Correct Answer: 3

NCLEX-PN Free questions

1. The parent of a preschooler with chickenpox asks the nurse about measures to make thechild comfortable. The nurse instructs the parent to avoid administering aspirin or anyother product that contains salicylates. When given to children with chickenpox, aspirinhas been linked to which disorder?

1. Guillain-Barré syndrome2. Rheumatic fever3. Reye's syndrome4. Scarlet fever

Correct Answer: 3

RATIONALES: Research shows a correlation between the use of aspirin during chickenpoxand the development of Reye's syndrome (a disorder characterized by brain and livertoxicity). Therefore, the nurse should instruct the parents to avoid administering aspirinor other products that contain salicylates and to consult the physician or pharmacistbefore administering any medication to a child with chickenpox. No research has found alink between aspirin use, chickenpox, and the development of Guillain-Barré syndrome,rheumatic fever, or scarlet fever.

2. A client is to have an epidural block to relieve labor pain. The nurse anticipates that theanesthesiologist will inject the anesthetic agent into the:

1. subarachnoid space.2. area between the subarachnoid space and the dura mater.3. area between the dura mater and the ligamentum flavum.4. ligamentum flavum.

Correct Answer: 3

RATIONALES: For an epidural block, the nurse should anticipate that the anesthesiologistwill inject a local anesthetic agent into the epidural space, located between the duramater and the ligamentum flavum in the lumbar region of the spinal column. Whenadministering a spinal block, the anesthesiologist injects the anesthetic agent into thesubarachnoid space. The ligamentum flavum and the area between the subarachnoidspace and the dura mater are inappropriate injection sites.

3. The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in fourdivided doses for a client with anorexia nervosa who weighs 25 kg. The medicationdispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How manymilliliters of solution should the nurse administer with each dose?

Correct Answer: 14

RATIONALES: To determine the total daily dosage, set up the following proportion:25 kg/X = 1 kg/56 mgX = 1,400 mg.Next, divide the daily dosage by four doses to determine the dose to administer every 6hours:X = 1,400 mg/4 dosesX = 350 mg/dose.The adolescent should receive 350 mg every 6 hours.Lastly, calculate the volume to give for each dose by setting up this proportion:X/350 mg = 5 ml/125 mgX = 14 ml.

4. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using apiston syringe. How should the nurse proceed?

1. Irrigate continuously until the solution becomes clear or all of the solution has been used.2. Moisten the area around the wound with normal saline after the irrigation.3. Apply a wet-to-dry dressing to the wound after the irrigation.4. Rapidly instill a stream of irrigating solution into the wound.

Correct Answer: 1

RATIONALES: To wash away tissue debris and drainage effectively, the nurse should irrigate thewound until the solution becomes clear or all of the solution has been used. After the irrigation,the nurse should dry the area around the wound; moistening it promotes microorganismgrowth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, ratherthan a wet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid orforceful instillation can damage tissues.As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nursecompletes an incident report based on the knowledge that identification of which of thefollowing is a goal of the report?

1. To reprimand the involved staff members for their actions

2. To identify the learning needs of staff to prevent incident recurrences

3. To reprimand the nurse-manager responsible for the unit

4. To hold people accountable for their actions Correct Answer: 2

RATIONALES: The purpose of an incident report is threefold: to identify ways to prevent incidentrecurrences, to identify patterns of care problems, and to identify facts surrounding eachincident. Incident reports aren't used to hold people accountable for their actions, to punishthose involved in the incident, or to punish the nurse-manager responsible for the unit.As a client progresses through pregnancy, she develops constipation. What is the primary causeof this problem during pregnancy?

1. Decreased appetite

2. Inadequate fluid intake

3. Prolonged gastric emptying

4. Reduced intestinal motility Correct Answer: 4

RATIONALES: During pregnancy, hormonal changes and mechanical pressure reduce motility inthe small intestine, enhancing water absorption and promoting constipation. Althoughdecreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute toconstipation, they aren't the primary cause.An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatmentapproach would be most effective for this client?

1. Administering insulin once per day

2. Administering multiple doses of insulin

3. Limiting dietary fat intake

4. Substituting an oral antidiabetic agent for insulin Correct Answer: 2

RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin doses achievesbetter control of the blood glucose level because it more closely simulates endogenous insulinrelease. A single daily dose of insulin wouldn't control this client's blood glucose level aseffectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level.An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receivean oral antidiabetic agent instead of insulin.A client is admitted to the health care facility with bowel obstruction secondary to colon cancer.The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds.Which step of the nursing process is the nurse performing?

1. Planning

2. Data collection

3. Evaluation

4. Implementation Correct Answer: 2

RATIONALES: During the data collection step of the nursing process, the nurse obtains theclient's health history, measures vital signs, and performs a physical examination to gather datafor use in formulating the nursing diagnoses. During the planning step, the nurse designsmethods to help resolve client problems and meet client needs. During evaluation, the nursedetermines the effectiveness of nursing interventions in achieving client goals. Duringimplementation, the nurse takes actions to meet the client's needs.The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child whohas just had abdominal surgery. When administering this drug, the nurse should use a needle ofwhich size?

1. 18G

2. 20G

3. 23G

4. 27G Correct Answer: 3

RATIONALES: For an infant, the nurse should use a needle with the smallest appropriate gaugefor the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle isappropriate.Which finding in a neonate suggests hypothermia?

1. Bradycardia

2. Hyperglycemia

3. Metabolic alkalosis

4. Shivering Correct Answer: 1

RATIONALES: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, nothyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates withhypothermia. Neonates typically don't shiver.Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urinespecimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nursewould expect the client to have which complaints?

1. Headache, blurred vision, and facial and extremity swelling

2. Abdominal pain, urinary frequency, and pedal edema

3. Diaphoresis, nystagmus, and dizziness

4. Lethargy, chest pain, and shortness of breath Correct Answer: 1

RATIONALES: The client is exhibiting signs of preeclampsia. In addition to hypertension andhyperreflexia, most preeclamptic clients have edema. Headache and blurred vision areindications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis,

nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with adiagnosis of preeclampsia.The nurse is performing a baseline assessment of a client's skin integrity. Which of the followingis a key assessment parameter?

1. Family history of pressure ulcers

2. Presence of existing pressure ulcers

3. Potential areas of pressure ulcer development

4. Overall risk of developing pressure ulcers Correct Answer: 4

RATIONALES: When assessing skin integrity, the overall risk potential for developing pressureulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areasfor development of pressure ulcers. Family history isn't important when assessing skin integrity.The nurse is preparing to boost a client up in bed. She instructs the client to use the overbedtrapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructingthe client to move in this manner?

1. Friction

2. Impaired circulation

3. Localized pressure

4. Shearing forces Correct Answer: 4

RATIONALES: Using a trapeze reduces shearing forces (opposing forces that cause layers of skinto move over each other, stretching and tearing capillaries and, eventually, resulting innecrosis), which increase the risk of pressure ulcer development. They can occur as clients slidedown in bed or when they're pulled up in bed. To reduce shearing forces, the nurse shouldinstruct the client to use an overbed trapeze, place a draw sheet under the client to move theclient up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction,impaired circulation, and localized pressure aren't decreased with trapeze use.A geriatric client with Alzheimer's disease has been living with his grown child's family for thelast 6 months. He wanders at night and needs help with activities of daily living. Whichstatement by his child suggests that the family is successfully adjusting to this livingarrangement?

1. "It's difficult dealing with Dad. It's a thankless job."

2. "We had no idea this would be so difficult. It's our cross to bear."

3. "Dad really seems to be making progress. We're hoping he'll be able to move back into hishouse soon."

4. "Dad has presented many challenges. We have alarms on all the outside doors now. Respitecare gives us a break." Correct Answer: 4

RATIONALES: This statement demonstrates a realistic understanding of the client's disorder andeffective family coping with the challenges it presents. Options 1 and 2 indicate that the familyis having difficulty adjusting. Option 3 suggests that the family is in denial or has an unrealisticview of the prognosis for a client with Alzheimer's disease.

The nurse is assessing an elderly client. When performing the assessment, the nurse shouldconsider that one normal age-related change is:

1. cloudy vision.

2. incontinence.

3. diminished reflexes.

4. tremors. Correct Answer: 3

RATIONALES: Degenerative changes can lead to decreased reflexes, which is a normal result ofaging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlyingpathology and shouldn't be considered normal results of aging.An agitated, confused client arrives in the emergency department. The client's history includestype 1 diabetes, hypertension, andangina pectoris. Assessment reveals pallor, diaphoresis,headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client istreated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treathypoglycemiaby ingesting:

1. 2 to 5 g of a simple carbohydrate.



4. 25 to 30 g of a simple carbohydrate. Correct Answer: 2

RATIONALES: To reverse hypoglycemia, the American Diabetes Association recommendsingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two tothree packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can berepeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the bloodglucose level sufficiently. Ingesting more than 15 g may raise it above normal, causinghyperglycemia.A 43-year-old man was transferring a load of firewood from his front driveway to his backyardwoodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stoppedworking and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wifetook him to the emergency department. Around 2 p.m., the emergency department physiciandiagnoses an anterior myocardial infarction (MI). The nurse should anticipate which immediateorder by the physician?

1. Lidocaine administration

2. Cardiac stress test

3. Serial liver enzyme testing

4. Tissue plasminogen activator (tPA)Correct Answer: 4

RATIONALES: If 6 hours or less have passed since the onset of symptoms related to MI,thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) Thepreferred choice is tPA. The client doesn't exhibit symptoms that indicate the use of lidocaine.Stress testing shouldn't be performed during the acute phase of an MI, but it may be orderedbefore discharge. Serial cardiac biomarkers, not serial liver enzymes, would be ordered for thisclient.

A nurse's neighbor complains of severe right flank pain. She explains that it began during thenight, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke,the pain increased in intensity. How should the nurse intervene?

1. Explain that she can't give medical advice.

2. Inform the neighbor that she might require surgery.

3. Advise the neighbor to seek medical attention.

4. Tell the neighbor that she'll be fine because she was able to get through the night. CorrectAnswer: 3

RATIONALES: The nurse should advise the neighbor to seek medical attention. Explaining thatshe can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope ofpractice to suggest that the neighbor might need surgery. Telling the neighbor she'll be finemight also delay treatment, and it isn't a professional response.A client has a history of chronic undifferentiated schizophrenia. Because she has a history ofnoncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (ProlixinDecanoate) injections every 4 weeks. Before discharge, what should the nurse include in herteaching plan?

1. Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms thatoccur

2. Sitting up for a few minutes before standing to minimize orthostatic hypotension

3. Notifying the physician if her thoughts don't normalize within 1 week

4. Expecting symptoms of tardive dyskinesia to occur and to be transient Correct Answer: 2

RATIONALES: The nurse should teach the client how to manage common adverse reactions,such as orthostatic hypotension and anticholinergic effects. The antipsychotic effects of thedrug may take several weeks to appear. Droperidol increases the risk ofextrapyramidal effectswhen given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is apossible adverse reaction and should be reported immediately.One day after being admitted with bipolar disorder, a client becomes verbally aggressive duringa group therapy session. Which response by the nurse would be therapeutic?

1. "You're behaving in an unacceptable manner, and you need to control yourself."

2. "If you continue to talk like that, no one will want to be around you."

3. "You're disturbing the other clients. I'll walk with you around the patio to help you releasesome of your energy."

4. "You're scaring everyone in the group. Leave the room immediately." Correct Answer: 3

RATIONALES: This response shows that the nurse finds the client's behavior unacceptable, yetstill regards the client as worthy of help. The other options give the false impression that theclient is in control of the behavior; the client hasn't been in treatment long enough to controlthe behavior.A client comes to the emergency department complaining of headache, malaise, chills, fever,and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart andrespiratory rates, and normal blood pressure. On physical examination, the nurse notes

confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What doesBrudzinski's sign indicate?

1. Increased intracranial pressure (ICP)

2. Cerebral edema

3. Low cerebrospinal fluid (CSF) pressure

4. Meningeal irritation Correct Answer: 4

RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs ofmeningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicateincreased ICP, cerebral edema, or low CSF pressure.During a routine examination, the nurse notes that the client seems unusually anxious. Anxietycan affect the genitourinary system by:

1. slowing the glomerular filtration rate.

2. increasing sodium resorption.

3. decreasing potassium excretion.

4. stimulating or hindering micturition. Correct Answer: 4

RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to causefrequent voiding and urinary urgency. However, when anxiety leads to generalized muscletension, it may hinder urination because the perineal muscles must relax to completemicturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, ordecrease potassium excretion.The nurse is advising a mother about foods to avoid to prevent choking in her toddler. Whichfoods should she include in her instruction?

1. Small pieces of banana

2. Large, round chunks of meat such as hot dog

3. Cooked vegetables such as lima beans and corn

4. Frozen desserts such as ice cream Correct Answer: 2

RATIONALES: The nurse should advise the mother to avoid giving her child large, round chunksof meat such as hot dog. The mother can safely give the toddler small pieces of banana; cookedvegetables, such as lima beans and corn; and frozen desserts such as ice cream.A client with a history of Addison's disease and flulike symptoms accompanied by nausea andvomiting over the past week is brought to the facility. The client's wife reports that she noticedthat he acted confused and was extremely weak when he woke up in the morning. The client'sblood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F(38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would thenurse expect to administer by I.V. infusion?

1. Insulin

2. Hydrocortisone

3. Potassium

4. Hypotonic saline Correct Answer: 2

RATIONALES: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V.infusion of hydrocortisone and saline solution. The client is usually given 100 mg ofhydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulinisn't indicated in this situation because adrenal insufficiency is usually associated withhypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. Theclient needs normal — not hypotonic — saline solution.A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the righthumerus. Which behavior most stronglysuggests that the child's injuries stem from abuse?

1. Trying to sit up on the stretcher

2. Trying to move away from the nurse

3. Not answering the nurse's questions

4. Not crying when moved Correct Answer: 4

RATIONALES: Not crying when moved most strongly suggests child abuse. A victim of childabuse typically doesn't complain of pain, even with obvious injuries, for fear of furtherdispleasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying tomove away from the nurse indicates fear of strangers, which is normal in a toddler. Difficultyanswering the nurse's questions is expected in a toddler because of poorly developed cognitiveskills.A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lockI.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and thephysician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at:

1. 7:30 a.m.

2. 6:30 a.m.

3. 9 a.m.

4. 9:30 a.m. Correct Answer: 1

RATIONALES: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach itsmaximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m., EMLA creamshould be applied at 7:30 a.m. Applying EMLA at 6:30 a.m. is too early. The other time optionsare too late for the local anesthetic to be effective.Which nursing action is essential when providing continuous enteral feeding?

1. Elevating the head of the bed at least 30 degrees

2. Positioning the client on the left side

3. Warming the formula before administering it

4. Hanging a full day's worth of formula at one time Correct Answer: 1

RATIONALES: Elevating the head of the bed at least 30 degrees during enteral feeding minimizesthe risk of aspiration and allows the formula to flow into the client's intestines. When suchelevation is contraindicated, the client should be positioned on the right side. The nurse shouldgive enteral feedings at room temperature to minimize GI distress. To limit microbial growth,the nurse should hang only the amount of formula that can be infused in 8 hours.When taking a dietary history from a newly admitted client, the nurse should remember thatwhich of the following foods is a commonallergen?

1. Bread

2. Carrots

3. Oranges

4. Strawberries Correct Answer: 4

RATIONALES: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish,and eggs. Bread, carrots, and oranges rarely cause allergic reactions.The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time dose for an infant withfluid overload. The infant's documented weight is 14 lb. The oral solution contains 10 mg/ml.How many milliliters of solution should the nurse administer? Correct Answer: 1.3

RATIONALES: To perform the dosage calculation, first convert the infant's weight from pounds tokilograms by setting up the following proportion:2.2 lb/1 kg = 14 lb/XX = 6.4 kg.Then perform the following calculation to determine the total dose prescribed:2 mg/kg = X/6.4 kgX = 12.8 mg.Then set up the following proportion to determine the volume of medication to administer:10 mg/ml = 12.8 mg/XX = 1.3 ml.For a client with Graves' disease, which nursing intervention promotes comfort?

1. Restricting intake of oral fluids

2. Placing extra blankets on the client's bed

3. Limiting intake of high-carbohydrate foods

4. Maintaining room temperature in the low-normal range Correct Answer: 4

RATIONALES: Graves' disease causes signs and symptoms of hypermetabolism, such as heatintolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heatintolerance and diaphoresis, the nurse should keep the client's room temperature in thelow-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, notrestrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerancewould cause discomfort. To provide needed energy and calories, the nurse should encouragethe client to eat high-carbohydrate foods.A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief thathe is:

1. highly important or famous.

2. being persecuted.

3. connected to events unrelated to himself.

4. responsible for the evil in the world. Correct Answer: 1

RATIONALES: A client with delusions of grandeur has a false belief that he is highly important orfamous. A delusion of persecution is a false belief that one is being persecuted. A delusion ofreference is a false belief that one is connected to events unrelated to oneself or a belief thatone is responsible for the evil in the world.A toddler is having a tonic-clonic seizure. What should the nurse do first?

1. Restrain the child.

2. Place a tongue blade in the child's mouth.

3. Remove objects from the child's surroundings.

4. Check the child's breathing. Correct Answer: 3

RATIONALES: During a seizure, the nurse's first priority is to protect the child from injury. Toprevent injury caused by uncontrolled movements, the nurse must remove objects from thechild's surroundings and pad objects that can't be removed. Restraining the child or placing an

object in the child's mouth during a seizure may cause injury. Once the seizure stops, the nurseshould check for breathing and, if indicated, initiate rescue breathing.A 40-year-old client is admitted to the hospital for alcohol abuse for the third time in the past 9months. The health care team recommends rehabilitative treatment for this client. Why wasthis treatment recommended?

1. It's the only option for controlling alcohol consumption.

2. It helps the client identify a new group of friends.

3. It helps the client understand the effects of alcohol on his body.

4. It helps the client identify the relationship between his problems and alcohol consumption.Correct Answer: 4

RATIONALES: The purpose of rehabilitative treatment in alcoholism is to help the client identifythe relationship between his problems and his alcohol consumption. Rehabilitative treatmentpromotes abstinence, not limiting or controlling consumption. It isn't intended to help the clientidentify a new group of friends or understand the effects of alcohol on his body.A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the backroom, the waiter spits on the man's pizza. This is an example of a behavior typical of whichdisorder?

1. Obsessive-compulsive

2. Narcissistic

3. Passive-aggressive

4. Dependent Correct Answer: 3

RATIONALES: This is an example of a negative attitude and passive-aggressive behavior inresponse to demands for adequate performance. People with this disorder won't confront ordiscuss issues with others but will go to great lengths to "get even." Obsessive-compulsivedisorder involves rituals or rules that interfere with normal functioning. A person with anarcissistic personality has an exaggerated sense of self-worth. A person with a dependentpersonality is submissive and frequently apologizes and backs down when confronted.A client with end-stage acquired immunodeficiency syndrome (AIDS) has profoundmanifestations of Cryptosporidium infectioncaused by the protozoa. In planning the client'scare, the nurse should focus on his need for:

1. pain management.

2. fluid replacement.

3. antiretroviral therapy.

4. high-calorie nutrition. Correct Answer: 2

RATIONALES: The protozoal enteric infection caused by Cryptosporidium results in profusewatery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluidreplacement. Pain management is also a concern in the care of a client with AIDS. However,with Cryptosporidium, the main concern is hydration. Antiretroviral therapy is most useful whena client with human immunodeficiency virus (HIV) doesn't have opportunistic infections. With

the wasting associated with AIDS, high-calorie nutrition is important but withCryptosporidium-related diarrhea, hydration takes precedence.Following a small-bowel resection, a client develops fever and anemia. The surface surroundingthe surgical wound is warm to the touch and necrotizing fasciitis is suspected. Anothermanifestation that would most suggest necrotizing fasciitis is:

1. erythema.

2. leukocytosis.

3. pressurelike pain.

4. swelling. Correct Answer: 3

RATIONALES: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizingfasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis andnecrotizing fasciitis.A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirmthis diagnosis?

Select all that apply:

1. Severe, deep pain around the thorax

2. Red, nodular skin lesions around the thorax

3. Fever

4. Malaise

5. Diarrhea Correct Answer: 1,2,3,4

RATIONALES: Shingles, also called herpes zoster, is an acute unilateral and segmentalinflammation of the dorsal root ganglia. It's caused by infection with the herpes virusvaricella-zoster, the same virus that causes chickenpox. It commonly causes severe, deep painalong a peripheral nerve on the trunk of the body and red, nodular skin lesions. Fever andmalaise typically accompany these findings. Diarrhea doesn't commonly occur with shingles.A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. Thecharge nurse asks the LPN if she understands the facility's rules of ethical conduct. Whichstatement by the LPN indicates the need for further teaching?

1. "I make sure that I do everything in my client's best interest."

2. "I maintain client confidentiality at all times."

3. "I always support the Patient's Bill of Rights."

4. "I don't discuss advance directives unless the client initiates the conversation." CorrectAnswer: 4

RATIONALES: The law mandates that health care agencies ask all clients if they have an advancedirective. Therefore, the LPN must address this question regardless of whether the clientinitiates a conversation about it. Nurses must always act in the best interest of their clients,maintain confidentiality, and support the Patient's Bill of Rights.Which safety device is most restrictive for a client with dementia?

1. Walker

2. Childproof locks on cabinets and doors

3. Electronic monitoring system

4. Lap tray placed on a wheelchair Correct Answer: 4

RATIONALES: The goal of care for clients with dementia is to maintain the highest level offunctioning. When restraints must be used, the least restrictive type of restraint possible shouldbe used. A lap tray over a wheelchair severely limits the client's mobility and can cause injury ifthe client tries to get out of the wheelchair. A walker can be very helpful to clients withdementia as they commonly have unsteady gaits. Childproof locks are helpful in preventingaccidental contact with harmful substances. An electronic monitoring system is an effective wayof managing a client who wanders.The nurse is teaching parents how to reduce the spread of impetigo. The nurse shouldencourage parents to:

1. teach children to cover mouths and noses when they sneeze.

2. have their children immunized against impetigo.

3. teach children the importance of proper hand washing.

4. isolate the child with impetigo from other members of the family. Correct Answer: 3

RATIONALES: The spread of childhood infections, including impetigo, can be reduced whenchildren are taught proper hand-washing technique. Because impetigo is spread through directcontact, covering the mouth and nose when sneezing won't prevent its spread. Currently, thereis no vaccine to prevent a child from contracting impetigo. Isolating the child with impetigo isunnecessary.A diabetic client develops sinusitis and otitis media accompanied by a temperature of 100.8° F(38.2° C). What effect may these findings have on his need for insulin?

1. They will have no effect.

2. They will decrease the need for insulin.

3. They will increase the need for insulin.

4. They will cause wide fluctuations in the need for insulin. Correct Answer: 3

RATIONALES: Insulin requirements are increased by growth, pregnancy, increased food intake,stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulinrequirements are decreased by hypothyroidism, decreased food intake, exercise, and somemedications.A school-age child with terminal leukemia is admitted to the pediatric unit. The nurse mustdiscuss advance directives with the child's parents. The nurse should include whichinformation?

1. Positive appraisal of the child's prognosis

2. Chemotherapy options

3. Comfort care options

4. Bone marrow transplantation informationCorrect Answer: 3

RATIONALES: The nurse shouldn't give a positive appraisal of the child's prognosis becausedoing so gives the parents false hope. The nurse must be honest about the child's prognosis andprovide them accurate information about treatment options, which include palliative care,comfort care, and pain management. The physician — not the nurse — should discuss suchtreatment options as chemotherapy or bone marrow transplantation, if indicated.A client is scheduled for surgery under general anesthesia. The night before surgery, the clienttells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurseshould formulate which nursing diagnosis?

1. Deficient knowledge related to food restrictions associated with anesthesia

2. Fear related to surgery

3. Risk for impaired skin integrity related to upcoming surgery

4. Ineffective coping related to the stress of surgery Correct Answer: 1

RATIONALES: The client's statement reveals a Deficient knowledge related to food restrictionsassociated with general anesthesia.The other options may be applicable but aren't related tothe client's statement.

The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs.During dressing changes, the nurse should be sure to:

1. apply maximum bandages to allow for absorption of drainage.

2. wrap elastic bandages distally to proximally on dependent areas.

3. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return.

4. put on sterile gloves only when removing bandages. Correct Answer: 2

RATIONALES: Wrapping elastic bandages on dependent areas limits edema formation andbleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs fromthe distal to proximal ends and use strict sterile technique throughout the dressing change.Applying maximum bandages should be avoided because bulky dressings limit mobility; instead,the nurse should use enough bandages to absorb wound drainage. Sterile gloves are requiredthroughout all phases of the dressing change to prevent contamination.A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:

1. milk and ice pops.

2. decaffeinated coffee and scrambled eggs.

3. tea and gelatin dessert.

4. apple juice and oatmeal. Correct Answer: 3

RATIONALES: A clear liquid diet consists of foods that are clear liquids at room temperature orbody temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts,carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal arepart of a full liquid diet.Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client'suremia. Which finding signals a significantproblem during this procedure?

1. Blood glucose level of 200 mg/dl

2. White blood cell (WBC) count of 20,000/mm3

3. Potassium level of 3.8 mEq/L

4. Hematocrit (HCT) of 35% Correct Answer: 2

RATIONALES: An increased WBC count indicates infection, probably resulting from peritonitis,which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity.Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore,peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occursduring peritoneal dialysis because of the high glucose content of the dialysate; it's readilytreatable with sliding-scale insulin. A potassium level of 3.8 mEq/L is an acceptable value. AnHCT of 35% is lower than normal. However, in this client, the value isn't abnormally low becauseof the daily blood samplings. A lower HCT is common in clients with chronic renal failurebecause of the lack of erythropoietin.The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of thefollowing is a normal developmental task for an infant this age?

1. Sitting without support

2. Saying two words

3. Feeding himself with a spoon

4. Playing patty-cake Correct Answer: 1

RATIONALES: According to the Denver Developmental Screening Test, most infants should beable to sit unsupported by age 7 months. A 15-month-old child should be able to say two words.By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infantshould be able to play patty-cake.The nurse is caring for a client with tuberculosis. Which precautions should the nurse take whenproviding care for this client?


1. Wear gloves when handling tissues containing sputum.

2. Wear a face mask at all times.

3. Keep the client in strict isolation.

4. When the client leaves the room for tests, have all people in contact with him wear a mask.

5. Keep the client's door open to allow fresh air into room and prevent social isolation.

6. Wash hands after direct contact with the client or contaminated articles. CorrectAnswer: 1,2,6

RATIONALES: The nurse should always wear gloves when handling items contaminated withsputum or body secretions. All staff and visitors must wear face masks when coming in contactwith the client in his room; masks must be discarded before leaving the client's room. Handwashing is required after direct contact with the client or contaminated articles. Strict isolationisn't required if the client adheres to special respiratory precautions. The client, not the peoplein contact with him, must wear a mask when leaving the room for tests. The client should be ina negative-pressure, private room, and the door should remain closed at all times to prevent thespread of infection.A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regionalanesthesia during labor and delivery. If she were to receive this form of anesthesia, she mightexperience:

1. hypotension.

2. hypertension.

3. seizures.

4. renal toxicity. Correct Answer: 1

RATIONALES: In a client with PIH, uteroplacental perfusion may be inadequate and gas exchangemay be poor. Regional anesthesia increases the risk of hypotension resulting from sympatheticblockade, possibly causing fetal and maternal hypoxia. Hypertension, seizures, and renal toxicityaren't associated with regional anesthesia.A postpartum client requires teaching about breast-feeding. To prevent breast engorgement,the nurse should instruct her to:

1. use an electric breast pump.

2. apply warm, moist compresses to the breasts.

3. breast-feed every 1½ to 3 hours.

4. wear a brassiere 24 hours per day. Correct Answer: 3

RATIONALES: Frequent breast-feeding empties the breasts and increases circulation, helping toremove fluid that may lead to engorgement. If the infant isn't ill or physically impaired and canbreast-feed, the client shouldn't use an electric breast pump because this deprives the infant ofoptimal sucking and skin-to-skin contact with the mother. Applying warm, moist compressesstimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. Abrassiere supports the breasts but doesn't prevent engorgement.A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should thenurse assess first?

1. Blood pressure

2. Respirations

3. Temperature

4. Cardiac rhythm Correct Answer: 4

RATIONALES: The nurse should assess the client's cardiac rhythm using electrocardiographybecause an elevated serum potassium level may lead to a life-threatening cardiac arrhythmia.The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, thenurse should assess blood pressure later. The nurse also can delay assessing respirations andtemperature because these aren't affected by the serum potassium level.A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "Youaren't sure if you should leave your husband?" The nurse is using which therapeutic technique?

1. Restating

2. Reframing

3. Reflecting

4. Offering a general lead Correct Answer: 3

RATIONALES: Reflecting is correct because the nurse is referring feelings back to the client toexplore. When restating, the nurse simply repeats what the client said. Reframing is offering anew way to look at a situation. The nurse's response is specific; it isn't offering a general lead.The nurse is teaching a client about malabsorption syndrome and its treatment. The client askswhich part of the GI tract absorbs food. The nurse tells the client that products of digestion areabsorbed mainly in the:

1. stomach.

2. small intestine.

3. large intestine.

4. rectum. Correct Answer: 2

RATIONALES: The small intestine absorbs products of digestion, completes food digestion, andsecretes hormones that help control the secretion of bile, pancreatic juice, and intestinalsecretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controlsfood passage into the duodenum; it doesn't absorb products of digestion. Although the largeintestine completes the absorption of water, chloride, and sodium, it plays no part in absorbingfood. The rectum is the portion of the large intestine that forms and expels feces from the body;its functions don't include absorption.Which interventions are appropriate when caring for a client with acute thrombophlebitis?

1. Apply cool soaks and keep the client's leg lower than the level of the heart.

2. Increase the client's activity level and encourage leg exercises.

3. Apply cool soaks and administer nitroglycerin.

4. Apply warm soaks and elevate the client's legs higher than the level of the heart. CorrectAnswer: 4

RATIONALES: To help treat thrombophlebitis, the nurse should prevent venostasis withmeasures such as applying warm soaks and elevating the client's legs. The client should remainon bed rest during the acute phase, after which the client may begin to walk while wearing

antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants toprolong clotting time.Damage to which area of the brain results in receptive aphasia?

1. Parietal lobe

2. Occipital lobe

3. Temporal lobe

4. Frontal lobe Correct Answer: 3

RATIONALES: The temporal lobe contains the auditory association area. If the area is damagedin the dominant hemisphere, the client hears words but doesn't know their meaning. Damageto the parietal lobe affects the client's ability to identify special relationships with theenvironment. When damaged, the occipital lobe affects visual associations. The client canvisualize objects but can't identify them. The frontal lobe acts as a storage area for memory.A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. Tohelp redirect the client's attention, the nurse should encourage the client to:

1. fold towels and pillowcases.

2. play cards with another client.

3. participate in a game of charades.

4. perform an aerobic exercise. Correct Answer: 1

RATIONALES: Folding towels and pillowcases is a simple activity that redirects the client'sattention. Also, because this activity is familiar, the client is likely to perform it successfully.Cards, charades, and aerobic exercise are too complicated for a confused client.The nurse is caring for a 16-year-old pregnant client who is taking an iron supplement. Whichinstruction should the nurse include when teaching the adolescent about ferrous sulfate?


1. Take the supplement with food.

2. Report black stools to the physician immediately.

3. Avoid taking the supplement with milk.

4. Avoid taking the supplement with antacids.

5. Avoid chewing the extended-release form of the drug. Correct Answer: 3,4,5

RATIONALES: Because food delays absorption, the nurse should instruct the client to take thesupplement between meals to increase absorption. The client should take the supplement withjuice (preferably orange juice) or water, but not with milk or antacids. The nurse should also tellthe client not to crush or chew extended-release forms of the drug.A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. Theclient has been wearing the same dirty clothes for several days. The nurse contacts the familyand asks them to bring in clean clothing. Which intervention would bestprevent furtherregression in the client's personal hygiene?

1. Encouraging the client to perform as much self-care as possible

2. Making the client assume responsibility for physical care

3. Assigning a staff member to take over the client's physical care

4. Accepting the client's desire to go without bathing Correct Answer: 1

RATIONALES: Clients with Alzheimer's-type dementia tend to fluctuate in their capabilities.Encouraging self-care to the extent possible helps increase the client's orientation and promotesa trusting relationship with the nurse. Making the client assume responsibility for physical careis unreasonable. Assigning a staff member to take over the client's physical care restricts theclient's independence. Accepting the client's desire to go without bathing promotes poorhygiene.A client, age 20, is being treated for depression. During a conversation with the nurse, she statesthat her father raped her when she was 7 years old. She says she has nightmares about theexperience and sometimes relives it. She also reveals that she fears older men. The client maybe exhibiting signs of:

1. posttraumatic stress disorder (PTSD), delayed onset.

2. multiple personality disorder.

3. anxiety disorder.

4. schizophrenia. Correct Answer: 1

RATIONALES: The client's memory of a traumatic childhood incident and her current symptoms(nightmares, flashbacks, and related fears) suggest that she has PTSD with delayed onset. Theclient doesn't occasionally lose track of her movements and actions, as in multiple personalitydisorder. Her anxiety isn't primary but results from severe emotional trauma. Although sheexperiences flashbacks, these aren't psychotic episodes, as in schizophrenia.In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:

1. hypothyroidism.

2. hyperglycemia.

3. hypertension.

4. antiseizure medication. Correct Answer: 1

RATIONALES: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolardisorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizuremedications.One aspect of implementation related to drug therapy is:

1. developing a content outline.

2. documenting drugs given.

3. establishing outcome criteria.

4. setting realistic client goals. Correct Answer: 2

RATIONALES: Although documentation isn't a step in the nursing process, the nurse is legallyrequired to document activities related to drug therapy, including the time of administration,the quantity, and the client's reaction. Developing a content outline, establishing outcomecriteria, and setting realistic client goals are parts of planning rather than implementation.A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse ifhe'll ever be able to walk again. Which response by the nurse is appropriate?

1. "If you keep a positive attitude, you can do anything."

2. "What makes you think you won't be able to walk again?"

3. "What has your physician told you about your ability to walk again?"

4. "Most likely you won't be able to, but we never know for sure." Correct Answer: 3

RATIONALES: The nurse should respond by asking the client what he's already been told abouthis ability to walk again. After assessing the client's knowledge, she can better respond to theclient's questioning. Option 1 provides the client with false hope, and option 2 may place theclient on the defensive. Option 4 is an inappropriate response.While obtaining a health history, the nurse learns that the client is allergic to bee stings. Whenobtaining this client's medication history, the nurse should determine if the client keeps whichmedication on hand?

1. diphenhydramine hydrochloride (Benadryl)

2. pseudoephedrine hydrochloride (Sudafed)

3. guaifenesin (Robitussin)

4. loperamide (Imodium) Correct Answer: 1

RATIONALES: A client who is allergic to bee stings should keep diphenhydramine on handbecause its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is adecongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which isused for coughs. Loperamide is an antidiarrheal agent.The nurse is caring for a client with delirium. Which of the following is most important for thenurse to provide the client?

1. A safe environment

2. An opportunity to release frustration

3. Prescribed medications

4. Medications as needed, judiciously Correct Answer: 1

RATIONALES: Providing a safe environment is the most important aspect of caring for a clientwith delirium. Although all other options are logical and appropriate, meeting the client's safetyneeds takes priority.The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visiblyshaken over the possibility of acolostomy. Based on the client's response, the surgeon shouldcollaborate with which health team member?

1. Social worker

2. Staff nurse

3. Clinical educator

4. Enterostomal nurseCorrect Answer: 4

RATIONALES: The surgeon should collaborate with the enterostomal nurse who can address theclient's concerns. The enterostomal nurse may schedule a visit from a client who has acolostomy to offer support to the client. The clinical educator can provide information about thecolostomy when the client is ready to learn. The staff nurse and social worker don't need to beconsulted in this situation.A client, age 21, is admitted with bacterial meningitis. Which hospital room would be theappropriate choice for this client?

1. A private room down the hall from the nurses' station

2. An isolation room close to the nurses' station

3. A semiprivate room with a 32-year-old client who has viral meningitis

4. A two-bed room with a client who previously had bacterial meningitis Correct Answer: 2

RATIONALES: A client with bacterial meningitis should be kept in isolation for at least 24 hoursafter admission and, during the initial acute phase, should be as close to the nurses' station aspossible to allow maximal observation. Placing the client in a room with a client who has viralmeningitis may cause harm to both clients because the organisms causing viral and bacterialmeningitis differ; either client may contract the other's disease. Immunity to bacterialmeningitis can't be acquired; therefore, a client who previously had bacterial meningitisshouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.Which psychological or personality factor is likely to predispose an individual to medicationabuse?

1. Low self-esteem and unresolved rage

2. Desire to inflict pain upon one's self

3. Dependent personality disorder

4. Antisocial personality disorder Correct Answer: 1

RATIONALES: Low self-esteem and repressed rage as well as depression can predispose anindividual to search for solace in addictive medications. Usually, medications are used tominimize or blot out pain, rather than inflict additional pain. Personality disorders don'tpredispose a client to medication abuse; however, personality disorders, especially theantisocial ones, may be intensified by abuse.Which detail of a client's drug therapy is the nurse legally responsible for documenting?

1. Peak concentration time of the drug

2. Safe ranges of the drug

3. Client's socioeconomic data

4. Client's reaction to the drug Correct Answer: 4

RATIONALES: The nurse legally must document the client's reaction to the drug in addition tothe time the drug was administered and the dosage given. The nurse isn't legally responsible fordocumenting the peak concentration time of the drug, safe drug ranges, or the client'ssocioeconomic data.The nurse is performing a neurologic assessment on a 1-day-old neonate. Which of thefollowing findings would indicate possible asphyxia in utero?


1. The neonate grasps the nurse's finger when she puts it in the palm of his hand.

2. The neonate does stepping movements when held upright with his sole touching a surface.

3. The neonate's toes don't curl downward when his soles are stroked.

4. The neonate doesn't respond when the nurse claps her hands above him.

5. The neonate turns toward an object when the nurse touches his cheek with it.

6. The neonate displays weak, ineffective sucking. Correct Answer: 3,4,6

RATIONALES: Failure of the toes to curl downward when the baby's soles are stroked and lack ofresponse to a loud sound can be evidence that neurological damage from asphyxia hasoccurred. The normal responses would be that the toes curl downward with stroking and thatthe arms and legs extend in response to a loud noise. Weak, ineffective sucking is another signof neurologic damage; a neonate should root and suck when the side of his cheek is stroked. Aneonate should also grasp a person's finger when it's placed in the palm of his hand, dostepping movements when held upright with the soles touching a surface, and turn toward anobject when his cheek is touched by it.The mother of a 3-year-old has been told that her child has a brain tumor. She initially begins tocry and accuses the physicians oflying. Which of the following stages is the mother most likelyexperiencing?

1. Acceptance

2. Psychotic episode

3. Anger

4. Denial Correct Answer: 3

RATIONALES: Anger is the stage of grief in which a person expresses anger about the diagnosisor situation. Acceptance occurs when the person comes to terms with the diagnosis. Thissituation isn't an example of a psychotic episode; it's a normal stage of the grieving process.Denial is the stage of grief when a person refuses to believe the truth.

A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in 50%solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to thisclient?

1. To lower blood pressure

2. To prevent seizures

3. To inhibit labor

4. To block dopamine receptors Correct Answer: 2

RATIONALES: Magnesium sulfate is given to prevent and control seizures in clients with PIH.Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally actingblockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has noeffect on labor or dopamine receptors.The nurse assesses a client who gave birth 24 hours earlier. Which of the following findingsreveals the need for further evaluation?

1. Chills

2. Scant lochia rubra

3. Thirst and fatigue

4. Temperature of 100.2° F (37.9° C) Correct Answer: 2

RATIONALES: During the early postpartum period, lochia rubra should be moderate tosignificant. Scant lochia rubra suggests that large clots are blocking the lochial flow. Afterdelivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of upto 100.4° F (38° C) also are common at 24 hours postpartum.A client with chronic obstructive pulmonary disease, who has been receiving mechanicalventilation for the past 5 days, expresses to a nurse his desire to have treatment withdrawn.Which statement about the client's legal rights is true in this situation?

1. The nurse's assessment of the client and communication with the family guides thedecision-making process.

2. The nurse is an advocate for the client and should encourage the client to accept his currenttreatment regimen.

3. The health care team must follow the treatment plan that was already established with clientand family input.

4. The client has the right to refuse treatment at any time. Correct Answer: 4

RATIONALES: Health care professionals must ensure a health care ethic that respects the role ofthe client in the decision-making process. According to the Patient's Bill of Rights, the client hasthe right to make decisions about his care at any time. The nurse should be a client advocateand be supportive of the decision he made.A client with newly diagnosed breast cancer asks the nurse, "Why me? I've always been a goodperson. What have I done to deserve this?" Which response by the nurse would be mosttherapeutic?

1. "Don't worry. You'll probably live longer than I will."

2. "I'm sure a cure will be found soon."

3. "You seem upset. Let's talk about something happy."

4. "Would you like to talk about this?" Correct Answer: 4

RATIONALES: Listening, responding quickly, and providing support promote therapeuticcommunication. Offering to talk about the client's feelings validates those feelings and allowsthe client to express them. Options 1 and 2 ignore the client's feelings. Option 3 identifies theclient's feelings but doesn't follow through by exploring them.The mother of a 3-year-old child is complaining that her son still throws temper tantrums whenhe doesn't get his way. How should the nurse advise the mother to respond?

1. Tell the mother to ignore the child because eventually he will stop having temper tantrums.

2. Tell the mother to promise him a new toy if he stops the tantrum.

3. Tell the mother to give in to his demands; he is only 3-years-old.

4. Tell the mother to mimic him so that he can see what his behavior looks like. CorrectAnswer: 1

RATIONALES: This child is in Erikson's developmental stage of initiative versus guilt. Guiltdevelops when the child is made to feel bad about his behavior. Ignoring the negative behaviorshows the child that he'll gain nothing through negative behavior such as temper tantrums.Promising the child a new toy or giving in to his demands will reinforce his negative behavior byrewarding his tantrums. Mimicking the child will make him feel guilty.A client asks the nurse about the rhythm (calendar-basal body temperature) method of familyplanning. The nurse explains that this method involves:

1. chemical barriers that act as spermicidal agents.

2. hormones that prevent ovulation.

3. mechanical barriers that prevent sperm from reaching the cervix.

4. determination of the fertile period to identify safe times for sexual intercourse.CorrectAnswer: 4

RATIONALES: The rhythm method of family planning combines basal body temperaturemeasurement with analysis of cervical mucus changes to determine the fertile period. Thismethod helps identify safe and unsafe periods for sexual intercourse. A natural family planningmethod, the rhythm method doesn't involve use of chemical barriers, hormones, or mechanicalbarriers.The nurse-manager overhears a nurse tell a client, "If I were you, I'd ask the doctor forsomething for pain; you shouldn't have to suffer during labor." How should the nurse-managerrespond to the nurse's comment?

1. Don't respond because the nurse's statement is correct.

2. Confront the nurse in the client's room and remind her that it's inappropriate to administerpain medications to clients in labor.

3. Inform the nurse that she'd like to speak with her, then discuss the inappropriateness of hercomment in a private location.

4. Notify the physician of the client's pain and request that he prescribe pain medication for theclient. Correct Answer: 3

RATIONALES: The nurse-manager should inform the nurse that she wishes to speak with her.Then, in a private location, she should discuss the inappropriateness of the nurse's commentand an action plan to improve her care. If the client is experiencing pain the nurse should act asa client advocate and notify the physician of the client's pain. However, because the client isn'trequesting pain medication, there's no need to request pain medication from the physician.A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgeryto remove a brain tumor. To determine whether this drug is producing its therapeutic effect, thenurse should consider which finding the most significant?

1. Decreased level of consciousness (LOC)

2. Elevated blood pressure

3. Increased urine output

4. Decreased heart rate Correct Answer: 3

RATIONALES: The therapeutic effect of mannitol is diuresis, which is confirmed by an increasedurine output. A decreased LOC and elevated blood pressure may indicate lack of therapeuticeffectiveness. A decreased heart rate doesn't indicate that mannitol is effective.A hospitalized client asks the nurse for "something for pain." Which information is mostimportant for the nurse to gather before administering the medication?


1. Administration time of the last dose

2. Client's pain level on a scale of 1 to 10

3. Type of medication the client has been taking

4. Client's reaction to the previous dose

5. Client's most current height and weight

6. Effectiveness of prior dose of medication Correct Answer: 1,2,3,4,6

RATIONALES: The nurse needs to know when the last dose was administered. Some clientsrequest pain medication earlier than is ordered by the physician. Pain, the fifth vital sign, shouldbe assessed using a pain scale and documented in the nursing notes whenever a painmedication is given. Pain is usually reassessed about 30 minutes after the medication is given.Physicians commonly order several different types of pain medication based on the client'scondition. The nurse should know which medication and which route was used to administerprior dosages. Evaluating the effectiveness of medications is also an important nursing functionwhen managing the client's pain. Therefore, she should ask the client if the prior dose washelpful. The nurse should also note whether the client experienced any adverse effects of themedication. Most medications are ordered based on the client's admission weight, not currentweight and height. A client's weight may fluctuate when he's in the hospital, so it's unlikely thatthe nurse will have the most current weight available. Also, taking steps to obtain the client'scurrent weight postpones the pain treatment and can potentially worsen pain.

The nurse collects data on a client shortly after kidney transplant surgery. Which postoperativefinding must the nurse report to the physician immediately?

1. Serum potassium level of 4.9 mEq/L

2. Serum sodium level of 135 mEq/L

3. Temperature of 99.2° F (37.3° C)

4. Urine output of 20 ml/hour Correct Answer: 4

RATIONALES: Because kidney transplantation carries the risk of transplant rejection, infection,and other serious complications, the nurse should monitor the client's urinary function closely.A decrease from the normal urine output of 30 ml/hour is significant and warrants immediatephysician notification. The other options are normal data collection findings.A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a24-hour urine specimen, the collectiontime should:

1. start with the first voiding.

2. start after a known voiding that empties the bladder.

3. always be with first morning urine.

4. always be the last evening's void as the last sample. Correct Answer: 2

RATIONALES: When initiating a 24-hour urine specimen, have the client void, and then starttiming. The collection should start on an empty bladder. The exact time the test starts isn'timportant, but it's commonly started in the morning.A client is receiving nitroglycerin ointment (Nitrol) to treat angina pectoris. The nurse evaluatesthe therapeutic effectiveness of this drug by assessing the client's response and checking foradverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?

1. Heart rate

2. Respiratory rate

3. Blood pressure

4. Temperature Correct Answer: 3

RATIONALES: Hypotension and headache are the most common adverse effects of nitroglycerin.Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug.The nurse should check the client's blood pressure 1 hour after administering nitroglycerinointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If bloodpressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment andreport the finding to the physician immediately. An above-normal heart rate (tachycardia) is aless common adverse effect of nitroglycerin. Respiratory rate and temperature don't changesignificantly after nitroglycerin administration.Which drugs may be abused because of tolerance and physiologic dependence?

1. Lithium (Lithobid) and divalproex (Depakote).

2. Verapamil (Calan) and chlorpromazine (Thorazine)

3. Alprazolam (Xanax) and phenobarbital (Luminal)

4. Clozapine (Clozaril) and amitriptyline (Elavil) Correct Answer: 3

RATIONALES: Both benzodiazepines (such as alprazolam) and barbiturates (such asphenobarbital) are addictive, controlled substances. None of the other drugs listed are addictivesubstances.

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Correct Answer: 3