A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance Directives. This document specifies the client's
wishes
Question 2
You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing
assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for
A) Yourself
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
Review Information: The correct answer is:A) Yourself.
While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a
new admission. Only tasks that do not require independent judgment should be delegated.
3Question 3
A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of
the following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and restlessness.
,Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require
follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D+) "We notice muscle weakness and some unsteadiness."
Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that
clothing is tight is significant, and should be followed by additional assessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally
married and signed the consent form for treatment. What would be the appropriate INITIAL action by the
nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school
graduation, independent living or service in the military. Therefore, this client, who is married, has the legal
capacity of an adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the
following is an appropriate task for an Unlicensed Assistive Personnel (UAP)?
,A) Obtain a history of fluid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review Information: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with specific
instructions on what must be reported. Because the RN is responsible for all care-related decisions,only
implementation tasks should be assigned because they do not require independent judgment.
Question 7
The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse
suspect is related to this diagnosis?
A) Diagnosis of chickenpox six months ago
B) Exposure to strep throat in daycare last month
C) Treatment for ear infection two months ago
D) Episode of fungal skin infection last week
Review Information: The correct answer is:B) Exposure to strep throat in daycare last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent
rheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep
throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat.
Sometimes, such an infection has no clinical symptoms.
Question 8
When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action
by the nurse is to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcing the manipulative behavior
C) Confront the client regarding the negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or
supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through
supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-
client relationship.
, Question 9
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the
nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The
nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client's history of violence
D) Was necessary to maintain the therapeutic milieu of the unit
Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint.
Seclusion should only be used when there is an immediate threat of violence or threatening behavior.
Question 10
A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following
nursing diagnosis should have PRIORITY?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety
Review Information: The correct answer is:A) Pain related to ischemia.
Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood
pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and
increased preload, further increasing myocardial demands.
Question 11
The nurse manager who is responsible for hiring professional nursing staff is required to comply with the
Americans with Disabilities Act. The provisions of the law require the nurse manager to
A) Maintain an environment free from hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
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