Question a Ire Nursing

7/31/2019 Question a Ire Nursing

1/49

1.Which of the following disorders is characterized by joint inflammation that is usually

accompanied by pain and frequently accompanied by changes in structure?

a.Synovitis

b.Arthritis

c.Bursitis

d.Tendinitis

2.Which term refers to the expectoration of blood from the respiratory tract?

a.A hemorrhage

b.Hematopoiesis

c.Hemoptysis

d.Hemopexis

3.Which term describes lack of coordination in performing planned, purposeful movements,

resulting from a neurologic deficit?

a.Apraxia

b.Ataxia

c.Fasciculation

d.Myokymia

4.An elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2) indicates thatthe patient has:

a.Hypernatremia

b.Hypocalcemia

c.Hypoxemia

d.Hypercapnia

5.The latest laboratory values indicate that the patient has thrombocytopenia. The combiningform penia means:


2/49

a.Rupture

b.Deficiency

c.Formation

d.Stupor

6.A patient is admitted to the hospital with a urine specific gravity of 1.030, a temperature of102F (38.9 C), and flushed, dry skin. Based on these data, the nurse writes which of the

following nursing diagnoses?

a.Potential for impaired skin integrity

b.Fluid volume deficit related to fever

c.Potential for fluid volume deficit caused by fever

d.Altered cardiopulmonary tissue perfusion related to fluid excess

7.The guidelines for writing an appropriate nursing diagnosis include all of the following except:

a.State the diagnosis in terms of a problem, not a need

b.Use nursing terminology to describe the patients response

c.Use statements that assist in planning independent nursing interventions

d.Use medical terminology to describe the probable cause of the patients response

8.Based on a physicians order for oxygen by nasal catheter at 3 liters/ minute, an appropriatenursing order would be:

a.Cover the tip of the catheter with a water-soluble lubricant before insertion.

b.Measure the length of the catheter from the tip of the patients nose to the tip of theearlobe before insertion

c.Add sterile distilled water to the humidification container, as needed

d.All of the above

9.A nurse observes a dazed and apparently confused co-worker taking two diazepam (Valium)

tablets by mouth as the co-worker is about to pour medications. What should the nurse do?


3/49

a.Call the head nurse immediately before the co-worker pours and administers the

medications

b.Pour the medications for the co-worker while she goes for a cup of coffee

c.Report the co-worker to hospital security because she may be addicted to drugs

d.Watch the co-worker closely and report the incident to the head nurse at the end of the

day.

10.A nurse manager notices that one of the staff nurses is always 15 to 20 minutes late. When

the nurse manager discusses the problem with her, the nurse says that she has been latebecause her sons nursery school does not open until 7 am. The nurse manager shouldrespond by telling her to:

a.Ask one of the night nurses to cover for her

b.See if a neighbor can take the child to school

c.Find out if other schools open earlier

d.Find some way to solve the problem and be on time

11.A nurse has just moved to a new state, where she has accepted employment in a hospital-

based hemodialysis unit. She needs information about her specific duties in caring for

hemodialysis patients. She will find this information in:

a.Policy statements set by the National Kidney Foundation

b.The states nurse practice act

c.Medicare and Medicaid regulations

d.The hospitals procedure manual

12.Which of the following is an example of nursing malpractice?

a.The nurse administers penicillin to a patient with a documented history of allergy to the

drug. The patient experiences an allergic reaction and has cerebral damage resultingfrom anoxia.

b.The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with

abdominal cramping

c.The nurse assists a patient out of bed with the bed locked in position; the patient slips

and fractures his right humerus


4/49

d.The nurse administers the wrong medication to a patient and the patient vomits. This

information is documented and reported to the physician and the nursing supervisor

13.Therapeutic communication is a significant aspect of patient care. Which of the following

statements most clearly defines this concept?

a.Therapeutic communication conveys feelings of warmth, acceptance, and empathyfrom the nurse to the patient in a nonjudgmental atmosphere

b.Therapeutic communication is a reciprocal interaction based on trust and aimed atidentifying patient needs and developing mutual goals

c.Therapeutic communication is the assessment component of the nursing process, in

which the nurse gathers health history information from the patients perspective

d.Therapeutic communication is an interactional process in which the nurse purposefully

reviews and assesses the conversation and its potential outcomes

14.Many factors can become barriers to communication. In which of the following situationswould communication least likely be hindered?

a.Mr. S., a 30-year-old Vietnamese immigrant, is admitted to the hospital with a

fractured tibia; he speaks limited English

b.Ms. M., age 58 and unmarried, is admitted to the hospital for breast surgery

c.Mrs. R, age 26, is admitted to the hospital for a scheduled cesarean section; this is her

first admission

d.Mr. G., age 78, arrives at the hospital by ambulance after suffering a stroke at home

15.The assessment component of the nursing process requires effective communication to elicit

a complete, relevant history from the patient and to identify patient problems. What role doescommunication play in the other areas of the nursing process?

a.In the planning phase, effective therapeutic communication helps to establish nursing

care priorities and patient-oriented goals

b.During the implementation phase, communication skills allow the nurse to assess thepatients response to planned interventions

c.During the evaluation phase, effective communication allows the nurse to find out from

the patient if he is responding to treatment or if changes in treatment are necessary

d.All of the above


5/49

16.All of the following would be considered objective assessment data for a patient admitted

with diabetes mellitus except:

a.+ 2 urine glucose level; negative urine acetone level

b.Chemstrip reading of 240 mg/dl

c.Patient complaints of polydipsia

d.Serum glucose level of 263 mg/dl

17.Which of the following statements about bowel sounds is accurate?

a.Peristalsis causes bowel sounds

b.Rapid, high-pitched, hyperactive bowel sounds indicate increased peristalsis

c.Decreased bowel sounds can be a symptom of paralytic ileus

d.All of the above

18.Independent nursing intervention commonly used for immobilized patients include all of the

following except:

a.Active or passive ROM exercises, body repositioning, and activities of daily living

(ADLs) as tolerated

b.Deep-breathing and coughing exercises with change of position every 2 hours

c.Diaphragmatic and abdominal breathing exercises and increased hydration

d.Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy

19.Independent nursing interventions commonly used for patients with pressure ulcers include:

a.Changing the patients position regularly to minimize pressure

b.Applying a drying agent such as an antacid to decrease moisture at the ulcer site

c.Debriding the ulcer to remove necrotic tissue, which can impede healing

d.Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated

20.A female patient has gained 24 lb after being admitted to the hospital . Im such a horse; I

just cant stand myself like this, she tells the nurse. After assessing the patient, the nurse


6/49

writes the following nursing diagnosis: Body image disturbance. To arrive at this diagnosis,

the nurse should include which of the following assessment findings?

a.The patients perception of her body before the hospitalization and weight gain

b.The significance the patient places on these changes

c.The patients feelings about her body

d.All of the above

21.Stressors cause the release of the mineralocorticoid aldosterone, which regulates sodiumabsorption and potassium excretion in the renal tubules, resulting in:

a.The need for supplemental potassium

b.The need for a low-sodium (500-mg) diet

c.The conservation of water and maintenance of blood volume

d.Increased diuresis

22.In planning the care of a patient who is exposed to multiple stressors such as separation fromloved ones, anxiety about impending surgery, and concern about potential complications or

death, the nurse must:

a.Use both a structured and an unstructured format when interviewing the patient

b.Know the stressors affecting the patient

c.Develop the expected outcomes for each nursing diagnosis written for this patient

d.All of the above

23.An accurate method of calculating the daily urine output of an incontinent patient wearing

pads or diapers is to:

a.Estimate the urine output

b.Count the number of urine saturated pads

c.Weigh a dry pad and each urine saturated pad and use a conversion calibration tocalculate the urine output

d.Weigh all the urine-saturated pads together and use a conversion calibration tocalculate the urine output


7/49

24.A fashion model is admitted via the emergency room with facial and chest burns. Her

hospital stay includes 10 days in the intensive care unit and 5 days on the regular hospitalunit. The patient has not been eating or sleeping and refuses to perform her activities of daily

living (ADLs). She refuses to work with speech and physical therapists. Which of the

following nursing diagnoses might appears on the patients current care plan?

a.Potential for noncompliance: Self-harm related to disturbed body image

b.Self-care deficit related to knowledge deficit and disturbed body image

c.Disturbance in self-concept: Personal identifying related to self-esteem

d.Disturbance in self-concept related to altered thought process

25.White the nurse is providing a patients personal hygiene, she observes that his skin is

excessively dry. During this procedure the patient tells her that he is very thirsty. An

appropriate nursing diagnosis would be:

a.Potential for impaired skin integrity related to altered gland function

b.Potential for impaired skin integrity related to dehydration

c.Impaired skin integrity relate to dehydration

d.Impaired skin integrity related to altered circulation


8/49

1. AnswerB. Arthritis is characterized by joint inflammation that is usually accompanied by

pain and frequently accompanied by changes in structure. Synovitis is the inflammation of

the synovial membrane, typically resulting from a traumatic injury or an aseptic wound.

Bursitis is the inflammation of a bursa, typically one located between a bony prominence anda muscle or tendon. Tendinitis is the inflammation of tendon.

2. AnswerC. Hemoptysis is the expectoration of blood from the respiratory tract. A

hemorrhage is abnormal internal or external bleeding. Hematopoiesis is blood cell formation.

Hemopexis is blood coagulation.

3. AnswerB. Ataxia is lack of coordination in performing planned, purposeful movements,

typically resulting from a neurologic deficit. Apraxia is the inability to perform purposefulmovements even though no neuromuscular deficit exists. Fasciculations are fine twitching

movements. Myokymia is a transient, spontaneous movement that occurs in muscle groups

after strenuous exercise.

4. AnswerD. Hypercapnia is an elevation in the partial pressure of carbon dioxide in arterial

blood (PaCO2). Hypernatremia is an elevated level of sodium in venous blood (more than145 mEq/liter). Hypocalcemia is a decreased level of calcium in venous blood (less than 9

mg/dl). Hypoxemia is a reduced level of oxygen in arterial blood (less than 80 mm Hg whilebreathing room air).

5. AnswerB. The combining form penia means deficiency, as in thrombocytopenia

(deficiency in the number of circulating blood plates). Rrhexis is a combining form meaningrupture, as in enterorrhexis (rupture of the intestine). Plast is a combining form meaning

formation, as in rhino-plasty (formation of a nose using plastic surgery). Narco is acombining form meaning stupor, as in narcolepsy (a condition marked by recurrent attacks of

drowsiness and sleep).

6. AnswerB. Fluid volume deficit related to fever is the appropriate nursing diagnosis basedon this assessment. Potential for impaired skin integrity states a possible patient response.

Potential for fluid volume deficit caused by fever implies a cause-and-effect relationship,

which a nursing diagnosis should never do. Altered cardiopulmonary tissue perfusion related

to fluid excess is an incorrect diagnosis based on a misinterpretation of the data.

7. AnswerD. A nursing diagnosis is a statement about a patients actual or potential heal th

problem that is within the scope of independent nursing intervention. Medical terminology isnever a part of the nursing diagnosis. An appropriate nursing diagnosis would be ineffective

breathing pattern related to chest pain rather than ineffective breathing pattern caused by

angina.

8. AnswerD. A water-soluble lubricant must be applied to the tip of the catheter to decrease

friction and the risk of injury to the patients nasal mucosa. (If petrolatum or mineral oil wereapplied to the catheter and then aspirated, the patient could develop a lipoid pneumonia) The


9/49

distance from the tip of the nose to the tip of the earlobe is the approximate distance from the

point of insertion to the oropharynx. Sterile distilled water must be used to humidity theoxygen because oxygen administered by itself is a dry gas that can irritate the mucosa.

9. AnswerA. Patient safety is the major concern in this situation. According to the

International Council of Nurses Code for Nurses: The nurse [should] take appropriateaction to safeguard the individual when his or her care is endangered by a co-worker or any

other person. In this case, talking with the head nurse immediately would be the best way to

safeguard the patients safety. The nurse isnt necessarily an addict, she may be abusing a

prescription medication.

10. AnswerD. It is the staff nurses responsibility to be on time. The nurse manager shouldnot assume a responsibility that belongs to the nurse.

11. AnswerD. Although Medicare and Medicaid regulations and suggestions made by such

groups as the National Kidney Foundation may serve as guidelines, a hospitals procedure

manual details how the nurse should perform her specific duties. A states nurse practice actdefines the scope of practice within that state, but not the specifics for each area of practice.

12. AnswerA. The three elements necessary to establishes nursing malpractice are nursingerror (administering penicillin to a patient with a documented allergy to the drug), injury

(cerebral damage), and proximal cause (administering the penicillin caused the cerebraldamage). Applying a hot water bottle or healing pad to a patient without a physicians orderdoes not include the three required components. Assisting a patient out of bed with the bed

locked in position is the correct nursing practice; therefore, the fracture was not the result of

malpractice. Administering an incorrect medication is a nursing error; however, if such

action resulted in a serious illness or chronic problem, the nurse could be sued for

malpractice.

13. AnswerB. Therapeutic communication is a two way, deliberative interaction between thepatient and nurse in which they establish mutually acceptable, achievable goals of care.

Before the patient can feel comfortable discussing his problems, however, and atmosphere of

trust and acceptance must be established.

14. AnswerC. Many variables affect patient nurse communication, including the patients

cultural beliefs, experiences with hospitalization, age, emotional needs, and problems withspeech, hearing, or comprehension. A patient admitted to the hospital for the first time for a

scheduled cesarean section is probably anxious, but she had time to plan for the procedure,

does not bring negative experiences from previous hospitalizations, and in most cases looks

forward to the birth.

15. AnswerD. Therapeutic communication is a fundamental component at all phases of the

nursing process. In the planning phase, it allows the patient and nurse to formulate mutuallyacceptable and patient-oriented goals, which are the basis for developing an individualized

care plan. In the implementation phase, effective communication is necessary for teaching

the patient, motivating him to achieve goals, and assessing patient outcomes. Finally, in the


10/49

evaluation phase, it is required to determine how well the patient has responded to

interventions.

16. AnswerC. Objective data are those which can be measured, like glucose levels. A

complaint of polydipsia is subjective information obtained from the patient.

17. AnswerD. Peristalsis is the muscular, rhythmic movement in the bowel wall that pushesfood along the digestive tract distally. Increased bowel motility is indicated by rapid, high-

pitched, hyperactive bowel sounds. Decreased bowel sounds, caused by decreased bowel

motility, can be the initial sign of paralytic ileus (adynamic intestinal obstruction resulting

from the lack of peristalsis), a common occurrence following abdominal surgery.

18. AnswerD. The use of a tilt table for weight-beating exercises, parenteral nutrition, and

vitamin therapy are not independent nursing interventions because they require a physiciansorder. Unless specifically contraindicated, the independent nursing interventions listed in A,

B, and C may be part of the nursing care plan for an immobilized patient.

19. AnswerA. Independent nursing interventions for a patient with pressure ulcers commonly

include changing his position several times each day to avoid pressure to any part of his

body, especially the involved area. Drying agents, which are prescribed by a physician, arecontraindicated because wounds need moisture to heal. Whirlpool therapy and chemical

debridement must be prescribed, and surgical debridement is done by the physician.

20. AnswerD. All of the choices will help the nurse determine the extent of the problem. For

example, asking how the patient felt about her body before hospitalization will help the nurse

determine whether the disturbed body image is a crisis brought on by the weight gain or along-standing problem. Asking what the change means to her will reveal whether she feels

she has control over what is happening or believes the change is permanent. Body image isalso related to how we think we compare to others or whether others find us attractive.

21. AnswerC. Because aldosterone regulates the bodys sodium and potassium levels, it acts

as an adaptive mechanism in maintaining blood volume and conserving water. Supplementalpotassium usually is given to a patient with a low serum potassium level or one who is

receiving a diuretic or other medicationsuch as digoxinthat has a mild diuretic effect. A

low-sodium diet is usually prescribed for a patient with a high serum sodium level, as in

congestive heart failure (CHF), hypertension, or prolonged episodes of edema. Diuresis isincreased naturally when a healthy patient increases his intake of fluids, especially those

containing caffeine. Patients receiving diuretics also experience increased diuresis.

22. AnswerD. Interviewing the patientin both a structured and an unstructured formatis

an important part of the initial nursing assessment. The structured format uses questions that

require a yea-or-no answer to help the nurse obtain information; the unstructured format uses

open-ended questions that allow the patient to express himself more fully. The interviewhelps the nurse and patient identify the stressors and develop appropriate outcomes.


11/49

23. AnswerC. Calculating the difference in weight between a dry pad and a urine saturated

pad using conversion calibration will provide an accurate measure of urine output. Forexample, if the difference between the dry pad and the urine-saturated pad is 200 g, the urine

output would be 200 ml (1g = 1 ml). The other methods will provide only an estimate of

urine output.

24. AnswerC. Disturbances in self-concept may manifest themselves as signs and symptoms

of depression, such as changes in sleep patterns, eating habits, and energy levels. The othernursing diagnoses are not supported by the given situation.

25. AnswerC. An appropriate nursing diagnosis for a patient with excessively dry skin isImpaired skin integrity (actual not potential)in this case, related to dehydration because the

patient complains of thirst. Altered circulation is not usually an etiologic factor for dry skin.


12/49

1. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause ageriatric patient to have difficulty retaining knowledge about prescribed medications?a. Decreased plasma drug levels

b. Sensory deficits

c. Lack of family support

d. History of Tourette syndrome

2. When examining a patient with abdominal pain the nurse in charge should assess:a. Any quadrant first

b. The symptomatic quadrant first

c. The symptomatic quadrant lastd. The symptomatic quadrant either second or third

3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse

document as subjective data?a. Vital signs

b. Laboratory test resultc. Patients description of paind. Electrocardiographic (ECG) waveforms

4. A male patient has a soft wrist-safety device. Which assessment finding should the nurseconsider abnormal?

a. A palpable radial pulse

b. A palpable ulnar pulsec. Cool, pale fingers

d. Pink nail beds

5. Which of the following planes divides the body longitudinally into anterior and posteriorregions?

a. Frontal plane

b. Sagittal planec. Midsagittal plane

d. Transverse plane

6. A female patient with a terminal illness is in denial. Indicators of denial include:

a. Shock dismayb. Numbness

c. Stoicism

d. Preparatory grief

7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the

nurse take during this patient transfer?

a. Position the head of the bed flatb. Helps the patient dangle the legs

c. Stands behind the patient

d. Places the chair facing away from the bed


13/49

8. A female patient who speaks a little English has emergency gallbladder surgery, during

discharge preparation, which nursing action would best help this patient understand wound careinstruction?

a. Asking frequently if the patient understands the instruction

b. Asking an interpreter to replay the instructions to the patient.

c. Writing out the instructions and having a family member read them to the patientd. Demonstrating the procedure and having the patient return the demonstration

9. Before administering the evening dose of a prescribed medication, the nurse on the evening

shift finds an unlabeled, filled syringe in the patients medication drawer. What should the nurse

in charge do?a. Discard the syringe to avoid a medication error

b. Obtain a label for the syringe from the pharmacy

c. Use the syringe because it looks like it contains the same medication the nurse was prepared

to gived. Call the day nurse to verify the contents of the syringe

10. When administering drug therapy to a male geriatric patient, the nurse must stay especiallyalert for adverse effects. Which factor makes geriatric patients to adverse drug effects?

a. Faster drug clearance

b. Aging-related physiological changesc. Increased amount of neurons

d. Enhanced blood flow to the GI tract

11. A female patient is being discharged after cataract surgery. After providing medication

teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which

professional role?

a. Managerb. Educator

c. Caregiver

d. Patient advocate

12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most

likely to reduce the patients anxiety?a. Everything will be fine. Dont worry.

b. Read this manual and then ask me any questions you may have.

c. Why dont you listen to the radio?

d. Lets talk about whats bothering you.

13. A scrub nurse in the operating room has which responsibility?a. Positioning the patient

b. Assisting with gowning and gloving

c. Handling surgical instruments to the surgeon

d. Applying surgical drapes


14/49

14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What

should the nurse in charge do?a. Leave the medication at the patients bedside

b. Tell the patient to be sure to take the medication. And then leave it at the bedside

c. Return shortly to the patients room and remain there until the patient takes the medication

d. Wait for the patient to return to bed, and then leave the medication at the bedside

15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much

heparin for each dose?

a. mlb. ml

c. ml

d. 1 ml

16. The nurse in charge measures a patients temperature at 102 degrees F. what is the

equivalent Centigrade temperature?a. 39 degrees Cb. 47 degrees C

c. 38.9 degrees C

d. 40.1 degrees C

17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory

test?a. Red blood cell count

b. Sputum culture

c. Total hemoglobin

d. Arterial blood gas (ABG) analysis

18. The nurse uses a stethoscope to auscultate a male patients chest. Which statement about a

stethoscope with a bell and diaphragm is true?a. The bell detects high-pitched sounds best

b. The diaphragm detects high-pitched sounds best

c. The bell detects thrills bestd. The diaphragm detects low-pitched sounds best

19. A male patient is to be discharged with a prescription for an analgesic that is a controlled

substance. During discharge teaching, the nurse should explain that the patient must fill this

prescription how soon after the date on which it was written?

a. Within 1 monthb. Within 3 months

c. Within 6 months

d. Within 12 months

20. Which human element considered by the nurse in charge during assessment can affect drug

administration?


15/49

a. The patients ability to recover

b. The patients occupational hazardsc. The patients socioeconomic status

d. The patients cognitive abilities

21. An employer establishes a physical exercise area in the workplace and encourages allemployees to use it. This is an example of which level of health promotion?

a. Primary preventionb. Secondary prevention

c. Tertiary prevention

d. Passive prevention

22. What does the nurse in charge do when making a surgical bed?

a. Leaves the bed in the high position when finished

b. Places the pillow at the head of the bedc. Rolls the patient to the far side of the bed

d. Tucks the top sheet and blanket under the bottom of the bed

23. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of

the drug should the nurse give?

a. 2 mlb. 1 ml

c. ml

d. ml

24. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy.

What is the major disadvantage of barbiturate use?

a. Prolonged half-lifeb. Poor absorption

c. Potential for drug dependence

d. Potential for hepatotoxicity

25. Which nursing action is essential when providing continuous enteral feeding?a. Elevating the head of the bed

b. Positioning the patient on the left side

c. Warming the formula before administering itd. Hanging a full days worth of formula at one time

26. When teaching a female patient how to take a sublingual tablet, the nurse should instruct

the patient to place the table on the:a. Top of the tongue

b. Roof of the mouth

c. Floor of the mouthd. Inside of the cheek


16/49

27. Which action by the nurse in charge is essential when cleaning the area around a Jackson-

Pratt wound drain?a. Cleaning from the center outward in a circular motion

b. Removing the drain before cleaning the skin

c. Cleaning briskly around the site with alcohol

d. Wearing sterile gloves and a mask

28. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V.tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate

of:

a. 15 drop per minuteb. 21 drop per minute

c. 32 drop per minute

d. 125 drops per minute

29. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10

hours later, the nurse identifies which finding as an early sign of shock?a. Restlessnessb. Pale, warm, dry skin

c. Heart rate of 110 beats/minute

d. Urine output of 30 ml/hour

30. Which pulse should the nurse palpate during rapid assessment of an unconscious male

adult?a. Radial

b. Brachial

c. Femoral

d. Carotid


17/49

Answer B. Sensory deficits could cause a geriatric patient to have difficulty retainingknowledge about prescribed medications. Decreased plasma drug levels do not alterthe patients knowledge about the drug. A lack of family support may affect compliance,not knowledge retention. Toilette syndrome is unrelated to knowledge retention.

Answer C. The nurse should systematically assess all areas of the abdomen, if time

and the patients condition permit, concluding with the symptomatic area. Otherwise, thenurse may elicit pain in the symptomatic area, causing the muscles in other areas totighten. This would interfere with further assessment.

Answer C. Subjective data come directly from the patient and usually are recorded asdirect quotations that reflect the patients opinions or feelings about a situation. Vitalsigns, laboratory test result, and ECG waveforms are examples of objective data.

Answer C. A safety device on the wrist may impair circulation and restrict bloodsupply to body tissues. Therefore, the nurse should assess the patient for signs ofimpaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pinknail beds are normal findings.

Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal

plane dividing the body in anterior and posterior regions. A sagittal plane runslongitudinally dividing the body into right and left regions; if exactly midline, it is called amidsagittal plane. A transverse plane runs horizontally at a right angle to the verticalaxis, dividing the structure into superior and inferior regions.

Answer A. Shock and dismay are early signs of denial-the first stage of grief. Theother options are associated with depressiona later stage of grief.

Answer B.After placing the patient in high Fowlers position and moving the patient tothe side of the bed, the nurse helps the patient sit on the edge of the bed and danglethe legs; the nurse then faces the patient and places the chair next to and facing thehead of the bed.

Answer D. Demonstrating by the nurse with a return demonstration by the patient

ensures that the patient can perform wound care correctly. Patients may claim tounderstand discharge instruction when they do not. An interpreter of family membermay communicate verbal or written instructions inaccurately.

Answer A. As a safety precaution, the nurse should discard an unlabeled syringe thatcontains medication. The other options are considered unsafe because they promoteerror.

Answer B. Aging-related physiological changes account for the increased frequencyof adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugsto clear more slowly in these patients. With increasing age, neurons are lost and bloodflow to the GI tract decreases.

Answer B. When teaching a patient about medications before discharge, the nurse is

acting as an educator. The nurse acts as a manager when performing such activities asscheduling and making patient care assignments. The nurse performs the care givingrole when providing direct care, including bathing patients and administeringmedications and prescribed treatments. The nurse acts as a patient advocate whenmaking the patients wishes known to the doctor.

Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity.This response helps reduce anxiety by encouraging the patient to express feelings. Thenurse should be supportive and develop goals together with the patient to give the


18/49

patient some control over an anxiety-inducing situation. Because the other optionsignore the patients feeling and block communication, they would not reduce anxiety.

Answer C. The scrub nurse assist the surgeon by providing appropriate surgicalinstruments and supplies, maintaining strict surgical asepsis and, with the circulatingnurse, accounting for all gauze, sponges, needles, and instruments. The circulating

nurse assists the surgeon and scrub nurse, positions the patient, applies appropriateequipment and surgical drapes, assists with gowning and gloving, and provides thesurgeon and scrub nurse with supplies.

Answer C. The nurse should return shortly to the patients room and remain there untilthe patient takes the medication to verify that it was taken as directed. The nurse shouldnever leave medication at the patients bedside unless specifically requested to do so.

Answer C. The nurse solves the problem as follows:10,000 units/7,500 units = 1 ml/X

10,000 X = 7,500

X= 7,500/10,000 or ml Answer C. To convert Fahrenheit degrees to centigrade, use this formula:

C degrees = (F degrees32) x 5/9

C degrees = (10232) 5/9

+ 70 x 5/9

38.9 degrees C

Answer D. All of these test help evaluate a patient with respiratory problems.However, ABG analysis is the only test evaluates gas exchange in the lungs, providing

information about patients oxygenation status. Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the belldetects low pitched sounds best. Palpation detects thrills best.

Answer C. In most cases, an outpatient must fill a prescription for a controlledsubstance within 6 months of the date on which the prescription was written.

Answer D. The nurse must consider the patients cognitive abilities to understanddrug instructions. If not, the nurse must find a family member or significant other to takeon the responsibility of administering medications in the home setting. The patientsability to recover, occupational hazards, and socioeconomic status do not affect drugadministration.

Answer A. Primary prevention precedes disease and applies to health patients.

Secondary prevention focuses on patients who have health problems and are at risk fordeveloping complications. Tertiary prevention enables patients to gain health fromothers activities without doing anything themselves.

Answer A. When making a surgical bed, the nurse leaves the bed in the high positionwhen finished. After placing the top linens on the bed without pouching them, the nursefanfolds these linens to the side opposite from where the patient will enter and placesthe pillow on the bedside chair. All these actions promote transfer of the postoperativepatient from the stretcher to the bed. When making an occupied bed or unoccupied bed,


19/49

the nurse places the pillow at the head of the bed and tucks the top sheet and blanketunder the bottom of the bed. When making an occupied bed, the nurse rolls the patientto the far side of the bed.

Answer C. The nurse should give ml of the drug. The dosage is calculated asfollows:

250 mg/X=500 mg/1 ml

500x=250

X=1/2 ml

Answer C. Patients can become dependent on barbiturates, especially with prolongeduse. Because of the rapid distribution of some barbiturates, no correlation existsbetween duration of action and half-life. Barbiturates are absorbed well and do notcause hepatotoxicity, although existing hepatic damage does require cautions use ofthe drug because barbiturates are metabolized in the liver.

Answer A. Elevating the head of the bed during enteral feeding minimizes the risk of

aspiration and allows the formula to flow in the patients intestines. When such elevationis contraindicated, the patient should be positioned on the right side. The nurse shouldgive enteral feeding at room temperature to minimize GI distress. To limit microbialgrowth, the nurse should hang only the amount of formula that can be infused in 3hours.

Answer C. The nurse should instruct the patient to touch the tip of the tongue to theroof of the mouth and then place the sublingual tablet on the floor of the mouth.Sublingual medications are absorbed directly into the bloodstream form the oralmucosa, bypassing the GI and hepatic systems. No drug is administered on top of thetongue or on the roof of the mouth. With the buccal route, the tablet is placed betweenthe gum and the cheek.

Answer A. The nurse always should clean around a wound drain, moving from centeroutward in ever-larger circles, because the skin near the drain site is morecontaminated than the site itself. The nurse should never remove the drain beforecleaning the skin. Alcohol should never be used to clean around a drain; it may irritatethe skin and has no lasting effect on bacteria because it evaporates. The nurse shouldwear sterile gloves to prevent contamination, but a mask is not necessary.

Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60minutes) to find the number of milliliters per minute:

125/60 min = X/1 minute

60X = 125X = 2.1 ml/minute

To find the number of drops/minute:

2.1 ml/X gtts = 1 ml/15 gtts

X = 32 gtts/minute, or 32 drops/minute

Answer A. Early in shock, hyperactivity of the sympathetic nervous system causesincreased epinephrine secretion, which typically makes the patient restless, anxious,


20/49

nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, coolclammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30ml/hour is within normal limits.

Answer D. During a rapid assessment, the nurses first priority is to check the

patients vital functions by assessing his airway, breathing, and circulation. To check a

patients circulation, the nurse must assess his heart and vascular network function.This is done by checking his skin color, temperature, mental status and, most

importantly, his pulse. The nurse should use the carotid artery to check a patients

circulation. In a patient with a circulatory problems or a history of compromised

circulation, the radial pulse may not be palpable. The brachial pulse is palpated during

rapid assessment of an infant.


21/49

Psytchiatric

1.Which statement describes how elderly clients react to medication?

a.At increased risk for adverse reactions

b.Tolerate medication better because theyre less active

c.Metabolize medications quickly

d.All of the above

2.Nursing interventions for a male client taking central nervous system (CNS) stimulants include

monitoring the client for which condition?

a.Hyperpyrexia, slow pulse, and weight gain

b.Tachycardia, weight loss, and mood swings

c.Hypotension, weight gain, and listlessness

d.All of the above

3.The charge nurse in an acute care setting assigns to a male client, whos on one-to-one suicide

precautions, to a psychiatric aide. This assignment is considered:

a.Poor nursing practice because a registered nurse should work with this client

b.Reasonable nursing practice because one-to-one supervision requires the total attention

of a staff member

c.Outside the responsibility of an aide

d.Illegal to delegate to an aide

4.Whats a nurse most important role in caring for an adult client with a mental disorder?

a.To offer advice

b.To know how to solve the clients problem

c.To establish trust and rapport

d.To set limits with the client


22/49

5.Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive

role models. Unhealthy boundaries may also be a result of:

a.Structured limit setting

b.A supportive environment

c.Abuse and neglect

d.Direction and attention

6.The nurse in-charge is displaying assertive behavior when she:

a.Says whats on her mind at the expense of others

b.Expresses an air of superiority

c.Avoids unpleasant situations and circumstances

d.Stands up for her rights while respecting the rights of others.

7.In a group therapy setting, one male member is very demanding, repeatedly interrupting others

and taking most of the group time. The nurses best response would be:

a.Will you briefly summarize your point because others need time also?

b.Your behavior is obnoxious and drains the group.

c.To ignore the behavior and allow him vent

d.Im so frustrated with your behavior

8.The nurse is aware that the primary indication for the use of electroconvulsive therapy (ECT)is:

a.Severe agitation

b.Antisocial behavior

c.Noncompliance with treatment

d.Major depression with psychotic features

9.Two nurses are discussing a female clients condition in the elevator. The employer of thementioned client overhears the conversation and fires the client. The nurses may be liable for

which act?


23/49

a.Assault

b.Battery

c.Neglect

d.Breach of confidentiality

10.A nurse at a substance abuse center answers the phone. A probation officer asks if the male

client is in treatment. The nurse responds, No, the client youre looking for isnt here.Which statement best describes the nurses response?

a.Correct because she didnt give out information about the client

b.A violation of confidentiality because she informed the officer that the client wasntthere

c.A breach of the principle of veracity because the nurse is misleading the officer

d.Illegal because shes withholding information from law enforcement agents.

11.The employer of a female client on the psychiatric unit calls the nursing station inquiring

about the clients progress. The nurse doesnt know if consent has been given by the client toallow the staff to give information out to caller on the phone. Which response by the nurse

would be best?

a.Im not permitted to discuss her progress.

b.Ill give you the name and telephone number of her physician.

c.Illhave her call you.

d.I cant confirm whether your employee is a client here.

12.A voluntary male client in a health care facility decided to leave the unit before treatment is

complete. To detain the client, the nurse refuses to return his personal effects. This is an

example of:

a.False imprisonment

b.Limit setting

c.Slander

d.Violation of confidentiality


24/49

13.Which statement is guideline to help nurses avoid liability?

a.Follow every physicians order

b.Do what the client desires even though you may disagree

c.Practice within the scope of the Nurse Practice Act

d.Obtain malpractice insurance

14.A nurse places a male client in full leather restraints. How often must the nurse check the

clients circulation?

a.Once per hour

b.Once per 8-hour shift

c.Every 15 minutes

d.Every 2 hours

15.Which clinical condition meets the criteria for involuntary commitment?

a.A single parent who leaves her minor children unattended and stays out all night

drinking

b.A person who lives alone and has schizophrenia with delusions of persecution

c.A man who threatens to kill his wife

d.A person with depression who says hes tired of living but doesnt have a suicide plan

16.An adult client in an acute care mental health program refuses his morning dose of an oralantipsychotic medication and believes hes being poisoned. The nurse should respond bytaking which action?

a.Administering the medication by injection

b.Omitting the dose and trying again the next day

c.Crushing the medication and putting it in his food

d.Consulting with the physician about a care plan


25/49

17.A nurse is working with a female dying client and his family. Which communication

technique is most important to use?

a.Reflection

b.Interpretation

c.Clarification

d.Active listening

18.A male client receiving morphine for long-term pain management develops tolerance.Tolerance is defined as:

a.An increased response to a medication

b.A diminished response to a drug so that more is required to achieve the same effect

c.An allergic reaction to a medication

d.An ability to take the same drug for extended periods of time.

19.The nurse is aware that the goal of crisis intervention is:

a.To solve the clients problems for him

b.Psychological resolution of the immediate crisis

c.To establish a means for long-term therapy

d.To provide a means for admission to an acute care facility

20.A male client in a group therapy is restless. His face is flushed and he makes sarcasticremarks to group members. The nurse responds by saying, You look angry. The nurse isusing which technique?

a.A broad opening statement

b.Reassurance

c.Clarifying

d.Making observations

21.A male patient with antisocial personality disorder smokes where it is prohibited and refuses

to follow other unit and hospital rules. The patient gets others to do the laundry and other


26/49

personal chores, splits the staff, and will work only with certain nurses. The plan of care for

this patient should focus primarily on:

a.A consistently enforcing unit rules and hospital policy

b.Isolating the patient to decrease contact with easily manipulated patients

c.Engaging in power struggles with the patient to minimize manipulative behavior

d.Using behavior modification to decrease negative behavior by using negative

reinforcement

22.The nurse knows that the doctor in charge has ordered the liquid form of the drug

chlorpromazine rather than the tablet form because the liquid?

a.Has a more predictable onset of action

b.Produces fewer anticholinergic effects

c.Produces fewer drug infections

d.Has a longer duration of action

23.A male patient receiving fluphenazine (Prolixen) therapy develops pseudoparkinsonism. The

doctor is likely to prescribe which drug to control this extrapyramidal effect?

a.Phenytoin (Dilantin)

b.Amantadine (Symmetrel)

c.Benztropine (Cogentin)

d.Diphenhydramine

24.During a panic attack, a male patient runs to the nurse and reports breathing difficulty, chest

pain, and palpitations. The patient is pale, with the mouth wide open and eyebrows raised.What should the nurse do first?

a.Assist the patient to breath deeply into a paper bag

b.Orient the patient to person, place and time

c.Set limits for acting out delusional behaviors

d.Administer an I.M. anxiolytic agent


27/49

25.A husband and wife seek emergency crisis intervention because he slapped her repeatedly the

night before. The husband says he grew up in a household where his father frequently abusedboth his mother and him. When interviewing with this couple, the nurse in charge knows

they are at risk for repeated violence because the husband:

a.Has only moderate impulse control

b.Denies feelings of jealousy or possessiveness

c.Has learned violence as an acceptable behavior

d.Feels secure in his relationship with his wife

26.What occurs during the working phase of the nurse-patient relationship?

a.The nurse assesses the patients needs and develops a plan of care

b.The nurse and patient together evaluate and modify the goals of the relationship

c.The nurse and patient discuss their feelings about terminating the relationship

d.The nurse and patient explore each others expectations of the relationship

27.When caring for a male adolescent patient diagnosed with depression, the nurse should

remember that depression manifests differently in adolescents and adult. In an adolescent,

signs and symptoms of depression are likely to include:

a.Helplessness, hopelessness, hypersomnolence, and anorexia

b.Truancy, a change of friends, social withdrawal, and oppositional behavior

c.Curfew breaking, stealing from family members, truancy, and oppositional behavior

d.Hypersomnolence, obsession with body image, and valuing of peers opinion.

28.During the admission assessment, a male patient with a panic disorder begins tohyperventilate and says, Im going to die if I dont get out of here right now! What is the

nurses best response?

a.Just calm down. Youre getting overly anxious.

b.What do you think is causing your panic attack?

c.You can rest alone in your room untilyou feel better.

d.Youre having panic attack. Ill stay here with you.


28/49

29.In a female patient with a conversion disorder who reports blindness, ophthalmologic

examinations reveal that no organic disorder is causing progressive vision loss. The most

likely source of this patients blindness is:

a.A family history of major depression

b.Having been forced to watch a loved ones torture

c.Noncompliance with a psychotropic medication regimen

d.Daily use of antianxiety agents and alcoholic beverages

30.A busy attorney with a successful law practice is admitted to an acute care facility with

epigastric pain. Since admission, the patient has called the nurse 15 minutes with one request

or another. This patient is exhibiting:

a.Repression

b.Somatization

c.Regression

d.Conversion


29/49

View Questions

i. Answer A. As individuals become older, their livers metabolize drugs at a slower rate.Cumulative effects can occur and increase the risk of adverse reactions. Level of activity

typically doesnt affect a persons reaction to medication. Elderly clients typically need

lower doses, not higher.ii. Answer B. Stimulants produce mood swings, weight loss, and tachycardia. The othersymptoms indicate CNS depression.

iii. Answer B. A psychiatric aide can sit with the client and provide safety. The nurse is stillresponsible for assessing the client and ensuring that one-to-one supervision occurs. Aides

are capable of providing one-to-one observation. It isnt illegal to delegate observation toan aide.

iv. Answer C. Its extremely important that the nurse establish trust and rapport. The nurseshouldnt offer advice. Instead, she should help the client develop the coping mechanisms

necessary to solve his own problems. Setting limits is also important as developing trustand rapport.

v. Answer C. Abuse and neglect lead to poor self-concept and role confusion, which are thebasis for unhealthy personal boundaries. Healthy boundaries are established in childhoodwhen parents provide consistent, supportive environment, and direction and attention.

vi. Answer C. The basic element of assertive behavior includes the ability to express feelingsand thoughts while respecting the rights of others. Doing so at the expense of others and

expressing superiority are aggressive behaviors, and avoiding unpleasant situation is a formof passive behavior.

vii. Answer A. Asking the client to summarize his point redirects the clients to focus hiscomments and allows him to make his point. Telling the client that his behavior is

obnoxious is judgmental, and ignoring the behavior doesnt help facilitate communication.

Expressing frustration focuses more on the nurse than on the clients need.viii. Answer D. ECT is indicated for major depression. ECT isnt indicated severe agitation,

antisocial behavior, or treatment noncompliance.ix. Answer D. Breach of confidentiality occurs when a nurse shares information that can cause

harm to an individual. Assault is an act that results in fear that one will be touched without

consent.Battery involves unconsented touching of another person. Neglect is the failure to do

whats deemed reasonable in a situation.

x. Answer B. The nurse violated confidentiality by informing the officer that the client wasntin treatment. Even with law enforcement agents, the nurse must be a client advocate and

protect the clients confidentiality. Because its unknown in this question whether the clientis actually in treatment, it cant be concluded that the nurse is misleading the officer

because her statement may be truthful. Information can be legally withheld when a court

order isnt in place.xi. Answer D. The nurses release of information to the clients employer without the clients

consent is a breach of confidentiality. The stigma associated with psychiatric illness may

affect the clients employment; therefore, its better to maintain confidentiality and refrain

from disclosing any information about the client, including whether shes a client in the

hospital.
http://nclexreviewers.com/nclex-sample-questions/psychiatric-nursing-nclex-sample-questions/psychiatric-nursing-nclex-review-part-1.htmlhttp://nclexreviewers.com/nclex-sample-questions/psychiatric-nursing-nclex-sample-questions/psychiatric-nursing-nclex-review-part-1.htmlhttp://nclexreviewers.com/nclex-sample-questions/psychiatric-nursing-nclex-sample-questions/psychiatric-nursing-nclex-review-part-1.html


30/49

xii. Answer A. Confining a voluntary client against his will be considered false imprisonment.Limit setting is a therapeutic technique used to achieve a desired behavior, and wouldntinvolve confining a voluntary client. Slander is oral defamation of character. The nurse

hasnt given out any information about the client, so confidentiality hasnt been violated.

xiii. Answer C. The Nurse Practice Act outlines acceptable standards for nursing. Practicing

within those guidelines will protect the nurse from liability. Physicians may not be aware ofguidelines for nurses and may inadvertently delegate inappropriate treatment of practice for

the nurse. The client doesnt know standards of care and isnt responsible for the nurses

actions. Insurance wont prevent a liability suit, but only assist the nurse if a suit would befiled.

xiv. Answer C. Circulatory as well as skin and nerve damage can occur within 15 minutes.Checking every hour, 2 hours, or 8 hours isnt often enough and could result is permanent

damage to the clients extremities.xv. Answer C. One of the criteria for involuntary commitment is an emergency in which the

client is a threat to himself or others, such as a man who threatens to kill his wife. A parent

might have a child removed from the home because of neglect, but that doesnt meet the

criteria for involuntary commitment. Many individuals with schizophrenia can learn to livewith hallucinations and delusions and dont require hospitalization. To meet criteria for

involuntary commitment, a depressed individual must have a suicide plan and be a directthreat to himself.

xvi. Answer D. To determine care plan for clients who are noncompliant with medications, thenurse should consult with the physician. Unless the client presents a danger to himself of

others, medications cant be forced on a client. A dose shouldnt be omitted without firstchecking with the physician. Intentionally deceiving of misleading a client violates the

therapeutic relationship.

xvii. Answer D. When working with a dying patient and his family, the nurse uses activelistening to assess their feelings, coping skills, and immediate and long-term needs. It also

helps the nurse select other appropriate strategies, such as reflection and clarification.

Interpretation should be used sparingly to avoid making false interference or putting the

client on the defensive.xviii. Answer B. Tolerance occurs when the body requires higher doses of substances, such

alcohol, opioids, or benzodiazepines, to achieve desired effect. Increased response indicates

a need for less of a drug to achieve the same effects. Allergic reactions are autoimmuneresponse to a particular drug or class of drugs. A client may be able to take, or tolerate, the

same drug for an extended period; however this isnt the definition of developing tolerance.

xix. Answer B. The goal of crisis intervention is the resolution of an immediate problem. Theclient must learn to solve his own problems. Although some clients do enter long-term

therapy or are admitted to an acute care facility, neither is the goal of crisis intervention.

xx. Answer D. The nurse is using observation to give the client feedback about his behaviorand attitude. A broad statement doesnt give feedback to the client. The nurse didntreassure the client or ask him to explain his actions (clarifying).

xxi. Answer A. Firmness and consistency regarding rules are the hallmarks of a plan of care fora patient with a personality disorder. Isolation is inappropriate and would violate thepatients rights. Power struggles should be avoided because the patient may try tomanipulate people through them. Behavior modification usually fails because of staff

inconsistency and patient manipulation.


31/49

xxii. Answer A. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. Theonset with tablet is unpredictable.

xxiii. Answer B. An antiparkinsonian agent, such as amantadine, may be used to controlpseudoparkinsonism, diphenhydramine or benztropine may be used to control other

extrapyramidal effects.

xxiv. Answer A. Physiological needs, particularly breathing, are the first priorities during a panicattack. Having the patient breathe deeply into a paper bag corrects hyperventilation;restoring a normal breathing pattern should relieve the patients other symptoms.

Orientation usually is unnecessary because most patients respond to external control andreduce stimulation. During a panic attack, the patient is not likely to act out but may strike

out if feeling threatened. An anxiolytic agent may be effective but is not the first priority.

xxv. Answer C. Family violence usually is a learned behavior begets violence, putting thiscouple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent

people commonly are jealous and possessive and feel insecure in their relationships.

xxvi. Answer B. The therapeutic nurse-patient relationship consists of four phases:preinteraction, introduction or orientation, working and termination. During the working

phase, the nurse and patient together evaluate and refine the goals established during theorientation phase, in addition, major therapeutic work takes place and insight is integrated

into a plan of action. The orientation phase involves assessing the patient, formulating acontract, exploring feelings, and establishing expectation about relationship. During the

termination phase, the nurse prepares the patient for separation and explores feelings about

the end of the relationship.xxvii. Answer B. In adolescents, depression typically manifests as truancy, a change of friends,

social withdrawal, and oppositional behavior. In adults, it usually produces helplessness,

hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking,

stealing, truancy, and oppositional behavior. Adolescents normally displayhypersomnelence, and obsession with body image, and valuing of peers opinions.

xxviii. Answer D. During a panic attack, the nurses best approach is to orient the patient to whatis happening and provide reassurance that the patient will not be left alone. The anxiety

level is likely to increase and the panic attack is likely to continueif the patient is told tocalm down (as in option A), asked the reasons for the attack (as in option B), or left alone

(as in option C).

xxix. Answer B. Conversion disorder, or hysterical neurosis, is characterized by alteration or lossof physical function with no physiological basis; the patients symptoms result frompsychological conflict. For example, a patient may report blindness after having observed a

distressing act. None of the other opinions causes conversion disorder.xxx. Answer C. The patient is exhibiting the defense mechanism of regressiona return to

behavior characteristic of an earlier developmental level. Dependent, attentiongetting

behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the

symptoms. Somatization is the channeling of anxiety into a preoccupation with physicalcomplaints. Conversion involves transfer of a mental conflict into a physical symptom to

relieve anxiety.

1.Which of the following medications would the nurse in-charge expect the doctor to order

to reverse a dystonic reaction?


32/49

a.Procholorperazine (Compazine)

b.Diphenhydramine (Benadryl)

c.Haloperidol (Haldol)

d.Midazolam (Versed)

2.While pacing in the hall, a female patient with paranoid schizophrenia runs to the nurse

and says, Why are you poisoning me? I know you work for central thought control! You cankeep my thoughts. Give me back my soul! how should the nurse respond?

a.Im a nurse, Im not poisoning you. Its against the nursing code of ethics.

b.Im a nurse, and youre a patient in the hospital. Im not going to harm you.

c.Im not poisoning you. And how could I possibly steal your soul?

d.I sense anger, Are you feeling angry today?

3.After completing chemical detoxification and a 12-step program to treat crack addiction, a

male patient is being prepared for discharge. Which remark by the patient indicates a realistic

view of the future?

a.Im never going to use crack again.

b.I know what I have to do. I have to limit my crack use.

c.Im going to take 1 day at a time. Im not making any promises.

d.I cant touch crack again, but I sure could use a drink. Ive earned it.

4.The nurse formulates a nursing diagnosis of impaired verbal communication for a male

patient with schizotypal personality disorder. Based on this nursing diagnosis, which nursingintervention is most appropriate?

a.Helping the patient to participate in social interactions

b.Establishing a one-on-one relationship with the patient

c.Establishing alternative forms of communication

d.Allowing the patient to decide when he wants to participate in verbal communication with

you


33/49

5.A female patient with obsessive-compulsive disorder tells the nurse that he must check the

lock on his apartment door 25 times before leaving for an appointment. The nurse knows that

this behavior represents the patients attempt to:

a.Call attention to himself

b.Control his thoughts

c.Maintain the safety of his home

d.Reduce anxiety

6.A patient, age 42, is admitted for surgical biopsy of a suspicious lump in her left breast.

When the nurse comes to her surgery, she is tearfully finishing a letter to her children. She

tells the nurse, I want to leave this for my children in case anything goes wrong today.

Which response by the nurse would be most therapeutic?

a.In case anything goes wrong? What are your thoughts and feelings right now?

b.Icant understand that youre nervous, but this is really a minor procedure. Youll be

back in your room before you know it.

c.Try to take a few deep breaths and relax. I have some medication that will help.

d.Im sure your children know how much you love them. Youll be able to talk to them on

the phone in a few hours.

7.Which nursing intervention is most important when restraining a violent male patient?

a.Reviewing hospital policy regarding how long the patient can be restrained

b.Preparing a p.r.n. dose of the patients psychotropic medication

c.Checking that the restraints have been applied correctly

d.Asking if the patient needs to use the bathroom or is thirsty

8.How soon after chlorpromazine administration should the nurse in charge expect to see a

patients delusion thoughts and hallucinations eliminated?

a.Several minutes

b.Several hours

c.Several days


34/49

d.Several weeks

9.Mental health laws in each state specify when restraints can be used and which type of

restraints are allowed. Most laws stipulate that restraints can be used:

a.For a maximum of 2 hours

b.As necessary to control the patient

c.If the patient poses a present danger to self or others

d.Only with the patients consent

10.A female patient has been severely depressed since her husband died 6 months ago. Her

doctor prescribes amitriptyline hydrochloride (Elavil), 50 mg P.O. daily. Beforeadministering amitriptyline, the nurse reviews the patients medical history. Which

preexisting condition would require cautions use of this drug?

a.Hiatal hernia

b.Hypernatremia

c.Hepatic disease

xxxi. d.Hypokalemiaxxxii. 11.The physician orders a new medication for a male client with generalized anxiety

disorder. During medication teaching, which statement or question by the nurse would be

most appropriate?xxxiii. a.Take this medication. It will reduce your anxiety.xxxiv. b.Do you have any concern about taking the medication?xxxv. c.Trust us. This medication has helped many people. We wouldnt have you take it if it

were dangerous.

xxxvi. d.How can we help you if you wont cooperate?xxxvii. 12.The nurse is aware that the Hormonal effects of the antipsychotic medications include

which of the following?

xxxviii. a.Retrograde ejaculation and gynecomastiaxxxix. b.Dysmenorrhea and increased vaginal bleeding

xl. c.Polydipsia and dysmenorrheal

xli. d.

Akinesia and dysphasiaxlii. 13.The nurse is caring for a female client in the manic phase of bipolar disorder whos readyfor discharge from the psychiatric unit. As the nurse begins to terminate the nurse-clientrelationship, which client response is most appropriate?

xliii. a.Expressing feeling of anxietyxliv. b.Displaying anger, shouting, and banging the tablexlv. c.Withdrawing from the nurse in silence

xlvi. d.Rationalizing the termination, saying that everything comes to an end


35/49

xlvii. 14.The nurse is caring for a male client with schizophrenia. Which outcome is the leastdesirable?

xlviii. a.The client spends more time by himselfxlix. b.The client doesnt engage in delusional thinking

l. c.The client doesnt harm himself or others

li. d.The client demonstrates the ability to meet his own self-care needslii. 15.The nurse is assigned to care for a recently admitted female client who has attemptedsuicide. What should the nurse do?

liii. a.Search the clients belongings and room carefully for items that could be used to attemptsuicide

liv. b.Express trust that the client wont cause self-harm while in the facilitylv. c.Respect the clients privacy by not searching any belongings

lvi. d.Remind all staff members to check on the client frequentlylvii. 16.A male client becomes angry and belligerent toward the nurse after speaking on the phone

with his mother. The nurse recognizes this as what defense mechanism?

lviii. a.Rationalization

lix. b.

Repressionlx. c.Displacementlxi. d.Suppression

lxii. 17.Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemblesthose used for:

lxiii. a.Physical therapylxiv. b.Neurologic examinationlxv. c.General anesthesia

lxvi. d.Cardiac stress testinglxvii. 18.Nursing care for a male client with schizophrenia must be based on valid psychiatric and

nursing theories. The nurses interpersonal communication with the client and specificnursing intervention must be:

lxviii. a.Clearly identified with boundaries and specifically defined roleslxix. b.Warn and non threateninglxx. c.Centered on clearly defined limits and expression of empathy

lxxi. d.Flexible enough for the nurse to adjust the care plan as the situation warrantslxxii. 19.Before eating a meal, a female client with obsessive-compulsive disorder (OCD) must

wash his hands for 18 minutes, comb his hair 444 strokes, and switch the bathroom lights

44 times. What is the most appropriate goal of care for this client?

lxxiii. a.Omit one unacceptable behavior each daylxxiv. b.Increase the clients acceptance of therapeutic drug uselxxv. c.Allow ample time for the client to complete all rituals before each meal

lxxvi. d.Systematically decrease the number of repetitions of rituals and the amount of time spentperforming them.

lxxvii. 20.A male client with a history of medication noncompliance is receiving outpatienttreatment for chronic undifferentiated schizophrenia. The physician is most likely to

prescribe which medication for this client?lxxviii. a.Chlorpromazine (Thorazine)

lxxix. b.Imipramine (Tofranil)lxxx. c.Lithium carbonate (Lithane)


36/49

lxxxi. d.Fluphenazine decanoate (Prolixin Decanoate)lxxxii. 21.A 23-year-old client is diagnosed with dependent personality disorder. Which behavior is

most likely to be evidence of ineffective individual coping?

lxxxiii. a.In ability to make choices and decisions without advicelxxxiv. b.Showing interest only in solitary activities

lxxxv. c.Avoiding developing relationshiplxxxvi. d.Recurrent self-destructive behavior with history of depressionlxxxvii. 22.During the mental status examination, a female client may be asked to explain such

proverbs as Dont cry over spilled milk. The purpose is to evaluate the clients ability tothink:

lxxxviii. a.Rationallylxxxix. b.Concretely

xc. c.Abstractlyxci. d.Tangentially

xcii. 23.After an upsetting divorce, a male client threatens to commit suicide with a handgun andis involuntarily admitted to the psychiatric unit with major depression. Which nursing

diagnosis takes highest priority for this client?xciii. a.Hopelessness related to recent divorcexciv. b.Ineffective coping related to inadequate stress managementxcv. c.Spiritual distress related to conflicting thoughts about suicide and sin

xcvi. d.Risk for self-directed-violence related to planning to commit suicide with a handgunxcvii. 24.A 25-year-old man reports losing his sight in both eyes. Hes diagnosed as having

conversion disorder and is admitted to the psychiatric unit. Which nursing intervention

would be most appropriate for this client?

xcviii. a.Not focusing on his blindnessxcix. b.Providing self-care for him

c. c.Telling him that his blindness isnt realci. d.Teaching eye exercises to strengthen his eyes

cii. 25.In group therapy, a male client angrily speaks up and responds to a peer, Youre alwayswhining and Im getting tired of listening to you! Here is the worlds smallest violin

playing for you. Which role is the client playing?ciii. a.Blockerciv. b.Monopolizercv. c.Recognition seeker

cvi. d.Aggressorcvii. 26.A nurse places a female client in full leather restraints. How often must the nurse check

the clients circulation?cviii. a.Once per hour

cix. b.Once per shiftcx. c.Every 10 to 15 minutes

cxi. d.Every 2 hourscxii. 27.When interviewing the parents of an injured child, which sign is the strongest indicator

that child abuse may be a problem?cxiii. a.The injury isnt consistent with the history of the childs agecxiv. b.The mother and father tell different stories regarding what happenedcxv. c.The family is poor


37/49

cxvi. d.The parents are argumentative and demanding with emergency department personnelcxvii. 28.Unhealthy personal boundaries are a product of dysfunctional families and a lack of

positive role models. Unhealthy boundaries may also be a result of:

cxviii. a.Structured limit settingcxix. b.Supportive environment

cxx. c.Abuse and neglectcxxi. d.Direction and attentioncxxii. 29.When monitoring a male client recently admitted for treatment of cocaine addiction, the

nurse notes sudden increase in the arterial blood pressure and heart rate. To correct theseproblems, the nurse expects the physician to prescribe:

cxxiii. a.Norepinephrine (Levophed) and lidocaine (Xylocaine)cxxiv. b.Nifedipine (Procardia) and lidocainecxxv. c.Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc)

cxxvi. d.Nifedipine and nitroglycerincxxvii. 30.Conditions necessary for the development of a positive sense of self-esteem include:

cxxviii. a.Consistent limits

cxxix. b.

Critical environmentcxxx. c.Inconsistent boundariescxxxi. d.Physical discipline


38/49

1.A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. Forwhich of the following would the nurse be alert?

a.Endometritis

b.Endometriosis

c.Salpingitis

d.Pelvic thrombophlebitis

2.A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis.After teaching the client about the purpose for the ultrasound, which of the following client

statements would indicate to the nurse in charge that the client needs further instruction?

a.The ultrasound will help to locate the placenta

b.The ultrasound identifies blood flow through the umbilical cord

c.The test will determine where to insert the needle

d.The ultrasound locates a pool of amniotic fluid

3.While the postpartum client is receiving herapin for thrombophlebitis, which of the following

drugs would the nurse Mica expect to administer if the client develops complications related

to heparin therapy?

a.Calcium gluconate

b.Protamine sulfate

c.Methylegonovine (Methergine)

d.Nitrofurantoin (macrodantin)

4.When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nursein charge would expect to do which of the following?

a.Turn the neonate every 6 hours

b.Encourage the mother to discontinue breast-feeding

c.Notify the physician if the skin becomes bronze in color

d.Check the vital signs every 2 to 4 hours


39/49

5.A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal

block anesthesia before delivery. After the nurse explains this type of anesthesia to the client,which of the following locations identified by the client as the area of relief would indicate to

the nurse that the teaching was effective?

a.Back

b.Abdomen

c.Fundus

d.Perineum

6.The nurse is caring for a primigravida at about 2 months and 1 week gestation. After

explaining self-care measures for common discomforts of pregnancy, the nurse determines

that the client understands the instructions when she says:

a.Nausea and vomiting can be decreased if I eat a few crackers before arising

b.If I start to leak colostrum, I should cleanse my nipples with soap and water

c.If I have a vaginal discharge, I should wear nylon underwear

d.Leg cramps can be alleviated if I put an ice pack on the area

7.Thirty hours after delivery, the nurse in charge plans discharge teaching for the client aboutinfant care. By this time, the nurse expects that the phase of postpartal psychological

adaptation that the client would be in would be termed which of the following?

a.Taking in

b.Letting go

c.Taking hold

d.Resolution

8.A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the

nurse tells the client that the usual treatment for partial placenta previa is which of thefollowing?

a.Activity limited to bed rest

b.Platelet infusion

c.Immediate cesarean delivery


40/49

d.Labor induction with oxytocin

9.Nurse Julia plans to instruct the postpartum client about methods to prevent breast

engorgement. Which of the following measures would the nurse include in the teaching plan?

a.Feeding the neonate a maximum of 5 minutes per side on the first day

b.Wearing a supportive brassiere with nipple shields

c.Breast-feeding the neonate at frequent intervals

d.Decreasing fluid intake for the first 24 to 48 hours

10.When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms,

hands opened, and begins to cry. The nurse interprets this reaction as indicative of which ofthe following reflexes?

a.Startle reflex

b.Babinski reflex

c.Grasping reflex

d.Tonic neck reflex

11.A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lowerback aches when she arrives home from work. The nurse should suggest that the client

perform:

a.Tailor sitting

b.Leg lifting

c.Shoulder circling

d.Squatting exercises

12.Which of the following would the nurse in charge do first after observing a 2-cm circle of

bright red bleeding on the diaper of a neonate who just had a circumcision?

a.Notify the neonates pediatrician immediately

b.Check the diaper and circumcision again in 30 minutes

c.Secure the diaper tightly to apply pressure on the site


41/49

d.Apply gently pressure to the site with a sterile gauze pad

13.Which of the following would the nurse Sandra most likely expect to find when assessing a

pregnant client with abruption placenta?

a.Excessive vaginal bleeding

b.Rigid, boardlike abdomen

c.Titanic uterine contractions

d.Premature rupture of membranes

14.While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes

contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the

following would be the nurses most appropriate action?

a.Note the fetal heart rate patterns

b.Notify the physician immediately

c.Administer oxygen at 6 liters by mask

d.Have the client pant-blow during the contractions

15.A client tells the nurse, I think my baby likes to hear me talk to him. When discussingneonates and stimulation with sound, which of the following would the nurse include as a

means to elicit the best response?

a.High-pitched speech with tonal variations

b.Low-pitched speech with a sameness of tone

c.Cooing sounds rather than words

d.Repeated stimulation with loud sounds

16.A 31-year-old multipara is admitted to the birthing room after initial examination reveals her

cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is shein?

a.Active phase

b.Latent phase

c.Expulsive phase


42/49

d.Transitional phase

17.A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How

should the nurse respond?

a.Yes, it produces no adverse effect.

b.No, it can initiate premature uterine contractions.

c.No, it can promote sodium retention.

d.No, it can lead to increased absorption of fat-soluble vitamins.

18.A patient in her 14th

week of pregnancy has presented with abdominal cramping and vaginal

bleeding for the past 8 hours. She has passed several cloth. What is the primary nursingdiagnosis for this patient?

a.Knowledge deficit

b.Fluid volume deficit

c.Anticipatory grieving

d.Pain

19.Immediately after a delivery, the nurse-midwife assesses the neonates head for signs ofmolding. Which factors determine the type of molding?

a.Fetal body flexion or extension

b.Maternal age, body frame, and weight

c.Maternal and paternal ethnic backgrounds

d.Maternal parity and gravidity

20.For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal

monitoring (EFM) device. What must occur before the internal EFM can be applied?

a.The membranes must rupture

b.The fetus must be at 0 station

c.The cervix must be dilated fully

d.The patient must receive anesthesia


43/49

21.A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in

early part of the first stage of labor. Her pain is likely to be most intense:

a.Around the pelvic girdle

b.Around the pelvic girdle and in the upper arms

c.Around the pelvic girdle and at the perineum

d.At the perineum

22.A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin usemay increase the patients risk for:

a.Endometriosis

b.Female hypogonadism

c.Premenstrual syndrome

d.Tubal or ectopic pregnancy

23.A patient with pregnancy-induced hypertension probably exhibits which of the followingsymptoms?

a.Proteinuria, headaches, vaginal bleeding

b.Headaches, double vision, vaginal bleeding

c.Proteinuria, headaches, double vision

d.Proteinuria, double vision, uterine contractions

24.Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith

orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patients

fluid intake and output closely during oxytocin administration?

a.Oxytoxin causes water intoxication

b.Oxytocin causes excessive thirst

c.Oxytoxin is toxic to the kidneys

d.Oxytoxin has a diuretic effect


44/49

25.Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to

prevent hypothermia. What is a common source of radiant heat loss?

a.Low room humidity

b.Cold weight scale

c.Cools incubator walls

d.Cool room temperature

26.After administering bethanechol to a patient with urine retention, the nurse in chargemonitors the patient for adverse effects. Which is most likely to occur?

a.Decreased peristalsis

b.Increase heart rate

c.Dry mucous membranes

d.Nausea and Vomiting

27.The nurse in charge is caring for a patient who is in the first stage of labor. What is theshortest but most difficult part of this stage?

a.Active phase

b.Complete phase

c.Latent phase

d.Transitional phase

28.After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her

discomfort, the nurse should suggest that she:

a.Apply warm compresses to her nipples just before feedings

b.Lubricate her nipples with expressed milk before feeding

c.Dry her nipples with a soft towel after feedings

d.Apply soap directly to her nipples, and then rinse

29.The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse

should tell the patient that she can expect to feel the fetus move at which time?


45/49

a.Between 10 and 12 weeks gestation

b.Between 16 and 20 weeks gestation

c.Between 21 and 23 weeks gestation

d.Between 24 and 26 weeks gestation

30.Normal lochial findings in the first 24 hours post-delivery include:

a.Bright red blood

b.Large clots or tissue fragments

c.A foul odor

d.The complete absence of lochia


46/49

1. Answer A. Endometritis is an infection of the uterine lining and can occur after prolongedrupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture

of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated.

Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolongedrupture of membranes.

2. Answer B. Before amniocentesis, a routine ultrasound is valuable in locating the placenta,locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color

Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine

ultrasound does not accomplish this.

3. Answer B. Protamine sulfate is a heparin antagonist given intravenously to counteract

bleeding complications cause by heparin overdose.

4. Answer D. While caring for an infant receiving phototherapy for treatment of jaundice, vital

signs are checked every 2

Question a Ire Nursing

Documents

Transcript of Question a Ire Nursing