NCLEX practice #8

1. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?

A) Altered tissue perfusion

B) Risk for fluid volume deficit

C) High risk for hemorrhage

D) Risk for infection

The correct answer is D: Risk for infection

Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.

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

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

2. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to

A) convince the client that the hospital staff is trying to help

B) help the client to enter into group recreational activities

C) provide interactions to help the client learn to trust staff

D) arrange the environment to limit the client’s contact with other clients

The correct answer is C: provide interactions to help the client learn to trust staff

Establishing trust helps clients feel safer, and facilitates a therapeutic alliance between staff and client.

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.

3. A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should

A) Expose the cast to air and turn the child frequently

B) Use a heat lamp to reduce the drying time

C) Handle the cast with the abductor bar

D) Turn the child as little as possible

The correct answer is A: Expose the cast to air and turn the child frequently

The child should be turned every two hours, with the cast''s surface exposed to the air.

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.

4. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend _________ exercises

A) isometric

B) range of motion

C) aerobic

D) isotonic

The correct answer is A: isometric

The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.

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

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

5. A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?

A) Use only cloth diapers that are rinsed in bleach

B) Do not use occlusive ointments on the rash

C) Use commercial baby wipes with each diaper change

D) Discontinue a new food that was added to the infant's diet just prior to the rash

The correct answer is D: Discontinue a new food that was added to the infant''s diet just prior to the rash

The addition of new foods to the infant''s diet can be a cause of diaper dermatitis.

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.

6. The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect?

A) confusion

B) loss of half of visual field

C) shallow respirations

D) tonic-clonic seizures

The correct answer is C: shallow respirations

ALS is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.

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.

7. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?

A) Institute seizure precautions

B) Weigh the child twice per shift

C) Encourage the child to eat protein-rich foods

D) Relieve boredom through physical activity

The correct answer is A: Institute seizure precautions

The severity of the acute phase of AGN is variable and unpredictable; therefore a child with edema, hypertension, and gross hematuria may be subject to complications. Anticipatory preparation such as seizure precautions are needed.

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.

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

8. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

A) "Focus on your sons' needs during the first days at home."

B) "Tell each child what he can do to help with the baby."

C) "Suggest that your husband spend more time with the boys."

D) "Ask the children what they would like to do for the newborn."

The correct answer is A: "Focus on your sons'' needs during the first days at home."

In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

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.

9. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mg of Lidocaine/minute?

A) 60 microdrops/minute

B) 20 microdrops/minute

C) 30 microdrops/minute

D) 40 microdrops/minute

The correct answer is A: 60 microdrops/minute

2 gm=2000 mg

2000 mgm/500 cc = 4 mg/x cc

2000x = 2000

x= 2000/2000 = 1 cc of IV solution/minute

CC x 60 microdrops = 60 microdrops/minute

Olsen, J.L., Giangrasso, A.P., and Shrimpton, D. (2004). Medical Dosage Calculations. (8th Edition). Upper Saddle River, New Jersey: Pearson Prentice Hall.

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

10. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

A) Raise the head of the bed at least 30 degrees

B) Encourage ambulation within 24 hours

C) Maintain in a flat position, logrolling as needed

D) Encourage leg contraction and relaxation after 48 hours

The correct answer is C: Maintain in a flat position, logrolling as needed

The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn the client who is on bed rest.

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.

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

11. Which behavioral characteristic describes the domestic abuser?

A) Alcoholic

B) Over confident

C) High tolerance for frustrations

D) Low self-esteem

The correct answer is D: Low self-esteem

Batterers were usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.

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. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

A) unequal leg length

B) limited adduction

C) diminished femoral pulses

D) symmetrical gluteal folds

The correct answer is A: unequal leg length

Shortening of the affected leg is a sign of developmental dysplasia of the hip.

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.

13. A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect?

A) Oculogyric crisis

B) Tardive dyskinesia

C) Nystagmus

D) Dysphagia

The correct answer is A: Oculogyric crisis

This refers to involuntary muscles spasm of the eye. There are medications to treat these side effects, for example Artane.

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

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

14. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

A) Give the client orientation materials and review the unit rules and regulations

B) Introduce him/herself and accompany the client to the client’s room

C) Take the client to the day room and introduce her to the other clients

D) Ask the nursing assistant to get the client’s vital signs and complete the admission search

The correct answer is B: Introduce him/herself and accompany the client to the client’s room

Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.

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. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would

A) assist the client to use the bedside commode

B) administer stool softeners every day as ordered

C) administer antidysrhythmics prn as ordered

D) maintain the client on strict bed rest

The correct answer is B: administer stool softeners every day as ordered

Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation (the Valsalva maneuver) produced rhythm disturbances, then antidysrhythmics would be appropriate.

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.

16. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?

A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior."

B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"

C) "Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs."

D) "You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done."

The correct answer is B: "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"

This response encourages the client to get in touch with their feelings and utilize problem solving steps to reduce guilt 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.

17. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?

A) Ask the client if he has noticed any bleeding or dark stools

B) Tell the client to call 911 and go to the emergency department immediately

C) Schedule a repeat Hemoglobin and Hematocrit in 1 month

D) Tell the client to schedule an appointment with a hematologist

The correct answer is A: Ask the client if he has noticed any bleeding or dark stools

Normal hemoglobin for males is 13.0 - 18 g/100 ml. Normal hematocrit for males is 42 - 52%. These values are below normal and indicate mild anemia. The first thing the nurse should do is ask the client if he''s noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

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.

18. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

A) has increased airway obstruction

B) has improved airway obstruction

C) needs to be suctioned

D) exhibits hyperventilation

The correct answer is A: has increased airway obstruction

The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, no data supports the need for suctioning.

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.

19. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

A) Check vital signs

B) Massage the fundus

C) Offer a bedpan

D) Check for perineal lacerations

The correct answer is B: Massage the fundus

The nurse’s first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.

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

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

20. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?

A) Norplant is safe and may be removed easily

B) Oral contraceptives should not be used by smokers

C) Depo-Provera is convenient with few side effects

D) The IUD gives protection from pregnancy and infection

The correct answer is B: Oral contraceptives should not be used by smokers

The use of oral contraceptives in a woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.

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.

21. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report

A) loss of consciousness

B) feeding problems

C) poor weight gain

D) fatigue with crying

The correct answer is A: loss of consciousness

While parents should report any of these findings, they need to call the provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages.

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.

22. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to

A) A social worker from the local hospital

B) A physical therapist to improve fine motor coordination

C) An activity therapist from the community center

D) Another client with diabetes mellitus and takes insulin

The correct answer is B: A physical therapist to improve fine motor coordination

A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.

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

Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing. Upper Saddle River, N.J.: Pearson Prentice Hall.

23. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the

A) surgical repair of a diseased coronary artery

B) placement of an automatic internal cardiac defibrillator

C) procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

D) non-invasive radiographic examination of the heart

The correct answer is C: procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass (CABG) is the surgical procedure to repair a diseased coronary artery.

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.

24. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: “We just don’t know how he caught the disease!” The nurse's response is based on an understanding that

A) AGN is a streptococcal infection that involves the kidney tubules

B) the disease is easily transmissible in schools and camps

C) the illness is usually associated with chronic respiratory infections

D) it is not "caught" but is a response to a previous B-hemolytic strep infection

The correct answer is D: it is not "caught" but is a response to a previous B-hemolytic strep infection

AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior, and is considered as a noninfectious renal disease.

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.

25. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?

A) Trust

B) Initiative

C) Independence

D) Self-esteem

The correct answer is C: Independence

In Erikson’s theory of development, toddlers struggle to assert independence. They often use the word “no” even when they mean yes. This stage is called autonomy versus shame and doubt

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

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

26. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?

A) "I have constant blurred vision."

B) "I can't see on my left side."

C) "I have to turn my head to see my room."

D) "I have specks floating in my eyes."

The correct answer is C: "I have to turn my head to see my room."

Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.

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

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

27. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight change at 6 months of age?

A) Double the birth weight

B) Triple the birth weight

C) Gain 6 ounces each week

D) Add 2 pounds each month

The correct answer is A: Double the birth weight

Although growth rates vary, infants normally double their birth weight by 6 months.

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.

28. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?

A) These side effects are common and should subside in a few days

B) The client is probably having an allergic reaction and should discontinue the drug

C) Taking the lithium on an empty stomach should decrease these symptoms

D) Decreasing dietary intake of sodium and fluids should minimize the side effects

The correct answer is A: These side effects are common and should subside in a few days

Nausea, metallic taste and fine hand tremors are common side effects that usually subside quickly. Informing clients of these possible reactions can help them tolerate these initial difficulties and continue taking the drug, obtaining therapeutic effects.

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

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

29. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?

A) "Nursing will help contract the uterus and reduce your risk of bleeding."

B) "Breastfeeding twins will take too much energy after the hemorrhage."

C) "The blood transfusion may increase the risks to you and the babies."

D) "Lactation should be delayed until the "real milk" is secreted."

The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding."

Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.

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

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

30. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing

A) "This position of my lips helps to keep my airway open."

B) "I can expel more when I pucker up my lips to breathe out."

C) "My mouth doesn't get as dry when I breathe with pursed lips."

D) "With prolonging breathing out with pursed lips the little areas in my lungs don't collapse."

The correct answer is D: "With prolonging breathing out with pursed lips the little areas in my lungs don''t collapse."

Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of the weak alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the major reason to use it. The other options are secondary beneficial effects of pursed-lip breathing.

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

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

31. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

A) Review the client's weight pattern over the year

B) Ask the mother to record her diet for the last 24 hours

C) Encourage her to talk about her view of herself

D) Give her several pamphlets on postpartum nutrition

The correct answer is C: Encourage her to talk about her view of herself

To an adolescent, body image is very important. The nurse must acknowledge this before assessment and teaching.

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.

32. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of "suppression"?

A) "I don't remember anything about what happened to me."

B) "I'd rather not talk about it right now."

C) "It's all the other guy's fault! He was going too fast."

D) "My mother is heartbroken about this."

The correct answer is A: "I don''t remember anything about what happened to me."

Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion, "voluntary forgetting," is generally used to protect one’s own self esteem.

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

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

33. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

A) Place pillows under the knees

B) Use elastic stockings continuously

C) Encourage range of motion and ambulation

D) Massage the legs twice daily

The correct answer is C: Encourage range of motion and ambulation

Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.

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.

34. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse would be to inform them that

A) circumcision is delayed so the foreskin can be used for the surgical repair

B) this procedure is contraindicated because of the permanent defect

C) there is no medical indication for performing a circumcision on any child

D) the procedure should be performed as soon as the infant is stable

The correct answer is A: circumcision is delayed so the foreskin can be used for the surgical repair

Even if only mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair if needed.

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.

35. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is

A) Progressive failure to adapt

B) Feelings of anger or hostility

C) Reunion wish or fantasy

D) Feelings of alienation or isolation

The correct answer is D: Feelings of alienation or isolation

The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self imposed or can occur as a result of the inability to express feelings. At this stage of development it is important to achieve a sense of identity and peer acceptance.

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 client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would

A) instruct the client to maintain a regular diet the day prior to the examination

B) restrict the client's fluid intake 4 hours prior to the examination

C) administer a laxative to the client the evening before the examination

D) inform the client that only 1 x-ray of his abdomen is necessary

The correct answer is C: administer a laxative to the client the evening before the examination

Bowel prep is important because it will allow greater visualization of the bladder and ureters.

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.

37. The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is

A) re-orientation to reality

B) elimination of symptoms

C) protection from harm to self or others

D) return to independent functioning

The correct answer is C: protection from harm to self or others

Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.

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.

38. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?

A) 3 episodes of vomiting in 1 hour

B) Periodic crying and irritability

C) Vigorous sucking on a pacifier

D) No measurable voiding in 4 hours

The correct answer is D: No measurable voiding in 4 hours

The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.

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.

39. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

A) a cerebral vascular accident

B) postoperative meningitis

C) medication reaction

D) metabolic alkalosis

The correct answer is A: a cerebral vascular accident

Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

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.

40. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize

A) they can expect the child will be mentally retarded

B) administration of thyroid hormone will prevent problems

C) this rare problem is always hereditary

D) physical growth/development will be delayed

The correct answer is B: administration of thyroid hormone will prevent problems

Early identification and continued treatment with hormone replacement corrects this condition.

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.