The nurse is has just admitted a client with severe depression. From which focus
should the nurse identify a priority nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety
The correct answer is D: Safety
2. While explaining an illness to a 10 year-old, what should the nurse ke...
1. The nurse is has just admitted a client with severe depression. From which focus
should the nurse identify a priority nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety
The correct answer is D: Safety
2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about
the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences
The correct answer is B: Think logically in organizing facts
3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which
intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant
The correct answer is B: Place the child on the side
4. The nurse is reviewing a depressed client's history from an earlier admission.
Documentation of anhedonia is noted. The nurse understands that this finding refers to
A) Reports of difficulty falling and staying asleep
B) Expression of persistent suicidal thoughts
C) Lack of enjoyment in usual pleasures
D) Reduced senses of taste and smell
The correct answer is C: Lack of enjoyment in usual pleasures
5. A client has just returned to the medical-surgical unit following a segmental lung
resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cough
,D) Monitor oxygen saturation
The correct answer is B: Suction excessive tracheobronchial secretions
6. While assessing a client in an outpatient facility with a panic disorder, the nurse
completes a thorough health history and physical exam. Which finding is most significant
for this client?
A) Compulsive behavior
B) Sense of impending doom
C) Fear of flying
D) Predictable episodes
The correct answer is B: Sense of impending doom
7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to
this child enters the hospital room for the first time, the toddler runs to the mother, clings
to her and begins to cry. What would be the initial action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention
The correct answer is B: Explain that this behavior is expected
8. A 15 year-old client with a lengthy confining illness is at risk for altered growth and
development of which task?
A) Loss of control
B) Insecurity
C) Dependence
D) Lack of trust
The correct answer is C: Dependence
9. Which playroom activities should the nurse organize for a small group of 7 year-old
hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs
The correct answer is A: Sports and games with rules
10. The nurse is discussing dietary intake with an adolescent who has acne. The most
,appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."
The correct answer is A: "Eat a balanced diet for your age."
11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks
the nurse about how it is determined that a person has AIDS other than a positive HIV
test. The nurse responds
A) "The complaints of at least 3 common findings."
B) "The absence of any opportunistic infection."
C) "CD4 lymphocyte count is less than 200."
D) "Developmental delays in children."
The correct answer is C: "CD4 lymphocyte count is less than 200."
12. The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns
The correct answer is D: Observe swallowing patterns
13. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the
nurse that she has everything ready for the baby and has made plans for the first weeks
together at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy
The correct answer is C: Anticipation of the birth
14. The nurse is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in removing respiratory secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
C) Maintaining bed rest with bathroom privileges
D) Performing chest physiotherapy twice a day
, The correct answer is B: Increasing oral fluid intake to 3000 cc per day
15. The nurse in a well-child clinic examines many children on a daily basis. Which of
the following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sip cup
The correct answer is D: A 30 month-old only drinking from a sip cup
16. Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
The correct answer is D: Observe a return demonstration
17. A client has developed thrombophlebitis of the left leg. Which nursing intervention
should be given the highest priority?
A) Elevate leg on 2 pillows
B) Apply support stockings
C) Apply warm compresses
D) Maintain complete bed rest
The correct answer is A: Elevate leg on 2 pillows
18. A nurse from the surgical department is reassigned to the pediatric unit. The charge
nurse should recognize that the child at highest risk for cardiac arrest and is the least
likely to be assigned to
this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma
The correct answer is C: Prolonged hypoxemia
19. A home health nurse is at the home of a client with diabetes and arthritis. The client
has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the
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