1.

Nurse Michelle should know that the drainage is normal 4 days after
a sigmoid colostomy when the stool is:
A. Green liquid
B. Solid formed
C. Loose, bloody
D. Semiformed
2. Where would nurse Kristine place the call light for a male client with a right-
sided brain attack and left homonymous hemianopsia?
A. On the client’s right side
B. On the client’s left side
C. Directly in front of the client
D. Where the client like
3. A male client is admitted to the emergency department following
an accident. What are the first nursing actions of the nurse?
A. Check respiration, circulation, neurological response.
B. Align the spine, check pupils, and check for hemorrhage.
C. Check respirations, stabilize spine, and check circulation.
D. Assess level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that
it reduces preload and relieves angina by:
A. Increasing contractility and slowing heart rate.
B. Increasing AV conduction and heart rate.
C. Decreasing contractility and oxygen consumption.
D. Decreasing venous return through vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial infarction
(MI) slumped on the side rails of the bed and unresponsive to shaking
or shouting. Which is the nurse next action?
A. Call for help and note the time.
B. Clear the airway
C. Give two sharp thumps to the precordium, and check the pulse.
D. Administer two quick blows.
6. Nurse Monett is caring for a client recovering from gastro-
intestinal bleeding. The nurse should:
A. Plan care so the client can receive 8 hours of uninterrupted
sleep each night.
B. Monitor vital signs every 2 hours.
 C. Make sure that the client takes food and medications at
prescribed intervals.
D. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and has been
receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68
seconds. What should Nurse Carla do?
A. Stop the I.V. infusion of heparin and notify the physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the PTT.
D. Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage appliance
be applied to the stoma?
A. 24 hours later, when edema has subsided.
B. In the operating room.
C. After the ileostomy begin to function.
D. When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that the
nurse immediately position the client in:
A. On the side, to prevent obstruction of airway by tongue.
B. Flat on back.
C. On the back, with knees flexed 15 degrees.
D. Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor
vehicle accident, which assessment data suggest increasing
intracranial pressure?
A. Blood pressure is decreased from 160/90 to 110/70.
B. Pulse is increased from 87 to 95, with an occasional skipped beat.
C. The client is oriented when aroused from sleep, and goes back
to sleep immediately.
D. The client refuses dinner because of anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of
the following symptoms may appear first?
A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which of the following
symptoms will be exhibit?
A. Chest and lower back pain
B. Chills, fever, night sweats, and hemoptysis
C. Fever of more than 104°F (40°C) and nausea
D. Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency department.
He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute
and has a nonproductive cough. He recently had a cold. Form this history; the
client may have which of the following conditions?
A. Acute asthma
B. Bronchial pneumonia
C. Chronic obstructive pulmonary disease (COPD)
D. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and
her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might
have which of the following reactions?
A. Asthma attack
B. Respiratory arrest
C. Seizure
D. Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery.
Physical examination reveals shallow respirations but no sign of respiratory
distress. Which of the following is a normal physiologic change related to
aging?
A. Increased elastic recoil of the lungs
B. Increased number of functional capillaries in the alveoli
C. Decreased residual volume
D. Decreased vital capacity
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor
is the most relevant to administration of this medication?
A. Decrease in arterial oxygen saturation (SaO2) when measured with
a pulse oximeter.
B. Increase in systemic blood pressure.
C. Presence of premature ventricular contractions (PVCs) on a
cardiac monitor.
 D. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant. The
nurse should teach the client to:
A. Report incidents of diarrhea.
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving.
D. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter.
The nurse should treat excess hair at the site by:
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly female with osteoporosis.
When teaching the client, the nurse should include information about which
major complication:
A. Bone fracture
B. Loss of estrogen
C. Negative calcium balance
D. Dowager’s hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse
should explain that the purpose of performing the examination is to discover:
A. Cancerous lumps
B. Areas of thickness or fullness
C. Changes from previous examinations.
D. Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it
is important to:
A. Provide extra blankets and clothing to keep the client warm.
B. Monitor the client for signs of restlessness, sweating, and
excessive weight loss during thyroid replacement therapy.
C. Balance the client’s periods of activity and rest.
D. Encourage the client to be active to prevent constipation.
22. Nurse Kris is teaching a client with history of atherosclerosis. To
decrease the risk of atherosclerosis, the nurse should encourage the client to:
A. Avoid focusing on his weight.
 B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a
client following a:
A. Laminectomy
B. Thoracotomy
C. Hemorrhoidectomy
D. Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens
implant. Nurse Oliver is giving the client discharge instructions. These
instructions should include which of the following?
A. Avoid lifting objects weighing more than 5 lb (2.25 kg).
B. Lie on your abdomen when in bed
C. Keep rooms brightly lit.
D. Avoiding straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations during:
A. when sexual activity starts
B. After age 69
C. After age 40
D. Before age 20.
26. A male client undergone a colon resection. While turning him,
wound dehiscence with evisceration occurs. Nurse Trish first response is to:
A. Call the physician
B. Place a saline-soaked sterile dressing on the wound.
C. Take a blood pressure and pulse.
D. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has suffered a
severe cerebrovascular accident. During routine assessment, the nurse
notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:
A. A progressively deeper breaths followed by shallower breaths
with apneic periods.
B. Rapid, deep breathing with abrupt pauses between each breath.
C. Rapid, deep breathing and irregular breathing without pauses.
D. Shallow breathing with an increased respiratory rate.
28. Nurse Bea is assessing a male client with heart failure. The breath
sounds commonly auscultated in clients with heart failure are:
A. Tracheal
B. Fine crackles
C. Coarse crackles
D. Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack.
The client stops wheezing and breath sounds aren’t audible. The reason for
this change is that:
A. The attack is over.
B. The airways are so swollen that no air cannot get through.
C. The swelling has decreased.
D. Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During the active seizure phase,
the nurse should:
A. Place the client on his back remove dangerous objects, and insert
a bite block.
B. Place the client on his side, remove dangerous objects, and insert
a bite block.
C. Place the client o his back, remove dangerous objects, and hold
down his arms.
D. Place the client on his side, remove dangerous objects, and protect
his head.
31. After insertion of a cheat tube for a pneumothorax, a client
becomes hypotensive with neck vein distention, tracheal shift, absent breath
sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax
has occurred. What cause of tension pneumothorax should the nurse check
for?
A. Infection of the lung.
B. Kinked or obstructed chest tube
C. Excessive water in the water-seal chamber
D. Excessive chest tube drainage
32. Nurse Maureen is talking to a male client, the client begins choking on
his lunch. He’s coughing forcefully. The nurse should:
A. Stand him up and perform the abdominal thrust maneuver from
behind.
 B. Lay him down, straddle him, and perform the abdominal
thrust maneuver.
C. Leave him to get assistance
D. Stay with him but not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old client.
Which information will be most useful to the nurse for planning care?
A. General health for the last 10 years.
B. Current health promotion activities.
C. Family history of diseases.
D. Marital status.
34. When performing oral care on a comatose client, Nurse Krina should:
A. Apply lemon glycerin to the client’s lips at least every 2 hours.
B. Brush the teeth with client lying supine.
C. Place the client in a side lying position, with the head of the
bed lowered.
D. Clean the client’s mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of dehydration
and change in mental status. He’s being hydrated with L.V. fluids. When the
nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a
cough producing yellow sputum and pleuritic chest pain. The nurse suspects
this client may have which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Myocardial infarction (MI)
C. Pneumonia
D. Tuberculosis
36. Nurse Oliver is working in a out patient clinic. He has been alerted that
there is an outbreak of tuberculosis (TB). Which of the following clients
entering the clinic today most likely to have TB?
A. A 16-year-old female high school student
B. A 33-year-old day-care worker
C. A 43-yesr-old homeless man with a history of alcoholism
D. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray.
The nurse is aware that which of the following reasons this is done?
A. To confirm the diagnosis
B. To determine if a repeat skin test is needed
 C. To determine the extent of lesions
D. To determine if this is a primary or secondary infection
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes
and a decreased forced expiratory volume should be treated with which of
the following classes of medication right away?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
D. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to
two packs of cigarettes per day has a chronic cough producing thick sputum,
peripheral edema and cyanotic nail beds. Based on this information, he
most likely has which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Situation: Francis, age 46 is admitted to the hospital with diagnosis of
Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow
transplantation. Which statement about bone marrow transplantation is not
correct?
A. The patient is under local anesthesia during the procedure
B. The aspirated bone marrow is mixed with heparin.
C. The aspiration site is the posterior or anterior iliac crest.
D. The recipient receives cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.
41. After several days of admission, Francis becomes disoriented and
complains of frequent headaches. The nurse in-charge first action would be:
A. Call the physician
B. Document the patient’s status in his charts.
C. Prepare oxygen treatment
D. Raise the side rails
42. During routine care, Francis asks the nurse, “How can I be anemic if
this disease causes increased my white blood cell production?” The nurse in-
charge best response would be that the increased number of white blood cells
(WBC) is:
A. Crowd red blood cells
B. Are not responsible for the anemia.
C. Uses nutrients from other cells
D. Have an abnormally short life span of cells.
43. Diagnostic assessment of Francis would probably not reveal:
A. Predominance of lymhoblasts
B. Leukocytosis
C. Abnormal blast cells in the bone marrow
D. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left
leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t
able to obtain pulses in his left foot using Doppler ultrasound. The nurse
immediately notifies the physician, and asks her to prepare the client for
surgery. As the nurse enters the client’s room to prepare him, he states that he
won’t have any more surgery. Which of the following is the best initial
response by the nurse?
A. Explain the risks of not having the surgery
B. Notifying the physician immediately
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the nurses’ notes
45. During the endorsement, which of the following clients should the on-
duty nurse assess first?
A. The 58-year-old client who was admitted 2 days ago with heart
failure, blood pressure of 126/76 mm Hg, and a respiratory rate of
22 breaths/minute.
B. The 89-year-old client with end-stage right-sided heart failure,
blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
C. The 62-year-old client who was admitted 1 day ago
with thrombophlebitis and is receiving L.V. heparin
D. The 75-year-old client who was admitted 1 hour ago with new-
onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and
states that her heart feels like “it’s racing out of the chest”. She reports no
history of cardiac disorders. The nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are
clear and the respiratory rate is 26 breaths/minutes. Which of the following
drugs should the nurse question the client about using?
A. Barbiturates
B. Opioids
C. Cocaine
D. Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge that she has found
a painless lump in her right breast during her monthly self-examination.
Which assessment finding would strongly suggest that this client’s lump is
cancerous?
A. Eversion of the right nipple and mobile mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is soft and easily delineated
D. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse, “What is the
usual treatment for this type of cancer?” Which treatment should the nurse
name?
A. Surgery
B. Chemotherapy
C. Radiation
D. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy
report classifies the lesion according to the TNM staging system as follows:
TIS, N0, M0. What does this classification mean?
A. No evidence of primary tumor, no abnormal regional lymph nodes,
and no evidence of distant metastasis
B. Carcinoma in situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis
C. Can’t assess tumor or regional lymph nodes and no evidence
of metastasis
D. Carcinoma in situ, no demonstrable metastasis of the regional
lymph nodes, and ascending degrees of distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When
teaching the client how to care for the neck stoma, the nurse should include
which instruction?
 A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially until you get
used to the procedure.”
D. “Keep the stoma moist.”
51. A 37-year-old client with uterine cancer asks the nurse, “Which is the
most common type of cancer in women?” The nurse replies that it’s breast
cancer. Which type of cancer causes the most deaths in women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
52. Antonio with lung cancer develops Horner’s syndrome when the
tumor invades the ribs and affects the sympathetic nerve ganglia. When
assessing for signs and symptoms of this syndrome, the nurse should note:
A. miosis, partial eyelid ptosis, and anhidrosis on the affected side of
the face.
B. chest pain, dyspnea, cough, weight loss, and fever.
C. arm and shoulder pain and atrophy of arm and hand muscles, both
on the affected side.
D. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
A. prostate-specific antigen, which is used to screen for prostate
cancer.
B. protein serum antigen, which is used to determine protein levels.
C. pneumococcal strep antigen, which is a bacteria that
causes pneumonia.
D. Papanicolaou-specific antigen, which is used to screen for
cervical cancer.
54. What is the most important postoperative instruction that nurse Kate
must give a client who has just returned from the operating room after
receiving a subarachnoid block?
A. “Avoid drinking liquids until the gag reflex returns.”
B. “Avoid eating milk products for 24 hours.”
C. “Notify a nurse if you experience blood in your urine.”
D. “Remain supine for the time specified by the physician.”
55. A male client suspected of having colorectal cancer will require
which diagnostic study to confirm the diagnosis?
A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT) scan
56. During a breast examination, which finding most strongly suggests that
the Luz has breast cancer?
A. Slight asymmetry of the breasts.
B. A fixed nodular mass with dimpling of the overlying skin
C. Bloody discharge from the nipple
D. Multiple firm, round, freely movable masses that change with
the menstrual cycle
57. A female client with cancer is being evaluated for possible metastasis.
Which of the following is one of the most common metastasis sites for
cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI)
to confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
D. The client wears a watch and wedding band.
59. Nurse Cecile is teaching a female client about preventing
osteoporosis. Which of the following teaching points is correct?
A. Obtaining an X-ray of the bones every 3 years is recommended
to detect bone loss.
B. To avoid fractures, the client should avoid strenuous exercise.
C. The recommended daily allowance of calcium may be found in a
wide variety of foods.
D. Obtaining the recommended daily allowance of calcium requires
taking a calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse reviews the
assessment findings for contraindications for this procedure. Which finding is
a contraindication?
A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form
of arthritis is characterized by urate deposits and joint pain, usually in the feet
and legs, and occurs primarily in men over age 30?
A. Septic arthritis
B. Traumatic arthritis
C. Intermittent arthritis
D. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client
with stroke in evolution. The infusion contains 25,000 units of heparin in 500
ml of saline solution. How many milliliters per hour should be given?
A. 15 ml/hour
B. 30 ml/hour
C. 45 ml/hour
D. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm
is swollen. Which of the following conditions may cause swelling after a
stroke?
A. Elbow contracture secondary to spasticity
B. Loss of muscle contraction decreasing venous return
C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
D. Hypoalbuminemia due to protein escaping from an
inflamed glomerulus
64. Heberden’s nodes are a common sign of osteoarthritis. Which of the
following statement is correct about this deformity?
A. It appears only in men
B. It appears on the distal interphalangeal joint
C. It appears on the proximal interphalangeal joint
D. It appears on the dorsolateral aspect of the interphalangeal joint.
65. Which of the following statements explains the main difference
between rheumatoid arthritis and osteoarthritis?
A. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
D. Osteoarthritis has dislocations and subluxations, rheumatoid
arthritis doesn’t
66. Mrs. Cruz uses a cane for assistance in walking. Which of the
following statements is true about a cane or other assistive devices?
A. A walker is a better choice than a cane.
B. The cane should be used on the affected side
C. The cane should be used on the unaffected side
D. A client with osteoarthritis should be encouraged to ambulate
without the cane
67. A male client with type 1 diabetes is scheduled to receive 30 U of
70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse
may give the client:
A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
B. 21 U regular insulin and 9 U NPH.
C. 10 U regular insulin and 20 U NPH.
D. 20 U regular insulin and 10 U NPH.
68. Nurse Len should expect to administer which medication to a client
with gout?
A. aspirin
B. furosemide (Lasix)
C. colchicines
D. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with
primary hyperaldosteronism. This diagnosis indicates that the client’s
hypertension is caused by excessive hormone secretion from which of the
following glands?
A. Adrenal cortex
B. Pancreas
C. Adrenal medulla
D. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a
wetto- dry dressing change every shift, and blood glucose monitoring before
meals and bedtime. Why are wet-to-dry dressings used for this client?
A. They contain exudate and provide a moist wound environment.
B. They protect the wound from mechanical trauma and promote
healing.
C. They debride the wound and promote healing by secondary
intention.
D. They prevent the entrance of microorganisms and minimize
wound discomfort.
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which
laboratory data would the nurse expect to find?
A. Hyperkalemia
B. Reduced blood urea nitrogen (BUN)
C. Hypernatremia
D. Hyperglycemia
72. A client is admitted for treatment of the syndrome of inappropriate
antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
A. Infusing I.V. fluids rapidly as ordered
B. Encouraging increased oral intake
C. Restricting fluids
D. Administering glucose-containing I.V. fluids as ordered
73. A female client tells nurse Nikki that she has been working hard for the
last 3 months to control her type 2 diabetes mellitus with diet and exercise.
To determine the effectiveness of the client’s efforts, the nurse should check:
A. urine glucose level.
B. fasting blood glucose level.
C. serum fructosamine level.
D. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to
a diabetic client at 7 a.m. At what time would the nurse expect the client to be
most at risk for a hypoglycemic reaction?
A. 10:00 am
B. Noon
C. 4:00 pm
D. 10:00 pm
75. The adrenal cortex is responsible for producing which substances?
A. Glucocorticoids and androgens
B. Catecholamines and epinephrine
C. Mineralocorticoids and catecholamines
D. Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy, Proserfina exhibits
muscle twitching and hyperirritability of the nervous system. When
questioned, the client reports numbness and tingling of the mouth and
fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse
notifies the surgeon immediately. Which electrolyte disturbance most
commonly follows thyroid surgery?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
77. Which laboratory test value is elevated in clients who smoke and can’t
be used as a general indicator of cancer?
A. Acid phosphatase level
B. Serum calcitonin level
C. Alkaline phosphatase level
D. Carcinoembryonic antigen level
78. Francis with anemia has been admitted to the medical-surgical unit.
Which assessment findings are characteristic of iron-deficiency anemia?
A. Nights sweats, weight loss, and diarrhea
B. Dyspnea, tachycardia, and pallor
C. Nausea, vomiting, and anorexia
D. Itching, rash, and jaundice
79. In teaching a female client who is HIV-positive about pregnancy, the
nurse would know more teaching is necessary when the client says:
A. The baby can get the virus from my placenta.”
B. “I’m planning on starting on birth control pills.”
C. “Not everyone who has the virus gives birth to a baby who has
the virus.”
D. “I’ll need to have a C-section if I become pregnant and have a baby.”
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS)
for discharge to the home, the nurse should be sure to include which
instruction?
A. “Put on disposable gloves before bathing.”
B. “Sterilize all plates and utensils in boiling water.”
C. “Avoid sharing such articles as toothbrushes and razors.”
D. “Avoid eating foods from serving dishes shared by other
family members.”
81. Nurse Marie is caring for a 32-year-old client admitted with
pernicious anemia. Which set of findings should the nurse expect when
assessing the
client?
A. Pallor, bradycardia, and reduced pulse pressure
B. Pallor, tachycardia, and a sore tongue
C. Sore tongue, dyspnea, and weight gain
D. Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a client develops dyspnea
and hypotension. Nurse Celestina suspects the client is experiencing
anaphylactic shock. What should the nurse do first?
A. Page an anesthesiologist immediately and prepare to intubate
the client.
B. Administer epinephrine, as prescribed, and prepare to intubate
the client if necessary.
C. Administer the antidote for penicillin, as prescribed, and continue
to monitor the client’s vital signs.
D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids
as ordered.
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy
to reduce inflammation. When teaching the client about aspirin, the nurse
discusses adverse reactions to prolonged aspirin therapy. These include:
A. weight gain.
B. fine motor tremors.
C. respiratory acidosis.
D. bilateral hearing loss.
84. A 23-year-old client is diagnosed with human immunodeficiency virus
(HIV). After recovering from the initial shock of the diagnosis, the client
expresses a desire to learn as much as possible about HIV and acquired
immunodeficiency syndrome (AIDS). When teaching the client about the
immune system, the nurse states that adaptive immunity is provided by which
type of white blood cell?
A. Neutrophil
B. Basophil
C. Monocyte
D. Lymphocyte
85. In an individual with Sjögren’s syndrome, nursing care should focus on:
A. moisture replacement.
B. electrolyte balance.
C. nutritional supplementation.
D. arrhythmia management.
86. During chemotherapy for lymphocytic leukemia, Mathew develops
abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most
important for the nurse to advise the physician to order:
A. enzyme-linked immunosuppressant assay (ELISA) test.
B. electrolyte panel and hemogram.
C. stool for Clostridium difficile test.
D. flat plate X-ray of the abdomen.
87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-
lb weight loss in 6 weeks. To confirm that the client has been infected with the
human immunodeficiency virus (HIV), the nurse expects the physician to
order:
A. E-rosette immunofluorescence.
B. quantification of T-lymphocytes.
C. enzyme-linked immunosorbent assay (ELISA).
D. Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe goes
into surgery. What does this test seek to identify?
A. Potential hepatic dysfunction indicated by decreased blood
urea nitrogen (BUN) and creatinine levels
B. Low levels of urine constituents normally excreted in the urine
C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
D. Electrolyte imbalance that could affect the blood’s ability to
coagulate properly
89. While monitoring a client for the development of disseminated
intravascular coagulation (DIC), the nurse should take note of what
assessment parameters?
A. Platelet count, prothrombin time, and partial thromboplastin time
B. Platelet count, blood glucose levels, and white blood cell (WBC)
count
C. Thrombin time, calcium levels, and potassium levels
D. Fibrinogen level, WBC, and platelet count
90. When taking a dietary history from a newly admitted female client, Nurse
Len should remember that which of the following foods is a common
allergen?
A. Bread
B. Carrots
C. Orange
D. Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the
following phone calls should the nurse return first?
A. A client with hepatitis A who states, “My arms and legs are itching.”
B. A client with cast on the right leg who states, “I have a funny feeling
in my right leg.”
C. A client with osteomyelitis of the spine who states, “I am so
nauseous that I can’t eat.”
D. A client with rheumatoid arthritis who states, “I am having
trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical floor and has just
received report from the previous shift. Which of the following clients should
the nurse see first?
A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5
cm area of dark drainage noted on the dressing.
B. A 43-year-old who had a mastectomy two days ago; 23 ml
of serosanguinous fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due to an accident; no
drainage noted in the previous eight hours.
D. A 62-year-old who had an abdominal-perineal resection three
days ago; client complaints of chills.
93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago
for treatment of Grave’s disease. The nurse would be most concerned if which
of the following was observed?
A. Blood pressure 138/82, respirations 16, oral temperature 99
degrees Fahrenheit.
B. The client supports his head and neck when turning his head to
the right.
C. The client spontaneously flexes his wrist when the blood pressure
is obtained.
D. The client is drowsy and complains of sore throat.
94. Julius is admitted with complaints of severe pain in the lower right
quadrant of the abdomen. To assist with pain relief, the nurse should take
which of the following actions?
A. Encourage the client to change positions frequently in bed.
B. Administer Demerol 50 mg IM q 4 hours and PRN.
C. Apply warmth to the abdomen with a heating pad.
D. Use comfort measures and pillows to position the client.
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the
following actions should the nurse take first?
A. Assess for a bruit and a thrill.
B. Warm the dialysate solution.
C. Position the client on the left side.
D. Insert a Foley catheter
96. Nurse Jannah teaches an elderly client with right-sided weakness how to
use cane. Which of the following behaviors, if demonstrated by the client to
the nurse, indicates that the teaching was effective?
A. The client holds the cane with his right hand, moves the can
forward followed by the right leg, and then moves the left leg.
B. The client holds the cane with his right hand, moves the cane
forward followed by his left leg, and then moves the right leg.
C. The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
D. The client holds the cane with his left hand, moves the cane
forward followed by his left leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The client
is occasionally confused and her gait is often unsteady. Which of the
following actions, if taken by the nurse, is most appropriate?
A. Ask the woman’s family to provide personal items such as photos
or mementos.
B. Select a room with a bed by the door so the woman can look down
the hall.
C. Suggest the woman eat her meals in the room with her roommate.
D. Encourage the woman to ambulate in the halls twice a day.
98. Nurse Evangeline teaches an elderly client how to use a standard
aluminum walker. Which of the following behaviors, if demonstrated by the
client, indicates that the nurse’s teaching was effective?
A. The client slowly pushes the walker forward 12 inches, then
takes small steps forward while leaning on the walker.
B. The client lifts the walker, moves it forward 10 inches, and then
takes several small steps forward.
C. The client supports his weight on the walker while advancing it
forward, then takes small steps while balancing on the walker.
D. The client slides the walker 18 inches forward, then takes small
steps while holding onto the walker for balance.
99. Nurse Deric is supervising a group of elderly clients in a residential
home setting. The nurse knows that the elderly are at greater risk of
developing sensory deprivation for what reason?
A. Increased sensitivity to the side effects of medications.
B. Decreased visual, auditory, and gustatory abilities.
C. Isolation from their families and familiar surroundings.
D. Decrease musculoskeletal function and mobility.
100. A male client with emphysema becomes restless and confused. What
step should nurse Jasmine take next?
A. Encourage the client to perform pursed lip breathing.
B. Check the client’s temperature.
C. Assess the client’s potassium level.
D. Increase the client’s oxygen flow rate.
Answers and Rationales
1. Answer: (C) Loose, bloody. Normal bowel function and soft-formed
stool usually do not occur until around the seventh day following
surgery. The stool consistency is related to how much water is
being absorbed.
2. Answer: (A) On the client’s right side. The client has left visual field
blindness. The client will see only from the right side.
3. Answer: (C) Check respirations, stabilize spine, and check
circulation. Checking the airway would be priority, and a neck injury
should be suspected.
4. Answer: (D) Decreasing venous return through vasodilation. The
significant effect of nitroglycerin is vasodilation and decreased
venous return, so the heart does not have to work hard.
5. Answer: (A) Call for help and note the time. Having established, by
stimulating the client, that the client is unconscious rather than
sleep, the nurse should immediately call for help. This may be done
by dialing the operator from the client’s phone and giving the
hospital code for cardiac arrest and the client’s room number to the
operator, of if the phone is not available, by pulling the emergency
call button. Noting the time is important baseline information for
cardiac arrest procedure.
6. Answer: (C) Make sure that the client takes food and medications
at prescribed intervals. Food and drug therapy will prevent the
accumulation of hydrochloric acid, or will neutralize and buffer the
acid that does accumulate.
7. Answer: (B) Continue treatment as ordered. The effects of heparin are
monitored by the PTT is normally 30 to 45 seconds; the therapeutic
level is 1.5 to 2 times the normal level.
8. Answer: (B) In the operating room. The stoma drainage bag is applied
in the operating room. Drainage from the ileostomy contains
secretions that are rich in digestive enzymes and highly irritating to
the skin. Protection of the skin from the effects of these enzymes is
begun at once. Skin exposed to these enzymes even for a short time
becomes reddened, painful, and excoriated.
9. Answer: (B) Flat on back. To avoid the complication of a painful
spinal headache that can last for several days, the client is kept in
flat in a supine position for approximately 4 to 12 hours
 postoperatively. Headaches are believed to be causes by the
seepage of cerebral spinal fluid from the puncture site. By keeping
the client flat, cerebral spinal fluid pressures are equalized, which
avoids trauma to the neurons.
10. Answer: (C) The client is oriented when aroused from sleep, and
goes back to sleep immediately. This finding suggest that the level of
consciousness is decreasing.
11. Answer: (A) Altered mental status and dehydration. Fever, chills,
hemortysis, dyspnea, cough, and pleuritic chest pain are the
common symptoms of pneumonia, but elderly clients may
first appear with only an altered lentil status and dehydration due to
a blunted immune response.
12. Answer: (B) Chills, fever, night sweats, and hemoptysis. Typical signs
and symptoms are chills, fever, night sweats, and hemoptysis. Chest
pain may be present from coughing, but isn’t usual. Clients with TB
typically have low-grade fevers, not higher than 102°F (38.9°C).
Nausea, headache, and photophobia aren’t usual TB symptoms.
13. Answer:(A) Acute asthma. Based on the client’s history and
symptoms, acute asthma is the most likely diagnosis. He’s unlikely
to have bronchial pneumonia without a productive cough and fever
and he’s too young to have developed (COPD) and emphysema.
14. Answer: (B) Respiratory arrest. Narcotics can cause respiratory
arrest if given in large quantities. It’s unlikely the client will have
asthma attack or a seizure or wake up on his own.
15. Answer: (D) Decreased vital capacity.  Reduction in vital capacity is a
normal physiologic changes include decreased elastic recoil of the
lungs, fewer functional capillaries in the alveoli, and an increased in
residual volume.
16. Answer: (C) Presence of premature ventricular contractions (PVCs) on
a cardiac monitor. Lidocaine drips are commonly used to treat clients
whose arrhythmias haven’t been controlled with oral medication and
who are having PVCs that are visible on the cardiac monitor. SaO2,
blood pressure, and ICP are important factors but aren’t as
significant as PVCs in the situation.
17. Answer: (B) Avoid foods high in vitamin K. The client should avoid
consuming large amounts of vitamin K because vitamin K can
 interfere with anticoagulation. The client may need to report
diarrhea, but isn’t effect of taking an anticoagulant. An
electric razor-not a straight razor-should be used to prevent cuts
that cause bleeding. Aspirin may increase the risk of bleeding;
acetaminophen should be used to pain relief.
18. Answer: (C) Clipping the hair in the area. Hair can be a source of
infection and should be removed by clipping. Shaving the area can
cause skin abrasions and depilatories can irritate the skin.
19. Answer: (A) Bone fracture. Bone fracture is a major complication of
osteoporosis that results when loss of calcium and phosphate
increased the fragility of bones. Estrogen deficiencies result from
menopause-not osteoporosis. Calcium and vitamin D supplements
may be used to support normal bone metabolism, But a negative
calcium balance isn’t a complication of osteoporosis. Dowager’s
hump results from bone fractures. It develops when repeated
vertebral fractures increase spinal curvature.
20. Answer: (C) Changes from previous examinations. Women are
instructed to examine themselves to discover changes that have
occurred in the breast. Only a physician can diagnose lumps that are
cancerous, areas of thickness or fullness that signal the presence of
a malignancy, or masses that are fibrocystic as opposed
to malignant.
21. Answer: (C) Balance the client’s periods of activity and rest. A client
with hyperthyroidism needs to be encouraged to balance periods of
activity and rest. Many clients with hyperthyroidism are hyperactive
and complain of feeling very warm.
22. Answer: (B) Increase his activity level. The client should be
encouraged to increase his activity level. Maintaining an ideal
weight; following a low-cholesterol, low sodium diet; and avoiding
stress are all important factors in decreasing the risk
of atherosclerosis.
23. Answer: (A) Laminectomy. The client who has had spinal surgery,
such as laminectomy, must be log rolled to keep the spinal column
straight when turning. Thoracotomy and cystectomy may turn
themselves or may be assisted into a comfortable position. Under
normal circumstances, hemorrhoidectomy is an outpatient
 procedure, and the client may resume normal activities immediately
after surgery.
24. Answer: (D) Avoiding straining during bowel movement or bending at
the waist. The client should avoid straining, lifting heavy objects,
and coughing harshly because these activities increase intraocular
pressure. Typically, the client is instructed to avoid lifting objects
weighing more than 15 lb (7kg) – not 5lb. instruct the client when
lying in bed to lie on either the side or back. The client should avoid
bright light by wearing sunglasses.
25. Answer: (D) Before age 20. Testicular cancer commonly occurs in
men between ages 20 and 30. A male client should be taught how to
perform testicular selfexamination before age 20, preferably when
he enters his teens.
26. Answer: (B) Place a saline-soaked sterile dressing on the wound. The
nurse should first place saline-soaked sterile dressings on the open
wound to prevent tissue drying and possible infection. Then
the nurse should call the physician and take the client’s vital signs.
The dehiscence needs to be surgically closed, so the nurse should
never try to close it.
27. Answer: (A) A progressively deeper breaths followed by
shallower breaths with apneic periods. Cheyne-Strokes respirations are
breaths that become progressively deeper fallowed by shallower
respirations with apneas periods. Biot’s respirations are rapid, deep
breathing with abrupt pauses between each breath, and equal depth
between each breath. Kussmaul’s respirations are rapid, deep
breathing without pauses. Tachypnea is shallow breathing with
increased respiratory rate.
28. Answer: (B) Fine crackles. Fine crackles are caused by fluid in the
alveoli and commonly occur in clients with heart failure. Tracheal
breath sounds are auscultated over the trachea. Coarse crackles are
caused by secretion accumulation in the airways. Friction rubs
occur with pleural inflammation.
29. Answer: (B) The airways are so swollen that no air cannot get
through. During an acute attack, wheezing may stop and breath
sounds become inaudible because the airways are so swollen that
air can’t get through. If the attack is over and swelling has
 decreased, there would be no more wheezing and less emergent
concern. Crackles do not replace wheezes during an acute asthma
attack.
30. Answer: (D) Place the client on his side, remove dangerous objects,
and protect his head. During the active seizure phase, initiate
precautions by placing the client on his side, removing dangerous
objects, and protecting his head from injury. A bite block should
never be inserted during the active seizure phase. Insertion can
break the teeth and lead to aspiration.
31. Answer: (B) Kinked or obstructed chest tube. Kinking and blockage of
the chest tube is a common cause of a tension pneumothorax.
Infection and excessive drainage won’t cause a tension
pneumothorax. Excessive water won’t affect the chest
tube drainage.
32. Answer: (D) Stay with him but not intervene at this time. If the client is
coughing, he should be able to dislodge the object or cause a
complete obstruction. If complete obstruction occurs, the nurse
should perform the abdominal thrust maneuver with the
client standing. If the client is unconscious, she should lay him
down. A nurse should never leave a choking client alone.
33. Answer: (B) Current health promotion activities. Recognizing an
individual’s positive health measures is very useful. General health
in the previous 10 years is important, however, the current activities
of an 84 year old client are most significant in planning care. Family
history of disease for a client in later years is of minor significance.
Marital status information may be important for discharge planning
but is not as significant for addressing the immediate
medical problem.
34. Answer: (C) Place the client in a side lying position, with the head of
the bed lowered.  The client should be positioned in a side-lying
position with the head of the bed lowered to prevent aspiration. A
small amount of toothpaste should be used and the mouth swabbed
or suctioned to remove pooled secretions. Lemon glycerin can be
drying if used for extended periods. Brushing the teeth with the
client lying supine may lead to aspiration. Hydrogen peroxide is
caustic to tissues and should not be used.
35. Answer: (C) Pneumonia. Fever productive cough and pleuritic chest
pain are common signs and symptoms of pneumonia. The client
with ARDS has dyspnea and hypoxia with worsening hypoxia over
time, if not treated aggressively. Pleuritic chest pain varies with
respiration, unlike the constant chest pain during an MI; so this
client most likely isn’t having an MI. the client with TB typically has a
cough producing blood-tinged sputum. A sputum culture should be
obtained to confirm the nurse’s suspicions.
36. Answer: (C) A 43-yesr-old homeless man with a history of
alcoholism. Clients who are economically disadvantaged,
malnourished, and have reduced immunity, such as a client with a
history of alcoholism,  are at extremely high risk for developing TB.
A high school student, daycare worker, and businessman probably
have a much low risk of contracting TB.
37. Answer: (C ) To determine the extent of lesions. If the lesions are
large enough, the chest X-ray will show their presence in the lungs.
Sputum culture confirms the diagnosis. There can be false-positive
and false-negative skin test results. A chest X-ray can’t determine if
this is a primary or secondary infection.
38. Answer: (B) Bronchodilators. Bronchodilators are the first line of
treatment for asthma because broncho-constriction is the cause of
reduced airflow. Beta adrenergic blockers aren’t used to treat
asthma and can cause bronchoconstriction. Inhaled oral steroids
may be given to reduce the inflammation but aren’t used for
emergency relief.
39. Answer: (C) Chronic obstructive bronchitis. Because of this extensive
smoking history and symptoms the client most likely has chronic
obstructive bronchitis. Client with ARDS have acute symptoms of
hypoxia and typically need large amounts of oxygen. Clients with
asthma and emphysema tend not to have chronic cough or
peripheral edema.
40. Answer: (A) The patient is under local anesthesia during the
procedure. Before the procedure, the patient is administered with
drugs that would help to prevent infection and rejection of the
transplanted cells such as antibiotics, cytotoxic, and corticosteroids.
 During the transplant, the patient is placed under general
anesthesia.
41. Answer: (D) Raise the side rails. A patient who is disoriented is at
risk of falling out of bed. The initial action of the nurse should be
raising the side rails to ensure patients safety.
42. Answer: (A) Crowd red blood cells. The excessive production of
white blood cells crowd out red blood cells production which causes
anemia to occur.
43. Answer: (B) Leukocytosis. Chronic Lymphocytic leukemia (CLL) is
characterized by increased production of leukocytes and
lymphocytes resulting in leukocytosis, and proliferation of these
cells within the bone marrow, spleen and liver.
44. Answer: (A) Explain the risks of not having the surgery. The best initial
response is to explain the risks of not having the surgery. If the
client understands the risks but still refuses the nurse should notify
the physician and the nurse supervisor and then record the client’s
refusal in the nurses’ notes.
45. Answer: (D) The 75-year-old client who was admitted 1 hour ago
with new-onset atrial fibrillation and is receiving L.V. dilitiazem
(Cardizem). The client with atrial fibrillation has the greatest potential
to become unstable and is on L.V. medication that requires close
monitoring. After assessing this client, the nurse should assess the
client with thrombophlebitis who is receiving a heparin infusion, and
then the 58- year-old client admitted 2 days ago with heart failure
(his signs and symptoms are resolving and don’t require immediate
attention). The lowest priority is the 89-year-old with end stage right-
sided heart failure, who requires time-consuming supportive
measures.
46. Answer: (C) Cocaine. Because of the client’s age and negative
medical history, the nurse should question her about cocaine use.
Cocaine increases myocardial oxygen consumption and can cause
coronary artery spasm, leading to tachycardia, ventricular fibrillation,
myocardial ischemia, and myocardial infarction. Barbiturate
overdose may trigger respiratory depression and slow pulse.
Opioids can cause marked respiratory depression, while
benzodiazepines can cause drowsiness and confusion.
47. Answer: (B) Nonmobile mass with irregular edges. Breast cancer
tumors are fixed, hard, and poorly delineated with irregular edges. A
mobile mass that is soft and easily delineated is most often a fluid-
filled benign cyst. Axillary lymph nodes may or may not be palpable
on initial detection of a cancerous mass. Nipple retraction — not
eversion — may be a sign of cancer.
48. Answer: (C) Radiation. The usual treatment for vaginal cancer is
external or intravaginal radiation therapy. Less often, surgery is
performed. Chemotherapy typically is prescribed only if vaginal
cancer is diagnosed in an early stage, which is rare. Immunotherapy
isn’t used to treat vaginal cancer.
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes,
and no evidence of distant metastasis. TIS, N0, M0 denotes carcinoma in
situ, no abnormal regional lymph nodes, and no evidence of distant
metastasis. No evidence of primary tumor, no abnormal regional
lymph nodes, and no evidence of distant metastasis is classified as
T0, N0, M0. If the tumor and regional lymph nodes can’t be
assessed and no evidence of metastasis exists, the lesion is
classified as TX, NX, M0. A progressive increase in tumor size, no
demonstrable metastasis of the regional lymph nodes, and
ascending degrees of distant metastasis is classified as T1, T2, T3,
or T4; N0; and M1, M2, or M3.
50. Answer: (D) “Keep the stoma moist.” The nurse should instruct the
client to keep the stoma moist, such as by applying a thin layer of
petroleum jelly around the edges, because a dry stoma may become
irritated. The nurse should recommend placing a stoma bib over the
stoma to filter and warm air before it enters the stoma. The client
should begin performing stoma care without assistance as soon as
possible to gain independence in self-care activities.
51. Answer: (B) Lung cancer.  Lung cancer is the most deadly type of
cancer in both women and men. Breast cancer ranks second in
women, followed (in descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine cancer, lymphoma,
leukemia, liver cancer, brain cancer, stomach cancer, and multiple
myeloma.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. Horner’s syndrome, which occurs when a
lung tumor invades the ribs and affects the sympathetic nerve
ganglia, is characterized by miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the face. Chest pain, dyspnea,
cough, weight loss, and fever are associated with pleural tumors.
Arm and shoulder pain and atrophy of the arm and hand muscles on
the affected side suggest Pancoast’s tumor, a lung tumor involving
the first thoracic and eighth cervical nerves within the brachial
plexus. Hoarseness in a client with lung cancer suggests that
the tumor has extended to the recurrent laryngeal nerve; dysphagia
suggests that the lung tumor is compressing the esophagus.
53. Answer: (A) prostate-specific antigen, which is used to screen for
prostate cancer. PSA stands for prostate-specific antigen, which is
used to screen for prostate cancer. The other answers are incorrect.
54. Answer: (D) “Remain supine for the time specified by the
physician.” The nurse should instruct the client to remain supine for
the time specified by the physician. Local anesthetics used in a
subarachnoid block don’t alter the gag reflex. No interactions
between local anesthetics and food occur. Local anesthetics don’t
cause hematuria.
55. Answer: (C) Sigmoidoscopy. Used to visualize the lower GI tract,
sigmoidoscopy and proctoscopy aid in the detection of two-thirds of
all colorectal cancers. Stool Hematest detects blood, which is a sign
of colorectal cancer; however, the test doesn’t confirm the
diagnosis. CEA may be elevated in colorectal cancer but isn’t
considered a confirming test. An abdominal CT scan is used to
stage the presence of colorectal cancer.
56. Answer: (B) A fixed nodular mass with dimpling of the overlying
skin. A fixed nodular mass with dimpling of the overlying skin
is common during late stages of breast cancer. Many women have
slightly asymmetrical breasts. Bloody nipple discharge is a sign of
intraductal papilloma, a benign condition. Multiple firm, round, freely
movable masses that change with the menstrual cycle indicate
fibrocystic breasts, a benign condition.
57. Answer: (A) Liver. The liver is one of the five most common cancer
metastasis sites. The others are the lymph nodes, lung, bone, and
brain. The colon, reproductive tract, and WBCs are occasional
metastasis sites.
58. Answer: (D) The client wears a watch and wedding band. During an
MRI, the client should wear no metal objects, such as jewelry,
because the strong magnetic field can pull on them, causing injury
to the client and (if they fly off) to others. The client must lie
still during the MRI but can talk to those performing the test by way
of the microphone inside the scanner tunnel. The client should hear
thumping sounds, which are caused by the sound waves thumping
on the magnetic field.
59. Answer: (C) The recommended daily allowance of calcium may be
found in a wide variety of foods. Premenopausal women require 1,000
mg of calcium per day. Postmenopausal women require 1,500 mg
per day. It’s often, though not always, possible to get the
recommended daily requirement in the foods we eat. Supplements
are available but not always necessary. Osteoporosis doesn’t show
up on ordinary X-rays until 30% of the bone loss has occurred. Bone
densitometry can detect bone loss of 3% or less. This test is
sometimes recommended routinely for women over 35 who are at
risk. Strenuous exercise won’t cause fractures.
60. Answer: (C) Joint flexion of less than 50%. Arthroscopy is
contraindicated in clients with joint flexion of less than 50% because
of technical problems in inserting the instrument into the joint to see
it clearly. Other contraindications for this procedure include skin and
wound infections. Joint pain may be an indication, not
a contraindication, for arthroscopy. Joint deformity and joint
stiffness aren’t contraindications for this procedure.
61. Answer: (D) Gouty arthritis. Gouty arthritis, a metabolic disease, is
characterized by urate deposits and pain in the joints, especially
those in the feet and legs. Urate deposits don’t occur in septic or
traumatic arthritis. Septic arthritis results from bacterial invasion of
a joint and leads to inflammation of the synovial lining. Traumatic
arthritis results from blunt trauma to a joint or ligament. Intermittent
 arthritis is a rare, benign condition marked by regular, recurrent joint
effusions, especially in the knees.
62. Answer: (B) 30 ml/hour. An infusion prepared with 25,000 units of
heparin in 500 ml of saline solution yields 50 units of heparin per
milliliter of solution. The equation is set up as 50 units times X (the
unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.
63. Answer: (B) Loss of muscle contraction decreasing venous return. In
clients with hemiplegia or hemiparesis loss of muscle contraction
decreases venous return and may cause swelling of the affected
extremity. Contractures, or bony calcifications may occur with
a stroke, but don’t appear with swelling. DVT may develop in clients
with a stroke but is more likely to occur in the lower extremities. A
stroke isn’t linked to protein loss.
64. Answer: (B) It appears on the distal interphalangeal joint. Heberden’s
nodes appear on the distal interphalageal joint on both men and
women. Bouchard’s node appears on the dorsolateral aspect of the
proximal interphalangeal joint.
65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis
is systemic.  Osteoarthritis is a localized disease, rheumatoid arthritis
is systemic. Osteoarthritis isn’t gender-specific, but rheumatoid
arthritis is. Clients have dislocations and subluxations in both
disorders.
66. Answer: (C) The cane should be used on the unaffected side. A cane
should be used on the unaffected side. A client with osteoarthritis
should be encouraged to ambulate with a cane, walker, or other
assistive device as needed; their use takes weight and stress
off joints.
67. Answer: (A) 9 U regular insulin and 21 U neutral protamine
Hagedorn (NPH).  A 70/30 insulin preparation is 70% NPH and 30%
regular insulin. Therefore, a correct substitution requires mixing 21
U of NPH and 9 U of regular insulin. The other choices are incorrect
dosages for the prescribed insulin.
68. Answer: (C) colchicines. A disease characterized by joint
inflammation (especially in the great toe), gout is caused by urate
crystal deposits in the joints. The physician prescribes colchicine to
reduce these deposits and thus ease joint inflammation. Although
 aspirin is used to reduce joint inflammation and pain in clients with
osteoarthritis and rheumatoid arthritis, it isn’t indicated for gout
because it has no effect on urate crystal formation. Furosemide, a
diuretic, doesn’t relieve gout. Calcium gluconate is used to reverse a
negative calcium balance and relieve muscle cramps, not to treat
gout.
69. Answer: (A) Adrenal cortex. Excessive secretion of aldosterone in
the adrenal cortex is responsible for the client’s hypertension. This
hormone acts on the renal tubule, where it promotes reabsorption of
sodium and excretion of potassium and hydrogen ions. The
pancreas mainly secretes hormones involved in fuel metabolism.
The adrenal medulla secretes the catecholamines — epinephrine
and norepinephrine. The parathyroids secrete parathyroid hormone.
70. Answer: (C) They debride the wound and promote healing by
secondary intention. For this client, wet-to-dry dressings are most
appropriate because they clean the foot ulcer by debriding exudate
and necrotic tissue, thus promoting healing by secondary intention.
Moist, transparent dressings contain exudate and provide a moist
wound environment. Hydrocolloid dressings prevent the entrance of
microorganisms and minimize wound discomfort. Dry sterile
dressings protect the wound from mechanical trauma and promote
healing.
71. Answer: (A) Hyperkalemia. In adrenal insufficiency, the client has
hyperkalemia due to reduced aldosterone secretion. BUN increases
as the glomerular filtration rate is reduced. Hyponatremia is caused
by reduced aldosterone secretion. Reduced cortisol secretion leads
to impaired glyconeogenesis and a reduction of glycogen in the liver
and muscle, causing hypoglycemia.
72. Answer: (C) Restricting fluids. To reduce water retention in a client
with the SIADH, the nurse should restrict fluids. Administering fluids
by any route would further increase the client’s already heightened
fluid load.
73. Answer: (D) glycosylated hemoglobin level. Because some of the
glucose in the bloodstream attaches to some of the hemoglobin and
stays attached during the 120-day life span of red blood cells,
glycosylated hemoglobin levels provide information about blood
 glucose levels during the previous 3 months. Fasting blood glucose
and urine glucose levels only give information about glucose levels
at the point in time when they were obtained. Serum
fructosamine levels provide information about blood glucose
control over the past 2 to 3 weeks.
74. Answer: (C) 4:00 pm. NPH is an intermediate-acting insulin that
peaks 8 to 12 hours after administration. Because the nurse
administered NPH insulin at 7 a.m., the client is at greatest risk for
hypoglycemia from 3 p.m. to 7 p.m.
75. Answer: (A) Glucocorticoids and androgens. The adrenal glands have
two divisions, the cortex and medulla. The cortex produces three
types of hormones: glucocorticoids, mineralocorticoids, and
androgens. The medulla produces catecholamines — epinephrine
and norepinephrine.
76. Answer: (A) Hypocalcemia. Hypocalcemia may follow thyroid
surgery if the parathyroid glands were removed accidentally. Signs
and symptoms of hypocalcemia may be delayed for up to 7 days
after surgery. Thyroid surgery doesn’t directly cause serum sodium,
potassium, or magnesium abnormalities. Hyponatremia may occur
if the client inadvertently received too much fluid; however, this can
happen to any surgical client receiving I.V. fluid therapy, not just one
recovering from thyroid surgery. Hyperkalemia
and hypermagnesemia usually are associated with reduced renal
excretion of potassium and magnesium, not thyroid surgery.
77. Answer: (D) Carcinoembryonic antigen level. In clients who smoke,
the level of carcinoembryonic antigen is elevated. Therefore, it can’t
be used as a general indicator of cancer. However, it is helpful in
monitoring cancer treatment because the level usually falls to
normal within 1 month if treatment is successful. An elevated acid
phosphatase level may indicate prostate cancer. An elevated
alkaline phosphatase level may reflect bone metastasis. An elevated
serum calcitonin level usually signals thyroid cancer.
78. Answer: (B) Dyspnea, tachycardia, and pallor. Signs of iron-deficiency
anemia include dyspnea, tachycardia, and pallor as well as fatigue,
listlessness, irritability, and headache. Night sweats, weight loss,
and diarrhea may signal acquired immunodeficiency syndrome
 (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B.
Itching, rash, and jaundice may result from an allergic or hemolytic
reaction.
79. Answer: (D) “I’ll need to have a C-section if I become pregnant and
have a baby.” The human immunodeficiency virus (HIV) is
transmitted from mother to child via the transplacental route, but a
Cesarean section delivery isn’t necessary when the mother is HIV-
positive. The use of birth control will prevent the conception of a
child who might have HIV. It’s true that a mother who’s HIV positive
can give birth to a baby who’s HIV negative.
80. Answer: (C) “Avoid sharing such articles as toothbrushes and
razors.” The human immunodeficiency virus (HIV), which
causes AIDS, is most concentrated in the blood. For this reason, the
client shouldn’t share personal articles that may be blood-
contaminated, such as toothbrushes and razors, with other family
members. HIV isn’t transmitted by bathing or by eating from plates,
utensils, or serving dishes used by a person with AIDS.
81. Answer: (B) Pallor, tachycardia, and a sore tongue. Pallor, tachycardia,
and a sore tongue are all characteristic findings in pernicious
anemia. Other clinical manifestations include anorexia; weight loss;
a smooth, beefy red tongue; a wide pulse pressure; palpitations;
angina; weakness; fatigue; and paresthesia of the hands and feet.
Bradycardia, reduced pulse pressure, weight gain, and double
vision aren’t characteristic findings in pernicious anemia.
82. Answer: (B) Administer epinephrine, as prescribed, and prepare
to intubate the client if necessary. To reverse anaphylactic shock, the
nurse first should administer epinephrine, a potent bronchodilator as
prescribed. The physician is likely to order additional medications,
such as antihistamines and corticosteroids; if these medications
don’t relieve the respiratory compromise associated with
anaphylaxis, the nurse should prepare to intubate the client. No
antidote for penicillin exists; however, the nurse should continue to
monitor the client’s vital signs. A client who remains hypotensive
may need fluid resuscitation and fluid intake and output monitoring;
however, administering epinephrine is the first priority.
83. Answer: (D) bilateral hearing loss. Prolonged use of aspirin and
other salicylates sometimes causes bilateral hearing loss of 30 to
40 decibels. Usually, this adverse effect resolves within 2 weeks
after the therapy is discontinued. Aspirin doesn’t lead to weight gain
or fine motor tremors. Large or toxic salicylate doses may cause
respiratory alkalosis, not respiratory acidosis.
84. Answer: (D) Lymphocyte. The lymphocyte provides adaptive
immunity — recognition of a foreign antigen and formation of
memory cells against the antigen. Adaptive immunity is mediated by
B and T lymphocytes and can be acquired actively or passively. The
neutrophil is crucial to phagocytosis. The basophil plays an
important role in the release of inflammatory mediators. The
monocyte functions in phagocytosis and monokine production.
85. Answer: (A) moisture replacement. Sjogren’s syndrome is an
autoimmune disorder leading to progressive loss of lubrication of
the skin, GI tract, ears, nose, and vagina. Moisture replacement is
the mainstay of therapy. Though malnutrition and electrolyte
imbalance may occur as a result of Sjogren’s syndrome’s effect on
the GI tract, it isn’t the predominant problem. Arrhythmias aren’t
a problem associated with Sjogren’s syndrome.
86. Answer: (C) stool for Clostridium difficile test. Immunosuppressed
clients — for example, clients receiving chemotherapy, — are at risk
for infection with C. difficile, which causes “horse barn” smelling
diarrhea. Successful treatment begins with an accurate diagnosis,
which includes a stool test. The ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn’t indicated in this case. An
electrolyte panel and hemogram may be useful in the
overall evaluation of a client but aren’t diagnostic for specific
causes of diarrhea. A flat plate of the abdomen may provide useful
information about bowel function but isn’t indicated in the case of
“horse barn” smelling diarrhea.
87. Answer: (D) Western blot test with ELISA. HIV infection is detected
by analyzing blood for antibodies to HIV, which form approximately
2 to 12 weeks after exposure to HIV and denote infection. The
Western blot test — electrophoresis of antibody proteins — is more
than 98% accurate in detecting HIV antibodies when used in
 conjunction with the ELISA. It isn’t specific when used alone.
Erosette immunofluorescence is used to detect viruses in general; it
doesn’t confirm HIV infection. Quantification of T-lymphocytes is a
useful monitoring test but isn’t diagnostic for HIV. The ELISA test
detects HIV antibody particles but may yield inaccurate results; a
positive ELISA result must be confirmed by the Western blot test.
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin
(Hb) levels. Low preoperative HCT and Hb levels indicate the client
may require a blood transfusion before surgery. If the HCT and Hb
levels decrease during surgery because of blood loss, the potential
need for a transfusion increases. Possible renal failure is indicated
by elevated BUN or creatinine levels. Urine constituents aren’t found
in the blood. Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.
89. Answer: (A) Platelet count, prothrombin time, and partial
thromboplastin time. The diagnosis of DIC is based on the results of
laboratory studies of prothrombin time, platelet count, thrombin
time, partial thromboplastin time, and fibrinogen level as well as
client history and other assessment factors. Blood glucose levels,
WBC count, calcium levels, and potassium levels aren’t used to
confirm a diagnosis of DIC.
90. Answer: (D) Strawberries. Common food allergens include berries,
peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots,
and oranges rarely cause allergic reactions.
91. Answer: (B) A client with cast on the right leg who states, “I have a
funny feeling in my right leg.” It may indicate neurovascular
compromise, requires immediate assessment.
92. Answer: (D) A 62-year-old who had an abdominal-perineal resection
three days ago; client complaints of chills. The client is at risk for
peritonitis; should be assessed for further symptoms and infection.
93. Answer: (C) The client spontaneously flexes his wrist when the
blood pressure is obtained. Carpal spasms indicate hypocalcemia.
94. Answer: (D) Use comfort measures and pillows to position the
client.Using comfort measures and pillows to position the client is
a non-pharmacological methods of pain relief.
95. Answer: (B) Warm the dialysate solution. Cold dialysate increases
discomfort. The solution should be warmed to body temperature in
warmer or heating pad; don’t use microwave oven.
96. Answer: (C) The client holds the cane with his left hand, moves the
cane forward followed by the right leg, and then moves the left leg. The
cane acts as a support and aids in weight bearing for the weaker
right leg.
97. Answer: (A) Ask the woman’s family to provide personal items such
as photos or mementos.Photos and mementos provide visual
stimulation to reduce sensory deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches,
and then takes several small steps forward. A walker needs to be picked
up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar
surroundings. Gradual loss of sight, hearing, and taste interferes with
normal functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing. Purse
lip breathing prevents the collapse of lung unit and helps client
control rate and depth of breathing.
1. Randy has undergone kidney transplant, what assessment would prompt
Nurse Katrina to suspect organ rejection?
A. Sudden weight loss
B. Polyuria
C. Hypertension
D. Shock
2. The immediate objective of nursing care for an overweight, mildly
hypertensive male client with ureteral colic and hematuria is to decrease:
A. Pain
B. Weight
C. Hematuria
D. Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a
subtotal thyroidectomy is performed. The nurse is aware that this medication
is given to:
A. Decrease the total basal metabolic rate.
B. Maintain the function of the parathyroid glands.
C. Block the formation of thyroxine by the thyroid gland.
D. Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute
hypoglycemia also can develop in the client who is diagnosed with:
A. Liver disease
B. Hypertension
C. Type 2 diabetes
D. Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of metastatic
carcinoma. Nurse Ruby should monitor the client for the systemic side effect
of:
A. Ascites
B. Nystagmus
C. Leukopenia
D. Polycythemia
6. Norma, with recent colostomy expresses concern about the inability to
control the passage of gas. Nurse Oliver should suggest that the client plan to:
A. Eliminate foods high in cellulose.
B. Decrease fluid intake at meal times.
 C. Avoid foods that in the past caused flatus.
D. Adhere to a bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform colostomy
irrigations. The nurse would evaluate that the instructions were understood
when the client states, “I should:
A. Lie on my left side while instilling the irrigating solution.”
B. Keep the irrigating container less than 18 inches above the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to
stimulate evacuation of the bowel.”
D. Insert the irrigating catheter deeper into the stoma if
cramping occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing
fluid and electrolyte imbalances. The client is somewhat confused and
complains of nausea and muscle weakness. As part of the prescribed therapy
to correct this electrolyte imbalance, the nurse would expect to:
A. Administer Kayexalate
B. Restrict foods high in protein
C. Increase oral intake of cheese and milk.
D. Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2
liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10
gtt/ml. The nurse should set the flow to provide:
A. 18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
D. 36 gtt/min
10.Terence suffered form burn injury. Using the rule of nines, which has the
largest percent of burns?
A. Face and neck
B. Right upper arm and penis
C. Right thigh and penis
D. Upper trunk
11. Herbert, a 45 year old construction engineer is brought to the hospital
unconscious after falling from a 2-story building. When assessing the client,
the nurse would be most concerned if the assessment revealed:
A. Reactive pupils
 B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial
pacemaker. Which information given by the nurse shows her knowledge
deficit about the artificial cardiac pacemaker?
A. take the pulse rate once a day, in the morning upon awakening
B. May be allowed to use electrical appliances
C. Have regular follow up care
D. May engage in contact sports
13.The nurse is ware that the most relevant knowledge about oxygen
administration to a male client with COPD is
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing.
B. Hypoxia stimulates the central chemoreceptors in the medulla that
makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.
14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy.
Chest tubes are inserted, and one-bottle water-seal drainage is instituted in
the operating room. In the postanesthesia care unit Tonny is placed in
Fowler’s position on either his right side or on his back. The nurse is aware
that this position:
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to
expect afterward, the nurse’s highest priority of information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The nurse
should expect hypertonic glucose, insulin infusions, and sodium bicarbonate
to be used to treat:
 A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata (genital
warts). What information is appropriate to tell this client?
A. This condition puts her at a higher risk for cervical cancer; therefore,
she should have a Papanicolaou (Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
D. The human papillomavirus (HPV), which causes condylomata
acuminata, can’t be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem and is being
examined in the emergency department. When palpating the her kidneys, the
nurse should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm
(¾” to 1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The
nurse is aware that the diagnostic test are consistent with CRF if the result is:
A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/
dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP)
excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting
that she read her chart while the nurse was out of the room, Katrina asks what
dysplasia means. Which definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that don’t
resemble cells of the tissues of their origin.
 B. Increase in the number of normal cells in a normal arrangement in a
tissue or an organ.
C. Replacement of one type of fully differentiated cell by another in
tissues where the second type normally isn’t found.
D. Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client with
acquired immunodeficiency syndrome (AIDS) for signs and symptoms of
cancer. What is the most common AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma
22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans
to use a spinal (subarachnoid) block during surgery. In the operating room, the
nurse positions the client according to the anesthesiologist’s instructions.
Why does the client require special positioning for this type of anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now complaining of
abdominal pressure and nausea. The first nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this test
initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an ileostomy. On
the first day after surgery, Nurse Oliver notes that the client’s stoma appears
dusky. How should the nurse interpret this finding?
 A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention helps
prevent contractures?
A. Applying knee splints
B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-degree
burns on the face, arms, and chest. Which finding indicates a potential
problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too
weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia
should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a female client
who has dermatitis over the anterior chest. How should the nurse apply this
topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected
area
C. In long, even, outward, and downward strokes in the direction of hair
growth
D. In long, even, outward, and upward strokes in the direction opposite
hair growth
30.Nurse Kate is aware that one of the following classes of medication
protect the ischemic myocardium by blocking catecholamines
and sympathetic nerve stimulation is:
A. Beta -adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
31.A male client has jugular distention. On what position should the nurse
place the head of the bed to obtain the most accurate reading of jugular vein
distention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
32.The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by increasing
ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL) level and
an elevated low-density lipoprotein (LDL) level. Which of the following dietary
modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories form fat
C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2
days ago with an acute myocardial infarction. Which of the following actions
would breach the client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry
unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a change in the
client’s condition
 C. The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress.
D. At the client’s request, the CCU nurse updates the client’s wife on
his condition
35. A male client arriving in the emergency department is receiving
cardiopulmonary resuscitation from paramedics who are giving ventilations
through an endotracheal (ET) tube that they placed in the client’s home.
During a pause in compressions, the cardiac monitor shows narrow QRS
complexes and a heart rate of beats/minute with a palpable pulse. Which of
the following actions
should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cardarone), 300 mg
L.V. over 10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg.
Nurse Katrina determines that mean arterial pressure (MAP) is which of the
following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg
37. A female client arrives at the emergency department with chest and
stomach pain and a report of black tarry stool for several months. Which of
the following order should the nurse Oliver anticipate?
A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase
levels
B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin
split product values.
C. Electrocardiogram, complete blood count, testing for occult blood,
comprehensive serum metabolic panel.
D. Electroencephalogram, alkaline phosphatase and aspartate
aminotransferase levels, basic serum metabolic panel
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago.
Which of the following conditions is suspected by the nurse when a decrease
in platelet count from 230,000 ul to 5,000 ul is noted?
A. Pancytopenia
B. Idiopathic thrombocytopemic purpura (ITP)
C. Disseminated intravascular coagulation (DIC)
D. Heparin-associated thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve
the platelet count in a male client with idiopathic thrombocytopenic purpura
(ITP)?
A. Acetylsalicylic acid (ASA)
B. Corticosteroids
C. Methotrezate
D. Vitamin K
40. A female client is scheduled to receive a heart valve replacement with a
porcine valve. Which of the following types of transplant is this?
A. Allogeneic
B. Autologous
C. Syngeneic
D. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following
actions shows the initial response to the injury in the extrinsic pathway?
A. Release of Calcium
B. Release of tissue thromboplastin
C. Conversion of factors XII to factor XIIa
D. Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE) would
include information about which of the following blood dyscrasias?
A. Dressler’s syndrome
B. Polycythemia
C. Essential thrombocytopenia
D. Von Willebrand’s disease
43. The nurse is aware that the following symptoms is most commonly an
early indication of stage 1 Hodgkin’s disease?
A. Pericarditis
B. Night sweat
 C. Splenomegaly
D. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions
must frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma
(MM) usually involve which of the following body system?
A. Brain
B. Muscle spasm
C. Renal dysfunction
D. Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
A. Less than 5 years
B. 5 to 7 years
C. 10 years
D. More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs
of disseminated intravascular coagulation (DIC). Which of the following
laboratory findings is most consistent with DIC?
A. Low platelet count
B. Elevated fibrinogen levels
C. Low levels of fibrin degradation products
D. Reduced prothrombin time
48. Mario comes to the clinic complaining of fever, drenching night sweats,
and unexplained weight loss over the past 3 months. Physical examination
reveals a single enlarged supraclavicular lymph node. Which of the following
is the most probable diagnosis?
A. Influenza
B. Sickle cell anemia
C. Leukemia
D. Hodgkin’s disease
49. A male client with a gunshot wound requires an emergency blood
transfusion. His blood type is AB negative. Which blood type would be the
safest for him to receive?
A. AB Rh-positive
B. A Rh-positive
C. A Rh-negative
D. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and
beginning chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy
treatments. Which statement of Stacy’s mother indicated that she
understands when she will contact the physician?
A. “I should contact the physician if Stacy has difficulty in sleeping”.
B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
C. “My physician should be called if Stacy is irritable and unhappy”.
D. “Should Stacy have continued hair loss, I need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is:
A. “Stacy looks very nice wearing a hat”.
B. “You should not worry about her hair, just be glad that she is alive”.
C. “Yes it is upsetting. But try to cover up your feelings when you are
with her or else she may be upset”.
D. “This is only temporary; Stacy will re-grow new hair in 3-6 months,
but may be different in texture”.
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the
nurse in-charge should:
A. Provide frequent mouthwash with normal saline.
B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy agents, Nurse Oliver observed
that the IV site is red and swollen, when the IV is touched Stacy shouts in pain.
The first nursing action to take is:
A. Notify the physician
B. Flush the IV line with saline solution
 C. Immediately discontinue the infusion
D. Apply an ice pack to the site, followed by warm compress.
54. The term “blue bloater” refers to a male client which of the following
conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
55. The term “pink puffer” refers to the female client with which of the
following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
56. Jose is in danger of respiratory arrest following the administration of a
narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would
expect the paco2 to be which of the following values?
A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2
80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respirator y alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes after she
takes the drug, she develops chest tightness and becomes short of breath and
tachypneic. She has a decreased level of consciousness. These signs indicate
which of the following conditions?
A. Asthma attack
B. Pulmonary embolism
C. Respiratory failure
D. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and
jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
A. Decreased red blood cell count
B. Decreased serum acid phosphate level
C. Elevated white blood cell count
D. Elevated serum aminotransferase
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr.
Gonzales is at increased risk for excessive bleeding primarily because of:
A. Impaired clotting mechanism
B. Varix formation
C. Inadequate nutrition
D. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical
manifestation is most common with this condition?
A. Increased urine output
B. Altered level of consciousness
C. Decreased tendon reflex
D. Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of
Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best
action would be:
A. “I’ll see if your physician is in the hospital”.
B. “Maybe your reacting to the drug; I will withhold the next dose”.
C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4
stools a day”.
D. “Frequently, bowel movements are needed to reduce sodium level”.
63. Which of the following groups of symptoms indicates a ruptured
abdominal aortic aneurysm?
A. Lower back pain, increased blood pressure, decreased re blood cell
(RBC) count, increased white blood (WBC) count.
B. Severe lower back pain, decreased blood pressure, decreased RBC
count, increased WBC count.
C. Severe lower back pain, decreased blood pressure, decreased RBC
count, decreased RBC count, decreased WBC count.
 D. Intermitted lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of
blood under his buttocks. Which of the following steps should the nurse take
first?
A. Call for help.
B. Obtain vital signs
C. Ask the client to “lift up”
D. Apply gloves and assess the groin site
65. Which of the following treatment is a suitable surgical intervention for a
client with unstable angina?
A. Cardiac catheterization
B. Echocardiogram
C. Nitroglycerin
D. Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe reduced
cardiac output and perfusion impairment due to ineffective pumping of the
heart is:
A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause blood
pressure to drop to normal levels?
A. Kidneys’ excretion to sodium only.
B. Kidneys’ retention of sodium and water
C. Kidneys’ excretion of sodium and water
D. Kidneys’ retention of sodium and excretion of water
68. Nurse Rose is aware that the statement that best explains why furosemide
(Lasix) is administered to treat hypertension is:
A. It dilates peripheral blood vessels.
B. It decreases sympathetic cardioacceleration.
C. It inhibits the angiotensin-coverting enzymes
D. It inhibits reabsorption of sodium and water in the loop of Henle.
69. Nurse Nikki knows that laboratory results supports the diagnosis of
systemic lupus erythematosus (SLE) is:
 A. Elavated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA) titer
D. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
70. Arnold, a 19-year-old client with a mild concussion is discharged from the
emergency department. Before discharge, he complains of a headache. When
offered acetaminophen, his mother tells the nurse the headache is severe and
she would like her son to have something stronger. Which of the following
responses by the nurse is appropriate?
A. “Your son had a mild concussion, acetaminophen is strong enough.”
B. “Aspirin is avoided because of the danger of Reye’s syndrome in
children or young adults.”
C. “Narcotics are avoided after a head injury because they may hide a
worsening condition.”
D. Stronger medications may lead to vomiting, which increases the
intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a subdural
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following
responses best describes the result?
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP)
B. Emergent; the client is poorly oxygenated
C. Normal
D. Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the nurse
Olivia assess first?
A. A 17-year-old clients 24-hours postappendectomy
B. A 33-year-old client with a recent diagnosis of Guillain-Barre
syndrome
C. A 50-year-old client 3 days postmyocardial infarction
D. A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to know why colchicine is
used in the treatment of gout. Which of the following actions of colchicines
explains why it’s effective for gout?
A. Replaces estrogen
B. Decreases infection
 C. Decreases inflammation
D. Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
A. Osteoarthritis is rarely debilitating
B. Osteoarthritis is a rare form of arthritis
C. Osteoarthritis is the most common form of arthritis
D. Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets
to take her thyroid replacement medicine. The nurse understands that
skipping this medication will put the client at risk for developing which of the
following lifethreatening complications?
A. Exophthalmos
B. Thyroid storm
C. Myxedema coma
D. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which
observation should the nurse report to the physician immediately?
A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to
the intensive care unit. Thirty-six hours later, the client’s urine output suddenly
rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus.
Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal serum osmolality
level
D. Below-normal urine osmolality level, above-normal serum osmolality
level
78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS) is stabilized and prepared for discharge. When preparing
the client for discharge and home management, which of the following
statements indicates that the client understands her condition and how to
control it?
A. “I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink, or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I should drink a
glass of soda that contains sugar.”
C. “I will have to monitor my blood glucose level closely and notify the
physician if it’s constantly elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in
carbohydrates.”
79. A 66-year-old client has been complaining of sleeping more, increased
urination, anorexia, weakness, irritability, depression, and bone pain that
interferes with her going outdoors. Based on these assessment findings, the
nurse would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about
the need to take fludrocortisone acetate and hydrocortisone at home. Which
statement by the client indicates an understanding of the instructions?
A. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right after I wake
up.”
C. “I’ll take two-thirds of the dose when I wake up and one-third in the
late afternoon.”
D. “I’ll take the entire dose at bedtime.”
81. Which of the following laboratory test results would suggest to the nurse
Len that a client has a corticotropin-secreting pituitary adenoma?
A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal hypophysectomy to
remove a pituitary tumor. Preoperatively, the nurse should assess  for
potential complications by doing which of the following?
 A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for which he receives 8 U of regular
insulin. Nurse Mariner should expect the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism in a
female client with classic signs and symptoms of this disorder. Which test
result would confirm the diagnosis?
A. No increase in the thyroid-stimulating hormone (TSH) level after 30
minutes during the TSH stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the TSH
stimulation test
D. Below-normal levels of serum triiodothyronine (T3) and serum
thyroxine (T4) as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100
isophane insulin suspension (NPH) to be taken before breakfast. When
teaching the client how to select and rotate insulin injection sites, the nurse
should provide which instruction?
A. “Inject insulin into healthy tissue with large blood vessels and
nerves.”
B. “Rotate injection sites within the same anatomic region, not among
different regions.”
C. “Administer insulin into areas of scar tissue or hypotrophy whenever
possible.”
D. “Administer insulin into sites above muscles that you plan to
exercise heavily later that day.”
86. Nurse Sarah expects to note an elevated serum glucose level in a client
with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other
laboratory finding should the nurse anticipate?
A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
D. Below-normal serum potassium level
87. For a client with Graves’ disease, which nursing intervention promotes
comfort?
A. Restricting intake of oral fluids
B. Placing extra blankets on the client’s bed
C. Limiting intake of high-carbohydrate foods
D. Maintaining room temperature in the low-normal range
88. Patrick is treated in the emergency department for a Colles’ fracture
sustained during a fall. What is a Colles’ fracture?
A. Fracture of the distal radius
B. Fracture of the olecranon
C. Fracture of the humerus
D. Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
development of this disorder?
A. Calcium and sodium
B. Calcium and phosphorous
C. Phosphorous and potassium
D. Potassium and sodium
90. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the
incident, requiring intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia
91. A 67-year-old client develops acute shortness of breath and progressive
hypoxia requiring right femur. The hypoxia was probably caused by which of
the following conditions?
 A. Asthma attack
B. Atelectasis
C. Bronchitis
D. Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds
on the right side, from the apex to the base. Which of the following conditions
would best explain this?
A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an
unrestrained driver. He’s now in the emergency department complaining of
difficulty of breathing and chest pain. On auscultation of his lung field, no
breath sounds are present in the upper lobe. This client may have which of the
following conditions?
A. Bronchitis
B. Pneumonia
C. Pneumothorax
D. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic
cavity?
A. The space remains filled with air only
B. The surgeon fills the space with a gel
C. Serous fluids fills the space and consolidates the region
D. The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism
because of which of the following reasons?
A. Alveolar damage in the infracted area
B. Involvement of major blood vessels in the occluded area
C. Loss of lung parenchyma
D. Loss of lung tissue
96. Aldo with a massive pulmonary embolism will have an arterial blood gas
analysis performed to determine the extent of hypoxia. The acid-base disorder
that may be present is?
A. Metabolic acidosis
 B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted
with a pneumothorax. The surgeon inserts a chest tube and attaches it to a
chest drainage system. Bubbling soon appears in the water seal chamber.
Which of the following is the most likely cause of the bubbling?
A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours.
The IV infusion set has a drop factor of 10 drops per milliliter. The nurse
should regulate the client’s IV to deliver how many drops per minute?
A. 18
B. 21
C. 35
D. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The
bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the
following statements, if made by the client, indicates to the   nurse that the
teaching was successful?
A. “I will wear the stockings until the physician tells me to remove
them.”
B. “I should wear the stockings even when I am sleep.”
C. “Every four hours I should remove the stockings for a half hour.”
D. “I should put on the stockings before getting out of bed in the
morning.”
Answers and Rationales
1. Answer: (C) Hypertension. Hypertension, along with fever, and
tenderness over the grafted kidney, reflects acute rejection.
2. Answer: (A) Pain. Sharp, severe pain (renal colic) radiating toward the
genitalia and thigh is caused by uretheral distention and smooth
muscle spasm; relief form pain is the priority.
3. Answer: (D) Decrease the size and vascularity of the thyroid
gland. Lugol’s solution provides iodine, which aids in decreasing
the vascularity of the thyroid gland, which limits the risk of
hemorrhage when surgery is performed.
4. Answer: (A) Liver Disease. The client with liver disease has a
decreased ability to metabolize carbohydrates because of a
decreased ability to form glycogen (glycogenesis) and to form
glucose from glycogen.
5. Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is a
systemic effect of chemotherapy as a result of myelosuppression.
6. Answer: (C) Avoid foods that in the past caused flatus. Foods that
bothered a person preoperatively will continue to do so after a
colostomy.
7. Answer: (B) Keep the irrigating container less than 18 inches above
the stoma.”  This height permits the solution to flow slowly with little
force so that excessive peristalsis is not immediately precipitated.
8. Answer: (A) Administer Kayexalate. Kayexalate,a potassium exchange
resin, permits sodium to be exchanged for potassium in the
intestine, reducing the serum potassium level.
9. Answer:(B) 28 gtt/min.  This is the correct flow rate; multiply the
amount to be infused (2000 ml) by the drop factor (10) and divide
the result by the amount of time in minutes (12 hours x 60 minutes)
10. Answer: (D) Upper trunk.  The percentage designated for each
burned part of the body using the rule of nines: Head and neck 9%;
Right upper extremity 9%; Left upper extremity 9%; Anterior trunk
18%; Posterior trunk 18%; Right lower extremity 18%; Left lower
extremity 18%; Perineum 1%.
11. Answer: (C) Bleeding from ears.  The nurse needs to perform a
thorough assessment that could indicate alterations in cerebral
 function, increased intracranial pressures, fractures and bleeding.
Bleeding from the ears occurs only with basal skull fractures that
can easily contribute to increased intracranial pressure and brain
herniation.
12. Answer: (D) may engage in contact sports. The client should be
advised by the nurse to avoid contact sports. This will prevent
trauma to the area of the pacemaker generator.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic
stimulus for breathing. COPD causes a chronic CO2 retention that
renders the medulla insensitive to the CO2 stimulation for breathing.
The hypoxic state of the client then becomes the stimulus for
breathing. Giving the client oxygen in low concentrations will
maintain the client’s hypoxic drive.
14. Answer: (B) Facilitate ventilation of the left lung. Since only a partial
pneumonectomy is done, there is a need to promote expansion of
this remaining Left lung by positioning the client on the opposite
unoperated side.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours.  Prior
to bronchoscopy, the doctors sprays the back of the throat with
anesthetic to minimize the gag reflex and thus facilitate
the insertion of the bronchoscope. Giving the client food and drink
after the procedure without checking on the return of the gag reflex
can cause the client to aspirate. The gag reflex usually returns after
two hours.
16. Answer: (C) hyperkalemia. Hyperkalemia is a common complication
of acute renal failure. It’s life-threatening if immediate action isn’t
taken to reverse it. The administration of glucose and regular
insulin, with sodium bicarbonate if necessary, can temporarily
prevent cardiac arrest by moving potassium into the cells and
temporarily reducing serum potassium levels. Hypernatremia,
hypokalemia, and hypercalcemia don’t usually occur with acute
renal failure and aren’t treated with glucose, insulin, or
sodium bicarbonate.
17. Answer: (A) This condition puts her at a higher risk for cervical
cancer; therefore, she should have a Papanicolaou (Pap) smear
annually. Women with condylomata acuminata are at risk for cancer
 of the cervix and vulva. Yearly Pap smears are very important for
early detection. Because condylomata acuminata is a virus, there is
no permanent cure. Because condylomata acuminata can occur on
the vulva, a condom won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right
one. The left kidney usually is slightly higher than the right one.
An adrenal gland lies atop each kidney. The average kidney
measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼”)
wide, and 2.5 cm (1″) thick. The kidneys are located
retroperitoneally, in the posterior aspect of the abdomen, on either
side of the vertebral column. They lie between the 12th thoracic and
3rd lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23 mg/dl; the
normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test
results in option C are abnormally elevated, reflecting CRF and the
kidneys’ decreased ability to remove nonprotein nitrogen waste
from the blood. CRF causes decreased pH and increased hydrogen
ions — not vice versa. CRF also increases serum levels of
potassium, magnesium, and phosphorous, and decreases serum
levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the
normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls
with the normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization
of differentiated cells. Dysplasia refers to an alteration in the size,
shape, and organization of differentiated cells. The presence of
completely undifferentiated tumor cells that don’t resemble cells of
the tissues of their origin is called anaplasia. An increase in the
number of normal cells in a normal arrangement in a tissue or an
organ is called hyperplasia. Replacement of one type of fully
differentiated cell by another in tissues where the second type
normally isn’t found is called metaplasia.
21. Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most
common cancer associated with AIDS. Squamous cell carcinoma,
 multiple myeloma, and leukemia may occur in anyone and aren’t
associated specifically with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The client
receiving a subarachnoid block requires special positioning to
prevent CSF leakage and headache and to ensure proper anesthetic
distribution. Proper positioning doesn’t help prevent
confusion, seizures, or cardiac arrhythmias.
23. Answer: (A) Auscultate bowel sounds. If abdominal distention is
accompanied by nausea, the nurse must first auscultate bowel
sounds. If bowel sounds are absent, the nurse should suspect
gastric or small intestine dilation and these findings must be
reported to the physician. Palpation should be avoided
postoperatively with abdominal distention. If peristalsis is absent,
changing positions and inserting a rectal tube won’t relieve the
client’s discomfort.
24. Answer: (B) Lying on the left side with knees bent. For a colonoscopy,
the nurse initially should position the client on the left side with
knees bent. Placing the client on the right side with legs straight,
prone with the torso elevated, or bent over with hands touching the
floor wouldn’t allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted. An
ileostomy stoma forms as the ileum is brought through
the abdominal wall to the surface skin, creating an artificial opening
for waste elimination. The stoma should appear cherry red,
indicating adequate arterial perfusion. A dusky stoma suggests
decreased perfusion, which may result from interruption of the
stoma’s blood supply and may lead to tissue damage or necrosis. A
dusky stoma isn’t a normal finding. Adjusting the ostomy bag
wouldn’t affect stoma color, which depends on blood supply to the
area. An intestinal obstruction also wouldn’t change stoma color.
26. Answer: (A) Applying knee splints. Applying knee splints prevents
leg contractures by holding the joints in a position of function.
Elevating the foot of the bed can’t prevent contractures because this
action doesn’t hold the joints in a position of function.
Hyperextending a body part for an extended time is
inappropriate because it can cause contractures. Performing
 shoulder range-of-motion exercises can prevent contractures in the
shoulders, but not in the legs.
27. Answer: (B) Urine output of 20 ml/hour. A urine output of less than
40 ml/hour in a client with burns indicates a fluid volume deficit.
This client’s PaO2 value falls within the normal range (80 to 100 mm
Hg). White pulmonary secretions also are normal. The client’s rectal
temperature isn’t significantly elevated and probably results from
the fluid volume deficit.
28. Answer: (A) Turn him frequently. The most important intervention to
prevent pressure ulcers is frequent position changes, which relieve
pressure on the skin and underlying tissues. If pressure isn’t
relieved, capillaries become occluded, reducing circulation and
oxygenation of the tissues and resulting in cell death and ulcer
formation. During passive ROM exercises, the nurse moves each
joint through its range of movement, which improves joint mobility
and circulation to the affected area but doesn’t prevent
pressure ulcers. Adequate hydration is necessary to maintain
healthy skin and ensure tissue repair. A footboard prevents plantar
flexion and footdrop by maintaining the foot in a dorsiflexed
position.
29. Answer: (C) In long, even, outward, and downward strokes in
the direction of hair growth. When applying a topical agent, the nurse
should begin at the midline and use long, even, outward, and
downward strokes in the direction of hair growth. This application
pattern reduces the risk of follicle irritation and skin inflammation.
30. Answer: (A) Beta -adrenergic blockers. Beta-adrenergic blockers
work by blocking beta receptors in the myocardium, reducing the
response to catecholamines and sympathetic nerve stimulation.
They protect the myocardium, helping to reduce the risk of another
infraction by decreasing myocardial oxygen demand. Calcium
channel blockers reduce the workload of the heart by decreasing the
heart rate. Narcotics reduce myocardial oxygen demand, promote
vasodilation, and decrease anxiety. Nitrates reduce
myocardial oxygen consumption bt decreasing left ventricular end
diastolic pressure (preload) and systemic vascular resistance
(afterload).
31. Answer: (C) Raised 30 degrees. Jugular venous pressure is
measured with a centimeter ruler to obtain the vertical distance
between the sternal angle and the point of highest pulsation with the
head of the bed inclined between 15 to 30 degrees. Increased
pressure can’t be seen when the client is supine or when the head of
the bed is raised 10 degrees because the point that marks the
pressure level is above the jaw (therefore, not visible). In
high Fowler’s position, the veins would be barely discernible above
the clavicle.
32. Answer: (D) Inotropic agents. Inotropic agents are administered to
increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output.
Beta-adrenergic blockers and calcium channel blockers decrease
the heart rate and ultimately decreased the workload of the heart.
Diuretics are administered to decrease the overall vascular volume,
also decreasing the workload of the heart.
33. Answer: (B) Less than 30% of calories form fat. A client with low
serum HDL and high serum LDL levels should get less than 30% of
daily calories from fat. The other modifications are appropriate for
this client.
34. Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s progress. The
emergency department nurse is no longer directly involved with the
client’s care and thus has no legal right to information about his
present condition. Anyone directly involved in his care (such as the
telemetry nurse and the on-call physician) has the right to
information about his condition. Because the client requested that
the nurse update his wife on his condition, doing so doesn’t breach
confidentiality.
35. Answer: (B) Check endotracheal tube placement. ET tube placement
should be confirmed as soon as the client arrives in the emergency
department. Once the airways is secured, oxygenation and
ventilation should be confirmed using an end-tidal carbon dioxide
monitor and pulse oximetry. Next, the nurse should make sure L.V.
access is established. If the client experiences
symptomatic bradycardia, atropine is administered as ordered 0.5 to
 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should
try to find the cause of the client’s arrest by obtaining an ABG
sample. Amiodarone is indicated for ventricular tachycardia,
ventricular fibrillation and atrial flutter – not symptomatic
bradycardia.
36. Answer: (C) 95 mm Hg. Use the following formula to calculate MAP
 MAP = systolic + 2 (diastolic) /3
 MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
 MAP=286 mm HG/ 3
 MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel. An
electrocardiogram evaluates the complaints of chest
pain, laboratory tests determines anemia, and the stool test for
occult blood determines blood in the stool. Cardiac monitoring,
oxygen, and creatine kinase and lactate dehydrogenase levels are
appropriate for a cardiac primary problem. A basic metabolic panel
and alkaline phosphatase and aspartate aminotransferase levels
assess liver function. Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split products are measured to verify bleeding
dyscrasias, An electroencephalogram evaluates brain electrical
activity.
38. Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG surgery due
to heparin use during surgery. Although DIC and ITP cause platelet
aggregation and bleeding, neither is common in a client after
revascularization surgery. Pancytopenia is a reduction in all blood
cells.
39. Answer: (B) Corticosteroids. Corticosteroid therapy can decrease
antibody production and phagocytosis of the antibody-coated
platelets, retaining more functioning platelets. Methotrexate can
cause thrombocytopenia. Vitamin K is used to treat an excessive
anticoagulate state from warfarin overload, and ASA decreases
platelet aggregation.
40. Answer: (D) Xenogeneic. An xenogeneic transplant is between is
between human and another species. A syngeneic transplant is
 between identical twins, allogeneic transplant is between two
humans, and autologous is a transplant from the same individual.
41. Answer: (B). Tissue thromboplastin is released when damaged
tissue comes in contact with clotting factors. Calcium is released to
assist the conversion of factors X to Xa. Conversion of factors XII to
XIIa and VIII to VIII a are part of the intrinsic pathway.
42. Answer: (C) Essential thrombocytopenia. Essential thrombocytopenia
is linked to immunologic disorders, such as SLE and human
immunodeficiency vitus. The disorder known as von Willebrand’s
disease is a type of hemophilia and isn’t linked to SLE. Moderate to
severe anemia is associated with SLE, not polycythermia. Dressler’s
syndrome is pericarditis that occurs after a myocardial
infarction and isn’t linked to SLE.
43. Answer: (B) Night sweat. In stage 1, symptoms include a single
enlarged lymph node (usually), unexplained fever, night sweats,
malaise, and generalized pruritis. Although splenomegaly may be
present in some clients, night sweats are generally more prevalent.
Pericarditis isn’t associated with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly and pericarditis aren’t
symptoms. Persistent hypothermia is associated with Hodgkin’s but
isn’t an early sign of the disease.
44. Answer: (D) Breath sounds.  Pneumonia, both viral and fungal, is a
common cause of death in clients with neutropenia, so frequent
assessment of respiratory rate and breath sounds is required.
Although assessing blood pressure, bowel sounds, and heart
sounds is important, it won’t help detect pneumonia.
45. Answer: (B) Muscle spasm. Back pain or paresthesia in the lower
extremities may indicate impending spinal cord compression from a
spinal tumor. This should be recognized and treated promptly as
progression of the tumor may result in paraplegia. The other
options, which reflect parts of the nervous system, aren’t usually
affected by MM.
46. Answer: (C)10 years. Epidermiologic studies show the average time
from initial contact with HIV to the development of AIDS is 10 years.
47. Answer: (A) Low platelet count. In DIC, platelets and clotting factors
are consumed, resulting in microthrombi and excessive bleeding. As
 clots form, fibrinogen levels decrease and the prothrombin time
increases. Fibrin degeneration products increase as fibrinolysis
takes places.
48. Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically causes
fever night sweats, weight loss, and lymph mode enlargement.
Influenza doesn’t last for months. Clients with sickle cell anemia
manifest signs and symptoms of chronic anemia with pallor of the
mucous membrane, fatigue, and decreased tolerance for exercise;
they don’t show fever, night sweats, weight loss or lymph node
enlargement. Leukemia doesn’t cause lymph node enlargement.
49. Answer: (C) A Rh-negative. Human blood can sometimes contain
an inherited D antigen. Persons with the D antigen have Rh-positive
blood type; those lacking the antigen have Rh-negative blood. It’s
important that a person with Rhnegative blood receives Rh-negative
blood. If Rh-positive blood is administered to an Rh-negative person,
the recipient develops anti-Rh agglutinins, and sub sequent
transfusions with Rh-positive blood may cause serious reactions
with clumping and hemolysis of red blood cells.
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting
and diarrhea”.  Persistent (more than 24 hours) vomiting, anorexia,
and diarrhea are signs of toxicity and the patient should stop the
medication and notify the health care provider. The other
manifestations are expected side effects of chemotherapy.
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-
6 months, but may be different in texture”. This is the appropriate
response. The nurse should help the mother how to cope with her
own feelings regarding the child’s disease so as not to affect the
child negatively. When the hair grows back, it is still of the same
color and texture.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as
needed. Stomatitis can cause pain and this can be relieved by
applying topical anesthetics such as lidocaine before mouth care.
When the patient is already comfortable, the nurse can proceed with
providing the patient with oral rinses of saline solution mixed with
equal part of water or hydrogen peroxide mixed water in 1:3
concentrations to promote oral hygiene. Every 2-4 hours.
53. Answer: (C) Immediately discontinue the infusion. Edema or swelling
at the IV site is a sign that the needle has been dislodged and the IV
solution is leaking into the tissues causing the edema. The patient
feels pain as the nerves are irritated by pressure and the IV solution.
The first action of the nurse would be to discontinue the infusion
right away to prevent further edema and other complication.
54. Answer: (C) Chronic obstructive bronchitis. Clients with chronic
obstructive bronchitis appear bloated; they have large barrel chest
and peripheral edema, cyanotic nail beds, and at times, circumoral
cyanosis. Clients with ARDS are acutely short of breath and
frequently need intubation for mechanical ventilation and
large amount of oxygen. Clients with asthma don’t exhibit
characteristics of chronic disease, and clients with emphysema
appear pink and cachectic.
55. Answer: (D) Emphysema. Because of the large amount of energy it
takes to breathe, clients with emphysema are usually cachectic.
They’re pink and usually breathe through pursed lips, hence the term
“puffer.” Clients with ARDS are usually acutely short of breath.
Clients with asthma don’t have any particular characteristics, and
clients with chronic obstructive bronchitis are bloated and cyanotic
in appearance.
56. Answer: D 80 mm Hg. A client about to go into respiratory arrest
will have inefficient ventilation and will be retaining carbon dioxide.
The value expected would be around 80 mm Hg. All other values are
lower than expected.
57. Answer: (C) Respiratory acidosis. Because Paco2 is high at 80 mm
Hg and the metabolic measure, HCO3- is normal, the client has
respiratory acidosis. The pH is less than 7.35, academic, which
eliminates metabolic and respiratory alkalosis as possibilities. If the
HCO3- was below 22 mEq/L the client would have metabolic
acidosis.
58. Answer: (C) Respiratory failure. The client was reacting to the drug
with respiratory signs of impending anaphylaxis, which could lead to
eventually respiratory failure. Although the signs are also related to
an asthma attack or a pulmonary embolism, consider the new drug
first. Rheumatoid arthritis doesn’t manifest these signs.
59. Answer: (D) Elevated serum aminotransferase. Hepatic cell death
causes release of liver enzymes alanine aminotransferase (ALT),
aspartate aminotransferase (AST) and lactate dehydrogenase (LDH)
into the circulation. Liver cirrhosis is a chronic and irreversible
disease of the liver characterized by generalized inflammation and
fibrosis of the liver tissues.
60. Answer: (A) Impaired clotting mechanism. Cirrhosis of the liver
results in decreased Vitamin K absorption and formation of clotting
factors resulting in impaired clotting mechanism.
61. Answer: (B) Altered level of consciousness. Changes in behavior and
level of consciousness are the first sins of hepatic encephalopathy.
Hepatic encephalopathy is caused by liver failure and develops
when the liver is unable to convert protein metabolic product
ammonia to urea. This results in accumulation of ammonia
and other toxic in the blood that damages the cells.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2
to 4 stools a day”. Lactulose is given to a patients with hepatic
encephalopathy to reduce absorption of ammonia in the intestines
by binding with ammonia and promoting more frequent bowel
movements. If the patient experience diarrhea, it indicates over
dosage and the nurse must reduce the amount of medication given
to the patient. The stool will be mashy or soft. Lactulose is also very
sweet and may cause cramping and bloating.
63. Answer: (B) Severe lower back pain, decreased blood
pressure, decreased RBC count, increased WBC count.Severe lower back
pain indicates an aneurysm rupture, secondary to pressure being
applied within the abdominal cavity. When ruptured occurs, the pain
is constant because it can’t be alleviated until the aneurysm is
repaired. Blood pressure decreases due to the loss of blood. After
the aneurysm ruptures, the vasculature is interrupted and blood
volume is lost, so blood pressure wouldn’t increase. For the
same reason, the RBC count is decreased – not increased. The WBC
count increases as cell migrate to the site of injury.
64. Answer: (D) Apply gloves and assess the groin site. Observing
standard precautions is the first priority when dealing with any blood
fluid. Assessment of the groin site is the second priority. This
 establishes where the blood is coming from and determineshow
much blood has been lost. The goal in this situation is to stop
the bleeding. The nurse would call for help if it were warranted after
the assessment of the situation. After determining the extent of the
bleeding, vital signs assessment is important. The nurse should
never move the client, in case a clot has formed. Moving can disturb
the clot and cause rebleeding.
65. Answer: (D) Percutaneous transluminal coronary angioplasty
(PTCA). PTCA can alleviate the blockage and restore blood flow
and oxygenation. An echocardiogram is a noninvasive diagnosis
test. Nitroglycerin is an oral sublingual medication. Cardiac
catheterization is a diagnostic tool – not a treatment.
66. Answer: (B) Cardiogenic shock. Cardiogenic shock is shock related
to ineffective pumping of the heart. Anaphylactic shock results from
an allergic reaction. Distributive shock results from changes in the
intravascular volume distribution and is usually associated with
increased cardiac output. MI isn’t a shock state, though a severe MI
can lead to shock.
67. Answer: (C) Kidneys’ excretion of sodium and water. The kidneys
respond to rise in blood pressure by excreting sodium and excess
water. This response ultimately affects sysmolic blood pressure by
regulating blood volume. Sodium or water retention would only
further increase blood pressure. Sodium and water travel
together across the membrane in the kidneys; one can’t travel
without the other.
68. Answer: (D) It inhibits reabsorption of sodium and water in the loop
of Henle. Furosemide is a loop diuretic that inhibits sodium and
water reabsorption in the loop Henle, thereby causing a decrease in
blood pressure. Vasodilators cause dilation of peripheral blood
vessels, directly relaxing vascular smooth muscle and decreasing
blood pressure. Adrenergic blockers decrease sympathetic
cardioacceleration and decrease blood pressure. Angiotensin-
converting enzyme inhibitors decrease blood pressure due to their
action on angiotensin.
69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA)
titer. Laboratory findings for clients with SLE usually
 show pancytopenia, elevated ANA titer, and decreased serum
complement levels. Clients may have elevated BUN and creatinine
levels from nephritis, but the increase does not indicate SLE.
70. Answer: (C) Narcotics are avoided after a head injury because they
may hide a worsening condition. Narcotics may mask changes in the
level of consciousness that indicate increased ICP and shouldn’t
acetaminophen is strong enough ignores the mother’s question and
therefore isn’t appropriate. Aspirin is contraindicated in conditions
that may have bleeding, such as trauma, and for children or young
adults with viral illnesses due to the danger of Reye’s syndrome.
Stronger medications may not necessarily lead to vomiting but will
sedate the client, thereby masking changes in his level
of consciousness.
71. Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). A normal Paco2 value is 35 to 45
mm Hg CO2 has vasodilating properties; therefore, lowering Paco2
through hyperventilation will lower ICP caused by dilated cerebral
vessels. Oxygenation is evaluated through Pao2 and oxygen
saturation. Alveolar hypoventilation would be reflected in an
increased Paco2.
72. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-
Barre syndrome . Guillain-Barre syndrome is characterized by
ascending paralysis and potential respiratory failure. The order of
client assessment should follow client priorities, with disorder of
airways, breathing, and then circulation. There’s no information to
suggest the postmyocardial infarction client has an arrhythmia or
other complication. There’s no evidence to suggest hemorrhage or
perforation for the remaining clients as a priority of care.
73. Answer: (C) Decreases inflammation. Then action of colchicines is to
decrease inflammation by reducing the migration of leukocytes to
synovial fluid. Colchicine doesn’t replace estrogen, decrease
infection, or decrease bone demineralization.
74. Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis and can
be extremely debilitating. It can afflict people of any age, although
most are elderly.
75. Answer: (C) Myxedema coma. Myxedema coma, severe
hypothyroidism, is a life-threatening condition that may develop if
thyroid replacement medication isn’t taken. Exophthalmos,
protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid
storm is life-threatening but is caused by severe
hyperthyroidism. Tibial myxedema, peripheral mucinous edema
involving the lower leg, is associated with hypothyroidism but isn’t
life-threatening.
76. Answer: (B) An irregular apical pulse. Because Cushing’s syndrome
causes aldosterone overproduction, which increases urinary
potassium loss, the disorder may lead to hypokalemia. Therefore,
the nurse should immediately report signs and symptoms of
hypokalemia, such as an irregular apical pulse, to the physician.
Edema is an expected finding because aldosterone overproduction
causes sodium and fluid retention. Dry mucous membranes and
frequent urination signal dehydration, which isn’t associated with
Cushing’s syndrome.
77. Answer: (D) Below-normal urine osmolality level, above-normal
serum osmolality level. In diabetes insipidus, excessive polyuria
causes dilute urine, resulting in a below-normal urine osmolality
level. At the same time, polyuria depletes the body of water, causing
dehydration that leads to an above-normal serum osmolality level.
For the same reasons, diabetes insipidus doesn’t cause above-
normal urine osmolality or below-normal serum osmolality levels.
78. Answer: (A) “I can avoid getting sick by not becoming dehydrated and
by paying attention to my need to urinate, drink, or eat more than
usual.” Inadequate fluid intake during hyperglycemic episodes
often leads to HHNS. By recognizing the signs of hyperglycemia
(polyuria, polydipsia, and polyphagia) and increasing fluid intake, the
client may prevent HHNS. Drinking a glass of nondiet soda would be
appropriate for hypoglycemia. A client whose diabetes is controlled
with oral antidiabetic agents usually doesn’t need to monitor blood
glucose levels. A highcarbohydrate diet would exacerbate the
client’s condition, particularly if fluid intake is low.
79. Answer: (D) Hyperparathyroidism. Hyperparathyroidism is most
common in older women and is characterized by bone pain and
 weakness from excess parathyroid hormone (PTH). Clients also
exhibit hypercaliuria-causing polyuria. While clients with diabetes
mellitus and diabetes insipidus also have polyuria, they don’t have
bone pain and increased sleeping. Hypoparathyroidism
is characterized by urinary frequency rather than polyuria.
80. Answer: (C) “I’ll take two-thirds of the dose when I wake up and one-
third in the late afternoon.” Hydrocortisone, a glucocorticoid, should be
administered according to a schedule that closely reflects the
body’s own secretion of this hormone; therefore, two-thirds of the
dose of hydrocortisone should be taken in the morning and one-third
in the late afternoon. This dosage schedule reduces adverse effects.
81. Answer: (C) High corticotropin and high cortisol levels. A
corticotropin-secreting pituitary tumor would cause
high corticotropin and high cortisol levels. A high corticotropin level
with a low cortisol level and a low corticotropin level with a low
cortisol level would be associated with hypocortisolism. Low
corticotropin and high cortisol levels would be seen if there was a
primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every 4 hours. The
nurse should perform capillary glucose testing every 4 hours
because excess cortisol may cause insulin resistance, placing
the client at risk for hyperglycemia. Urine ketone testing isn’t
indicated because the client does secrete insulin and, therefore, isn’t
at risk for ketosis. Urine specific gravity isn’t indicated because
although fluid balance can be compromised, it usually isn’t
dangerously imbalanced. Temperature regulation may be affected
by excess cortisol and isn’t an accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4
p.m.. Regular insulin, which is a short-acting insulin, has an onset
of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse
gave the insulin at 2 p.m., the expected onset would be from 2:15
p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH)
level after 30 minutes during the TSH stimulation test. In the TSH test,
failure of the TSH level to rise after 30 minutes confirms
hyperthyroidism. A decreased TSH level indicates a pituitary
 deficiency of this hormone. Below-normal levels of T3 and T4,
as detected by radioimmunoassay, signal hypothyroidism. A below-
normal T4 level also occurs in malnutrition and liver disease and
may result from administration of phenytoin and certain other drugs.
85. Answer: (B) “Rotate injection sites within the same anatomic region,
not among different regions.”  The nurse should instruct the client to
rotate injection sites within the same anatomic region. Rotating
sites among different regions may cause excessive day-to-day
variations in the blood glucose level; also, insulin absorption differs
from one region to the next. Insulin should be injected only into
healthy tissue lacking large blood vessels, nerves, or scar tissue or
other deviations. Injecting insulin into areas of hypertrophy may
delay absorption. The client shouldn’t inject insulin into areas
of lipodystrophy (such as hypertrophy or atrophy); to prevent
lipodystrophy, the client should rotate injection sites systematically.
Exercise speeds drug absorption, so the client shouldn’t inject
insulin into sites above muscles that will be exercised heavily.
86. Answer: (D) Below-normal serum potassium level. A client with HHNS
has an overall body deficit of potassium resulting from diuresis,
which occurs secondary to the hyperosmolar, hyperglycemic state
caused by the relative insulin deficiency. An elevated serum acetone
level and serum ketone bodies are characteristic of diabetic
ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in
HHNS.
87. Answer: (D) Maintaining room temperature in the low-normal
range. Graves’ disease causes signs and symptoms
of hypermetabolism, such as heat intolerance, diaphoresis,
excessive thirst and appetite, and weight loss. To reduce heat
intolerance and diaphoresis, the nurse should keep the client’s room
temperature in the low-normal range. To replace fluids lost via
diaphoresis, the nurse should encourage, not restrict, intake of oral
fluids. Placing extra blankets on the bed of a client with heat
intolerance would cause discomfort. To provide needed energy and
calories, the nurse should encourage the client to eat high-
carbohydrate foods.
88. Answer: (A) Fracture of the distal radius. Colles’ fracture is a fracture
of the distal radius, such as from a fall on an outstretched hand. It’s
most common in women. Colles’ fracture doesn’t refer to a fracture
of the olecranon, humerus, or carpal scaphoid.
89. Answer: (B) Calcium and phosphorous. In osteoporosis, bones lose
calcium and phosphate salts, becoming porous, brittle, and
abnormally vulnerable to fracture. Sodium and potassium aren’t
involved in the development of osteoporosis.
90. Answer: (A) Adult respiratory distress syndrome (ARDS). Severe
hypoxia after smoke inhalation is typically related to ARDS. The
other conditions listed aren’t typically associated with
smoke inhalation and severe hypoxia.
91. Answer: (D) Fat embolism. Long bone fractures are correlated with
fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely
the client has developed asthma or bronchitis without a previous
history. He could develop atelectasis but it typically doesn’t produce
progressive hypoxia.
92. Answer: (D) Spontaneous pneumothorax. A spontaneous
pneumothorax occurs when the client’s lung collapses, causing an
acute decreased in the amount of functional lung used in
oxygenation. The sudden collapse was the cause of his chest
pain and shortness of breath. An asthma attack would show
wheezing breath sounds, and bronchitis would have rhonchi.
Pneumonia would have bronchial breath sounds over the area of
consolidation.
93. Answer: (C) Pneumothorax. From the trauma the client experienced,
it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with
bronchitis, bronchial breath sounds with TB would be heard.
94. Answer: (C) Serous fluids fills the space and consolidates the
region. Serous fluid fills the space and eventually
consolidates, preventing extensive mediastinal shift of the heart and
remaining lung. Air can’t be left in the space. There’s no gel that can
be placed in the pleural space. The tissue from the other lung can’t
cross the mediastinum, although a temporary mediastinal shift exits
until the space is filled.
95. Answer: (A) Alveolar damage in the infracted area. The infracted area
produces alveolar damage that can lead to the production of bloody
sputum, sometimes in massive amounts. Clot formation usually
occurs in the legs. There’s a loss of lung parenchyma and
subsequent scar tissue formation.
96. Answer: (D) Respiratory alkalosis. A client with massive pulmonary
embolism will have a large region and blow off large amount of
carbon dioxide, which crosses the unaffected alveolar-capillary
membrane more readily than does oxygen and results in respiratory
alkalosis.
97. Answer: (A) Air leak. Bubbling in the water seal chamber of a chest
drainage system stems from an air leak. In pneumothorax an air
leak can occur as air is pulled from the pleural space. Bubbling
doesn’t normally occur with either adequate or inadequate suction
or any preexisting bubbling in the water seal chamber.
98. Answer: (B) 21. 3000 x 10 divided by 24 x 60.
99. Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4
ml.
100. Answer: (D) “I should put on the stockings before getting out of bed
in the morning. Promote venous return by applying external pressure
on veins.
1. Mr. Marquez reports of losing his job, not being able to sleep at night, and
feeling upset with his wife. Nurse John responds to the client, “You may want
to talk about your employment situation in group today.” The Nurse is using
which therapeutic technique?

A. Observations
B. Restating
C. Exploring
D. Focusing
2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes
extremely agitated in the dayroom while other clients are watching television.
He begins cursing and throwing furniture. Nurse Oliver first action is to:

A. Check the client’s medical record for an order for an as-needed I.M.
dose of medication for agitation.
B. Place the client in full leather restraints.
C. Call the attending physician and report the behavior.
D. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug treatment
center. The nurse would not let this client join the group session because:

A. The client is disruptive.

B. The client is harmful to self.
C. The client is harmful to others.
D. The client needs to be on medication first.
4. Dervid, an adolescent boy was admitted for substance abuse and
hallucinations. The client’s mother asks Nurse Armando to talk with his
husband when he arrives at the hospital. The mother says that she is afraid of
what the father might say to the boy. The most appropriate nursing
intervention would be to:

A. Inform the mother that she and the father can work through this
problem themselves.
B. Refer the mother to the hospital social worker.
C. Agree to talk with the mother and the father together.
D. Suggest that the father and son work things out.
5. What is Nurse John likely to note in a male client being admitted for alcohol
withdrawal?

A. Perceptual disorders.
B. Impending coma.
C. Recent alcohol intake.
D. Depression with mutism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that
it “doesn’t help” and refuses to take it. What should the nurse say or do?

A. Withhold the drug.

B. Record the client’s response.
C. Encourage the client to tell the doctor.
D. Suggest that it takes awhile before seeing the results.
7. Dervid, an adolescent has a history of truancy from school, running away
from home and “barrowing” other people’s things without their permission.
The adolescent denies stealing, rationalizing instead that as long as no one
was using the items, it was all right to borrow them. It is important for the
nurse to understand the psychodynamically, this behavior may be largely
attributed to a developmental defect related to the:

A. Id
B. Ego
C. Superego
D. Oedipal complex
8. In preparing a female client for electroconvulsive therapy (ECT), Nurse
Michelle knows that succinylcoline (Anectine) will be administered for which
therapeutic effect?

A. Short-acting anesthesia
B. Decreased oral and respiratory secretions.
C. Skeletal muscle paralysis.
D. Analgesia.
9. Nurse Gina is aware that the dietary implications for a client in manic phase
of bipolar disorder is:
 A. Serve the client a bowl of soup, buttered French bread, and
apple slices.
B. Increase calories, decrease fat, and decrease protein.
C. Give the client pieces of cut-up steak, carrots, and an apple.
D. Increase calories, carbohydrates, and protein.
10.What parental behavior toward a child during an admission procedure
should cause Nurse Ron to suspect child abuse?

A. Flat affect
B. Expressing guilt
C. Acting overly solicitous toward the child.
D. Ignoring the child.
11.Nurse Lynnette notices that a female client with obsessive-compulsive
disorder washes her hands for long periods each day. How should the nurse
respond to this compulsive behavior?

A. By designating times during which the client can focus on

the behavior.
B. By urging the client to reduce the frequency of the behavior
as rapidly as possible.
C. By calling attention to or attempting to prevent the behavior.
D. By discouraging the client from verbalizing anxieties.
12.After seeking help at an outpatient mental health clinic, Ruby who
was raped while walking her dog is diagnosed with posttraumatic
stress disorder (PTSD). Three months later, Ruby returns to the
clinic, complaining of fear, loss of control, and helpless feelings. Which
nursing intervention is most appropriate for Ruby?

A. Recommending a high-protein, low-fat diet.

B. Giving sleep medication, as prescribed, to restore a normal
sleepwake cycle.
C. Allowing the client time to heal.
D. Exploring the meaning of the traumatic event with the client.
13.Meryl, age 19, is highly dependent on her parents and fears leaving
home to go away to college. Shortly before the semester starts, she
complains that her legs are paralyzed and is rushed to the emergency
department. When physical examination rules out a physical cause for her
paralysis, the physician admits her to the psychiatric unit where she is
diagnosed with conversion disorder. Meryl asks the nurse, “Why has this
happened to me?” What is the nurse’s best response?

A. “You’ve developed this paralysis so you can stay with your

parents. You must deal with this conflict if you want to walk again.”
B. “It must be awful not to be able to move your legs. You may
feel better if you realize the problem is psychological, not physical.”
C. “Your problem is real but there is no physical basis for it. We’ll
work on what is going on in your life to find out why it’s happened.”
D. “It isn’t uncommon for someone with your personality to develop
a conversion disorder during times of stress.”
14.Nurse Krina knows that the following drugs have been known to
be effective in treating obsessive-compulsive disorder (OCD):

A. benztropine (Cogentin) and diphenhydramine (Benadryl).

B. chlordiazepoxide (Librium) and diazepam (Valium)
C. fluvoxamine (Luvox) and clomipramine (Anafranil)
D. divalproex (Depakote) and lithium (Lithobid)
15.Alfred was newly diagnosed with anxiety disorder. The
physician prescribed buspirone (BuSpar). The nurse is aware that the
teaching instructions for newly prescribed buspirone should include which of
the following?

A. A warning about the drugs delayed therapeutic effect, which is

from 14 to 30 days.
B. A warning about the incidence of neuroleptic malignant
syndrome (NMS).
C. A reminder of the need to schedule blood work in 1 week to
check blood levels of the drug.
D. A warning that immediate sedation can occur with a resultant
drop in pulse.
16.Richard with agoraphobia has been symptom-free for 4 months.
Classic signs and symptoms of phobias include:

A. Insomnia and an inability to concentrate.

 B. Severe anxiety and fear.
C. Depression and weight loss.
D. Withdrawal and failure to distinguish reality from fantasy.
17.Which medications have been found to help reduce or eliminate
panic attacks?

A. Antidepressants
B. Anticholinergics
C. Antipsychotics
D. Mood stabilizers
18.A client seeks care because she feels depressed and has gained
weight. To treat her atypical depression, the physician prescribes
tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this
drug is used to treat atypical depression, what is its onset of action?

A. 1 to 2 days
B. 3 to 5 days
C. 6 to 8 days
D. 10 to 14 days
19. A 65 years old client is in the first stage of Alzheimer’s disease.
Nurse Patricia should plan to focus this client’s care on:

A. Offering nourishing finger foods to help maintain the

client’s nutritional status.
B. Providing emotional support and individual counseling.
C. Monitoring the client to prevent minor illnesses from turning
into major problems.
D. Suggesting new activities for the client and family to do together.
20.The nurse is assessing a client who has just been admitted to
the emergency department. Which signs would suggest an overdose of
an antianxiety agent?

A. Combativeness, sweating, and confusion

B. Agitation, hyperactivity, and grandiose ideation
C. Emotional lability, euphoria, and impaired memory
D. Suspiciousness, dilated pupils, and increased blood pressure
21.The nurse is caring for a client diagnosed with antisocial
personality disorder. The client has a history of fighting, cruelty to animals,
and stealing. Which of the following traits would the nurse be most likely
to uncover during assessment?

A. History of gainful employment

B. Frequent expression of guilt regarding antisocial behavior
C. Demonstrated ability to maintain close, stable relationships
D. d. A low tolerance for frustration
22.Nurse Amy is providing care for a male client undergoing
opiate withdrawal. Opiate withdrawal causes severe physical discomfort and
can be life-threatening. To minimize these effects, opiate users are
commonly detoxified with:

A. Barbiturates
B. Amphetamines
C. Methadone
D. Benzodiazepines
23.Nurse Cristina is caring for a client who experiences false
sensory perceptions with no basis in reality. These perceptions are known as:

A. Delusions
B. Hallucinations
C. Loose associations
D. Neologisms
24. Nurse Marco is developing a plan of care for a client with
anorexia nervosa. Which action should the nurse include in the plan?

A. Restricts visits with the family and friends until the client begins
to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her anxiety.
25.Tim is admitted with a diagnosis of delusions of grandeur. The nurse
is aware that this diagnosis reflects a belief that one is:

A. Highly important or famous.

 B. Being persecuted
C. Connected to events unrelated to oneself
D. Responsible for the evil in the world.
26.Nurse Jen is caring for a male client with manic depression. The plan
of care for a client in a manic state would include:

A. Offering a high-calorie meals and strongly encouraging the client

to finish all food.
B. Insisting that the client remain active through the day so that
he’ll sleep at night.
C. Allowing the client to exhibit hyperactive, demanding,
manipulative behavior without setting limits.
D. Listening attentively with a neutral attitude and avoiding
power struggles.
27.Ramon is admitted for detoxification after a cocaine overdose. The
client tells the nurse that he frequently uses cocaine but that he can control
his use if he chooses. Which coping mechanism is he using?

A. Withdrawal
B. Logical thinking
C. Repression
D. Denial
28.Richard is admitted with a diagnosis of schizotypal personality
disorder. Which signs would this client exhibit during social situations?

A. Aggressive behavior
B. Paranoid thoughts
C. Emotional affect
D. Independence needs
29. Nurse Mickey is caring for a client diagnosed with bulimia. The
most appropriate initial goal for a client diagnosed with bulimia is to:

A. Avoid shopping for large amounts of food.

B. Control eating impulses.
C. Identify anxiety-causing situations
D. Eat only three meals per day.
30.Rudolf is admitted for an overdose of amphetamines. When assessing
the client, the nurse should expect to see:

A. Tension and irritability

B. Slow pulse
C. Hypotension
D. Constipation
31.Nicolas is experiencing hallucinations tells the nurse, “The voices
are telling me I’m no good.” The client asks if the nurse hears the voices.
The most appropriate response by the nurse would be:

A. “It is the voice of your conscience, which only you can control.”
B. “No, I do not hear your voices, but I believe you can hear them”.
C. “The voices are coming from within you and only you can
hear them.”
D. “Oh, the voices are a symptom of your illness; don’t pay
any attention to them.”
32.The nurse is aware that the side effect of electroconvulsive therapy that
a client may experience:

A. Loss of appetite
B. Postural hypotension
C. Confusion for a time after treatment
D. Complete loss of memory for a time
33.A dying male client gradually moves toward resolution of
feelings regarding impending death. Basing care on the theory of Kubler-
Ross, Nurse Trish plans to use nonverbal interventions when
assessment reveals that the client is in the:

A. Anger stage
B. Denial stage
C. Bargaining stage
D. Acceptance stage
34.The outcome that is unrelated to a crisis state is:

A. Learning more constructive coping skills

B. Decompensation to a lower level of functioning.
 C. Adaptation and a return to a prior level of functioning.
D. A higher level of anxiety continuing for more than 3 months.
35.Miranda a psychiatric client is to be discharged with orders for
haloperidol (haldol) therapy. When developing a teaching plan for discharge,
the nurse should include cautioning the client against:

A. Driving at night
B. Staying in the sun
C. Ingesting wines and cheeses
D. Taking medications containing aspirin
36.Jen a nursing student is anxious about the upcoming board
examination but is able to study intently and does not become distracted by
a roommate’s talking and loud music. The student’s ability to
ignore distractions and to focus on studying demonstrates:

A. Mild-level anxiety
B. Panic-level anxiety
C. Severe-level anxiety
D. Moderate-level anxiety
37.When assessing a premorbid personality characteristics of a client with
a major depression, it would be unusual for the nurse to find that this
client demonstrated:

A. Rigidity
B. Stubbornness
C. Diverse interest
D. Over meticulousness
38.Nurse Krina recognizes that the suicidal risk for depressed client
is greatest:

A. As their depression begins to improve

B. When their depression is most severe
C. Before nay type of treatment is started
D. As they lose interest in the environment
39.Nurse Kate would expect that a client with vascular dementis
would experience:
 A. Loss of remote memory related to anoxia
B. Loss of abstract thinking related to emotional state
C. Inability to concentrate related to decreased stimuli
D. Disturbance in recalling recent events related to cerebral hypoxia.
40.Josefina is to be discharged on a regimen of lithium carbonate. In
the teaching plan for discharge the nurse should include:

A. Advising the client to watch the diet carefully

B. Suggesting that the client take the pills with milk
C. Reminding the client that a CBC must be done once a month.
D. Encouraging the client to have blood levels checked as ordered.
41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a
female client. Nurse Katrina would be aware that the teaching about the
side effects of this drug were understood when the client state, “I will call
my doctor immediately if I notice any:

A. Sensitivity to bright light or sun

B. Fine hand tremors or slurred speech
C. Sexual dysfunction or breast enlargement
D. d. Inability to urinate or difficulty when urinating
42.Nurse Mylene recognizes that the most important factor necessary for
the establishment of trust in a critical care area is:

A. Privacy
B. Respect
C. Empathy
D. Presence
43.When establishing an initial nurse-client relationship, Nurse Hazel
should explore with the client the:

A. Client’s perception of the presenting problem.

B. Occurrence of fantasies the client may experience.
C. Details of any ritualistic acts carried out by the client
D. Client’s feelings when external; controls are instituted.
44.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client
who has not responded to the tricyclic antidepressants. After teaching the
client about the medication, Nurse Marian evaluates that learning has
occurred when the client states, “I will avoid:

A. Citrus fruit, tuna, and yellow vegetables.”

B. Chocolate milk, aged cheese, and yogurt’”
C. Green leafy vegetables, chicken, and milk.”
D. Whole grains, red meats, and carbonated soda.”
45.Nurse John is a aware that most crisis situations should resolve in about:

A. 1 to 2 weeks
B. 4 to 6 weeks
C. 4 to 6 months
D. 6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent
suicide behavior:

A. Females use more dramatic methods than males

B. Males account for more attempts than do females
C. Females talk more about suicide before attempting it
D. Males are more likely to use lethal methods than are females
47. Dervid with paranoid schizophrenia repeatedly uses profanity during
an activity therapy session. Which response by the nurse would be
most appropriate?

A. “Your behavior won’t be tolerated. Go to your room immediately.”

B. “You’re just doing this to get back at me for making you come
to therapy.”
C. “Your cursing is interrupting the activity. Take time out in your
room for 10 minutes.”
D. “I’m disappointed in you. You can’t control yourself even for a
few minutes.”
48.Nurse Maureen knows that the nonantipsychotic medication used to
treat some clients with schizoaffective disorder is:

A. phenelzine (Nardil)
B. chlordiazepoxide (Librium)
C. lithium carbonate (Lithane)
 D. imipramine (Tofranil)
49.Which information is most important for the nurse Trinity to include in
a teaching plan for a male schizophrenic client taking clozapine (Clozaril)?

A. Monthly blood tests will be necessary.

B. Report a sore throat or fever to the physician immediately.
C. Blood pressure must be monitored for hypertension.
D. Stop the medication when symptoms subside.
50.Ricky with chronic schizophrenia takes neuroleptic medication is
admitted to the psychiatric unit. Nursing assessment reveals rigidity,
fever, hypertension, and diaphoresis. These findings suggest which
lifethreatening reaction:

A. Tardive dyskinesia.
B. Dystonia.
C. Neuroleptic malignant syndrome.
D. Akathisia.
51.Which nursing intervention would be most appropriate if a male
client develop orthostatic hypotension while taking amitriptyline (Elavil)?

A. Consulting with the physician about substituting a different type

of antidepressant.
B. Advising the client to sit up for 1 minute before getting out of bed.
C. Instructing the client to double the dosage until the
problem resolves.
D. Informing the client that this adverse reaction should
disappear within 1 week.
52.Mr. Cruz visits the physician’s office to seek treatment for
depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low
selfesteem, poor concentration, and difficulty making decisions. The
client states that these symptoms began at least 2 years ago. Based on
this report, the nurse Tyfany suspects:

A. Cyclothymic disorder.
B. Atypical affective disorder.
C. Major depression.
D. Dysthymic disorder.
53. After taking an overdose of phenobarbital (Barbita), Mario is admitted
to the emergency department. Dr. Trinidad prescribes activated
charcoal (Charcocaps) to be administered by mouth immediately.
Before administering the dose, the nurse verifies the dosage ordered. What is
the usual minimum dose of activated charcoal?

A. 5 g mixed in 250 ml of water

B. 15 g mixed in 500 ml of water
C. 30 g mixed in 250 ml of water
D. 60 g mixed in 500 ml of water
54.What herbal medication for depression, widely used in Europe, is
now being prescribed in the United States?

A. Ginkgo biloba
B. Echinacea
C. St. John’s wort
D. Ephedra
55.Cely with manic episodes is taking lithium. Which electrolyte level
should the nurse check before administering this medication?

A. Calcium
B. Sodium
C. Chloride
D. Potassium
56.Nurse Josefina is caring for a client who has been diagnosed with delirium.
Which statement about delirium is true?

A. It’s characterized by an acute onset and lasts about 1 month.

B. It’s characterized by a slowly evolving onset and lasts about 1 week.
C. It’s characterized by a slowly evolving onset and lasts about
1 month.
D. It’s characterized by an acute onset and lasts hours to a number
of days.
57.Edward, a 66 year old client with slight memory impairment and
poor concentration is diagnosed with primary degenerative dementia of
the Alzheimer’s type. Early signs of this dementia include subtle
personality changes and withdrawal from social interactions. To assess
for progression to the middle stage of Alzheimer’s disease, the nurse
should observe the client for:

A. Occasional irritable outbursts.

B. Impaired communication.
C. Lack of spontaneity.
D. Inability to perform self-care activities.
58.Isabel with a diagnosis of depression is started on imipramine
(Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that:

A. This medication may be habit forming and will be discontinued

as soon as the client feels better.
B. This medication has no serious adverse effects.
C. The client should avoid eating such foods as aged cheeses,
yogurt, and chicken livers while taking the medication.
D. This medication may initially cause tiredness, which should
become less bothersome over time.
59.Kathleen is admitted to the psychiatric clinic for treatment of
anorexia nervosa. To promote the client’s physical health, the nurse should
plan to:

A. Severely restrict the client’s physical activities.

B. Weigh the client daily, after the evening meal.
C. Monitor vital signs, serum electrolyte levels, and acid-base balance.
D. Instruct the client to keep an accurate record of food and
fluid intake.
60.Celia with a history of polysubstance abuse is admitted to the facility.
She complains of nausea and vomiting 24 hours after admission. The
nurse assesses the client and notes piloerection, pupillary dilation,
and lacrimation. The nurse suspects that the client is going through which
of the following withdrawals?

A. Alcohol withdrawal
B. Cannibis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
61.Mr. Garcia, an attorney who throws books and furniture around the
office after losing a case is referred to the psychiatric nurse in the law
firm’s employee assistance program. Nurse Beatriz knows that the
client’s behavior most likely represents the use of which defense mechanism?

A. Regression
B. Projection
C. Reaction-formation
D. Intellectualization
62.Nurse Anne is caring for a client who has been treated long term
with antipsychotic medication. During the assessment, Nurse Anne checks
the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse
Anne would most likely observe:

A. Abnormal movements and involuntary movements of the

mouth, tongue, and face.
B. Abnormal breathing through the nostrils accompanied by a “thrill.”
C. Severe headache, flushing, tremors, and ataxia.
D. Severe hypertension, migraine headache,
63.Dennis has a lithium level of 2.4 mEq/L. The nurse immediately
would assess the client for which of the following signs or symptoms?

A. Weakness
B. Diarrhea
C. Blurred vision
D. Fecal incontinence
64.Nurse Jannah is monitoring a male client who has been placed
inrestraints because of violent behavior. Nurse determines that it will be safe
to remove the restraints when:

A. The client verbalizes the reasons for the violent behavior.

B. The client apologizes and tells the nurse that it will never
happen again.
C. No acts of aggression have been observed within 1 hour after
the release of two of the extremity restraints.
D. The administered medication has taken effect.
65.Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD.
The side effects of the following may be noted by the nurse:

A. Increased attention span and concentration

B. Increase in appetite
C. Sleepiness and lethargy
D. Bradycardia and diarrhea
66.Kitty, a 9 year old child has very limited vocabulary and interaction
skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of
this classification:

A. Profound
B. Mild
C. Moderate
D. Severe
67.The therapeutic approach in the care of Armand an autistic child
include the following EXCEPT:

A. Engage in diversionary activities when acting -out

B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child
68.Jeremy is brought to the emergency room by friends who state that
he took something an hour ago. He is actively hallucinating, agitated,
with irritated nasal septum.

A. Heroin
B. Cocaine
C. LSD
D. Marijuana
69.Nurse Pauline is aware that Dementia unlike delirium is characterized by:

A. Slurred speech
B. Insidious onset
C. Clouding of consciousness
D. Sensory perceptual change
70.A 35 year old female has intense fear of riding an elevator. She claims “ As
if I will die inside.” The client is suffering from:

A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Xenophobia
71.Nurse Myrna develops a counter-transference reaction. This is
evidenced by:

A. Revealing personal information to the client

B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-
verbal behavior
D. The client feels angry towards the nurse who resembles his mother.
72.Tristan is on Lithium has suffered from diarrhea and vomiting. What should
the nurse in-charge do first:

A. Recognize this as a drug interaction

B. Give the client Cogentin
C. Reassure the client that these are common side effects of
lithium therapy
D. Hold the next dose and obtain an order for a stat serum lithium level
73.Nurse Sarah ensures a therapeutic environment for all the client. Which
of the following best describes a therapeutic milieu?

A. A therapy that rewards adaptive behavior

B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment
74.Anthony is very hostile toward one of the staff for no apparent reason.
He is manifesting:

A. Splitting
B. Transference
C. Countertransference
D. Resistance
75.Marielle, 17 years old was sexually attacked while on her way home
from school. She is brought to the hospital by her mother. Rape is an
example of which type of crisis:

A. Situational
B. Adventitious
C. Developmental
D. Internal
76. Nurse Greta is aware that the following is classified as an Axis I
disorder by the Diagnosis and Statistical Manual of Mental Disorders,
Text Revision (DSM-IV-TR) is:

A. Obesity
B. Borderline personality disorder
C. Major depression
D. Hypertension
77.Katrina, a newly admitted is extremely hostile toward a staff member
she has just met, without apparent reason. According to Freudian theory,
the nurse should suspect that the client is experiencing which of the
following phenomena?

A. Intellectualization
B. Transference
C. Triangulation
D. Splitting
78.An 83year-old male client is in extended care facility is anxious most of
the time and frequently complains of a number of vague symptoms
that interfere with his ability to eat. These symptoms indicate which of
the following disorders?

A. Conversion disorder
B. Hypochondriasis
C. Severe anxiety
D. Sublimation
79. Charina, a college student who frequently visited the health center during
the past year with multiple vague complaints of GI symptoms before
course examinations. Although physical causes have been eliminated, the
student continues to express her belief that she has a serious illness. These
symptoms are typically of which of the following disorders?

A. Conversion disorder
B. Depersonalization
C. Hypochondriasis
D. Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents
are sedative hypnotic medication is used to induce sleep for a client
experiencing a sleep disorder is:

A. Triazolam (Halcion)
B. Paroxetine (Paxil)\
C. Fluoxetine (Prozac)
D. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which
of the following statement refers to a secondary gain?

A. It brings some stability to the family

B. It decreases the preoccupation with the physical illness
C. It enables the client to avoid some unpleasant activity
D. It promotes emotional support or attention for the client
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with
the nurse in-charge about the progress made in treatment. Which of the
following statements indicates a positive client response?

A. “I went to the mall with my friends last Saturday”

B. “I’m hyperventilating only when I have a panic attack”
C. “Today I decided that I can stop taking my medication”
D. “Last night I decided to eat more than a bowl of cereal”
83. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in
client with posttraumatic stress disorder can be demonstrated by which of
the following client self –reports?

A. “I’m sleeping better and don’t have nightmares”

B. “I’m not losing my temper as much”
C. “I’ve lost my craving for alcohol”
 D. “I’ve lost my phobia for water”
84. Mark, with a diagnosis of generalized anxiety disorder wants to stop
taking his lorazepam (Ativan). Which of the following important facts should
nurse Betty discuss with the client about discontinuing the medication?

A. Stopping the drug may cause depression

B. Stopping the drug increases cognitive abilities
C. Stopping the drug decreases sleeping difficulties
D. Stopping the drug can cause withdrawal symptoms
85. Jennifer, an adolescent who is depressed and reported by his parents
as having difficulty in school is brought to the community mental health
center to be evaluated. Which of the following other health problems would
the nurse suspect?

A. Anxiety disorder
B. Behavioral difficulties
C. Cognitive impairment
D. Labile moods
86. Ricardo, an outpatient in psychiatric facility is diagnosed with
dysthymic disorder. Which of the following statement about dysthymic
disorder is true?

A. It involves a mood range from moderate depression to hypomania

B. It involves a single manic depression
C. It’s a form of depression that occurs in the fall and winter
D. It’s a mood disorder similar to major depression but of mild
to moderate severity
87. The nurse is aware that the following ways in vascular dementia
different from Alzheimer’s disease is:

A. Vascular dementia has more abrupt onset

B. The duration of vascular dementia is usually brief
C. Personality change is common in vascular dementia
D. The inability to perform motor activities occurs in vascular dementia
88. Loretta, a newly admitted client was diagnosed with delirium and has
history of hypertension and anxiety. She had been taking digoxin, furosemide
(Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be
related to which of the following conditions?

A. Infection
B. Metabolic acidosis
C. Drug intoxication
D. Hepatic encephalopathy
89. Nurse Ron enters a client’s room, the client says, “They’re crawling on
my sheets! Get them off my bed!” Which of the following assessment is the
most accurate?

A. The client is experiencing aphasia

B. The client is experiencing dysarthria
C. The client is experiencing a flight of ideas
D. The client is experiencing visual hallucination
90. Which of the following descriptions of a client’s experience and behavior
can be assessed as an illusion?

A. The client tries to hit the nurse when vital signs must be taken
B. The client says, “I keep hearing a voice telling me to run away”
C. The client becomes anxious whenever the nurse leaves the bedside
D. The client looks at the shadow on a wall and tells the nurse she sees
frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the
client shift from one topic to the next on a regular basis. Which of the
following terms describes this disorder?

A. Flight of ideas
B. Concrete thinking
C. Ideas of reference
D. Loose association
92. Francis tells the nurse that her coworkers are sabotaging the
computer. When the nurse asks questions, the client becomes argumentative.
This behavior shows personality traits associated with which of the
following personality disorder?

A. Antisocial
 B. Histrionic
C. Paranoid
D. Schizotypal
93. Which of the following interventions is important for a Cely experiencing
with paranoid personality disorder taking olanzapine (Zyprexa)?

A. Explain effects of serotonin syndrome

B. Teach the client to watch for extrapyramidal adverse reaction
C. Explain that the drug is less affective if the client smokes
D. Discuss the need to report paradoxical effects such as euphoria
94. Nurse Alexandra notices other clients on the unit avoiding a client
diagnosed with antisocial personality disorder. When discussing appropriate
behavior in group therapy, which of the following comments is expected about
this client by his peers?

A. Lack of honesty
B. Belief in superstition
C. Show of temper tantrums
D. Constant need for attention
95. Tommy, with dependent personality disorder is working to increase his
selfesteem. Which of the following statements by the Tommy shows teaching
was successful?

A. “I’m not going to look just at the negative things about myself”
B. “I’m most concerned about my level of competence and progress”
C. “I’m not as envious of the things other people have as I used to be”
D. “I find I can’t stop myself from taking over things other should
be doing”
96. Norma, a 42-year-old client with a diagnosis of chronic
undifferentiated schizophrenia lives in a rooming house that has a weekly
nursing clinic. She scratches while she tells the nurse she feels creatures
eating away at her skin. Which of the following interventions should be done
first?

A. Talk about his hallucinations and fears

B. Refer him for anticholinergic adverse reactions
C. Assess for possible physical problems such as rash
 D. Call his physician to get his medication increased to control
his psychosis
97. Ivy, who is on the psychiatric unit is copying and imitating the movements
of her primary nurse. During recovery, she says, “I thought the nurse was
my mirror. I felt connected only when I saw my nurse.” This behavior is known
by which of the following terms?

A. Modeling
B. Echopraxia
C. Ego-syntonicity
D. Ritualism
98. Jun approaches the nurse and tells that he hears a voice telling him that
he’s evil and deserves to die. Which of the following terms describes the
client’s perception?

A. Delusion
B. Disorganized speech
C. Hallucination
D. Idea of reference
99. Mike is admitted to a psychiatric unit with a diagnosis of
undifferentiated schizophrenia. Which of the following defense mechanisms
is probably used by mike?

A. Projection
B. Rationalization
C. Regression
D. Repression
100. Rocky has started taking haloperidol (Haldol). Which of the
following instructions is most appropriate for Ricky before taking haloperidol?

A. Should report feelings of restlessness or agitation at once

B. Use a sunscreen outdoors on a year-round basis
C. Be aware you’ll feel increased energy taking this drug
D. This drug will indirectly control essential hypertension
Answers and Rationales
1. Answer: (D) Focusing. The nurse is using focusing by suggesting that
the client discuss a specific issue. The nurse didn’t restate the
question, make observation, or ask further question (exploring).
2. Answer: (D) Remove all other clients from the dayroom. The nurse’s first
priority is to consider the safety of the clients in the therapeutic
setting. The other actions are appropriate responses after ensuring
the safety of other clients.
3. Answer: (A) The client is disruptive. Group activity provides too much
stimulation, which the client will not be able to handle (harmful to
self) and as a result will be disruptive to others.
4. Answer: (C) Agree to talk with the mother and the father together. By
agreeing to talk with both parents, the nurse can provide emotional
support and further assess and validate the family’s needs.
5. Answer: (A) Perceptual disorders. Frightening visual hallucinations are
especially common in clients experiencing alcohol withdrawal.
6. Answer: (D) Suggest that it takes awhile before seeing the results. The
client needs a specific response; that it takes 2 to 3 weeks (a
delayed effect) until the therapeutic blood level is reached.
7. Answer: (C) Superego.  This behavior shows a weak sense of moral
consciousness. According to Freudian theory, personality disorders
stem from a weak superego.
8. Answer: (C) Skeletal muscle paralysis. Anectine is a depolarizing
muscle relaxant causing paralysis. It is used to reduce the intensity
of muscle contractions during the convulsive stage, thereby
reducing the risk of bone fractures or dislocation.
9. Answer: (D) Increase calories, carbohydrates, and protein.This client
increased protein for tissue building and increased calories to
replace what is burned up (usually via carbohydrates).
10. Answer: (C) Acting overly solicitous toward the child. This behavior is
an example of reaction formation, a coping mechanism.
11. Answer: (A) By designating times during which the client can focus on
the behavior. The nurse should designate times during which the
client can focus on the compulsive behavior or obsessive thoughts.
The nurse should urge the client to reduce the frequency of the
compulsive behavior gradually, not rapidly. She shouldn’t call
attention to or try to prevent the behavior. Trying to prevent the
 behavior may cause pain and terror in the client. The nurse should
encourage the client to verbalize anxieties to help distract attention
from the compulsive behavior.
12. Answer: (D) Exploring the meaning of the traumatic event with the
client. The client with PTSD needs encouragement to examine
and understand the meaning of the traumatic event and consequent
losses. Otherwise, symptoms may worsen and the client may
become depressed or engage in self-destructive behavior such as
substance abuse. The client must explore the meaning of the event
and won’t heal without this, no matter how much time passes.
Behavioral techniques, such as relaxation therapy, may help
decrease the client’s anxiety and induce sleep. The physician may
prescribe antianxiety agents or antidepressants cautiously to avoid
dependence; sleep medication is rarely appropriate. A special diet
isn’t indicated unless the client also has an eating disorder or a
nutritional problem.
13. Answer: (C) “Your problem is real but there is no physical basis for
it. We’ll work on what is going on in your life to find out why it’s
happened.” The nurse must be honest with the client by telling her
that the paralysis has no physiologic cause while also conveying
empathy and acknowledging that her symptoms are real. The client
will benefit from psychiatric treatment, which will help her
understand the underlying cause of her symptoms. After the
psychological conflict is resolved, her symptoms will disappear.
Saying that it must be awful not to be able to move her legs wouldn’t
answer the client’s question; knowing that the cause is
psychological wouldn’t necessarily make her feel better. Telling her
that she has developed paralysis to avoid leaving her parents or
that her personality caused her disorder wouldn’t help her
understand and resolve the underlying conflict.
14. Answer: (C) fluvoxamine (Luvox) and clomipramine (Anafranil). The
antidepressants fluvoxamine and clomipramine have been effective
in the treatment of OCD. Librium and Valium may be helpful in
treating anxiety related to OCD but aren’t drugs of choice to treat
the illness. The other medications mentioned aren’t effective in the
treatment of OCD.
15. Answer: (A) A warning about the drugs delayed therapeutic effect,
which is from 14 to 30 days. The client should be informed that the
drug’s therapeutic effect might not be reached for 14 to 30 days.
The client must be instructed to continue taking the drug as
directed. Blood level checks aren’t necessary. NMS hasn’t been
reported with this drug, but tachycardia is frequently reported.
16. Answer: (B) Severe anxiety and fear. Phobias cause severe anxiety
(such as a panic attack) that is out of proportion to the threat of the
feared object or situation. Physical signs and symptoms of phobias
include profuse sweating, poor motor control, tachycardia, and
elevated blood pressure. Insomnia, an inability to concentrate, and
weight loss are common in depression. Withdrawal and failure to
distinguish reality from fantasy occur in schizophrenia.
17. Answer: (A) Antidepressants. Tricyclic and monoamine oxidase
(MAO) inhibitor antidepressants have been found to be effective in
treating clients with panic attacks. Why these drugs help control
panic attacks isn’t clearly understood. Anticholinergic agents, which
are smooth-muscle relaxants, relieve physical symptoms of anxiety
but don’t relieve the anxiety itself. Antipsychotic drugs are
inappropriate because clients who experience panic attacks aren’t
psychotic. Mood stabilizers aren’t indicated because panic attacks
are rarely associated with mood changes.
18. Answer: (B) 3 to 5 days.  Monoamine oxidase inhibitors, such as
tranylcypromine, have an onset of action of approximately 3 to 5
days. A full clinical response may be delayed for 3 to 4 weeks. The
therapeutic effects may continue for 1 to 2 weeks after
discontinuation.
19. Answer: (B) Providing emotional support and individual
counseling. Clients in the first stage of Alzheimer’s disease are aware
that something is happening to them and may become
overwhelmed and frightened. Therefore, nursing care typically
focuses on providing emotional support and individual counseling.
The other options are appropriate during the second stage of
Alzheimer’s disease, when the client needs continuous monitoring
to prevent minor illnesses from progressing into major problems
and when maintaining adequate nutrition may become a challenge.
 During this stage, offering nourishing finger foods helps clients to
feed themselves and maintain adequate nutrition.
20. Answer: (C) Emotional lability, euphoria, and impaired memory. Signs
of antianxiety agent overdose include emotional lability, euphoria,
and impaired memory. Phencyclidine overdose can
cause combativeness, sweating, and confusion. Amphetamine
overdose can result in agitation, hyperactivity, and grandiose
ideation. Hallucinogen overdose can produce suspiciousness,
dilated pupils, and increased blood pressure.
21. Answer: (D) A low tolerance for frustration. Clients with an antisocial
personality disorder exhibit a low tolerance for frustration, emotional
immaturity, and a lack of impulse control. They commonly have a
history of unemployment, miss work repeatedly, and quit work
without other plans for employment. They don’t feel guilt about their
behavior and commonly perceive themselves as victims. They also
display a lack of responsibility for the outcome of their actions.
Because of a lack of trust in others, clients with
antisocial personality disorder commonly have difficulty developing
stable, close relationships.
22. Answer: (C) Methadone. Methadone is used to detoxify opiate
users because it binds with opioid receptors at many sites in the
central nervous system but doesn’t have the same deterious effects
as other opiates, such as cocaine, heroin, and morphine.
Barbiturates, amphetamines, and benzodiazepines are highly
addictive and would require detoxification treatment.
23. Answer: (B) Hallucinations. Hallucinations are visual, auditory,
gustatory, tactile, or olfactory perceptions that have no basis in
reality. Delusions are false beliefs, rather than perceptions, that the
client accepts as real. Loose associations are rapid shifts among
unrelated ideas. Neologisms are bizarre words that have meaning
only to the client.
24. Answer: (C) Set up a strict eating plan for the client. Establishing a
consistent eating plan and monitoring the client’s weight are very
important in this disorder. The family and friends should be included
in the client’s care. The client should be monitored during meals-not
given privacy. Exercise must be limited and supervised.
25. Answer: (A) Highly important or famous. A delusion of grandeur is a
false belief that one is highly important or famous. A delusion of
persecution is a false belief that one is being persecuted. A delusion
of reference is a false belief that one is connected to events
unrelated to oneself or a belief that one is responsible for the evil in
the world.
26. Answer: (D) Listening attentively with a neutral attitude and
avoiding power struggles. The nurse should listen to the client’s
requests, express willingness to seriously consider the request, and
respond later. The nurse should encourage the client to take short
daytime naps because he expends so much energy. The nurse
shouldn’t try to restrain the client when he feels the need to move
around as long as his activity isn’t harmful. High calorie finger foods
should be offered to supplement the client’s diet, if he can’t remain
seated long enough to eat a complete meal. The nurse shouldn’t be
forced to stay seated at the table to finish a meal. The nurse should
set limits in a calm, clear, and self-confident tone of voice.
27. Answer: (D) Denial. Denial is unconscious defense mechanism in
which emotional conflict and anxiety is avoided by refusing to
acknowledge feelings, desires, impulses, or external facts that are
consciously intolerable. Withdrawal is a common response to
stress, characterized by apathy. Logical thinking is the ability to
think rationally and make responsible decisions, which would lead
the client admitting the problem and seeking help. Repression is
suppressing past events from the consciousness because of guilty
association.
28. Answer: (B) Paranoid thoughts. Clients with schizotypal personality
disorder experience excessive social anxiety that can lead to
paranoid thoughts. Aggressive behavior is uncommon, although
these clients may experience agitation with anxiety. Their behavior
is emotionally cold with a flattened affect, regardless of the
situation. These clients demonstrate a reduced capacity for close or
dependent relationships.
29. Answer: (C) Identify anxiety-causing situations. Bulimic behavior is
generally a maladaptive coping response to stress and underlying
issues. The client must identify anxiety-causing situations that
 stimulate the bulimic behavior and then learn new ways of coping
with the anxiety.
30. Answer: (A) Tension and irritability. An amphetamine is a nervous
system stimulant that is subject to abuse because of its ability to
produce wakefulness and euphoria. An overdose increases tension
and irritability. Options B and C are incorrect because
amphetamines stimulate norepinephrine, which increase the heart
rate and blood flow. Diarrhea is a common adverse effect so
option D in is incorrect.
31. Answer: (B) “No, I do not hear your voices, but I believe you can
hear them”. The nurse, demonstrating knowledge and
understanding, accepts the client’s perceptions even though they
are hallucinatory.
32. Answer: (C) Confusion for a time after treatment. The electrical energy
passing through the cerebral cortex during ECT results in a
temporary state of confusion after treatment.
33. Answer: (D) Acceptance stage. Communication and intervention
during this stage are mainly nonverbal, as when the client gestures
to hold the nurse’s hand.
34. Answer: (D) A higher level of anxiety continuing for more than 3
months. This is not an expected outcome of a crisis because
by definition a crisis would be resolved in 6 weeks.
35. Answer: (B) Staying in the sun. Haldol causes photosensitivity. Severe
sunburn can occur on exposure to the sun.
36. Answer: (D) Moderate-level anxiety. A moderately anxious person
can ignore peripheral events and focuses on central concerns.
37. Answer: (C) Diverse interest. Before onset of depression, these
clients usually have very narrow, limited interest.
38. Answer: (A) As their depression begins to improve. At this point the
client may have enough energy to plan and execute an attempt.
39. Answer: (D) Disturbance in recalling recent events related to
cerebral hypoxia. Cell damage seems to interfere with registering
input stimuli, which affects the ability to register and recall recent
events; vascular dementia is related to multiple vascular lesions of
the cerebral cortex and subcortical structure.
40. Answer: (D) Encouraging the client to have blood levels checked
as ordered. Blood levels must be checked monthly or bimonthly when
the client is on maintenance therapy because there is only a small
range between therapeutic and toxic levels.
41. Answer: (B) Fine hand tremors or slurred speech. These are common
side effects of lithium carbonate.
42. Answer: (D) Presence. The constant presence of a nurse provides
emotional support because the client knows that someone is
attentive and available in case of an emergency.
43. Answer: (A) Client’s perception of the presenting problem. The nurse
can be most therapeutic by starting where the client is, because it is
the client’s concept of the problem that serves as the starting point
of the relationship.
44. Answer: (B) Chocolate milk, aged cheese, and yogurt’. These high-
tyramine foods, when ingested in the presence of an MAO inhibitor,
cause a severe hypertensive response.
45. Answer: (B) 4 to 6 weeks. Crisis is self-limiting and lasts from 4 to 6
weeks.
46. Answer: (D) Males are more likely to use lethal methods than are
females.  This finding is supported by research; females account for
90% of suicide attempts but males are three times more successful
because of methods used.
47. Answer: (C) “Your cursing is interrupting the activity. Take time out in
your room for 10 minutes.”  The nurse should set limits on client
behavior to ensure a comfortable environment for all clients. The
nurse should accept hostile or quarrelsome client outbursts within
limits without becoming personally offended, as in option A. Option
B is incorrect because it implies that the client’s actions reflect
feelings toward the staff instead of the client’s own misery.
Judgmental remarks, such as option D, may decrease the
client’s self-esteem.
48. Answer: (C) lithium carbonate (Lithane). Lithium carbonate, an
antimania drug, is used to treat clients with cyclical schizoaffective
disorder, a psychotic disorder once classified under schizophrenia
that causes affective symptoms, including maniclike activity.
Lithium helps control the affective component of this
 disorder. Phenelzine is a monoamine oxidase inhibitor prescribed
for clients who don’t respond to other antidepressant drugs such as
imipramine. Chlordiazepoxide, an antianxiety agent, generally is
contraindicated in psychotic clients. Imipramine, primarily
considered an antidepressant agent, is also used to treat clients
with agoraphobia and that undergoing cocaine detoxification.
49. Answer: (B) Report a sore throat or fever to the physician
immediately. A sore throat and fever are indications of an infection
caused by agranulocytosis, a potentially life-threatening
complication of clozapine. Because of the risk of agranulocytosis,
white blood cell (WBC) counts are necessary weekly, not monthly. If
the WBC count drops below 3,000/μl, the medication must be
stopped. Hypotension may occur in clients taking this medication.
Warn the client to stand up slowly to avoid dizziness
from orthostatic hypotension. The medication should be continued,
even when symptoms have been controlled. If the medication must
be stopped, it should be slowly tapered over 1 to 2 weeks and only
under the supervision of a physician.
50. Answer: (C) Neuroleptic malignant syndrome. The client’s signs and
symptoms suggest neuroleptic malignant syndrome, a life-
threatening reaction to neuroleptic medication that requires
immediate treatment. Tardive dyskinesia causes
involuntary movements of the tongue, mouth, facial muscles, and
arm and leg muscles. Dystonia is characterized by cramps and
rigidity of the tongue, face, neck, and back muscles. Akathisia
causes restlessness, anxiety, and jitteriness.
51. Answer: (B) Advising the client to sit up for 1 minute before getting out
of bed. To minimize the effects of amitriptyline-induced
orthostatic hypotension, the nurse should advise the client to sit up
for 1 minute before getting out of bed. Orthostatic hypotension
commonly occurs with tricyclic antidepressant therapy. In these
cases, the dosage may be reduced or the physician may prescribe
nortriptyline, another tricyclic antidepressant. Orthostatic
hypotension disappears only when the drug is discontinued.
52. Answer: (D) Dysthymic disorder. Dysthymic disorder is marked by
feelings of depression lasting at least 2 years, accompanied by at
 least two of the following symptoms: sleep disturbance, appetite
disturbance, low energy or fatigue, low selfesteem, poor
concentration, difficulty making decisions, and hopelessness. These
symptoms may be relatively continuous or separated by intervening
periods of normal mood that last a few days to a few weeks.
Cyclothymic disorder is a chronic mood disturbance of at least 2
years’ duration marked by numerous periods of depression
and hypomania. Atypical affective disorder is characterized by
manic signs and symptoms. Major depression is a recurring,
persistent sadness or loss of interest or pleasure in almost all
activities, with signs and symptoms recurring for at least 2 weeks.
53. Answer: (C) 30 g mixed in 250 ml of water.  The usual adult dosage
of activated charcoal is 5 to 10 times the estimated weight of the
drug or chemical ingested, or a minimum dose of 30 g, mixed in 250
ml of water. Doses less than this will be ineffective; doses greater
than this can increase the risk of adverse reactions, although
toxicity doesn’t occur with activated charcoal, even at the maximum
dose.
54. Answer: (C) St. John’s wort. St. John’s wort has been found to have
serotonin-elevating properties, similar to prescription
antidepressants. Ginkgo biloba is prescribed to enhance mental
acuity. Echinacea has immune-stimulating properties. Ephedra is a
naturally occurring stimulant that is similar to ephedrine.
55. Answer: (B) Sodium. Lithium is chemically similar to sodium. If
sodium levels are reduced, such as from sweating or diuresis,
lithium will be reabsorbed by the kidneys, increasing the risk of
toxicity. Clients taking lithium shouldn’t restrict their intake of
sodium and should drink adequate amounts of fluid each day. The
other electrolytes are important for normal body functions but
sodium is most important to the absorption of lithium.
56. Answer: (D) It’s characterized by an acute onset and lasts hours to
a number of days. Delirium has an acute onset and typically can last
from several hours to several days.
57. Answer: (B) Impaired communication. Initially, memory impairment
may be the only cognitive deficit in a client with Alzheimer’s disease.
During the early stage of this disease, subtle personality changes
 may also be present. However, other than occasional irritable
outbursts and lack of spontaneity, the client is usually cooperative
and exhibits socially appropriate behavior. Signs of advancement to
the middle stage of Alzheimer’s disease include exacerbated
cognitive impairment with obvious personality changes
and impaired communication, such as inappropriate conversation,
actions, and responses. During the late stage, the client can’t
perform self-care activities and may become mute.
58. Answer: (D) This medication may initially cause tiredness, which
should become less bothersome over time. Sedation is a common early
adverse effect of imipramine, a tricyclic antidepressant, and usually
decreases as tolerance develops. Antidepressants aren’t habit
forming and don’t cause physical or psychological dependence.
However, after a long course of high-dose therapy, the dosage
should be decreased gradually to avoid mild withdrawal symptoms.
Serious adverse effects, although rare, include myocardial infarction,
heart failure, and tachycardia. Dietary restrictions, such as avoiding
aged cheeses, yogurt, and chicken livers, are necessary for a client
taking a monoamine oxidase inhibitor, not a tricyclic antidepressant.
59. Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-
base balance. An anorexic client who requires hospitalization is in
poor physical condition from starvation and may die as a result of
arrhythmias, hypothermia, malnutrition, infection, or cardiac
abnormalities secondary to electrolyte imbalances. Therefore,
monitoring the client’s vital signs, serum electrolyte level, and acid
base balance is crucial. Option A may worsen anxiety. Option B is
incorrect because a weight obtained after breakfast is more
accurate than one obtained after the evening meal. Option D
would reward the client with attention for not eating and reinforce
the control issues that are central to the underlying psychological
problem; also, the client may record food and fluid intake
inaccurately.
60. Answer: (D) Opioid withdrawal. The symptoms listed are specific to
opioid withdrawal. Alcohol withdrawal would show elevated vital
signs. There is no real withdrawal from cannibis. Symptoms of
cocaine withdrawal include depression, anxiety, and agitation.
61. Answer: (A) Regression. An adult who throws temper tantrums,
such as this one, is displaying regressive behavior, or behavior that
is appropriate at a younger age. In projection, the client blames
someone or something other than the source. In reaction formation,
the client acts in opposition to his feelings. In intellectualization, the
client overuses rational explanations orabstract thinking to
decrease the significance of a feeling or event.
62. Answer: (A) Abnormal movements and involuntary movements of
the mouth, tongue, and face. Tardive dyskinesia is a severe reaction
associated with long term use of antipsychotic medication. The
clinical manifestations include abnormal movements (dyskinesia)
and involuntary movements of the mouth, tongue (fly catcher
tongue), and face.
63. Answer: (C) Blurred vision. At lithium levels of 2 to 2.5 mEq/L the
client will experienced blurred vision, muscle twitching, severe
hypotension, and persistent nausea and vomiting. With levels
between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea,
muscle weakness, ataxia, dizziness, slurred speech, and confusion.
At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal
incontinence occurs, as well as seizures, cardiac dysrythmias,
peripheral vascular collapse, and death.
64. Answer: (C) No acts of aggression have been observed within 1
hour after the release of two of the extremity restraints. The best indicator
that the behavior is controlled, if the client exhibits no signs of
aggression after partial release of restraints. Options A, B, and D do
not ensure that the client has controlled the behavior.
65. Answer: (A) increased attention span and concentration. The
medication has a paradoxic effect that decrease hyperactivity and
impulsivity among children with ADHD. B, C, D. Side effects of Ritalin
include anorexia, insomnia, diarrhea and irritability.
66. Answer: (C) Moderate. The child with moderate mental retardation
has an I.Q. of 35- 50 Profound Mental retardation has an I.Q. of
below 20; Mild mental retardation 50-70 and Severe mental
retardation has an I.Q. of 20-35.
67. Answer: (D) Rearrange the environment to activate the child. The child
with autistic disorder does not want change. Maintaining a
 consistent environment is therapeutic. A. Angry outburst can be re-
channeling through safe activities. B. Acceptance enhances
a trusting relationship. C. Ensure safety from self-destructive
behaviors like head banging and hair pulling.
68. Answer: (B) cocaine. The manifestations indicate intoxication with
cocaine, a CNS stimulant. A. Intoxication with heroine is manifested
by euphoria then impairment in judgment, attention and the
presence of papillary constriction. C. Intoxication with hallucinogen
like LSD is manifested by grandiosity, hallucinations, synesthesia
and increase in vital signs D. Intoxication with Marijuana, a
cannabinoid is manifested by sensation of slowed time, conjunctival
redness, social withdrawal, impaired judgment and hallucinations.
69. Answer: (B) insidious onset. Dementia has a gradual onset and
progressive deterioration. It causes pronounced memory and
cognitive disturbances. A,C and D are all characteristics of delirium.
70. Answer: (C) Claustrophobia. Claustrophobia is fear of closed space.
A. Agoraphobia is fear of open space or being a situation where
escape is difficult. B. Social phobia is fear of performing in the
presence of others in a way that will be humiliating or embarrassing.
D. Xenophobia is fear of strangers.
71. Answer: (A) Revealing personal information to the client. Counter-
transference is an emotional reaction of the nurse on the client
based on her unconscious needs and conflicts. B and C. These are
therapeutic approaches. D. This is transference reaction where
a client has an emotional reaction towards the nurse based on her
past.
72. Answer: (D) Hold the next dose and obtain an order for a stat
serum lithium level. Diarrhea and vomiting are manifestations of
Lithium toxicity. The next dose of lithium should be withheld and
test is done to validate the observation. A. The manifestations are
not due to drug interaction. B. Cogentin is used to manage the extra
pyramidal symptom side effects of antipsychotics. C. The common
side effects of Lithium are fine hand tremors, nausea, polyuria and
polydipsia.
73. Answer: (C) A living, learning or working environment. A therapeutic
milieu refers to a broad conceptual approach in which all aspects of
 the environment are channeled to provide a therapeutic environment
for the client. The six environmental elements include structure,
safety, norms; limit setting, balance and unit modification. A.
Behavioral approach in psychiatric care is based on the premise that
behavior can be learned or unlearned through the use of reward and
punishment. B. Cognitive approach to change behavior is done by
correcting distorted perceptions and irrational beliefs to
correct maladaptive behaviors. D. This is not congruent with
therapeutic milieu.
74. Answer: (B) Transference. Transference is a positive or negative
feeling associated with a significant person in the client’s past that
are unconsciously assigned to another A. Splitting is a defense
mechanism commonly seen in a client with personality disorder in
which the world is perceived as all good or all bad C. Countert-
transference is a phenomenon where the nurse shifts feelings
assigned to someone in her past to the patient D. Resistance is the
client’s refusal to submit himself to the care of the nurse
75. Answer: (B) Adventitious. Adventitious crisis is a crisis involving a
traumatic event. It is not part of everyday life. A. Situational crisis is
from an external source that upset ones psychological equilibrium C
and D. Are the same. They are transitional or developmental periods
in life
76. Answer: (C) Major depression. The DSM-IV-TR classifies major
depression as an Axis I disorder. Borderline personality disorder as
an Axis II; obesity and hypertension, Axis III.
77. Answer: (B) Transference. Transference is the unconscious
assignment of negative or positive feelings evoked by a significant
person in the client’s past to another person. Intellectualization is a
defense mechanism in which the client avoids dealing with
emotions by focusing on facts. Triangulation refers to conflicts
involving three family members. Splitting is a defense mechanism
commonly seen in clients with personality disorder in which the
world is perceived as all good or all bad.
78. Answer: (B) Hypochondriasis. Complains of vague physical
symptoms that have no apparent medical causes are characteristic
of clients with hypochondriasis. In many cases, the GI system is
 affected. Conversion disorders are characterized by one or more
neurologic symptoms. The client’s symptoms don’t suggest severe
anxiety. A client experiencing sublimation channels maladaptive
feelings or impulses into socially acceptable behavior
79. Answer: (C) Hypochondriasis. Hypochodriasis in this case is shown
by the client’s belief that she has a serious illness, although
pathologic causes have been eliminated. The disturbance usually
lasts at lease 6 with identifiable life stressor such as, in this case,
course examinations. Conversion disorders are characterized by
one or more neurologic symptoms. Depersonalization refers to
persistent recurrent episodes of feeling detached from one’s self or
body. Somatoform disorders generally have a chronic course with
few remissions.
80. Answer: (A) Triazolam (Halcion). Triazolam is one of a group of
sedative hypnotic medication that can be used for a limited time
because of the risk of dependence. Paroxetine is a scrotonin-
specific reutake inhibitor used for treatment of depression panic
disorder, and obsessive-compulsive disorder. Fluoxetine is a
scrotonin-specific reuptake inhibitor used for depressive disorders
and obsessive-compulsive disorders. Risperidome is indicated for
psychotic disorders.
81. Answer: (D) It promotes emotional support or attention for the
client. Secondary gain refers to the benefits of the illness that
allow the client to receive emotional support or attention. Primary
gain enables the client to avoid some unpleasant activity. A
dysfunctional family may disregard the real issue, although some
conflict is relieved. Somatoform pain disorder is a preoccupation
with pain in the absence of physical disease.
82. Answer: (A) “I went to the mall with my friends last Saturday”. Clients
with panic disorder tent to be socially withdrawn. Going to the mall
is a sign of working on avoidance behaviors. Hyperventilating is a
key symptom of panic disorder. Teaching breathing control is a
major intervention for clients with panic disorder. The client taking
medications for panic disorder; such as tricylic antidepressants and
benzodiazepines, must be weaned off these drugs. Most clients
 with panic disorder with agoraphobia don’t have nutritional
problems.
83. Answer: (A) “I’m sleeping better and don’t have nightmares” MAO
inhibitors are used to treat sleep problems, nightmares, and
intrusive daytime thoughts in individual with posttraumatic
stress disorder. MAO inhibitors aren’t used to help control
flashbacks or phobias or to decrease the craving for alcohol.
84. Answer: (D) Stopping the drug can cause withdrawal
symptoms. Stopping antianxiety drugs such as benzodiazepines
can cause the client to have withdrawal symptoms. Stopping a
benzodiazepine doesn’t tend to cause depression, increase
cognitive abilities, or decrease sleeping difficulties.
85. Answer: (B) Behavioral difficulties. Adolescents tend to
demonstrate severe irritability and behavioral problems rather than
simply a depressed mood. Anxiety disorder is more commonly
associated with small children rather than with adolescents.
Cognitive impairment is typically associated with delirium
or dementia. Labile mood is more characteristic of a client with
cognitive impairment or bipolar disorder.
86. Answer: (D) It’s a mood disorder similar to major depression but of mild
to moderate severity. Dysthymic disorder is a mood disorder similar to
major depression but it remains mild to moderate in severity.
Cyclothymic disorder is a mood disorder characterized by a mood
range from moderate depression to hypomania. Bipolar I disorder is
characterized by a single manic episode with no past major
depressive episodes. Seasonalaffective disorder is a form of
depression occurring in the fall and winter.
87. Answer: (A) Vascular dementia has more abrupt onset.  Vascular
dementia differs from Alzheimer’s disease in that it has a more
abrupt onset and runs a highly variable course. Personally change is
common in Alzheimer’s disease. The duration of delirium is usually
brief. The inability to carry out motor activities is common
in Alzheimer’s disease.
88. Answer: (C) Drug intoxication. This client was taking several
medications that have a propensity for producing delirium; digoxin
(a digitalis glycoxide), furosemide (a thiazide diuretic), and
 diazepam (a benzodiazepine). Sufficient supporting data don’t exist
to suspect the other options as causes.
89. Answer: (D) The client is experiencing visual hallucination. The
presence of a sensory stimulus correlates with the definition of a
hallucination, which is a false sensory perception. Aphasia refers to
a communication problem. Dysarthria is difficulty in
speech production. Flight of ideas is rapid shifting from one topic to
another.
90. Answer: (D) The client looks at the shadow on a wall and tells the
nurse she sees frightening faces on the wall. Minor memory problems
are distinguished from dementia by their minor severity and their
lack of significant interference with the client’s social or
occupational lifestyle. Other options would be included in the history
data but don’t directly correlate with the client’s lifestyle.
91. Answer: (D) Loose association. Loose associations are
conversations that constantly shift in topic. Concrete thinking
implies highly definitive thought processes. Flight of ideas is
characterized by conversation that’s disorganized from the onset.
Loose associations don’t necessarily start in a cogently,
then becomes loose.
92. Answer: (C) Paranoid. Because of their suspiciousness, paranoid
personalities ascribe malevolent activities to others and tent to be
defensive, becoming quarrelsome and argumentative. Clients with
antisocial personality disorder can also be antagonistic and
argumentative but are less suspicious than paranoid personalities.
Clients with histrionic personality disorder are dramatic, not
suspicious and argumentative. Clients with schizoid personality
disorder are usually detached from other and tend to have eccentric
behavior.
93. Answer: (C) Explain that the drug is less affective if the client
smokes. Olanzapine (Zyprexa) is less effective for clients who
smoke cigarettes. Serotonin syndrome occurs with clients who take
a combination of antidepressant medications. Olanzapine doesn’t
cause euphoria, and extrapyramidal adverse reactions aren’t a
problem. However, the client should be aware of adverse effects
such as tardive dyskinesia.
94. Answer: (A) Lack of honesty. Clients with antisocial personality
disorder tent to engage in acts of dishonesty, shown by lying.
Clients with schizotypal personality disorder tend to be
superstitious. Clients with histrionic personality disorders tend to
overreact to frustrations and disappointments, have temper
tantrums, and seek attention.
95. Answer: (A) “I’m not going to look just at the negative things about
myself”. As the clients makes progress on improving self-esteem,
selfblame and negative self evaluation will decrease. Clients with
dependent personality disorder tend to feel fragile and inadequate
and would be extremely unlikely to discuss their level of
competence and progress. These clients focus on self and aren’t
envious or jealous. Individuals with dependent personality disorders
don’t take over situations because they see themselves as inept and
inadequate.
96. Answer: (C) Assess for possible physical problems such as rash. Clients
with schizophrenia generally have poor visceral recognition because
they live so fully in their fantasy world. They need to have as in-
depth assessment of physical complaints that may spill over into
their delusional symptoms. Talking with the client won’t provide
as assessment of his itching, and itching isn’t as adverse reaction
of antipsychotic drugs, calling the physician to get the client’s
medication increased doesn’t address his physical complaints.
97. Answer: (B) Echopraxia. Echopraxia is the copying of another’s
behaviors and is the result of the loss of ego boundaries. Modeling
is the conscious copying of someone’s behaviors. Ego-syntonicity
refers to behaviors that correspond with the individual’s sense of
self. Ritualism behaviors are repetitive and compulsive.
98. Answer: (C) Hallucination. Hallucinations are sensory experiences
that are misrepresentations of reality or have no basis in reality.
Delusions are beliefs not based in reality. Disorganized speech is
characterized by jumping from one topic to the next or using
unrelated words. An idea of reference is a belief that an unrelated
situation holds special meaning for the client.
99. Answer: (C) Regression. Regression, a return to earlier behavior to
reduce anxiety, is the basic defense mechanism in schizophrenia.
 Projection is a defense mechanism in which one blames others and
attempts to justify actions; it’s used primarily by people with
paranoid schizophrenia and delusional disorder. Rationalization is a
defense mechanism used to justify one’s action. Repression is the
basic defense mechanism in the neuroses; it’s an involuntary
exclusion of painful thoughts, feelings, or experiences
from awareness.
100. Answer: (A) Should report feelings of restlessness or agitation at
once. Agitation and restlessness are adverse effect of
haloperidol and can be treated with antocholinergic drugs.
Haloperidol isn’t likely to cause photosensitivity or control essential
hypertension. Although the client may experience increased
concentration and activity, these effects are due to a decreased in
symptoms, not the drug itself.