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Fundamentals of Nursing

"no good and don't care." The nurse


1. A mother complains that her 13-year-old has
recognizes that these statements at this age
started to grow rapidly, and asks the nurse if this is
indicate negative resolution of which task,
normal and how long it will last. The best nursing
according to Erikson?
response is:
A Integrity versus despair
B Identity versus role confusion
C Generativity versus stagnation
D Intimacy versus isolation

A "This is unusual at this age, and a physician


should be contacted."
B "This is normal, but will only last a few
months." 5 The nurse is developing a teaching plan for a
C "This is normal and can last until about age 9-year-old female client who is diabetic.
20." Which actions would be appropriate,
D "This is normal, but growth should be according to Piaget?
completed by about age 15 or 16."
A Teaching size of food portions and
importance of timing snacks and meals
B Discussing future hazards of pregnancy
for diabetic mothers
C Using hand puppets to teach proper
nutrition
2 A 21-year-old who has just graduated from D Using hypothetical problem situations to
college has had a serious automobile teach potential problem solving
accident and faces many months of
hospitalization and rehabilitation. The nurse,
in planning care, recognizes that according to
Havighurst, this client may delay or have
difficulty with successful accomplishment of 6 A client is hesitant to have needed surgery
which developmental task? because of multiple family, social, and church
obligations, saying, "I hate to let everybody
A Selecting a mate and getting started in an down." The nurse recognizes that this client's
occupation moral dilemma is a result of the client
B Exhibiting socially responsible behavior operating at which level of Kohlberg's stages
and developing an ethical system of of moral development?
behavior
C Developing a conscience and developing A Preconventional
appropriate masculine or feminine role B Conventional
D Selecting an occupation and developing C Postconventional
intellectual skills necessary for civic D Universal
competence

7 A 68-year-old female client of a spouse with


3 A mother is frustrated because her 2 1/2- Alzheimer's disease has been taking
year-old is not toilet trained and will not use caregiver classes. The nurse determines that
the potty when placed on it. What suggestion caregiver education has been effective and
by the nurse is most appropriate? that the client has progressed to Stage 3 in
Gilligan's moral development levels when the
A Do not let the child off the potty until client exhibits which behavior(s)?
stool or urine is evacuated.
B Do not try to toilet-train the child, as it is A States that she will never place her
too early. husband in a nursing home
C Give the child a laxative and place on the B Has complex locks put on all outside
potty in 30 minutes. doors so that the husband cannot wander
D Make up a game to encourage the child outside
to want to use the potty. C Has the backyard fenced in so that the
husband can go outside safely
D Arranges for a "sitter" weekly so that she
can take a yoga class

4 An 82-year-old client complains that he is


"sick, old, and useless," and that people are
Fundamentals of Nursing
11. A young woman who is contemplating pregnancy and has a
8 A client expresses fear over a complex,
"junk food" tells the nurse, "I will begin eating right and taking m
painful, sterile procedure, and asks that the
become pregnant." The best nursing response is:
minister be allowed to stay in the room and
close by while it is being performed. The best
nursing action would be to:
A "You must begin eating well and taking multiple vitamins a
suspect that you are pregnant."
A Explain that the procedure is sterile, and
B "You must eat well and take multiple vitamins both before
that the minister cannot stay, but can
pregnancy."
return as soon as it is completed
C "As long as you consume enough calories, there will not be
B Place the minister by a window where
become pregnant."
the client can see him during the
D "Eating well and taking multiple vitamins are not importan
procedure
trimester of pregnancy."
C Let the minister stand way back in a far
corner of the room during the procedure
D Place the minister in sterile apparel and
allow him to be close to the client during
the procedure

1 The nurse is seeing several pregnant women


2 at a community health clinic. Which woman
9 A mother expresses concern to the nurse
is at highest risk for having a low--birth
regarding her 5-year-old child's development.
weight infant or one with birth defects, and is
She says,: "I read Erikson and Piaget, and my
in need of prenatal education?
child does not seem to be on target. Also, my
neighbor's child seems more advanced. My
A A 25-year-old woman who smokes and
doctor says not to worry, but I do." The best
drinks two beers a day
nursing response is:
B An 18-year-old woman who is in her
eighth month and has gained 22 pounds
A "You are right to be concerned. Your
C A 30-year-old woman who was 10 pounds
child should meet all the guidelines for
overweight before becoming pregnant
the age."
D A 32-year-old, unmarried middle class
B "Tell me exactly what your child is or is
executive secretary.
not doing that causes you concern."
C "I wouldn't worry. All children progress at
their own rate."
D "Your child will probably catch up with
more age." 1 A new mother call the clinic crying because
3 her 2-day-old infant now weighs 7 pounds, 2
ounces, when he weighed 7 pounds, 8
ounces at birth. She says, "I must be doing
something wrong." The best nursing
1 A nurse who works in a long-term care
response would be:
0 facility notices that the elderly clients seem
depressed, and that they have little interest
A "You are right to be concerned. I will
in life. They spend their days watching
schedule an appointment for tomorrow."
television. When they attend crafts, they are
B "The baby is obviously not eating
disinterested in drawing pictures or coloring.
enough. Try feeding every two hours."
Based on these observations, and guided by
C "This is normal weight loss. The baby
Peck's theory on older adult development,
should be back to birth weight in 3-5
the nurse determines that:
days".
D "The baby should be taken to the nearest
A Activities such as gardening and baking
emergency room immediately."
may be indicated for these clients
B Humorous movies need to be shown
more frequently
C The activity director needs to bring in
musical groups more often 14 A 6-month-old infant is brought to the clinic
D Stringing glass beads and making seed by an aunt who says the baby's parents are
pictures may be more interesting to out of the country on business. The nurse
elderly clients notes that the infant seems healthy but
withdrawn, and is below the fifth percentile
for weight and height on the standard
growth chart. The aunt states the baby has
had a succession of undependable baby-
Fundamentals of Nursing
sitters since she was born, and that the for 7- and 8-year-old children. Based on the
parents are always working. Based on the nurse's knowledge of health problems for
assessment data, the nurse forms a this age group, an important component of
preliminary diagnosis of: the program should be:

A Weight loss related to infant colic A Identifying foods that contribute to


B Child abuse: shaken-baby syndrome obesity
C Failure to thrive related to organic B Distinguishing between saturated and
causes unsaturated fats
D Failure to thrive related to inorganic C Realizing the importance of taking
causes vitamins every day
D Getting the best food buy for the money

15 Parents of a 2 1/2-year-old child report that


the child has began to have temper 19 Parents of a 15-year-old who walks with a
tantrums, and ask the nurse what they very noticeable limp following recovery from
should do. Strategies that the nurse could a recent automobile accident ask the nurse
suggest include: what to do, because the teen refuses to
return to school, and says, "I'm a cripple."
A Determining the child's safety and then The best nursing response would to suggest
leaving the room when the child has a that the parents:
tantrum
B Attempting to reason with the child A Insist that the teen return to school as
during the tantrum soon as possible and learn to "deal with"
C Giving the child what is wanted to avoid reactions of others
the tantrums B Encourage their teen to attend a support
D Throwing cold water on the child during group of peers with similar handicaps
the tantrum to help the child "snap out before returning to school
of it" C Arrange for homeschooling for their teen
to avoid the rejection he experienced at
the previous school
D Ask the physician to prescribe an
antidepressant for their teen prior to
16 Using Snellen's E chart, the nurse assesses returning to school.
the visual acuity of a 5-year-old as
approximately 20/60. The nurse determines
that the findings at this age indicate:

A Normal vision 20 The nurse determines that a sex education


B Hyperopic vision program regarding risk behaviors for teens
C Myopic vision in a local school has been effective when:
D Emmetropic vision
A Teens report a reduction in masturbation
episodes
B Teens report more use of vaginal
douches
17 A nurse needs to complete diet and exercise C Teens report fewer sexual encounters
health assessments on preschool children. D The rate of STDs and teen pregnancy
Based on the nurse's knowledge of decreases
preschool cognitive and social development,
the nurse determines that the best way to
obtain complete and accurate information is
to:
21. A 25-year-old comes to the clinic with complaints
A Interview each child alone of difficulty sleeping, weight loss, stomach
B Interview a group of children together discomfort, and vague aches and pain. The history
C Interview each child's parents reveals that the client was laid off from work two
D Interview each child together with the months previously, is not seeking employment, has
parents no friends or family within 200 miles, and has almost
no social contact with anyone. The priority action of
the nurse should be to:

18 The nurse is developing a nutrition program


Fundamentals of Nursing
A Suggest that the client take over-the-
counter sleeping medications
B Schedule the client for stomach x-rays and 2 A 45-year-old male client who has attended
further tests 5 classes on coronary heart disease prevention
C Refer the client to a local employment reports that he quit smoking, doesn't have
service hypertension, and doesn't eat much red
D Refer the client to a mental health meat. What other important behavior would
professional indicate that the nurse's teaching has been
effective?

A Seeing a physician yearly for an EKG


B Swimming for an hour, four times weekly
C Drinking a glass of wine every day
D Avoiding strenuous activity
2 The nurse is providing a community
2 education program on hypertension to a
predominately African-American group of
young adults. The nurse should plan the 2 A 50-year-old client complains about getting
program to address which controllable 6 older, saying: "Everything is starting to sag
contributing factors for hypertension? and wrinkle! I don't want to go anywhere
looking like this." The nurse determines that,
A Vigorous physical activity and weight loss according to Erickson, this client is
B Obesity and stress experiencing:
C Biologic inheritance and socioeconomic
status A Generativity
D Alcohol and substance abuse B Stagnation
C Disengagement
D Continuity

2 A 22-year-old woman reports the following


3 health history: sexual activity beginning age
14, multiple sex partners, and previous 2 An 86-year-old client sitting up in a chair
Trichomonas vaginitis. Based on this history, 7 complains of being cold even though the
the nurse knows that an essential screening room thermometer measures 78 degrees.
exam to prepare the client for will be: The most appropriate nursing action would
be to:
A Papanicolaou (Pap) test
B Breast exam and mammography A Get the client a sweater, blanket, and
C Chest x-ray stockings
D Drug screen B Check the client's temperature
C Ignore the complaint, since the room is
sufficiently warm
D Put a space heater next to the client
2 A 43-year-old woman reports symptoms of
4 hot flashes, weight gain, and insomnia. She
says: "I can't be going through menopause,
something else must be wrong! My mother
didn't go through menopause until she was 2 A nurse is planning a community education
54 years old!" What is an appropriate 8 program on osteoporosis. Which group of
response by the nurse? high-risk individuals needs to be included in
the mailing list of invitations to attend the
A "You definitely are going through program?
menopause, even though it is unusual to
do so at such a young age." A Premenopausal women
B "These are not menopausal symptoms, B Physically active men and women ages
and you need tests to determine what is 40-55
happening." C Men and women who consume large
C "This is menopause, and you will have to amounts of dairy products
learn to live with it." D Inactive elderly men
D "Menopause usually happens anytime
between ages 40 and 55. It sounds like
you are upset about this."
Fundamentals of Nursing
2 The daughter of an 88-year-old female client D Give very complete and comprehensive
9 newly admitted to a nursing home states that explanations of all information
her mother does not socialize much at all,
and asks the nurse to "be sure to plan
activities to get her out more." Keeping
continuity theory in mind, what assessment
information does the nurse need to obtain 3 The nurse observes the following client behaviors: fidgeti
before planning any intervention? 3 tenseness, and wrinkled brow. How should the nurse best
nonverbal cues?
A The amount of social activity the client
was involved in when younger A Determine and document that the client is anxious
B The mobility ability of the client B Ask the client specific questions about possible cau
C The visual and hearing abilities of the as, "Are you afraid of something?"
client C Ask the client, "Why are you so nervous and jumpy
S The ability of the client to understand D Say to the client, "You look worried. Is something b
and engage in meaningful conversation

3 The nurse learns from a report that a client has suffered s


3 The nurse is preparing to discharge several 4 an accident. What is the best way for the nurse to prepar
0 clients from the hospital. All the clients this client?
require medications and special diets at
home. The nurse will assess financial status A Having all supplies and equipment ready to be abl
of which client in particular, who may be B Learning about the client's support systems (famil
most in need of financial assistance to obtain C Learning more about the specifics of the disfigurem
medications and proper food? reactions by the nurse
D Reviewing all medications and treatment procedur
A A 60-year-old Caucasian male
B A 90-year-old Caucasian female
C A 75-year-old African-American male
D A 87-year-old African-American female

31. The nurse notes that a client appears very worried and upset about an upcoming
procedure. After acknowledging the client's discomfort and providing
3 information
The nurseand
comes into a client's room to
support, the nurse evaluates that comfort care provided has been successful
5 by:
obtain an admission history, moves the
chair next to the top bed rail by the
client's head, and sits down to better hear
the client. The client draws back and
A Taking the client's blood pressure moves to the opposite side of the bed. The
B Asking the client to relate the information back to the nurse to confirm
best nursing response would be to:
understanding
C Asking if the client understands the information A Lean over and touch the client to
D Asking if the client is now more comfortable about having the procedureconvey reassurance
performed than previously B Move the chair a foot or two away
from the bed and observe the client's
response
C Say, "I will come back later when you
are ready to talk to me."
D Ignore the behavior and continue with
the interview, observing the client for
3 The nurse is preparing to communicate depression
2 educational information to an 83-year-old,
English-speaking client of Hispanic descent.
The nurse determines that the best way to
verbally communicate with this client is to: 3 A client is crying. The nurse is very busy,
6 but recognizes the client's need for
A Speak quickly and avoid facing the client interaction. The best way for the nurse to
directly, which could be perceived as convey a willingness to be with the client
threatening for support is to:
B Speak slowly and provide brief and
simple explanations A Ask the client, "Would you like to
C Get an interpreter or family member to talk?" from the doorway, and come
interpret for the nurse
Fundamentals of Nursing
back in if the client says, "Yes." the client
B State, "I'll be back later and we can C Using a paper and pencil to write
talk about your problems." questions and information
C State: "We can talk while I do your D Using pictures and gestures to
dressing change", accomplishing both communicate
getting work done and listening to the
client
D Pull up a chair, sit down, and state: "I
41. The nurse has offered a diabetic education program. What is
see that something is bothering you.
client compliance with a diabetic treatment plan?
Do you want to talk?"

3 The nurse is assessing a new client for possible impairment of verbal


7 communication. What components need to be in the assessment?
A The client expresses a desire to learn about diabetes trea
B The client can list foods that are not allowed on a diabetic
C The client willingly learns about diabetes treatment and fo
A Educational background and socioeconomic status plan.
B Level of education and past personal experiences D The client is able to discuss diabetes treatment and passe
C Hearing, vision, and cognitive functioning content with a score of 90%.
D Ability to read and write

3 A client asks about a procedure with which the nurse is unfamiliar. What is the
8 best nursing response? 4 The nurse is developing a teaching plan on
2 self-injection of insulin for a group of diabetic
clients. The plan includes information about
A "I don't know much about that procedure, but I will find out injections
and bring and
youtypes of insulin, and
information about it." demonstrations of injection technique. What
B affective
"I don't have time to explain that now, but I'll get back to you later."component is important for the
C "It is your doctor's responsibility to explain that procedurenurse to plan to include in educating these
to you."
D "The technicians in special care will explain the procedureclients?
to you when
you go for the test."
A Helping clients accept the need for daily
injections
B Having clients demonstrate injection
procedures on themselves
A client presents with the following: C Asking clients to describe the injection
3 history of cancer of the esophagus, procedure
9 treatment with surgery and radiation, D Giving a test on the types of insulin and
speech garbled and thick, able to read duration of action
and write English. The most appropriate
nursing diagnosis for the nurse to
determine, based upon this information,
is:
4 A nurse who is applying behaviorist learning theory offers
A Impaired communication 3 risk factors for heart disease in a straightforward, non-dis
B Impaired verbal communication strategies are appropriate for the nurse applying this lear
C Self-esteem disturbance
D Social isolation A Encourage positive teacher--learner relationships,
delivery methods
B Give a short test, and provide positive feedback
C Assess clients' developmental and individual learni
teaching strategies accordingly
40 A client is able to understand only D Encourage clients to establish goals, and promote
minimal English, and no interpreter is
available. What alternative measures
can the nurse to use to enhance
communication?
4 Prior to beginning a teaching session on self-care of a col
A Speaking loudly to the client 4 assess the client's readiness to learn by assessing:
B Speaking more slowly and facing
Fundamentals of Nursing
A Client's recognition of a need to learn, and belief that learning
besides,
will lead
I know
to self-
all that stuff." Based on
care ability these behaviors, the nurse may suspect
B Client's knowledge and previous experience with colostomies that:
C Client's pain and comfort levels, and willingness to learn
D Client's cognitive and sensory abilities A The client may be unable to read the
instructions
B The client is noncompliant
C The client doesn't understand the
instructions
4 A client who is doing a return demonstration D The client is confused
5 of how to change a wound dressing to the leg
contaminates the dressing after
appropriately cleansing the wound. The best
nursing response is to:
4 A client presents with the following: recent medical diagn
A Say, "You have done this all wrong! Let 9 failure, four new medications, and reduced activity levels
me show you again." breath. The most appropriate nursing diagnosis based up
B Remove the dressing, cleanse the wound
again, and apply a new dressing A Health-Seeking Behavior (exercise and activity) rel
C Say and do nothing to avoid upsetting health status
the client B Noncompliance with medical treatment plan relate
D Say, "You did a good job of cleansing the activity
wound. Let's look at ways to best put the C Risk for ineffective coping related to deficient know
dressing on." D Deficient Knowledge (medication) related to inexpe
ordered therapy

4 The nurse is assessing a client's psychomotor ability to learn how to care for a
6 colostomy. Aspects to include in the assessment are: 5 The nurse is teaching a client about reducing blood chole
0 dietary management. The most appropriate learning outc
would be:
A Muscle strength and motor coordination
B Memory and reading ability A The client will understand benefits of a low-fat diet
C Cultural values and beliefs reduction
D Emotional state and possible conflicts B The client will accurately select low-fat foods from
C The nurse will teach the client about low-fat foods
reduction
D The client will list some common low-fat foods
The nurse is planning an educational
4 program on cancer detection for a
7 community group. What should be 51. When considering delegation of responsibility, the
included in the plan to assure that the registered nurse should first consider which "right" of
program will address various learning delegation?
styles of clients?

A Multicolored posters with bright colors A Right task


B Lecture to the group, using many B Right circumstance
examples C Right person
C Audiovisuals, examples, group C Right supervision
discussions, and activities
D A game board, with clients matching
terms

4 A client from a homeless shelter who has 52 Which of the following describes the primary
8 had minor surgery and has been given an difference between a nurse leader and a
instruction sheet in preparation for nurse manager?
discharge is noted to be noncompliant
with instructions when dressing for A The manager plans and organizes work.
discharge. When asked by the nurse if the B The leader is an excellent listener.
instructions were clear, the client said, "I'll C The manager initiates change.
read them later, when I have my glasses; D The leader mentors others.
Fundamentals of Nursing

53 What leadership style does the nurse who 58 Which characteristic of a manager could
leads a discussion, then asks the undermine the manager's authority?
participants to vote on a topic for the next
meeting, represent? A Has confidence in directing the work of
others
A Autocratic B Is unsure of the authority given
B Bureaucratic C Changes management style based on
C Democratic the situation
D Laissez-faire D Accepts responsibility and
accountability for actions

5 Which type of leader would be best suited for


4 a group of individuals who will follow the 59 What can a nurse manager do to best help
leader's directions in spite of any hardships a new nurse learn his job?
they entail because they have faith in the
leader?
A Ask other nurses to keep an eye on the
A Charismatic new nurse
B Transactional B Assign a preceptor to the new nurse
C Transformational C Point out the nurse's weak areas at a
D Situational staff meeting
D Let the new nurse learn without
interference

5 Which person would be best suited for a


5 leadership position? 60 During which stage of change would
implementation take place?

A A person who has shown an ability to A Covert


gain cooperation from others B Moving
B A person who is quiet but persuasive C Unfreezing
through coercive tactics D Refreezing
C A person who has been a positive role
model in clinical practice
D A person with great vision for the future 61. Body heat that is lost when the nurse turns on the
of nursing air conditioning at the client's request is what type of
loss?

A Radiation
5 Which job would be the responsibility of a
B Conduction
6 first-level manager?
C Convection
D Vaporization

A A nurse case manager


B A head nurse
C A Director of Nursing
D A Nursing Supervisor

6 When should the nurse take a client's


2 temperature if the nurse wants to assess at
5 What management function is represented the point of highest body temperature?
7 when a nurse manager sets goals and
develops a budget for the nursing unit?
A 0400 and 0600 (4 a.m. & 6 a.m.)
B 1000 and 1400 (10 a.m. & 2 p.m.)
A Controlling C 1500 and 1800 (3 p.m. & 6 p.m.)
B Directing D 2000 and 2400 (8 p.m. & midnight)
C Planning
D Organizing
Fundamentals of Nursing
C Subtract the apical heart rate from the
systolic blood pressure.
6 What type of fever would the nurse D Subtract the radial pulse from the
3 document if the client had a wide range of diastolic blood pressure.
temperature fluctuations over normal for a
period of 24 hours?

A Intermittent
B Remittent
C Relapsing 68 A nurse checks the forehead temperature of
D Constant a 12-week-old infant. The temperature is
37.8°C (100°F). What immediate action
should the nurse take?

A Record the temperature and recheck in


one hour.
B Record the temperature, as this is
64 What intervention would be most normal range.
appropriate for a client with mild C Recheck the forehead temperature.
hypothermia? D Recheck an axillary temperature with an
electronic device.
A Applying blankets
B Applying an electronic hypothermia
blanket
C Administering warmed intravenous fluids
D Providing a warm air temperature 69 The blood pressure of a 50-year-old client is
168/100. Which nursing action is most
appropriate?

A Referring the client to a physician


65 When assessing the pulse of a client on B Rechecking the blood pressure in one
digitalis, what rate would the nurse expect week
as compared with the pulse prior to starting C Advising the client to go to the
digitalis? emergency room
D Rechecking the blood pressure annually
A It would be doubled.
B It would be slightly higher .
C It would not change.
D It would decrease.
7 Which technique is best for assessing the
0 respirations of a 3-year-old?

66 A nurse documents deep respirations on the


client record. Which criteria were most likely A Use a stethoscope and auscultate the
assessed? lungs.
B Place one hand against the chest when
A A large amount of air inhaled and a counting.
small amount exhaled C Observe the rise and fall of the
B A large amount of air inhaled and a large abdomen.
amount exhaled D Tell the child you will check his
C A small amount of air inhaled and a breathing.
small amount exhaled
D A small amount of air inhaled and a
large amount exhaled
71. Which exam technique is being used when the
nurse touches the client's abdomen to examine the
size of the liver?
67 A nurse needs to assess a client's pulse
pressure. What is the correct procedure?
A Inspection
B Palpation
A Subtract the diastolic from the systolic C Percussion
blood pressure. D Auscultation
B Subtract the systolic from the diastolic
blood pressure.
Fundamentals of Nursing
A Fully alert and oriented
B Sleepy or drowsy
C Stuporous
D Comatose

7 In a client with long-term emphysema, the 7 A nurse has a client close her eyes, and
2 nurse might expect to see which condition 7 the nurse places a paper clip in the client's
when inspecting the nails? palm. The client correctly identifies the
object. What test did the nurse perform?
A A rapid blanch test
B Clubbing A Paresthesia
C Koilonychia B Extinction
D Paronychia C Stereognosis
D One- and two-point discrimination

73 A client is diagnosed with a conduction


hearing loss. What might the nurse indicate 78 What evidence most likely told the nurse a
to the client could be a reason for this loss? client had a negative Romberg test?

A There has been damage to the inner A Maintains an upright posture and foot
ear. stance
B Something has happened to the hearing B Unable to maintain foot stance
center of the brain. C Moves feet apart
C An ear infection has torn the tympanic D Increased swaying
membrane.
D The auditory nerve is not functioning.

79 An adolescent male has dark pubic hair that


is beginning to curl, elongation of the penis,
74 How would the nurse document a high- and continuing enlargement of the testes
pitched musical sound that was auscultated and scrotum. What stage of development
during expiration? would the nurse indicate in the client
record?
A Friction rub
B Rales A Stage 2
C Rhonchi B Stage 3
D Wheeze C Stage 4
D Stage 5

75 A client begins to tremor when he holds a


coffee cup. What is the correct term to use
when the nurse documents this event? 80 When assessing a client's skin, the nurse
notes a deep, irregular-shaped area of skin
A A fasciculation loss that extends below the dermis. What
B A tremor term would the nurse use when
C An intention tremor documenting this?
D A resting tremor
A An ulcer
B A fissure
C A keloid
D An erosion

76 A client has a 5 on the Glasgow Coma Scale. 881.A client has a yeast infection. What category of
When assessing this client, the nurse would microorganism is yeast?
expect what level of consciousness?
Fundamentals of Nursing
A Bacteria
8 A mother is planning on weaning her 5-
B Fungi
6 month-old infant from breastfeeding. She
C Parasites
says that the infant may get my
D Viruses
infections, since the baby will not be
getting immunity through her breast milk.
What response by the nurse would be
most appropriate?

A "Infections are a major cause of death


in newborns, so you may want to
8 A client has a disease. The nurse knows that reconsider."
2 an infection becomes a disease when what B "You baby will be fine; the natural
occurs? immunity will continue until the baby
produces its own antibodies."
C "Infants begin to make their own
A When the signs and symptoms are
immunity between 1 and 3 months of
unique
age."
B When the pathogen can be identified
D "Just don't allow your infant to get the
C When microorganisms invade a part of
DPT until 1 year of age if you stop
the body
breastfeeding now."
D When bacteremia are present

8 A hospitalized client is in a private room.


8 A client is identified as having Rocky
7 When outside the room, the client must wear
3 Mountain Spotted Fever. This is an example
a surgical mask. What type of isolation
of what type of indirect transmission?
precaution is in use?

A Airborne transmission A Airborne


B Droplet transmission B Contact
C Vector-borne transmission C Droplet
D Vehicle-borne transmission D Standard

8 A home health nurse has just changed a


8 soiled dressing from an infected wound of
a client's. After placing the soiled dressing
in a paper bag provided by the client, how
should the nurse dispose of it?
8 The nurse notes hyperemia when
4 evaluating the incision of a client. The A Place the paper bag inside a plastic
nurse knows that this indicates what stage bag for disposal.
in the inflammatory response? B Throw the paper bag into a garbage
can.
A Vascular and cellular response C Take the bag home and dispose of it.
B Exudate production D Ask the client to dispose of the bag.
C Reparative phase
D Margination

8 A client with tuberculosis is expecting visitors, and asks if


9 masks if they are healthy. What response by the nurse w
85 What type of immunity is lost when a client
develops human immunodeficiency virus
(HIV)?
A "Only the visitors who will have close contact with
mask."
A Active immunity
B "Visitors do not need to be concerned. Only the hea
B Passive immunity
a mask."
C Humoral immunity
C "Everyone who enters your room must wear a mas
D Cellular immunity
from tuberculosis."
D "Only visitors who might be at risk to get this disea
mask."
Fundamentals of Nursing
A An African-American male
B A Caucasian female
90 A client has been diagnosed with a urinary C A European-American female
tract infection. What is the most likely D An male of French descent
cause of this infection?

A Staphylococcus aureus
B Escherichia coli enterococci
C Neisseria gonorrhoeae
D Streptococcus beta-hemolytic A or B 96 When planning a safety seminar in the
workplace for a group of middle-aged
adults, what should be a primary focus?
91. The nurse is preparing a presentation at a senior A Motor vehicle accidents
citizens center on the leading cause of accidents in B Occupational accidents
older adults. What topic should the nurse concentrate C Falls
on presenting? D Fires

7 What test would be most appropriate to


A Automobile accidents 7 perform on an elderly person on admission to
B Accidental medication overdose a care facility?
C Falls
D Home fires A The Get Up and Go test
B The sundowner's test
C The Denver Developmental Screening
test
D A vision screening exam

9 An elderly client, hospitalized with a cerebral


2 vascular accident, is unable to ambulate
without help. This client becomes disoriented 8 What statement by a nurse to a new nurse,
and tries to get out of bed. What safety 8 orienting to the unit, is correct regarding
measure is most appropriate for this client? seizure precautions?

A Use a bed exit safety monitoring device A Any seizure can lead to status
B Restrain the client in bed epilepticus.
C Check the client every 15 minutes B Apply oxygen if the client turns cyanotic.
D Ask a family member to stay with the C Do not force a tongue depressor between
client the teeth.
D Administering an anticonvulsant drug is
not beneficial.
9 Which statement by a father indicates
4 understanding of safety measures for his 3-
year-old child?
9 When evaluating the decibel level at a
A "I shouldn't give him ice cream bars on a 9 concert lasting one hour, the nurse would be
stick." especially concerned with what level?
B "He knows how to swim, so I usually read
a book by the pool." A 40 decibels
C "I can leave him for a few minutes only B 80 decibels
when he is asleep." C 100 decibels
D "He can cross the street by himself to D 130 decibels
play with his best friend."

10 A nurse applies restraints to a client who is


9 Which adolescent would be at the highest 0 combative. The nurse informs the physician
5 risk for committing suicide or homicide? and knows that the physician must see the
client within what time frame for
evaluation?
Fundamentals of Nursing
A 1 hour
B 4 hours
C 12 hours
D 24 hours