NCLEX practice #5

1. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to

A) dehydration

B) diminished blood volume

C) decreased cardiac output

D) renal failure

The correct answer is C: decreased cardiac output

Cardiac output and urinary output are directly correlated. The nurse should suspect a drop in cardiac output if the urinary output drops.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

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

2. When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?

A) Try to vigorously stimulate normal breathing

B) Ask the RN to assess the vital signs

C) Measure the pulse oximetry

D) Continue to monitor respirations

The correct answer is D: Continue to monitor respirations

12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause for concern. At that point pulse oximetry is taken to determine whether that rate is providing sufficient oxygenation. Vigorous stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask the registered nurse (RN) to check the findings.

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

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

3. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?

A) Tell the parents to bring the child to the clinic for further evaluation

B) Refer the school officials to printed materials about this viral illness

C) Inform the teacher that the child is receiving antibiotics for the rash

D) Explain that this rash is not contagious and does not require isolation

The correct answer is D: Explain that this rash is not contagious and does not require isolation

Fifth Disease is a viral illness with an uncertain period of communicability (perhaps 1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the provider.

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.

4. The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the provider?

A) Lifts head from the prone position

B) Rolls from abdomen to back

C) Responds to parents' voices

D) Falls forward when sitting

The correct answer is D: Falls forward when sitting

Sitting without support is expected at this age.

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.

5. When a client is having a general tonic clonic seizure, the nurse should

A) hold the client's arms at their side

B) place the client on their side

C) insert a padded tongue blade in client's mouth

D) elevate the head of the bed

The correct answer is B: place the client on their side

This position keeps the airway patent and prevents aspiration.

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.

6. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

A) S3 heart sound

B) Thready pulse

C) Flattened neck veins

D) Hypoventilation

The correct answer is A: S3 heart sound

Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.

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

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

7. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?

A) follow-up on lab values before the visit

B) observe client findings for the effectiveness of antibiotics

C) ask for a log of urinary output

D) ask for the log of the oral intake

The correct answer is C: ask for a log of urinary output

The nurse must monitor the urine output as a priority because it is the best indictor of renal function. The other options would be appropriate after an evaluation of the urine output.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

8. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be

A) "Do you want to discuss this with your pastor?"

B) "We will help you deal with those thoughts."

C) "Is your life so terrible that you want to end it?"

D) "Have you thought about how you would do it?"

The correct answer is D: "Have you thought about how you would do it?"

This response provides an opening to discuss intent and means of committing suicide. It helps in assessing the severity of the risk, since clients who have formulated a suicide plan are closer to suicidal behavior than those who have had vague, non-specific thoughts.

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.

9. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?

A) Low tar cigarettes are less harmful during pregnancy

B) There is a relationship between smoking and low birth weight

C) The placenta serves as a barrier to nicotine

D) Moderate smoking is effective in weight control

The correct answer is B: There is a relationship between smoking and low birth weight

Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta previa, decreasing the growth potential of the fetus.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

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

10. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?

A) Hold the infant at frequent intervals.

B) Assess for neonatal withdrawal syndrome

C) Offer fluids to prevent dehydration

D) Administer paregoric to stop diarrhea

The correct answer is B: Assess for neonatal withdrawal syndrome

Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyper irritability and gastro-intestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the period of withdrawal.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

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

11. Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?

A) Direct confrontation

B) Reality orientation

C) Projective identification

D) Active listening

The correct answer is D: Active listening

Use of therapeutic communication skills such as silence and active listening encourages verbalization of feelings.

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.

12. Clients with mitral stenosis would likely manifest findings associated with congestion in the

A) pulmonary circulation

B) descending aorta

C) superior vena cava

D) bundle of His

The correct answer is A: pulmonary circulation

Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left ventricle and the lack of a competent valve to prevent back-flow into the pulmonary vein.

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.

13. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse should understand that adolescents with hemophilia _______.

A) must have structured activities

B) often take part in active sports

C) explain limitations to peer groups

D) avoid risks after bleeding episodes

The correct answer is B: often take part in active sports

An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of this age group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.

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.

14. When an autistic client begins to eat with her hands, the nurse can best handle the problem by

A) placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."

B) commenting, "I believe you know better than to eat with your hand."

C) jokingly stating, "Well I guess fingers sometimes work better than spoons."

D) removing the food and stating, "You can’t have anymore food until you use the spoon."

The correct answer is A: placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."

This response identifies instruction and verbal expectation with adaptive 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.

15. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?

A) The disease will incubate longer and progress more slowly in this infant

B) The infant is very susceptible to infections

C) Growth and development patterns will proceed at a normal rate

D) Careful monitoring of renal function is indicated

The correct answer is B: The infant is very susceptible to infections

HIV infected children are susceptible to opportunistic infections due to a compromised immune system.

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.

16. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

A) Arterial septal defect

B) Patent ductus arteriosus

C) Aortic stenosis

D) Ventricular septal defect

The correct answer is D: Ventricular septal defect

While assessments for conduction disturbance should be included following repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances.

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.

17. The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when

A) an individual displays restlessness

B) there are obvious signs of depression

C) conducting any health assessment

D) the resident reports memory lapses

The correct answer is C: conducting any health assessment

A mental status assessment is a critical part of baseline information, and should be a part of every examination.

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

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

18. While teaching a client about their medications, the client asks how long it will take before the therapeutic effects of lithium occur. What is the best response of the nurse?

A) Immediately

B) Several days

C) 2 weeks

D) 1 month

The correct answer is C: 2 weeks

Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s symptoms.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

19. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize

A) learning relaxation techniques

B) limiting alcohol use

C) eating smaller meals

D) avoiding passive smoke

The correct answer is A: learning relaxation techniques

The only factor that can enhance the client''s response to pain medication for angina is reducing anxiety through relaxation methods. Anxiety can be great enough to make the pain medication totally ineffective.

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.

20. The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?

A) Younger siblings adapt very well

B) Visitation is helpful for both

C) The siblings may enjoy privacy

D) Those cared for at home cope better

The correct answer is B: Visitation is helpful for both

Contact with the ill child helps siblings understand the reasons for hospitalization and maintains their relationships.

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.

21. The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism?

A) Denial

B) Projection

C) Intellectualization

D) Rationalization

The correct answer is D: Rationalization

Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for unacceptable actions. Both the teller and the listener find the rationalizations more satisfactory than the reality.

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.

22. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?

A) Maintain a low sodium diet

B) Take a diuretic with lithium and avoid excessive fluids

C) Don't be overly concerned if feelings of depression occur

D) Come in for evaluation of serum lithium levels regularly

The correct answer is D: Come in for evaluation of serum lithium levels regularly

This is especially important during hot weather, which may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration. Diuretics should be avoided, as they could result in an increased serum lithium level. Excessive thirst is a common early finding that subsides over time but may recur. Initiation of treatment for elevated mood at times results in onset of a depressive episode that can be accompanied by risk for self-harm. Clients should be cautioned to report any symptoms of mood instability.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

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

23. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called

A) craving

B) crashing

C) outward bound

D) nodding out

The correct answer is B: crashing

Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling referred to as crashing.

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.

24. Clients taking which of the following drugs are at risk for depression?

A) Steroids

B) Diuretics

C) Folic acid

D) Aspirin

The correct answer is A: Steroids

Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples of drugs that can lead to ongoing side effects include: phenothiazines, corticosteroids, and reserpine.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

25. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these describes the normal pathway?

A) AV node, SA node, Bundle of His, Purkinje fibers

B) Purkinje fibers, SA node, AV node, Bundle of His

C) Bundle of His, Purkinje fibers, SA node , AV node

D) SA node, AV node, Bundle of His, Purkinje fibers

The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers

This is the pathway of a normal electrical impulse through the heart.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

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

26. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to

A) check for subcutaneous emphysema in the upper torso

B) reposition the client to improve the level of comfort

C) call the provider as soon as possible

D) check for any increase in the amount of thoracic drainage

The correct answer is A: check for subcutaneous emphysema in the upper torso

Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an air leak in the system. Thus the conclusion is that the problem is one of an air leak in the lung. This client may need to be returned to surgery to deal with the sustained air leak. Action by the provider is required to prevent further complications.

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

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

27. In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?

A) White patches

B) Green drainage

C) Reddened tissue

D) Eschar development

The correct answer is C: Reddened tissue

As the wound granulates, redness indicates healing.

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

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

28. The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is

A) pain

B) impaired gas exchange

C) cardiac output altered: decreased

D) fluid volume excess

The correct answer is C: cardiac output altered: decreased

All nursing interventions should be focused on improving cardiac output. Increasing cardiac output is the primary goal of therapy. Comfort will improve as the client improves and the respiratory status will improve as cardiac output increases.

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.

29. The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that

A) circumcision can be performed at any time

B) initial repair is delayed until 6-8 years of age

C) post-operative appearance will be normal

D) surgery will be performed in stages

The correct answer is D: surgery will be performed in stages

Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery.

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.

30. While planning care for a preschool aged child, the nurse takes developmental needs into consideration. Which of the following would be of the most concern to the nurse?

A) Playing imaginatively

B) Expressing shame

C) Identifying with family

D) Exploring the playroom

The correct answer is B: Expressing shame

Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage.

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.

31. The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

A) assess the client's airway

B) call for help

C) establish that the client is unresponsive

D) see if anyone saw the client fall

The correct answer is C: establish that the client is unresponsive

The first step in CPR is to establish responsiveness. The second is to call for help, and the third is to ensure an open airway.

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

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

32. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment, but I don’t want my husband to leave me." Which response by the nurse would assist the client?

A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can’t get well."

B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come."

C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an outpatient basis."

D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."

The correct answer is D: "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."

This response gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. Dependency issues are significant for the client, fostering ambivalence.

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. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response?

A) "You’ve made some decisions."

B) "Are you thinking about killing yourself?"

C) "I’m so glad to hear that you’ve made some decisions."

D) "You need to discuss your decisions with your therapist."

The correct answer is B: "Are you thinking about killing yourself?"

Sudden mood elevation and energy may signal increased risk of suicide. The nurse must validate suicidal ideation as a beginning step in evaluating seriousness of risk.

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.

34. What is the best way for the nurse to obtain the health history of a 14 year-old client?

A) Have the mother present to verify information

B) Allow an opportunity for the teen to express feelings

C) Use the same type of language as the adolescent

D) Focus the discussion of risk factors in the peer group

The correct answer is B: Allow an opportunity for the teen to express feelings

Adolescents need to express their feelings. Generally, they talk freely when given an opportunity and some privacy to do so.

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.

35. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include

A) pointing out inconsistencies in speech patterns to correct thought disorders

B) accepting client and the client's behavior unconditionally

C) encouraging dependency in order to develop ego controls

D) consistent limit-setting enforced 24 hours per day

The correct answer is D: consistent limit-setting enforced 24 hours per day

Treatment approaches that include restructuring the personality, assisting the person with advancing developmental level and setting limits for maladaptive behavior such as acting out.

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.

36. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next?

A) Give the medication as ordered

B) Call the provider to clarify the dose

C) Recognize that antibiotics are over-prescribed

D) Hold the medication as the dosage is too low

The correct answer is A: Give the medication as ordered

Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th 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.

37. A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is

A) Participative or democratic

B) Ultraliberal or communicative

C) Autocratic or authoritarian

D) Laissez faire or permissive

The correct answer is C: Autocratic or authoritarian

Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction, while a participative or democratic style is usually more successful on nursing units

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

Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

38. The nurse understands that one reason domestic violence remains extensively undetected is

A) few battered victims seek medical care

B) there is typically a series of minor, vague complaints

C) expenses due to police and court costs are prohibitive

D) very little knowledge is currently known about batterers and battering relationships

The correct answer is B: there is typically a series of minor, vague complaints

Signs of abuse may not be clearly manifested and include a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness. These may be covert indications of abuse that go undetected. Victim complaints may be vague reflecting their ambivalence about disclosing the abuse.

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.

39. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?

A) Have respiratory support equipment available

B) Immediately place her in the seclusion room

C) Assess the client for anxiety and agitation

D) Administer prn dose of IM antipsychotic medication

The correct answer is A: Have respiratory support equipment available

Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

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

40. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?

A) observe for edema proximal to the site

B) irrigate with 5 ml of 0.9% Normal Saline

C) palpate for a thrill over the fistula

D) check color and warmth in the extremity

The correct answer is C: palpate for a thrill over the fistula

To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. The other options are not related to evaluation of patency.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.