prometric review

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2

CORRECTA nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3

CORRECTThe clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.

Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be

administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the

cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control

over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: 

Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: 

A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: 

A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen

supply.Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

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Practice Mode Exam Mode Text ModePractice Mode  – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam.Question 1

CORRECTAn adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status

of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when

demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third

will continue with symptoms into adulthood. Physical activity is an integral part of therapy

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status

of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.

If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.

Most children progress to adult rheumatoid arthritis.Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: 

Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-

limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall

or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when

demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

 child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status

of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has

ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.

Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.

Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.

It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity,

and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: 

The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: 

Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-

limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall

or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when

demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Question 20

CORRECTWhich of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.Elevate head of bed 30 degrees before meals.

Question 20 Explanation: It is specific in what to do and when.

Question 21WRONG

A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A Each child has a 1 in 4 (25%) chance of developing the disorder.Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.

D Sons only have a 1 in 4 (25%) chance of developing the disorder.

Question 21 Explanation: The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.

Question 22CORRECT

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Self-destructive behavior

B Ritualistic behavior

C psychomotor retardationImpulsivenessLability of mood

Question 23WRONG

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 24CORRECT

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Parent support groups are helpful for sharing strategies and managing health care issues.Regular developmental screening is important to avoid secondary developmental delays.

C Developmental milestones may be slightly delayed but usually will require no additional interventionCerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.

Question 24 Explanation: Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be

loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Question 20CORRECT

Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.Elevate head of bed 30 degrees before meals.

Question 20 Explanation: It is specific in what to do and when.

Question 21WRONG

A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A Each child has a 1 in 4 (25%) chance of developing the disorder.Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.

D Sons only have a 1 in 4 (25%) chance of developing the disorder.

Question 21 Explanation: The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.

Question 22CORRECT

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Self-destructive behaviorB Ritualistic behavior

C psychomotor retardationImpulsivenessLability of mood

Question 23WRONG

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 24CORRECT

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Parent support groups are helpful for sharing strategies and managing health care issues.Regular developmental screening is important to avoid secondary developmental delays.

C Developmental milestones may be slightly delayed but usually will require no additional interventionCerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.

Question 24 Explanation: Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

Question 25CORRECT

A child is admitted to the hospital with a diagnosis of Wilm's tumor, stage II. Which of the following statements most accurately describes this stage?

A The tumor has spread into the abdominal cavity and cannot be resected.The tumor extended beyond the kidney but was completely resected.

C The tumor is less than 3 cm. in size and requires no chemotherapy.

D The tumor did not extend beyond the kidney and was completely resected.

Question 25 Explanation: The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

Question 26CORRECT

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?

A Use antibacterial ointment to treat skin lesions at risk of infection.Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.Question 26 Explanation: Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status

of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has

ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: 

Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Question 20CORRECT

Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.Elevate head of bed 30 degrees before meals.

Question 20 Explanation: It is specific in what to do and when.

Question 21WRONG

A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A Each child has a 1 in 4 (25%) chance of developing the disorder.Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.

D Sons only have a 1 in 4 (25%) chance of developing the disorder.

Question 21 Explanation: The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.

Question 22CORRECT

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Self-destructive behaviorB Ritualistic behavior

C psychomotor retardationImpulsivenessLability of mood

Question 23WRONG

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 24CORRECT

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Parent support groups are helpful for sharing strategies and managing health care issues.Regular developmental screening is important to avoid secondary developmental delays.

C Developmental milestones may be slightly delayed but usually will require no additional interventionCerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.

Question 24 Explanation: Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

Question 25CORRECT

A child is admitted to the hospital with a diagnosis of Wilm's tumor, stage II. Which of the following statements most accurately describes this stage?

A The tumor has spread into the abdominal cavity and cannot be resected.The tumor extended beyond the kidney but was completely resected.

C The tumor is less than 3 cm. in size and requires no chemotherapy.

D The tumor did not extend beyond the kidney and was completely resected.

Question 25 Explanation: The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

Question 26CORRECT

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?

A Use antibacterial ointment to treat skin lesions at risk of infection.Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.Question 26 Explanation: Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

Question 27WRONG

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”“I should empty my ostomy pouch of urine when it is full.”

C “I can place an aspirin tablet in my pouch to decrease odor.”

D “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”“I must use a skin barrier to protect my skin from urine.”

Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s sign

B Fetal heart rate detected by nonelectric deviceBraxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above

the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinks

Place the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.

Inadequate tissue perfusion leading to nerve damage.Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: 

Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Question 20CORRECT

Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.Elevate head of bed 30 degrees before meals.

Question 20 Explanation: 

It is specific in what to do and when.

Question 21WRONG

A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A Each child has a 1 in 4 (25%) chance of developing the disorder.Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.

D Sons only have a 1 in 4 (25%) chance of developing the disorder.

Question 21 Explanation: The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.

Question 22CORRECT

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Self-destructive behaviorB Ritualistic behavior

C psychomotor retardationImpulsivenessLability of mood

Question 23WRONG

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 24CORRECT

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Parent support groups are helpful for sharing strategies and managing health care issues.Regular developmental screening is important to avoid secondary developmental delays.

C Developmental milestones may be slightly delayed but usually will require no additional interventionCerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.

Question 24 Explanation: Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

Question 25CORRECT

A child is admitted to the hospital with a diagnosis of Wilm's tumor, stage II. Which of the following statements most accurately describes this stage?

A The tumor has spread into the abdominal cavity and cannot be resected.The tumor extended beyond the kidney but was completely resected.

C The tumor is less than 3 cm. in size and requires no chemotherapy.

D The tumor did not extend beyond the kidney and was completely resected.

Question 25 Explanation: The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

Question 26CORRECT

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?

A Use antibacterial ointment to treat skin lesions at risk of infection.Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.Question 26 Explanation: Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

Question 27WRONG

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”“I should empty my ostomy pouch of urine when it is full.”

C “I can place an aspirin tablet in my pouch to decrease odor.”

D “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”“I must use a skin barrier to protect my skin from urine.”

Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not

limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

Question 28WRONG

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

The client has no remorse about the inability to control his anger.The client has a history of parental alcoholism and chaotic, abusive family life.The degree of aggressiveness is out of proportion to the stressor.

D The violent behavior is most often justified by the stressor.The client functions well in other areas of his life.

Question 28 Explanation: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.

Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.

It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: 

Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12

CORRECTAn infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: 

The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: 

Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Question 20CORRECT

Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.Elevate head of bed 30 degrees before meals.

Question 20 Explanation: It is specific in what to do and when.

Question 21WRONG

A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A Each child has a 1 in 4 (25%) chance of developing the disorder.Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.

D Sons only have a 1 in 4 (25%) chance of developing the disorder.

Question 21 Explanation: The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.

Question 22CORRECT

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline

personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Self-destructive behaviorB Ritualistic behavior

C psychomotor retardationImpulsivenessLability of mood

Question 23WRONG

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 24CORRECT

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Parent support groups are helpful for sharing strategies and managing health care issues.Regular developmental screening is important to avoid secondary developmental delays.

C Developmental milestones may be slightly delayed but usually will require no additional interventionCerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.

Question 24 Explanation: 

Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

Question 25CORRECT

A child is admitted to the hospital with a diagnosis of Wilm's tumor, stage II. Which of the following statements most accurately describes this stage?

A The tumor has spread into the abdominal cavity and cannot be resected.The tumor extended beyond the kidney but was completely resected.

C The tumor is less than 3 cm. in size and requires no chemotherapy.

D The tumor did not extend beyond the kidney and was completely resected.

Question 25 Explanation: The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

Question 26CORRECT

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?

A Use antibacterial ointment to treat skin lesions at risk of infection.Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.Question 26 Explanation: Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

Question 27

WRONGThe nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”“I should empty my ostomy pouch of urine when it is full.”

C “I can place an aspirin tablet in my pouch to decrease odor.”

D “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”“I must use a skin barrier to protect my skin from urine.”

Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

Question 28WRONG

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

The client has no remorse about the inability to control his anger.The client has a history of parental alcoholism and chaotic, abusive family life.The degree of aggressiveness is out of proportion to the stressor.

D The violent behavior is most often justified by the stressor.The client functions well in other areas of his life.

Question 28 Explanation: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of

proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

Question 29CORRECT

A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?

A Possible fracture of the radius.Possible fracture of the tibia.

C Bruising of the gastrocnemius muscle.

D No anatomic injury, the child wants his mother to carry him.Question 29 Explanation: The child's refusal to walk, combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign injury to be carried, and swelling indicates a physical injury

Question 1CORRECT

An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

The student experiences pain in the inferior aspect of the knee.

B The student is trying to avoid participation in physical education.

C The condition was caused by the student's competitive swimming schedule.

D The student will most likely require surgical intervention.Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-

limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

Question 2CORRECT

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

Chadwick’s signB Fetal heart rate detected by nonelectric device

Braxton Hicks contractionsUterine enlargementBallottement

F Outline of the fetus via radiography or ultrasoundQuestion 2 Explanation: The probable signs of pregnancy include: -Uterine Enlargement -Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. -Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month -Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. -Ballottement or rebounding of the fetus against the examiner’s fingers of palpation -Braxton-Hicks contractions -Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: -Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks -Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3CORRECT

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A Hypostatic blood pressure.Scoliosis

C Spinal flexibility.

D Leg length disparity.Question 3 Explanation: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam.

Question 4CORRECT

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A Congestive heart failure due to fluid overload.Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosisQuestion 4 Explanation: In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 5CORRECT

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

B Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.Inspect the insertion site for swelling, erythema, or drainage.If unable to aspirate blood, reposition the client and encourage the client to cough.Contact the health care provider about verifying placement if the status is questionable.

Question 5 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall

or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 6WRONG

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impactionAdminister antihypertensive medicationPlace the client in a supine position with legs elevatedElevate the HOB to 90 degreesUse a fan to reduce diaphoresisLoosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Question 7WRONG

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? (Choose 3 answers)

It is a result of tissue hypoxia.It is characterized by cramping and weakness.It is characterized by pain that often occurs duing rest.It results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when

demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

Question 8WRONG

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. (Select all that apply.)

Check the peritoneal dialysis system for kinksPlace the client in good body alignmentContact the physicianCheck the level of the drainage bagReposition the client to his or her side.

Question 8 Explanation: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question 9WRONG

A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

A Physical activity should be minimized.Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

C The child has a poor chance of recovery without joint deformity.Most children progress to adult rheumatoid arthritis.

Question 9 Explanation: Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy

Question 10CORRECT

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?

A Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.Inadequate tissue perfusion leading to nerve damage.

Question 10 Explanation: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

Question 11CORRECT

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate?Select all that apply.

Head tiltVomiting

C Polydipsia

D Increased pulseLethargy

F Increased appetiteQuestion 11 Explanation: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

Question 12CORRECT

An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A Referral to a surgeon for repair.

B Keeping the infant in a flat, supine position until the fluid is gone.No treatment is necessary; the fluid is reabsorbing normally.

D Massaging the groin area twice a day until the fluid is gone.Question 12 Explanation: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

Question 13WRONG

A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

An elderly woman.A young woman.

C An adolescent male.

D An elderly man.Question 13 Explanation: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

Question 14WRONG

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Self-blame for the injury to the child.B Low self-esteem

C UnemploymentSingle status

Question 14 Explanation: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

Question 15WRONG

A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A complete blood count with differential is drawn.B The parents arrive.

C The admission orders are written.A blood culture is drawn.

Question 15 Explanation: Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

Question 16WRONG

Which of the following conditions most commonly causes acute glomerulonephritis?Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.Prior infection with group A Streptococcus within the past 10-14 days.

D Nephrotic syndrome.Question 16 Explanation: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Question 17CORRECT

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

A Smoking

B AgeFamily history of heart disease.

D OverweightQuestion 17 Explanation: Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor

Question 18CORRECT

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

A Pain.

B Impaired Gas ExchangeActivity IntoleranceImbalanced Nutrition; Less than Body RequirementsExcess Fluid Volume

Question 18 Explanation: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

Question 19CORRECT

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct. (Choose 3 answer)

Urine specific gravity of 1.040B Generalized edema

Brown ("tea-colored") urineUrine output of 350 ml in 24 hours.

Question 19 Explanation: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

Question 20

CORRECTWhich of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.Elevate head of bed 30 degrees before meals.

Question 20 Explanation: It is specific in what to do and when.

Question 21WRONG

A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A Each child has a 1 in 4 (25%) chance of developing the disorder.Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.

D Sons only have a 1 in 4 (25%) chance of developing the disorder.

Question 21 Explanation: The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.

Question 22CORRECT

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

Self-destructive behavior

B Ritualistic behavior

C psychomotor retardationImpulsivenessLability of mood

Question 23WRONG

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.Cerebral hemorrhageResolution of the clot

Question 23 Explanation: Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

Question 24CORRECT

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Parent support groups are helpful for sharing strategies and managing health care issues.Regular developmental screening is important to avoid secondary developmental delays.

C Developmental milestones may be slightly delayed but usually will require no additional interventionCerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.

Question 24 Explanation: Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

Question 25CORRECT

A child is admitted to the hospital with a diagnosis of Wilm's tumor, stage II. Which of the following statements most accurately describes this stage?

A The tumor has spread into the abdominal cavity and cannot be resected.The tumor extended beyond the kidney but was completely resected.

C The tumor is less than 3 cm. in size and requires no chemotherapy.

D The tumor did not extend beyond the kidney and was completely resected.

Question 25 Explanation: The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

Question 26CORRECT

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?

A Use antibacterial ointment to treat skin lesions at risk of infection.Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.Question 26 Explanation: Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

Question 27WRONG

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“I can usually keep my ostomy pouch on for 3 to 7 days

before changing it.”“I should empty my ostomy pouch of urine when it is full.”

C “I can place an aspirin tablet in my pouch to decrease odor.”

D “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”“I must use a skin barrier to protect my skin from urine.”

Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

Question 28WRONG

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

The client has no remorse about the inability to control his anger.The client has a history of parental alcoholism and chaotic, abusive family life.The degree of aggressiveness is out of proportion to the stressor.

D The violent behavior is most often justified by the stressor.The client functions well in other areas of his life.

Question 28 Explanation: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

Question 29CORRECT

A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?

A Possible fracture of the radius.Possible fracture of the tibia.

C Bruising of the gastrocnemius muscle.

D No anatomic injury, the child wants his mother to carry him.Question 29 Explanation: The child's refusal to walk, combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign injury to be carried, and swelling indicates a physical injury.

Question 30CORRECT

An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?

A Hydrocephalus, with increased head size

B Plagiocephaly, with flattening of one side of the head.

C Craniosynostosis, with premature closure of the cranial sutures.Torticollis, with shortening of the sternocleidomastoid muscle.

Question 30 Explanation: In torticollis, the sternocleidomastoid muscle is contracted, limiting range of motion of the neck and causing the chin to point to the opposing side. In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape. Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time. Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size.