NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide
1 week ago. She has taken phenelzine sulfate (Nardil)... [Show More] , a monoamine oxidase
(MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains
that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom
relief is expected to occur within:
A. 10 days
B. 2-4 weeks
C. 2 months
D. 3 months
Answer: B
Explanation:
(A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication.
(B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before
improvement of symptoms is noted.
(C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication.
(D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug
therapy.
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
A. Mothers carry the gene and pass it to their sons
B. Fathers carry the gene and pass it to their daughters
C. Both parents must have the disease for a child to have the disease
D. Both parents must be carriers for a child to have the disease
Answer: D
Explanation:
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y
chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be
carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an
affected child.
NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse
identifies this as a:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
Answer: A
Explanation:
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(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory
experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion
is the expression of intrapsychic conflict through sensory or motor manifestations.
NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or
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even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during
the first few days or weeks of an acute episode to manage severe behavioral excitement and acute
psychotic symptoms. In addition to the lithium, which one of the following medications might the
physician prescribe?
A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)
Answer: B
Explanation:
(A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B)
Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C)
Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D)
Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
NO.5 A violent client remains in restraints for several hours. Which of the following interventions is
most appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are
removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
Answer: D
Explanation:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly
while the client is restrained, not only before restraints are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D)
Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle
tone, skin and joint integrity, and circulation.
NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral
griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
Answer: D
Explanation:
(A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a
fatty meal (ice cream or milk) increases absorption rate. (B) Griseofulvin may alter taste sensations
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and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient
intake should be reported to the physician. (C) The child may experience symptomatic relief after 48-
96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually
about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea,
vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to
the physician.
NO.7 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h
via nasogastric tube. The rationale for this therapy is to:
A. Prevent systemic infection
B. Promote diuresis
C. Decrease ammonia formation
D. Acidify the small bowel
Answer: C
Explanation:
(A) Neomycin is an antibiotic, but this is not the Rationale for administering it to a client in hepatic
coma. (B) Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the
liver. (C) Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break
down protein into ammonia. (D) Lactulose is administered to create an acid environment in the
bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and
excreted.
NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
Answer: D
Explanation:
(A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his
mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert.
Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to
distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous
toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur.
The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright
red blood, continuous swallowing, and changes in vital signs.
NO.9 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his
left leg that started approximately 20 minutes ago. When performing the admission assessment, the
nurse would expect to observe which of the following:
A. Both lower extremities warm to touch with 2_pedal pulses
B. Both lower extremities cyanotic when placed in a dependent position
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C. Decreased or absent pedal pulse in the left leg
D. The left leg warmer to touch than the right leg
Answer: C
Explanation:
(A) This statement describes a normal assessment finding of the lower extremities. (B) This
assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal
pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial
insufficiency would be cool to touch due to the decreased circulation.
NO.10 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing
assessment, which lab value should elicit further assessment and requires notification of physician?
A. pH 7.39
B. White blood cell (WBC) count 10,000 WBCs/mm3
C. Hematocrit 60%
D. Bleeding time of 4 minutes
Answer: C
Explanation:
(A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in
an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit
may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding
time is 2-7 minutes.
NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor.
What nursing intervention is appropriate when communicating with the pacing client?
A. Ask him to sit down. Speak slowly and use short, simple sentences.
B. Help him to recognize his anxiety.
C. Walk with him as he paces.
D. Increase the level of his supervision.
Answer: C
Explanation:
(A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal with his
anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B)
The client may already recognize the anxiety and is attempting to deal with it. (C) Walk with the client
as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of
supervision may be appropriate after he stops pacing. It would minimize self-injury and/or loss of
control.
NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to:
A. Evaluate fetal lung maturity
B. Evaluate the amount of amniotic fluid
C. Locate the position of the placenta and fetus
D. Ensure that the fetus is mature enough to perform the amniocentesis
Answer: C
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Explanation:
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for
gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can
evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C)
Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the
abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the
placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of
pregnancy.
NO.13 A 25-year-old client believes she may be pregnant with her first child. She schedules an
obstetric examination with the nurse practitioner to determine the status of her possible pregnancy.
Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule
is:
A. March 27
B. February 1
C. February 27
D. January 3
Answer: C
Explanation:
(A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct
answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from
the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a
miscalculation.
NO.14 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The
client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of
diabetes when she is pregnant, she is classified as having:
A. Insulin-dependent diabetes
B. Type II diabetes mellitus
C. Type I diabetes mellitus
D. Gestational diabetes mellitus
Answer: D
Explanation:
(A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the
age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related
to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in
older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as
insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during
pregnancy and usually disappears after delivery. These symptoms are usually mild and not life
threatening, although they are associated with increased fetal morbidity and other fetal
complications.
NO.15 A 44-year-old female client is receiving external radiation to her scapula for metastasis of
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breast cancer.
Teaching related to skin care for the client would include which of the following?
A. Teach her to completely clean the skin to remove all ointments and markings after each treatment
.
B. Teach her to cover broken skin in the treated area with a medicated ointment.
C. Encourage her to wear a tight-fitting vest to support her scapula.
D. Encourage her to avoid direct sunlight on the area being treated.
Answer: D
Explanation:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left
intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on
the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loosefitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to
sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and
covering the area when she is in the sun.
NO.16 The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for
tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
A. Vitamin C
B. Vitamin B1
C. Vitamin D
D. Vitamin A
Answer: A
Explanation:
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B)
Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and
is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium
and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the
formation and maintenance of skin and mucous membranes. It is also essential for normal growth
and development of bones and teeth.
NO.17 A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting
behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on
activities, and monotony. Which of the following nursing implementations would be most effective in
helping him cope with immobility?
A. Providing him with books, challenging puzzles, and games as diversionary activities
B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under
supervision
C. Having a volunteer come in to sit with the client and to read him stories
D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position
frequently
Answer: B
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Explanation:
(A) These activities could be frustrating for the client if he is having difficulty with problem solving
and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful
interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no
visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation
or breakdown related to immobility but will not help to prevent behavioral changes related to
immobility.
NO.18 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with
ingestion of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
Answer: A
Explanation:
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this
period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete
by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire
pregnancy.
NO.19 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the
client in the most appropriate position for a client in pulmonary edema, which is:
A. High Fowler
B. Lying on the left side
C. Sitting in a chair
D. Supine with feet elevated
Answer: A
Explanation:
(A) High Fowler position decreases venous return to the heart and permits greater lung expansion so
that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but
does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote
maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require
intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens,
it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous
return and will worsen pulmonary edema.
NO.20 A client has returned to the unit from the recovery room after having a thyroidectomy. The
nurse knows that a major complication after a thyroidectomy is:
A. Respiratory obstruction
B. Hypercalcemia
C. Fistula formation
D. Myxedema
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Answer: A
Explanation:
(A)
Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal
compression from hemorrhage is a major complication after a thyroidectomy.
(B)
Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a
major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated
with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is
hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy
client tends to develop thyroid storm, which is excess production of thyroid hormone.
NO.21 The nurse should facilitate bonding during the postpartum period. What should the nurse
expect to observe in the taking-hold phase?
A. Mother is concerned about her recovery.
B. Mother calls infant by name.
C. Mother lightly touches infant.
D. Mother is concerned about her weight gain.
Answer: B
Explanation:
(A) This observation can be made during the taking-in phase when the mother's needs are more
important. (B) This observation can be made during the taking-hold phase when the mother is
actively involved with herself and the infant. (C, D) This observation can be made during the taking-in
phase.
NO.22 A female client has just died. Her family is requesting that all nursing staff leave the room. The
family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the
room, requesting that only family members be present. The nurse assigned to the client should
perform the appropriate nursing action, which might include:
A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms
.
B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be
brought to the morgue.
C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse
must attend.
D. Respect the client's family's wishes.
Answer: D
Explanation:
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is
true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the
hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the
family's need to grieve in their own manner. (C) The nurse should leave the room and allow the
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family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room
is part of the grief process. The request is based on specific cultural and religious differences dictating
social customs. [Show Less]
