The nurse is has just admitted a client with severe depression. From which focus should
the nurse identify a priority nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety - Answers- D: Safety
While explaining an illness to a 10 year-old, what should the nurse keep in mind about
the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences - Answers- B: Think logically in
organizing facts
The nurse enters the room as a 3 year-old is having a generalized seizure. Which
intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant - Answers- B: Place the child on the side
Which playroom activities should the nurse organize for a small group of 7 year-old
hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs - Answers- A) Sports and games with rules
The nurse is discussing dietary intake with an adolescent who has acne. The most
appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate." - Answers- A) "Eat a
balanced diet for your age."
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the
nurse about how it is determined that a person has AIDS other than a positive HIV test.
The nurse responds
A) "The complaints of at least 3 common findings."
B) "The absence of any opportunistic infection."
C) "CD4 lymphocyte count is less than 200."
,D) "Developmental delays in children." - Answers- C) "CD4 lymphocyte count is less
than 200."
The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns - Answers- D: Observe swallowing patterns
A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse
that she has everything ready for the baby and has made plans for the first weeks
together at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy - Answers- C: Anticipation of the birth
The nurse is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in removing respiratory secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
C) Maintaining bed rest with bathroom privileges
D) Performing chest physiotherapy twice a day - Answers- B: Increasing oral fluid
intake to 3000 cc per day
15. The nurse in a well-child clinic examines many children on a daily basis. Which of
the following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sip cup - Answers- D: A 30 month-old only
drinking from a sip cup
Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration - Answers- D: Observe a return demonstration
A client has developed thrombophlebitis of the left leg. Which nursing intervention
should be given the highest priority?
A) Elevate leg on 2 pillows
B) Apply support stockings
C) Apply warm compresses
, D) Maintain complete bed rest - Answers- A: Elevate leg on 2 pillows
A nurse from the surgical department is reassigned to the pediatric unit. The charge
nurse should recognize that the child at highest risk for cardiac arrest and is the least
likely to be assigned to
this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma - Answers- C: Prolonged hypoxemia
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) An occupational therapist from the community center
C) A physical therapist from the rehabilitation agency
D) Another client with diabetes mellitus and takes insulin - Answers- B: An occupational
therapist from the community center
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 - Answers- C: Protection from self harm and
harm to others
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
A) Isometric
B) Range of motion
C) Aerobic
D) Isotonic - Answers- A: Isometric
The nurse is reviewing a depressed client's history from an earlier admission.
Documentation of anhedonia is noted. The nurse understands that this finding refers to
A) Reports of difficulty falling and staying asleep
B) Expression of persistent suicidal thoughts
C) Lack of enjoyment in usual pleasures
D) Reduced senses of taste and smell - Answers- C: Lack of enjoyment in usual
pleasures
A client has just returned to the medical-surgical unit following a segmental lung
resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cough
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