NCSBN QBANK 1-15 Questions & Answers 100% Correct(SCORED A+)
The nurse is admitting a client who is newly diagnosed with a frontal lobe brain tumor. Which statement made by a spouse may provide important information about this diagnosis and should be communicated to the health care provider?
"It seems our sex life is nonexistent over the past six months."
"His breathing rate is usually below 12."
"I find the mood swings and the change from being a calm person to being angry all the time hard to deal with."
"In the morning and evening he complains that reading is next to impossible because the print is blurry." - ANSWER"I find the mood swings and the change from being a calm person to being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.
A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
Weight reduction
Stress management
Smoking cessation
Physical exercise - ANSWERSmoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects
result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time.
A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement?
"You have been exposed to the organism Mycobacterium tuberculosis."
"This means you have never had or been around someone with tuberculosis." "You are mostly likely have a natural immunity to the bacteria."
"You most likely have a resistant form of active tuberculosis. - ANSWER"You have been
exposed to the organism Mycobacterium tuberculosis."
The PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is
the only definitive test to confirm a diagnosis of active TB.
The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective? - ANSWER"I can have a heart attack if I stop this medication suddenly."
Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart attack.
The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take
before starting the infusion? - ANSWERCheck the pH of the aspirate
Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations include assessing the feeding tube placement by testing the pH of aspirates, measuring the external portion of the tube, and observing for
changes in the volume and appearance of feeding tube aspirates. If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that are
no longer recommended.
The registered nurse (RN) is planning the care of an 80-year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse? - ANSWERPerform a head-to-toe assessment
The RN is responsible to conduct a thorough assessment and evaluation of all body systems for this client. The nurse would document information collected during the focused assessment, such as changes in skin color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility. A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention? - ANSWERShe has been taking an ACE inhibitor for her blood
pressure for the past two years.
A report by the client that she has been taking medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors, commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications and who are planning a pregnancy should be switched to medications that are not harmful to the developing fetus before they begin trying to get pregnant.
There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication? - ANSWERHigh serum creatinine
Gentamicin is excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for toxicity. Reduced renal function will delay the excretion of many medications.
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time? - ANSWERWhen the client's mood improves with an increase in energy level
Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide. The clients have the energy to carry through with the plan for suicide.
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150
beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process? - ANSWERFetal heart rate is 188 beats/minute
Prolonged ruptured membranes may lead to maternal infection (as suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188; fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and administer oxygen and intravenous fluids. A mother asks about expected motor skill development for her 3 year-old child. Which activity is considered a typical motor skill for the 3 year-old? - ANSWERRiding a tricycle
Three year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and are movement milestones for older children.
The nurse is developing a teaching plan for parents on safety and risk-reduction in the home. Which of the following should the nurse give priority consideration to during teaching? - ANSWERAge of children in the home
Age and developmental level of the child are the most important considerations in the provision of a framework for anticipatory guidance associated with safety, and should be
given priority when teaching safety.
A client has been prescribed dexamethasone by mouth daily for transplant rejection prophylaxis. The client asks the nurse for more information about the medication. What information should the nurse include? (Select all that apply) - ANSWER"Take the medication with food"
"Take acetaminophen for minor pain or aches."
Adverse effects (ADEs) of long-term corticosteroid therapy include: behavioral/psychological changes, eye changes such as cataracts and glaucoma, and increased susceptibility to infections, hyperglycemia, hypocalcemia, fluid retention, HTN, edema, myopathy, muscle wasting, osteoporosis and peptic ulcers.To reduce the aforementioned ADEs, it is recommended to take the drug with food, avoid using NSAIDs for pain and increase dietary intake of calcium, found in dairy products.To prevent or avoid adrenal atrophy and acute adrenal insufficiency, discontinue corticosteroids gradually. Never discontinue corticosteroids abruptly!
A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? - ANSWERThe baby is post-term
Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower scores; higher scores correlate with post-maturity. Fetal distress during labor can result in lower scores.
