NCLEX practice #2

1. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?

A) Teach the parents how to perform cardiopulmonary resuscitation

B) Recommend that the parents give in when he holds his breath to prevent anoxia

C) Advise the parents to ignore breath holding because breathing will begin as a reflex

D) Instruct the parents on how to reason with the child about possible harmful effects

The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex

If temper tantrums are accompanied by breath holding, the parents need to know that this behavior will not result in harm to the child. Ignoring the breath holding is the best response to this benign behavior.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

2. Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?

A) "I know there is a problem since my baby is always constipated."

B) "My child doesn't like many fruits and vegetables, but she really loves her milk."

C) "I can't understand why my child is not eating as much as she did 4 months ago."

D) "My child doesn't drink a whole glass of juice or water at 1 time."

The correct answer is B: "My child doesn''t like many fruits and vegetables, but she really loves her milk."

About 2 to 3 cups of milk a day are sufficient for the young child''s needs. Sometimes excess milk intake, a habit carried over from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called milk anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of excessive milk ingestion.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

3. Delirium tremens could best be described as

A) disorganized thinking, feelings of terror and non-purposeful behavior

B) a generalized shaking of the body accompanied by repetitive thoughts

C) an excited state accompanied by disorientation, hallucination and tachycardia

D) single or multiple jerks caused by rapid contracting muscles

The correct answer is C: an excited state accompanied by disorientation, hallucination and tachycardia

During delirium tremens syndrome (DTS), the client experiences confusion, disorientation, hallucinations, tachycardia, hypertension, extreme tremors, agitation, diaphoresis, and fever.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

4. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?

A) Fear

B) Helplessness

C) Self-blame

D) Rejection

The correct answer is C: Self-blame

Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, and may even have been told this by their abuser. This is an untrue but not uncommon myth.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?

A) Fluid restriction 1000cc per day

B) Ambulate in hallway 4 times a day

C) Administer analgesic therapy as ordered

D) Encourage increased caloric intake

The correct answer is C: Administer analgesic therapy as ordered

The main general interventions in the treatment of a sickle cell crisis are bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement, and antibiotics to treat any existing infection.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescence is most often associated with what other finding?

A) Sexual promiscuity

B) Poor body image

C) Dropping out of school

D) Drug experimentation

The correct answer is B: Poor body image

As the adolescent gains weight, there is a lessening sense of self esteem and poor body image.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

7. When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?

A) It has no clear etiology

B) Enuresis may be associated with sleep phobia

C) It has a definite genetic link

D) Enuresis is a sign of willful misbehavior

The correct answer is A: It has no clear etiology

Although predictive factors associated with enuresis have been identified, no clear etiology has been determined.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

8. The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?

A) Chest pain

B) Peripheral edema

C) Nail clubbing

D) Lethargy

The correct answer is B: Peripheral edema

When crackles are heard bibasilarly, congestive heart failure is suspected. This is often accompanied by peripheral edema secondary to fluid overload caused by ineffective cardiac pumping.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

9. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?

A) Food

B) Warmth

C) Security

D) Comfort

The correct answer is C: Security

While the infant has many physical needs, it must be touched, loved, and stimulated to develop security and trust.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

10. A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is

A) "You need to take your medicine, this is how you get well."

B) "If you refuse your medicine, we’ll just have to give you a shot."

C) "What is it about the medicine that you don’t like?"

D) "I can see that you are uncomfortable right now, I’ll wait until tomorrow."

The correct answer is C: "What is it about the medicine that you don’t like?"

Nursing interventions for clients with psychotic disorders are aimed at establishing a trusting relationship, establishing clear communications, presenting reality and reinforcing appropriate behavior.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

11. A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?

A) Information is clarified as needed

B) A teacher-coach role is taken by the mentor

C) The mentee accepts feedback objectively

D) The mentor is randomly assigned by administration

The correct answer is B: A teacher-coach role is taken by the mentor

Both the mentor and mentee, the nurse manager, initially need to be open to a positive learning experience. The teacher-coach is the priority for the outcome of an ideal relationship.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

12. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?

A) "Take at least 2 weeks off from work."

B) "You will need another chest x-ray in 6 weeks."

C) "Take your temperature every day."

D) "Complete all of the antibiotic even if your findings decrease."

The correct answer is D: "Complete all of the antibiotic even if your findings decrease."

To avoid a recurrence of the pneumonia the client must complete all of the prescribed medication at the prescribed dosing intervals.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

13. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider?

A) Height and weight percentiles vary widely

B) Growth pattern appears to have slowed

C) Recumbent and standing height are different

D) Short term weight changes are uneven

The correct answer is A: Height and weight percentiles vary widely

On the growth curve, height and weight should be close in percentiles at this age. A wide difference may indicate a problem.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

14. The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

A) "Do not worry. Epilepsy can be treated with medications."

B) "The seizure may or may not mean your child has epilepsy."

C) "Since this was the first convulsion, it may not happen again."

D) "Long term treatment will prevent future seizures."

The correct answer is B: "The seizure may or may not mean your child has epilepsy."

There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown) etiologies.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

15. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?

A) Gestational age assessment suggested growth retardation

B) Meconium was cleared from the airway at delivery

C) Phototherapy was used to treat Rh incompatibility

D) The infant received mechanical ventilation for 2 weeks

The correct answer is D: The infant received mechanical ventilation for 2 weeks

Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

16. The nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?

A) Reprimand the child and give a 15 minute "time out"

B) Maintain a permissive attitude for this behavior

C) Use patience and a sense of humor to deal with this behavior

D) Assert authority over the child through limit setting

The correct answer is C: Use patience and a sense of humor to deal with this behavior

The nurse should help the parents see that negativity as a normal part of growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

17. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to

A) begin mouth to mouth resuscitation

B) give the child water to help in swallowing

C) perform 5 abdominal thrusts

D) call for the emergency response team

The correct answer is C: perform 5 abdominal thrusts

At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

18. An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

A) "Have you had a recent heart attack?"

B) "Do you become short of breath during your normal daily activities?"

C) "How many pillows do you use at night to sleep comfortably?"

D) "Do you smoke?"

The correct answer is B: "Do you become short of breath during your normal daily activities?"

These are the findings of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

19. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?

A) Pre-interaction

B) Orientation

C) Working

D) Termination

The correct answer is C: Working

During the working phase alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

20, A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being "too sick to return to work." The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior

A) is controlled by their subconscious mind

B) is manipulative to avoid work responsibilities

C) would respond to psychoeducational strategies

D) could be modified through reality therapy

The correct answer is A: is controlled by their subconscious mind

Persons with somatoform disorder do not intend to feign illness; their complaints are not under their conscious control. Showing intention to use feigned physical complaints to accomplish some goal is called "malingering" or a factitious disorder.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

21. The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?

A) Protection for the granulation tissue

B) Heal infection

C) Debride eschar

D) Keep the tissue intact

The correct answer is D: Keep the tissue intact

If the black tissue, (eschar) is dry and intact no treatment is necessary. If the area changes (cellulitis, pain) this is a sign of infection, requiring debridement.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

22. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should

A) administer a placebo

B) encourage increased fluid intake

C) administer the prescribed analgesia

D) recommend relaxation exercises for pain control

The correct answer is C: administer the prescribed analgesia

Relief of pain is the expected outcome for treatment of sickle cell crisis. Pain, especially chronic pain, may be present even without overt signs.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

23. Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to

A) pass the catheter into the abdominal cavity

B) place the tubing into the urinary bladder

C) visualize abdominal organs for catheter placement

D) insert the catheter into the stomach

The correct answer is A: pass the catheter into the abdominal cavity

The preferred procedure in the surgical treatment of hydrocephalus is placement of a ventriculoperitoneal shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, usually the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt can be guided into the peritoneal cavity.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

24. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?

A) "My pain is deep in my chest behind my breast bone."

B) "When I sit up the pain gets worse."

C) "As I take a deep breath the pain gets worse."

D) "The pain is right here in my stomach area."

The correct answer is A: "My pain is deep in my chest behind my breast bone."

The pain of angina is usually localized chest pain.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

25. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child?

A) Make certain the child is maintained in correct body alignment.

B) Be sure the traction weights touch the end of the bed.

C) Adjust the head and foot of the bed for the child's comfort

D) Release the traction for 15-20 minutes every 6 hours PRN.

The correct answer is A: Make certain the child is maintained in correct body alignment.

Observe for correct body positioning with emphasis on alignment of shoulders, hips, and legs.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

26. A child is sent to the school nurse by a teacher who has a written note that fifth disease is suspected. Which characteristic would the nurse expect to find?

A) Macule that rapidly progresses to papule and then vesicles

B) Erythema on the face, primarily on cheeks giving a "slapped face" appearance

C) Discrete rose pink macules will appear first on the trunk and fade when pressure is applied

D) Koplik spots appear first followed by a rash that appears first on the face and spreads downward

The correct answer is B: Erythema on the face, primarily on cheeks giving a "slapped face" appearance

Fifth disease is also referred to it as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. It is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases that all have similar rashes. The other 4 diseases are measles, rubella, scarlet fever, and Dukes'' disease. People will not know that a child has parvovirus infection until the rash appears, and by that time the child is no longer contagious.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

27. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?

A) Cereal

B) Eggs

C) Meat

D) Juice

The correct answer is A: Cereal

The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

28. 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

All 3 stages of the chicken pox lesions will be present on the child''s body at the same time.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

29. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?

A) Risk for injury

B) Risk for knowledge deficit

C) Altered thought process

D) Disturbance in self-esteem

The correct answer is A: Risk for injury

Accidents increase as a result of intoxication. Studies indicate alcohol is a factor in 50% of motor vehicle fatalities, 53% of all deaths from accidental falls, 64% of fatal fires, and 80% of suicides.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

30. Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about

A) mental development delays

B) evil eye or envy of others

C) fright from spiritual beings

D) balance in body systems

The correct answer is B: evil eye or envy of others

Matiasma, "Bad eye" or "evil eye, " results from the envy or admiration of others. The belief is that the eye is able to harm a wide variety of things, including inanimate objects, but children are particularly susceptible to attack. Persons of Greek heritage employ a variety of preventive mechanisms to thwart the effects of envy, including protective charms in the form of amulets consisting of blessed wood or incense.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

31. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?

A) "I cannot give this medication as it is written. I have no idea of what you mean."

B) "Would you please clarify what you have written so I am sure I am reading it correctly?"

C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

D) "Please print in the future so I do not have to spend extra time attempting to read your writing."

The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?"

Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

32. The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is

A) recurring crises

B) continuing drug use

C) rationalizing comments

D) missing appointments

The correct answer is B: continuing drug use

Continuing to use the drug demonstrates lack of commitment to the treatment program. This fact must be understood by the nurse as part of the disease of addiction.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

33. The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?

A) Chronic vessel plaque formation

B) Pulmonary embolism

C) Occlusions at the vessel bifurcations

D) Coronary artery aneurysms

The correct answer is D: Coronary artery aneurysms

Kawasaki disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

34. The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize

A) the need for at least 5 servings of dairy products daily

B) restriction of fluid intake to less than 1 liter per day

C) the importance of walking as much as possible

D) early recognition of findings associated with tetany

The correct answer is C: the importance of walking as much as possible

Mobility must be emphasized to prevent demineralization and breakdown of bones.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

35. A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse would anticipate which of the following findings?

A) Lethargy

B) Heat intolerance

C) Diarrhea

D) Skin eruptions

The correct answer is A: Lethargy

In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption, decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client to complain of constipation, lethargy and an inability to get warm.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

36. When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?

A) Use medications to lower the temperature set point

B) Apply extra layers of clothing to prevent shivering

C) Immerse the child in a tub containing cool water

D) Give a tepid sponge bath prior to giving an antipyretic

The correct answer is A: Use medications to lower the temperature set point

Conditions such as infection, malignancy, allergy, central nervous system lesion and radiation cause the temperature set-point to be raised. Because the temperature set point is normal in hyperthermia and elevated in fever, different measures must be taken in order to be effective. The most effective intervention in the management of fever is the administration of antipyretics which lower the set point. Too rapid cooling of a febrile child can lead to seizure activity.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

37. The nurse should initiate discharge planning for a client

A) when the client or family demonstrate readiness to learn self care modalities

B) when informed that a date for discharge has been determined

C) upon admission to a hospital unit or the emergency room

D) when the client's condition is stabilized on the assigned unit

The correct answer is C: upon admission to a hospital unit or the emergency room

With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency room or hospital unit.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

38. What is the most important consideration when teaching parents how to reduce risks in the home?

A) Age and knowledge level of the parents

B) Proximity to emergency services

C) Number of children in the home

D) Age of children in the home

The correct answer is D: Age of children in the home

Age and developmental level of the child are most important considerations in providing a framework for anticipatory guidance.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

39. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?

A) "Name the year." "What season is this?" (pause for answer after each question)

B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number."

C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."

D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."

Recent memory is the ability to recall events in the immediate past and up to 2 weeks previously.

Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

40. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?

A) Respiratory rate of 42

B) Lethargy for the past hour

C) Apical pulse of 54

D) Coughing up copious secretions

The correct answer is A: Respiratory rate of 42

Signs of impending airway obstruction include increased respiratory rate and pulse; substernal, suprasternal and intercostal retractions; flaring nares; and increased restlessness or agitation.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.