about suicide, because suicide
attempt is unlikely.
B) Administer medication.
B) Anorexia, insomnia.
C) Diarrhea, anger.
A) Acknowledge that the word has some special meaning for the client.
D) State that what the client is saying has not been understood and then divert
attention to something that is really bound.
A) Repression.
B) Suppression.
C) Undoing.
D) Rationalization.
A) Hallucination.
B) Ideas of reference.
C) Delusion of persecution.
D) Illusion.
29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows
less awareness of the physical body. What problem would the nurse be most concerned?
A) Nausea.
B) Gait disturbances.
C) Bowel movements.
D) Voiding.
C) Complete the postmortem care and quietly accompany the family to the childs
room.
D) Suggest the parents to wait until the funeral service to say good-bye.
This allows the parents/family to grieve over the loss of the child, by going through the
steps of leave taking.
31. A 20-year-old female client is diagnosed with anxiety disorder. The physician
prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be
concerned?
A) Tremor, drowsiness.
Assess for suicidal tendencies, especially during early therapy. There is an increased risk
of seizures in debilitated client and those with a history of seizures.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?
D) Tell the client that the nurse needs a partner for an activity.
B) Lie still now and Ill let you have one of your presents before you even have
your operation.
C) Take a nice, big, deep breath and then let me hear you count to five.
D) You look so scared. Want to know a secret? This wont hurt a bit!
A) Hypertensive crisis.
B) Diet restrictions.
D) Exposure to sunlight.
This is the more inclusive answer, although diet restrictions (answer1) are important,
their purpose is to prevent hypertensive crisis (answer 2).
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the
nurse caring to her that her step-father has made sexual advances to her. She got the
chance to tell it to her mother but refuses to believe. What is the most therapeutic action
of the nurse would be:
A) Acknowledge that this is the clients belief but not the nurses belief.
The nurse should neither challenge nor use logic to dispel an irrational belief.
37. A nurse is completing the routine physical examination to a healthy 16-year-old male
client. The client shares to the nurse that he feels like killing his girlfriend because he
found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to
keep this a secret just between the two of them. The nurse reviews his chart and notes
that there is no previously history of violence or psychiatric illness. Which of the
following would be the best action of the nurse to take at this time?
A) Suggest the teen meet with a counselor to discuss his feelings about his
girlfriend.
B) Tell the teen that his feelings are normal, and recommend that he find another
girlfriend to take his mind off the problem.
C) Recall the teenage boys often say things they really do not mean and ignore the
comment.
D) Regard the comment seriously and notify the teens primary health care
provider and parents
Any threat to the safety of oneself or other should always be taken seriously and never
disregarded by the nurse.
38. Which of the following person will be at highest risk for suicide?
The likelihood of multiple contributing factors may make this person at higher risk for
suicide. Some factors that may exist are physical illness related to alcoholism, emotional
factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and
economic problems related to employment.
39. A male client is repetitively doing the handwashing every time he touches things. It is
important for a nurse to understand that the clients behavior is probably an attempt to:
C) Do what the voices the patient hears tell him or her to do.
A) Advance the science of psychiatry by initiating research and gathering data for
current statistics on emotional illness.
C) Understand various types of family therapy and psychological tests and how to
interpret them.
41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies
of respiratory failure. The mother of the boy becomes upset, shouting and abusive,
saying to the nurse, If it had been your son, they would have done more to save it.
What should the nurse say or do?
A) Touch her and tell her exactly what was done for her baby.
B) Allow the mother to continue her present behavior while sitting quietly with
her.
D) Yes, youre probably right. Your son did not get better care.
Personality disorders stem from a weak superego, implying a lack of adequate controls.
43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with
him in the recovery room after the surgery, or he will be upset for not granting his
request. What is the appropriate nursing response?
B) You wont need your glasses or hearing aid. The nurses will take care of you.
C) I understand. You will be able to cooperate best if you know what is going on,
so I will find out how I can arrange to have your glasses and hearing aid available
to you in the recovery room.
D) I understand you might be more cooperative if you have your aid and glasses,
but that is just not possible. Rules, you know.
The client will be easier to care for if he has his hearing aid and glasses.
44. The male client had fight with his roommates in the psychiatric unit. The client
agitated client is placed in isolation for seclusion. The nurse knows it is essential that:
Frequent contacts at times of stress are important, especially when a client is isolated.
45. A medical representative comes to the hospital unit for the promotion of a new
product. A female client, admitted for hysterical behavior, is found embracing him.
What should the nurse say?
B) Use restraints while the client is in bed to keep him or her from wandering off
during the night.
C) Use restraints while the client is sitting in a chair to keep him or her from
wandering off during the day.
This option is best to decrease confusion and disorientation to place and time.
47. A 30-year-old married woman comes to the hospital for treatment of fractures. The
woman tells the nurse that she was physically abused by her husband. The woman
receives a call from her husband telling her to get home and things will be different. He
felt sorry of what he did. What can the nurse advise her?
This option helps the woman to think through and elaborate on her own thoughts and
prognosis.
48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a
modified mastectomy is performed. After the procedure, what behaviors could the nurse
expects the client to display?