Q&A Random Selection #16

1. Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
A) "I know there is a problem since my baby is always constipated."
B) "My child doesn't like many fruits and vegetables, but she really loves her milk."
C) "I can't understand why my child is not eating as much as she did 4 months ago."
D) "My child doesn't drink a whole glass of juice or water at 1 time."

2. When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the
pathophysiological basis of this disorder?
A) It has no clear etiology
B) Enuresis may be associated with sleep phobia
C) It has a definite genetic link
D) Enuresis is a sign of willful misbehavior

3. Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents
question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the
incision was made in order to
A) pass the catheter into the abdominal cavity
B) place the tubing into the urinary bladder
C) visualize abdominal organs for catheter placement
D) insert the catheter into the stomach

4. A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by
the nurse to his refusal is
A) "You need to take your medicine, this is how you get well."
B) "If you refuse your medicine, we’ll just have to give you a shot."
C) "What is it about the medicine that you don’t like?"
D) "I can see that you are uncomfortable right now, I’ll wait until tomorrow."

5. Delirium tremens could best be described as

A) disorganized thinking, feelings of terror and non-purposeful behavior
B) a generalized shaking of the body accompanied by repetitive thoughts
C) an excited state accompanied by disorientation, hallucination and tachycardia
D) single or multiple jerks caused by rapid contracting muscles

6. When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is
the most effective intervention?
A) Use medications to lower the temperature set point
B) Apply extra layers of clothing to prevent shivering
C) Immerse the child in a tub containing cool water
D) Give a tepid sponge bath prior to giving an antipyretic

7. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
A) Food
B) Warmth
C) Security
D) Comfort

8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best
applies?
A) Risk for injury
B) Risk for knowledge deficit
C) Altered thought process
D) Disturbance in self-esteem

9. The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse
recognizes that the most revealing resistant behavior is
A) recurring crises
B) continuing drug use
C) rationalizing comments
D) missing appointments

10. A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness,
headache and fatigue. The client is agitated, fearful, tachycardic and complains of being "too sick to return to work."
The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that
the client's behavior
A) is controlled by their subconscious mind
B) is manipulative to avoid work responsibilities
C) would respond to psychoeducational strategies
D) could be modified through reality therapy

11. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey
to the client?
A) "Take at least 2 weeks off from work."
B) "You will need another chest x-ray in 6 weeks."
C) "Take your temperature every day."
D) "Complete all of the antibiotic even if your findings decrease."

12. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is
appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.

13. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes
what the victim may be experiencing?
A) Fear
B) Helplessness
C) Self-blame
D) Rejection

14. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is
typical of which phase in the therapeutic relationship?
A) Pre-interaction
B) Orientation
C) Working
D) Termination

15. A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial
assessment, the nurse would anticipate which of the following findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions

16. A child is sent to the school nurse by a teacher who has a written note that fifth disease is suspected. Which
characteristic would the nurse expect to find?
A) Macule that rapidly progresses to papule and then vesicles
B) Erythema on the face, primarily on cheeks giving a "slapped face" appearance
C) Discrete rose pink macules will appear first on the trunk and fade when pressure is applied
D) Koplik spots appear first followed by a rash that appears first on the face and spreads downward

17. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescence is
most often associated with what other finding?
A) Sexual promiscuity
B) Poor body image
C) Dropping out of school
D) Drug experimentation

18. The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is
the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."

19. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears
slightly blue. The appropriate initial action should be to
A) begin mouth to mouth resuscitation
B) give the child water to help in swallowing
C) perform 5 abdominal thrusts
D) call for the emergency response team

20. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums.
What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
D) Instruct the parents on how to reason with the child about possible harmful effects

21. The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would
be important for the nurse to emphasize
A) the need for at least 5 servings of dairy products daily
B) restriction of fluid intake to less than 1 liter per day
C) the importance of walking as much as possible
D) early recognition of findings associated with tetany

22. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following
demonstrates appropriate teaching by the nurse?
A) Chewable aspirin is the preferred analgesic
B) Topical cortisone ointment relieves itching
C) Papules, vesicles, and crusts will be present at one time
D) The illness is only contagious prior to lesion eruption

23. An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night.
What is the most appropriate follow-up question for the nurse to ask?
A) "Have you had a recent heart attack?"
B) "Do you become short of breath during your normal daily activities?"
C) "How many pillows do you use at night to sleep comfortably?"
D) "Do you smoke?"

24. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to
request something for pain. The nurse should
A) administer a placebo
B) encourage increased fluid intake
C) administer the prescribed analgesia
D) recommend relaxation exercises for pain control

25. The nurse should initiate discharge planning for a client

A) when the client or family demonstrate readiness to learn self care modalities
B) when informed that a date for discharge has been determined
C) upon admission to a hospital unit or the emergency room
D) when the client's condition is stabilized on the assigned unit

26. A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority
for the outcome of a positive experience with a mentor?
A) Information is clarified as needed
B) A teacher-coach role is taken by the mentor
C) The mentee accepts feedback objectively
D) The mentor is randomly assigned by administration

27. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute
angina?
A) "My pain is deep in my chest behind my breast bone."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."

28. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions

29. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following
should be added first?
A) Cereal
B) Eggs
C) Meat
D) Juice

30. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the
following actions would be most appropriate?
A) Fluid restriction 1000cc per day
B) Ambulate in hallway 4 times a day
C) Administer analgesic therapy as ordered
D) Encourage increased caloric intake
31. The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which
would be an appropriate goal in planning care for this client?
A) Protection for the granulation tissue
B) Heal infection
C) Debride eschar
D) Keep the tissue intact

32. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these
questions will best assess the functioning of the client's recent memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new
number."
C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

33. The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome)
should be based on the high risk for development of which problem?
A) Chronic vessel plaque formation
B) Pulmonary embolism
C) Occlusions at the vessel bifurcations
D) Coronary artery aneurysms

34. The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of
congestive heart disease. Which other finding is most likely to occur?
A) Chest pain
B) Peripheral edema
C) Nail clubbing
D) Lethargy

35. The nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents
to best respond to this behavior?
A) Reprimand the child and give a 15 minute "time out"
B) Maintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting

36. What is the most important consideration when teaching parents how to reduce risks in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age of children in the home

37. A nurse has just received a medication order which is not legible. Which statement best reflects assertive
communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your writing."

38. Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from
around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
A) mental development delays
B) evil eye or envy of others
C) fright from spiritual beings
D) balance in body systems

39. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia.
As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A) Gestational age assessment suggested growth retardation
B) Meconium was cleared from the airway at delivery
C) Phototherapy was used to treat Rh incompatibility
D) The infant received mechanical ventilation for 2 weeks

40. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report
immediately to the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven