When counseling a 6 year old who is experiencing enuresis, what must the nurse
understand about the pathophysiological basis of this disorder?
A) Has no
... [Show More] clear etiology
B) May be associated with sleep phobia
C) Has a definite genetic link
D) Is a sign of willful misbehavior
The correct answer is A: Has no clear etiology
17. The nurse is discussing negativism with the parents of a 30 month-old child. How
should the nurse tell the parents to best respond to this behavior?
A) Reprimand the child and give a 15 minute "time out"
B) Maintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting
The correct answer is C: Use patience and a sense of humor to deal with this behavior
18. The nurse is talking by telephone with a parent of a 4 year-old child who has
chickenpox. Which of the following demonstrates appropriate teaching by the nurse?
A) Chewable aspirin is the preferred analgesic
B) Topical cortisone ointment relieves itching
C) Papules, vesicles, and crusts will be present at one time
D) The illness is only contagious prior to lesion eruption
The correct answer is C: Papules, vesicles, and crusts will be present at one time
19. The nurse is assigned to a client who has heart failure . During the morning rounds
the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse
auscultates, crackles bilaterally.
Which nursing intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN anti anxiety agent
The correct answer is B: Place the client in a sitting position with legs dangling
20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the
parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special
family gatherings?" Which initial response by the nurse would be best?
A) "A recovering person has to be very careful not to lose control, therefore, confine your
drinking just at family gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your
sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction process
over."
The correct answer is D: "The recovering person cannot return to drinking without
starting the addiction process over."
22. In taking the history of a pregnant woman, which of the following would the nurse
recognize as the primary contraindication for breast feeding?
A) Age 40 years
B) Lactose intolerance
C) Family history of breast cancer
D) Uses cocaine on weekends
The correct answer is D: Uses cocaine on weekends
23. A client is receiving nitroprusside IV for the treatment of acute heart failure with
pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this
medication?
A) Potassium
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate
The correct answer is D: Thiocyanate
24. A victim of domestic violence tells the batterer she needs a little time away. How
would the nurse expect that the batterer might respond?
A) With acceptance and views the victim’s comment as an indication that their marriage
is in trouble
B) With fear of rejection causing increased rage toward the victim
C) With a new commitment to seek counseling to assist with their marital problems
D) With relief, and welcomes the separation as a means to have some personal time
The correct answer is B: With fear of rejection causing increased rage toward the victim
25. A postpartum mother is unwilling to allow the father to participate in the newborn's
care, although he is interested in doing so. She states, "I am afraid the baby will be
confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's
initial intervention should be what focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision
The correct answer is B: Set time aside to get the mother to express her feelings and
concerns
26. A client with emphysema visits the clinic. While teaching about proper nutrition, the
nurse should emphasize that the client
A) Eat foods high in sodium increases sputum liquefaction
B) Use oxygen during meals improves gas exchange
C) Perform exercise after respiratory therapy enhances appetite
D) Cleanse the mouth of dried secretions reduces risk of infection
The correct answer is B: Use oxygen during meals improves gas exchange
27. Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
The correct answer is C: Mild emesis progressing to projectile vomiting
28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
The correct answer is B: Tissue hypoxia
29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
A) High in carbohydrates and proteins
B) Low in carbohydrates and proteins
C) High in carbohydrates, low in proteins
D) Low in carbohydrates, high in proteins
The correct answer is A: High in carbohydrates and proteins
30. In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
A) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference
The correct answer is C: Tripled the birth weight
31. A Hispanic client in the postpartum period refuses the hospital food because it is
"cold." The best initial action by the nurse is to
A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
B) Ask the client what foods are acceptable or bad
C) Encourage her to eat for healing and strength
D) Schedule the dietitian to meet with the client as soon as possible
The correct answer is B: Ask the client what foods are acceptable [Show Less]