HESI EXIT V4 160 Questions and Answers
1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing
intervention is appropriate for this child?
A. Make certain the child is maintained in correct body alignment.
B. Be sure the traction weights touch the end of the bed.
C. Adjust the head and foot of the bed for the child's comfort
D. Release the traction for 15-20 minutes every 6 hours PRN.
Answer: A. Make certain the child is maintained in correct body alignment.
2. The nurse is assessing a healthy child at the 2 year check up. Which of the following
should the nurse report immediately to the health care provider?
A. Height and weight percentiles vary widely
B. Growth pattern appears to have slowed
C. Recumbent and standing height are different
D. Short term weight changes are uneven
Answer: A Height and weight percentiles vary widely
3. The parents of a 2 year-old child report that he has been holding his breath whenever he
has temper tantrums. What is the best action by the nurse?
A. Teach the parents how to perform cardiopulmonary resuscitation
B. Recommend that the parents give in when he holds his breath to prevent anoxia
C. Advise the parents to ignore breath holding because breathing will begin as a reflex
D. Instruct the parents on how to reason with the child about possible harmful effects
Answer: C. Advise the parents to ignore breath holding because breathing will begin as a
reflex
4. The nurse is assessing a client in the emergency room. Which statement suggests that the
problem is acute angina?
A. "My pain is deep in my chest behind my sternum."
B. "When I sit up the pain gets worse."
C. "As I take a deep breath the pain gets worse."
D. "The pain is right here in my stomach area."
Answer: A. "My pain is deep in my chest behind my sternum."
5. The nurse is assessing the mental status of a client admitted with possible organic brain
disorder. Which of these questions will best assess the function of the client's recent memory?
A. "Name the year." "What season is this?" (pause for answer after each question)
B. "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to
subtract 7 from the new number."
C. "I am going to say the names of three things and I want you to repeat them after me: blue,
ball, pen."
D. "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"
Answer: C. "I am going to say the names of three things and I want you to repeat them after
me: blue, ball, pen."
6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A. Food
B. Warmth
C. Security
D. Comfort
Answer: C. Security
7. A nurse has just received a medication order which is not legible. Which statement best
reflects assertive communication?
A. "I cannot give this medication as it is written. I have no idea of what you mean."
B. "Would you please clarify what you have written so I am sure I am reading it correctly?"
C. "I am having difficulty reading your handwriting. It would save me time if you would be
more careful."
D. "Please print in the future so I do not have to spend extra time attempting to read your
writing."
Answer: B. "Would you please clarify what you have written so I am sure I am reading it
correctly?"
8. What is the most important consideration when teaching parents how to reduce risks in the
home?
A. Age and knowledge level of the parents
B. Proximity to emergency services
C. Number of children in the home
D. Age of children in the home
Answer: D. Age of children in the home
9. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse
enters the room to request something for pain. The nurse should
A. Administer a placebo
B. Encourage increased fluid intake
C. Administer the prescribed analgesia
D. Recommend relaxation exercises for pain control
Answer: C. Administer the prescribed analgesia
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A. Respiratory rate of 42
B. Lethargy for the past hour
C. Apical pulse of 54
D. Coughing up copious secretions
Answer: A. Respiratory rate of 30
11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
A. Lethargy
B. Heat intolerance
C. Diarrhea
D. Skin eruptions
Answer: A. Lethargy
12. The emergency room nurse admits a child who experienced a seizure at school. The father
comments that this is the first occurrence, and denies any family history of epilepsy.
What is the best response by the nurse?
A. "Do not worry. Epilepsy can be treated with medications."
B. "The seizure may or may not mean your child has epilepsy."
C. "Since this was the first convulsion, it may not happen again."
D. "Long term treatment will prevent future seizures."
Answer: B. "The seizure may or may not mean your child has epilepsy."
13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A. Risk for injury
B. Risk for knowledge deficit
C. Altered thought process
D. Disturbance in self-esteem
Answer: A. Risk for injury
14. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important
for the nurse to maintain patency of which of these areas?
A. Mouth
B. Nasal passages
C. Back of throat
D. Bronchials
Answer: B. Nasal passages
15. The nurse is providing instructions for a client with pneumonia. What is the most
important information to convey to the client?
A. "Take at least 2 weeks off from work."
B. "You will need another chest x-ray in 6 weeks."
C. "Take your temperature every day."
D. "Complete all of the antibiotic even if your findings decrease."
Answer: D. "Complete all of the antibiotic even if your findings decrease."
16. When counseling a 6 year old who is experiencing enuresis, what must the nurse
understand about the pathophysiological basis of this disorder?
A. Has no clear etiology
B. May be associated with sleep phobia
C. Has a definite genetic link
D. Is a sign of willful misbehavior
Answer: A. Has no clear etiology
17. The nurse is discussing negativism with the parents of a 30 month-old child. How should
the nurse tell the parents to best respond to this behavior?
A. Reprimand the child and give a 15 minute "time out"
B. Maintain a permissive attitude for this behavior
C. Use patience and a sense of humor to deal with this behavior
D. Assert authority over the child through limit setting
Answer: C. Use patience and a sense of humor to deal with this behavior
18. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox.
Which of the following demonstrates appropriate teaching by the nurse?
A. Chewable aspirin is the preferred analgesic
B. Topical cortisone ointment relieves itching
C. Papules, vesicles, and crusts will be present at one time
D. The illness is only contagious prior to lesion eruption
Answer: C. Papules, vesicles, and crusts will be present at one time
19. The nurse is assigned to a client who has heart failure . During the morning rounds the
nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates,
crackles bilaterally. Which nursing intervention should be performed first?
A. Take the client's vital signs
B. Place the client in a sitting position with legs dangling
C. Contact the health care provider
D. Administer the PRN anti anxiety agent
Answer: B. Place the client in a sitting position with legs dangling
20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the
parents to
A. Dress the child warmly to avoid chilling
B. Keep the child away from other children for the duration of the rash
C. Clean the affected areas with tepid water and detergent
D. Wrap the child's hand in mittens or socks to prevent scratching
Answer: D. Wrap the child''s hand in mittens or socks to prevent scratching
21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special
family gatherings?" Which initial response by the nurse would be best?
A. "A recovering person has to be very careful not to lose control, therefore, confine your
drinking just at family gatherings."
B. "At your next AA meeting discuss the possibility of limited drinking with your sponsor."
C. "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D. "A recovering person cannot return to drinking without starting the addiction process
over."
Answer: D. "The recovering person cannot return to drinking without starting the addiction
process over."
22. In taking the history of a pregnant woman, which of the following would the nurse
recognize as the primary contraindication for breast feeding?
A. Age 40 years
B. Lactose intolerance
C. Family history of breast cancer
D. Uses cocaine on weekends
Answer: D. Uses cocaine on weekends
23. A client is receiving nitroprusside IV for the treatment of acute heart failure with
pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this
medication?
A. Potassium
B. Arterial blood gasses
C. Blood urea nitrogen
D. Thiocyanate
Answer: D. Thiocyanate
24. A victim of domestic violence tells the batterer she needs a little time away. How would
the nurse expect that the batterer might respond?
A. With acceptance and views the victim’s comment as an indication that their marriage is in
trouble
B. With fear of rejection causing increased rage toward the victim
C. With a new commitment to seek counseling to assist with their marital problems
D. With relief, and welcomes the separation as a means to have some personal time
Answer: B. With fear of rejection causing increased rage toward the victim
25. A postpartum mother is unwilling to allow the father to participate in the newborn's care,
although he is interested in doing so. She states, "I am afraid the baby will be confused about
who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention
should be what focus?
A. Discuss with the mother sharing parenting responsibilities
B. Set time aside to get the mother to express her feelings and concerns
C. Arrange for the parents to attend infant care classes
D. Talk with the father and help him accept the wife's decision
Answer: B. Set time aside to get the mother to express her feelings and concerns
26. A client with emphysema visits the clinic. While teaching about proper nutrition, the
nurse should emphasize that the client
A. Eat foods high in sodium increases sputum liquefaction
B. Use oxygen during meals improves gas exchange
C. Perform exercise after respiratory therapy enhances appetite
D. Cleanse the mouth of dried secretions reduces risk of infection
Answer: B. Use oxygen during meals improves gas exchange
27. Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A. I noticed a little lump a little above the belly button.
B. The baby seems hungry all the time.
C. Mild vomiting that progressed to vomiting shooting across the room.
D. Irritation and spitting up immediately after feedings.
Answer: C. Mild emesis progressing to projectile vomiting
28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A. Decreased cardiac output
B. Tissue hypoxia
C. Cerebral edema
D. Reduced oxygen saturation
Answer: B. Tissue hypoxia
29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
A. High in carbohydrates and proteins
B. Low in carbohydrates and proteins
C. High in carbohydrates, low in proteins
D. Low in carbohydrates, high in proteins
Answer: A. High in carbohydrates and proteins
30. In evaluating the growth of a 12 month-old child, which of these findings would the nurse
expect to be present in the infant?
A. Increased 10% in height
B. 2 deciduous teeth
C. Tripled the birth weight
D. Head > chest circumference
Answer: C. Tripled the birth weight
31. A Hispanic client in the postpartum period refuses the hospital food because it is "cold."
The best initial action by the nurse is to
A. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
B. Ask the client what foods are acceptable or bad
C. Encourage her to eat for healing and strength
D. Schedule the dietitian to meet with the client as soon as possible
Answer: B. Ask the client what foods are acceptable
32. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal
for his age. Which of the following would the nurse expect at this age?
A. Cooing
B. Imitation of sounds
C. Throaty sounds
D. Laughter
Answer: B. Imitation of Sounds
33. The nurse should recognize that physical dependence is accompanied by what findings
when alcohol consumption is first reduced or ended?
A. Seizures
B. Withdrawal
C. Craving
D. Marked tolerance
Answer: B. Withdrawal
34. Immediately following an acute battering incident in a violent relationship, the batterer
may respond to the partner’s injuries by
A. Seeking medical help for the victim's injuries
B. Minimizing the episode and underestimating the victim’s injuries
C. Contacting a close friend and asking for help
D. Being very remorseful and assisting the victim with medical care
Answer: B. Minimizing the episode and underestimating the victim’s injuries
35. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is
the best approach by the nurse?
A. "Do you want to take this pretty red medicine?"
B. "You will feel better if you take your medicine."
C. "This is your medicine, and you must take it all right now."
D. "Would you like to take your medicine from a spoon or a cup?"
Answer: D. "Would you like to take your medicine from a spoon or a cup?"
36. In planning care for a child diagnosed with minimal change nephrotic syndrome, the
nurse should understand the relationship between edema formation and
A. Increased retention of albumin in the vascular system
B. Decreased colloidal osmotic pressure in the capillaries
C. Fluid shift from interstitial spaces into the vascular space
D. Reduced tubular reabsorption of sodium and water
Answer: B. Decreased colloidal osmotic pressure in the capillaries
37. An eighteen month-old has been brought to the emergency room with irritability, lethargy
over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings,
the nurse would assess the child for additional findings of
A. Septicemia
B. Dehydration
C. Hypokalemia
D. Hypercalcemia
Answer: B. Dehydration
38. A client who has been drinking for five years states that he drinks when he gets upset
about "things" such as being unemployed or feeling like life is not leading anywhere. The
nurse understands that the client is using alcohol as a way to deal with
A. Recreational and social needs
B. Feelings of anger
C. Life’s stressors
D. Issues of guilt and disappointment
Answer: C. Life’s stressors
39. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as
beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the
frequency of the contractions?
A. 14 minutes
B. 10 minutes
C. 15 minutes
D. Nine minutes
Answer: C. 15 minutes
40. The nurse is performing an assessment on a child with severe airway obstruction. Which
finding would the nurse anticipate finding?
A. Retractions in the intercostal tissues of the thorax
B. Chest pain aggravated by respiratory movement
C. Cyanosis and mottling of the skin
D. Rapid, shallow respirations
Answer: A. Retractions in the soft tissues of the thorax
41. During the evaluation phase for a client, the nurse should focus on
A. All finding of physical and psychosocial stressors of the client and in the family
B. The client's status, progress toward goal achievement, and ongoing re-evaluation
C. Setting short and long-term goals to insure continuity of care from hospital to home
D. Select interventions that are measurable and achievable within selected timeframes
Answer: B. The client''s status, progress toward goal achievement, and ongoing re evaluation
42. The school nurse suspects that a third grade child might have Attention Deficit
Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
A. Observe the child's behavior on at least 2 occasions
B. Consult with the teacher about how to control impulsivity
C. Compile a history of behavior patterns and developmental accomplishments
D. Compare the child's behavior with classic signs and symptoms
Answer: C. Compile a history of behavior patterns and developmental accomplishments
43. Which of the actions suggested to the RN by the PN during a planning conference for a
10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to
add to the plan of care?
A. Measure head circumference
B. Place in airborne isolation
C. Provide passive range of motion
D. Provide an over-the-crib protective top
Answer: A. Measure head circumference
44. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory
results, the nurse would expect to find elevation in which of the following values?
A. Blood urea nitrogen
B. Acid phosphatase
C. Bilirubin
D. Sedimentation rate
Answer: C. Bilirubin
45. The nurse is discussing nutritional requirements with the parents of an 18 month-old
child. Which of these statements about milk consumption is correct?
A. May drink as much milk as desired
B. Can have milk mixed with other foods
C. Will benefit from fat-free cow's milk
D. Should be limited to 3-4 cups of milk daily
Answer: D. Should be limited to three to four cups of milk daily
46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full.
Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most
likely indicates
A. Neologisms
B. Dissociation
C. Flight of ideas
D. Word salad
Answer: C. Flight of ideas
47. A mother asks about expected motor skills for a 3 year-old child. Which of the following
would the nurse emphasize as normal at this age?
A. Jumping rope
B. Tying shoelaces
C. Riding a tricycle
D. Playing hopscotch
Answer: C. Riding a tricycle
48. A home health nurse is caring for a client with a pressure sore that is red, with serous
drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing
for this wound is
A. A transparent film dressing
B. Wet dressing with debridement granules
C. Wet to dry with hydrogen peroxide
D. Moist saline dressing
Answer: D. Moist saline dressing
49. The nurse enters a 2 year-old child's hospital room in order to administer an oral
medication. When the child is asked if he is ready to take his medicine, he immediately says,
"No!". What would be the most appropriate next action?
A. Leave the room and return five minutes later and give the medicine
B. Explain to the child that the medicine must be taken now
C. Give the medication to the father and ask him to give it
D. Mix the medication with ice cream or applesauce
Answer: A. Leave the room and return five minutes later and give the medicine
50. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy.
Which of the following statements suggests that the client understands the connection
between alcohol consumption and fetal alcohol syndrome?
A. "I understand that a glass of wine with dinner is healthy."
B. "Beer is not really hard alcohol, so I guess I can drink some."
C. "If I drink, my baby may be harmed before I know I am pregnant."
D. "Drinking with meals reduces the effects of alcohol."
Answer: C. "If I drink, my baby may be harmed before I know I am pregnant."
51. The client who is receiving enteral nutrition through a gastrostomy tube has had 4
diarrhea stools in the past 24 hours. The nurse should
A. Review the medications the client is receiving
B. Increase the formula infusion rate
C. Increase the amount of water used to flush the tube
D. Attach a rectal bag to protect the skin
Answer: A. Review the medications the client is receiving
52. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe
brain tumor. Which history offered by the family members would be anticipated by the nurse
as associated with the diagnosis and communicated?
A. "My partner's breathing rate is usually below 12."
B. "I find the mood swings and the change from a calm person to being angry all the time
hard to deal with."
C. "It seems our sex life is non existant over the past 6 months."
D. "In the morning and evening I hear complaints that reading is next to impossible from
blurred print."
Answer: B. "I find the mood swings and the change from a calm person to being angry all
the time hard to deal with."
53. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The
mother asks the nurse to explain the purpose of the test. What is the nurse’s best response
about the purpose of the Denver?
A. It measures a child’s intelligence.
B. It assesses a child's development.
C. It evaluates psychological responses.
D. It helps to determine problems.
Answer: B. It assesses a child''s development.
54. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The
parents are anxious and concerned about the child's reaction to impending surgery. Which
nursing intervention would be best to prepare the child?
A. Introduce the child to all staff the day before surgery
B. Explain the surgery 1 week prior to the procedure
C. Arrange a tour of the operating and recovery rooms
D. Encourage the child to bring a favourite toy to the hospital
Answer: B. Explain the surgery 1 week prior to the procedure
55. The nurse, assisting in applying a cast to a client with a broken arm, knows that
A. The cast material should be dipped several times into the warm water
B. The cast should be covered until it dries
C. The wet cast should be handled with the palms of hands
D. The casted extremity should be placed on a cloth-covered surface
Answer: C. The wet cast should be handled with the palms of hands
56. Based on principles of teaching and learning, what is the best initial approach to pre- op
teaching for a client scheduled for coronary artery bypass?
A. Touring the coronary intensive unit
B. Mailing a video tape to the home
C. Assessing the client's learning style
D. Administering a written pre-test
Answer: C. Assessing the client’s learning style
57. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to
have the child return to day care as soon as possible. In order to ensure that the illness is no
longer communicable, what should the nurse assess for in this child?
A. All lesions crusted
B. Elevated temperature
C. Rhinorrhea and coryza
D. Presence of vesicles
Answer: A. All lesions crusted
58. The nurse is providing instructions to a new mother on the proper techniques for breast
feeding her infant. Which statement by the mother indicates the need for additional
instruction?
A. "I should position my baby completely facing me with my baby's mouth in front of my
nipple."
B. "The baby should latch onto the nipple and areola areas."
C. "There may be times that I will need to manually express milk."
D. I can switch to a bottle if I need to take a break from breast feeding.
Answer: D. I can switch to a bottle if I need to take a break from breast feeding.
59. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for
schizophrenia. His symptoms have been managed for several months with fluphenazine
(Prolixin). Which should be a focus of the first assessment?
A. Stressors in the home
B. Medication compliance
C. Exposure to hot temperatures
D. Alcohol use
Answer: B. Medication compliance
60. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which
intervention should take priority in planning care?
A. Increase fluid intake to prevent dehydration
B. Place client on a pressure reducing support surface
C. Use skin care products designed for use with incontinence
D. Increase caloric intake to aid healing
Answer: B. Place client on a pressure reducing support surface
61. A nurse is conducting a community wide seminar on childhood safety issues. Which of
these children is at the highest risk for poisoning?
A. 9 month-old who stays with a sitter 5 days a week
B. 20 month-old who has just learned to climb stairs
C. 10 year-old who occasionally stays at home unattended
D. 15 year-old who likes to repair bicycles
Answer: B. Twenty month-old who has just learned to climb stairs
62. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor,
the nurse would be most concerned about which statement by the mother?
A. My child has lost 3 pounds in the last month.
B. Urinary output seemed to be less over the past 2 days.
C. All the pants have become tight around the waist.
D. The child prefers some salty foods more than others.
Answer: C. Clothing has become tight around the waist
63. What is the most important aspect to include when developing a home care plan for a
client with severe arthritis?
A. Maintaining and preserving function
B. Anticipating side effects of therapy
C. Supporting coping with limitations
D. Ensuring compliance with medications
Answer: A. Maintaining and preserving function
64. A mother asks the nurse if she should be concerned about the tendency of her child to
stutter. What assessment data will be most useful in counseling the parent?
A. Age of the child
B. Sibling position in family
C. Stressful family events
D. Parental discipline strategies
Answer: A. Age of the child
65. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk
preferred over formula for premature infants?
A. Contains less lactose
B. Is higher in calories/ounce
C. Provides antibodies
D. Has less fatty acid
Answer: C. Provides antibodies
66. Which of the following nursing assessments in an infant is most valuable in identifying
serious visual defects?
A. Red reflex test
B. Visual acuity
C. Pupil response to light
D. Cover test
Answer: A. Red reflex test
67. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is
4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is
intact. Which of the following coverings is most appropriate for this wound?
A. Transparent dressing
B. Dry sterile dressing with antibiotic ointment
C. Wet to dry dressing
D. Occlusive moist dressing
Answer: D. Occlusive moist dressing
68. A 30 month-old child is admitted to the hospital unit. Which of the following toys would
be appropriate for the nurse to select from the toy room for this child?
A. Cartoon stickers
B. Large wooden puzzle
C. Blunt scissors and paper
D. Beach ball
Answer: B. Large wooden puzzle
69. A nurse is to present information about Chinese folk medicine to a group of student
nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
A. Yang, the positive force that represents light, warmth, and fullness
B. Yin, the negative force that represents darkness, cold, and emptiness
C. Use of improper hot foods, herbs and plants
D. A failure to keep life in balance with nature and others
Answer: B. Yin, the negative force that represents darkness, cold, and emptiness
70. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the
nurse "What is our major concern now, and what will we have to deal with in the future?"
Which of the following is the best response?
A. "There is a probability of life-long complications."
B. "Cystic fibrosis results in nutritional concerns that can be dealt with."
C. "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D. "You will work with a team of experts and also have access to a support group that the
family can attend."
Answer: C. "Thin, tenacious secretions from the lungs are a constant struggle in cystic
fibrosis."
71. Which type of accidental poisoning would the nurse expect to occur in children under age
6?
A. Oral ingestion
B. Topical contact
C. Inhalation
D. Eye splashes
Answer: A. Oral ingestion
72. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He
constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured
speech and demands constant attention from the staff. Which activity would be best for the
client?
A. Reading
B. Checkers
C. Cards
D. Ping-pong
Answer: D. Ping-pong
73. The nurse is caring for a client who has developed cardiac tamponade. Which finding
would the nurse anticipate?
A. Widening pulse pressure
B. Pleural friction rub
C. Distended neck veins
D. Bradycardia
Answer: C. Distended neck veins
74. Which nursing action is a priority as the plan of care is developed for a 7 year-old child
hospitalized for acute glomerulonephritis?
A. Assess for generalized edema
B. Monitor for increased urinary output
C. Encourage rest during hyperactive periods
D. Note patterns of increased blood pressure
Answer: D. Note patterns of increased blood pressure
75. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the
following actions by the nurse would be appropriate?
A. Schedule the therapy thirty minutes after meals
B. Teach the child not to cough during the treatment
C. Confine the percussion to the rib cage area
D. Place the child in a prone position for the therapy
Answer: C. Confine the percussion to the rib cage area
76. A polydrug user has been in recovery for 8 months. The client has began skipping
breakfast and not eating regular dinners. The client has also started frequenting bars to "see
old buddies." The nurse understands that the client’s behavior is a warning sign to indicate
that the client may be
A. headed for relapse
B. feeling hopeless
C. approaching recovery
D. in need of increased socialization
Answer: A. headed for relapse
77. A client was admitted to the psychiatric unit with major depression after a suicide attempt.
In addition to feeling sad and hopeless, the nurse would assess for
A. Anxiety, unconscious anger, and hostility
B. Guilt, indecisiveness, poor self-concept
C. Psychomotor retardation or agitation
D. Meticulous attention to grooming and hygiene
Answer: C. Psychomotor retardation or agitation
78. A client is experiencing hallucinations that are markedly increased at night. The client is
very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond
the visiting time, in the client’s private room. What would be the best response by the nurse
demonstrating emotional support for the client?
A. "No, it would be best if you brought the client some reading material that she could read at
night."
B. "No, your presence may cause the client to become more anxious."
C. "Yes, staying with the client and orienting her to her surroundings may decrease her
anxiety."
D. "Yes, would you like to spend the night when the client’s behavior indicates that she is
frightened?"
Answer: C. "Yes, staying with the client and orienting her to her surroundings may decrease
her anxiety."
79. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these
developmental achievements would the nurse anticipate that the child would be able to
perform?
A. Say 2 words
B. Pull up to stand
C. Sit without support
D. Drink from a cup
Answer: C. Sit without support
80. The nurse is talking to parents about nutrition in school aged children. Which of the
following is the most common nutritional disorder in this age group?
A. Bulimia
B. Anorexia
C. Obesity
D. Malnutrition
Answer: C. Obesity
81. At the geriatric day care program a client is crying and repeating "I want to go home. Call
my daddy to come for me." The nurse should
A. Invite the client to join the exercise group
B. Tell the client you will call someone to come for her
C. Give the client simple information about what she will be doing
D. Firmly direct the client to her assigned group activity
Answer: C. Give the client simple information about what she will be doing
82. A victim of domestic violence states to the nurse, "If only I could change and be how my
companion wants me to be, I know things would be different." Which would be the best
response by the nurse?
A. "The violence is temporarily caused by unusual circumstances, don’t stop hoping for a
change."
B. "Perhaps, if you understood the need to abuse, you could stop the violence."
C. "No one deserves to be beaten. Are you doing anything to provoke your spouse into
beating you?"
D. "Batterers lose self-control because of their own internal reasons, not because of what
their partner did or did not do."
Answer: D. "Batterers lose self control because of their own internal reasons, not because of
what their partner did or did not do."
83. A 38 year-old female client is admitted to the hospital with an acute exacerbation of
asthma. This is her third admission for asthma in 7 months. She describes how she doesn't
really like having to use her medications all the time. Which explanation by the nurse best
describes the long-term consequence of uncontrolled airway inflammation?
A. Degeneration of the alveoli
B. Chronic broncho constriction of the large airways
C. Lung remodeling and permanent changes in lung function
D. Frequent pneumonia
Answer: C. Lung remodeling and permanent changes in lung function
84. A mother wants to switch her 9 month-old infant from an iron fortified formula to whole
milk because of the expense. Upon further assessment, the nurse finds that the baby eats table
foods well, but drinks less milk than before. What is the best advice by the nurse?
A. Change the baby to whole milk
B. Add chocolate syrup to the bottle
C. Continue with the present formula
D. Offer fruit juice frequently
Answer: C. Continue with the present formula
85. Privacy and confidentiality of all client information is legally protected. In which of these
situations would the nurse make an exception to this practice?
A. When a family member offers information about their loved one
B. When the client threatens self-harm and harm to others
C. When the health care provider decides the family has a right to know the client's diagnosis
D. When a visitor insists that the visitor has been given permission by the client
Answer: B. When the client threatens self-harm and harm to others
86. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the
following should be included in the plan of care?
A. Monitor for hyperkalemia
B. Place in protective isolation
C. Precautions with position changes
D. Administer diuretics as ordered
Answer: C. Precautions with position changes
87. The nurse is making a home visit to a client with chronic obstructive pulmonary disease
(COPD). The client tells the nurse that he used to be able to walk from the house to the
mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip.
Which diagnosis would be most appropriate for this client based on this assessment?
A. Activity intolerance caused by fatigue related to chronic tissue hypoxia
B. Impaired mobility related to chronic obstructive pulmonary disease
C. Self care deficit caused by fatigue related to dyspnea
D. Ineffective airway clearance related to increased bronchial secretions
Answer: A. Activity intolerance caused by fatigue related to chronic tissue hypoxia
88. The nurse admits a client newly diagnosed with hypertension. What is the best method for
assessing the blood pressure?
A. Standing and sitting
B. In both arms
C. After exercising
D. Supine position
Answer: B. In both arms
89. The nurse is caring for residents in a long term care setting for the elderly. Which of the
following activities will be most effective in meeting the growth and development needs for
persons in this age group?
A. Aerobic exercise classes
B. Transportation for shopping trips
C. Reminiscence groups
D. Regularly scheduled social activities
Answer: C. Reminiscence groups
90. Post-procedure nursing interventions for electroconvulsive therapy include
A. Applying hard restraints if seizure occurs
B. Expecting client to sleep for 4 to 6 hours
C. Remaining with client until oriented
D. Expecting long-term memory loss
Answer: C. Remaining with client until oriented
91. The nurse assesses delayed gross motor development in a 3 year-old child. The inability
of the child to do which action confirms this finding?
A. Stand on 1 foot
B. Catch a ball
C. Skip on alternate feet
D. Ride a bicycle
Answer: A. Stand on 1 foot
92. The mother of a 15 month-old child asks the nurse to explain her child's lab results and
how they show her child has iron deficiency anemia. The nurse's best response is
A. "Although the results are here, your doctor will explain them later."
B. "Your child has less red blood cells that carry oxygen."
C. "The blood cells that carry nutrients to the cells are too large."
D. "There are not enough blood cells in your child's circulation."
Answer: B. "Your child has less red blood cells that carry oxygen."
93. In a child with suspected coarctation of the aorta, the nurse would expect to find
A. Strong pedal pulses
B. Diminishing carotid pulses
C. Normal femoral pulses
D. Bounding pulses in the arms
Answer: D. Bounding pulses in the arms
94. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits
alone alertly watching the activities of clients and staff. The client is hostile when approached
and asserts that the doctor gives her medication to control her mind. The client's behavior
most likely indicates
A. Feelings of increasing anxiety related to paranoia
B. Social isolation related to altered thought processes
C. Sensory perceptual alteration related to withdrawal from environment
D. Impaired verbal communication related to impaired judgment
Answer: B. Social isolation related to altered thought processes
95. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0to10 scale. The client refuses all pain medication other than Motrin, which does not relieve
his pain. The next action for the nurse to take is to
A. Ask the client about the refusal of certain pain medications
B. Talk with the client's family about the situation
C. Report the situation to the health care provider
D. Document the situation in the notes
Answer: A. Ask the client about the refusal of certain pain medications
96. When teaching adolescents about sexually transmitted diseases, what should the nurse
emphasize that is the most common infection?
A. Gonorrhea
B. Chlamydia
C. Herpes
D. HIV
Answer: B. Chlamydia
97. First-time parents bring their 5 day-old infant to the pediatrician's office because they are
extremely concerned about its breathing pattern. The nurse assesses the baby and finds that
the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths
per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct
analysis of these findings?
A. The pediatrician must examine the baby
B. Emergency equipment should be available
C. This breathing pattern is normal
D. A future referral may be indicated
Answer: C. This breathing pattern is normal
98. A client is admitted with the diagnosis of meningitis. Which finding would the nurse
expect in assessing this client?
A. Hyperextension of the neck with passive shoulder flexion
B. Flexion of the hip and knees with passive flexion of the neck
C. Flexion of the legs with rebound tenderness
D. Hyper flexion of the neck with rebound flexion of the legs
Answer: B. Flexion of the hip and knees with passive flexion of the neck
99. Clients taking which of the following drugs are at risk for depression?
A. Steroids
B. Diuretics
C. Folic acid
D. Aspirin
Answer: A. Steroids
100. When a client is having a general tonic clonic seizure, the nurse should
A. Hold the client's arms at their side
B. Place the client on their side
C. Insert a padded tongue blade in client's mouth
D. Elevate the head of the bed
Answer: B. Place the client on their side
101. After talking with her partner, a client voluntarily admitted herself to the substance
abuse unit. After the second day on the unit the client states to the nurse, "My husband told
me to get treatment or he would divorce me. I don’t believe I really need treatment but I don’t
want my husband to leave me." Which response by the nurse would assist the client?
A. "In early recovery, it's quite common to have mixed feelings, but unmotivated people can’t
get well."
B. "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had
been pressured to come."
C. "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to
seek treatment on an out client bases."
D. "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of
sobriety for you."
Answer: D. "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the
benefits of sobriety for you."
102. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a
hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which
of these is a nursing priority?
A. Hold the infant at frequent intervals.
B. Assess for neonatal withdrawal syndrome
C. Offer fluids to prevent dehydration
D. Administer paregoric to stop diarrhea
Answer: B. Assess for neonatal withdrawal syndrome
103. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is
noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change
is most likely due to
A. Dehydration
B. Diminished blood volume
C. Decreased cardiac output
D. Renal failure
Answer: C. Decreased cardiac output
104. The primary nursing diagnosis for a client with congestive heart failure with pulmonary
edema is
A. Pain
B. Impaired gas exchange
C. Cardiac output altered: decreased
D. Fluid volume excess
Answer: C. Cardiac output altered decreased
105. The nurse is performing a developmental assessment on an 8 month-old. Which finding
should be reported to the health care provider?
A. Lifts head from the prone position
B. Rolls from abdomen to back
C. Responds to parents' voices
D. Falls forward when sitting
Answer: D. Falls forward when sitting. Sitting without support is expected at this age.
106. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly
experiences torticollis and involuntary spastic muscle movement. In addition to administering
the ordered anticholinergic drug, what other measure should the nurse implement?
A. Have respiratory support equipment available
B. Immediately place her in the seclusion room
C. Assess the client for anxiety and agitation
D. Administer PRN dose of IM antipsychotic medication
Answer: A. Have respiratory support equipment available
107. The nurse walks into a client's room and finds the client lying still and silent on the floor.
The nurse should first
A. Assess the client's airway
B. Call for help
C. Establish that the client is unresponsive
D. See if anyone saw the client fall
Answer: C. Establish that the client is unresponsive
108. The nurse is caring for a client 2 hours after a right lower lobectomy. During the
evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles
constantly in the water seal chamber. On inspection of the chest dressing and tubing, the
nurse does not find any air leaks in the system. The next best action for the nurse is to
A. Check for subcutaneous emphysema in the upper torso
B. Reposition the client to a position of comfort
C. Call the health care provider as soon as possible
D. Check for any increase in the amount of thoracic drainage
Answer: A. Check for subcutaneous emphysema in the upper torso
109. The nurse is teaching a client with dysrhythmia about the electrical pathway of an
impulse as it travels through the heart. Which of these demonstrates the normal pathway?
A. AV node, SA node, Bundle of His, Purkinje fibers
B. Purkinje fibers, SA node, AV node, Bundle of His
C. Bundle of His, Purkinje fibers, SA node , AV node
D. SA node, AV node, Bundle of His, Purkinje fibers
Answer: D. SA node, AV node, Bundle of His, Purkinje fibers
110. When assessing a client who has just undergone a cardioversion, the nurse finds the
respirations are 12. Which action should the nurse take first?
A. Try to vigorously stimulate normal breathing
B. Ask the RN to assess the vital signs
C. Measure the pulse oximetry
D. Continue to monitor respirations
Answer: D. Continue to monitor respirations
111. A new nurse on the unit notes that the nurse manager seems to be highly respected by the
nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes
all decisions and rarely asks for our input." The best description of the nurse manager's
management style is
A. Participative or democratic
B. Ultraliberal or communicative
C. Autocratic or authoritarian
D. Laissez faire or permissive
Answer: C. Autocratic or authoritarian
112. A depressed client who has recently been acting suicidal is now more social and
energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life."
What should be the nurse’s initial response?
A. "You’ve made some decisions."
B. "Are you thinking about killing yourself?"
C. "I’m so glad to hear that you’ve made some decisions."
D. "You need to discuss your decisions with your therapist."
Answer: B. "Are you thinking about killing yourself?"
113. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted
after a fall while playing basketball. In understanding his behavior and in planning care for
this client, what must the nurse understand about adolescents with hemophilia?
A. Must have structured activities
B. Often take part in active sports
C. Explain limitations to peer groups
D. Avoid risks after bleeding episodes
Answer: B. Often take part in active sports
114. When an autistic client begins to eat with her hands, the nurse can best handle the
problem by
A. Placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."
B. Commenting "I believe you know better than to eat with your hand."
C. Jokingly stating, "Well I guess fingers sometimes work better than spoons."
D. Removing the food and stating "You can’t have anymore food until you use the spoon."
Answer: A. Placing the spoon in the client’s hand and stating "Use the spoon to eat your
food."
115. In assessing the healing of a client's wound during a home visit, which of the following
is the best indicator of good healing?
A. White patches
B. Green drainage
C. Reddened tissue
D. Eschar development
Answer: C. Reddened tissue
116. Which therapeutic communication skill is most likely to encourage a depressed client to
vent feelings?
A. Direct confrontation
B. Reality orientation
C. Projective identification
D. Active listening
Answer: D. Active listening
117. In order to enhance a client's response to medication for chest pain from acute angina,
the nurse should emphasize
A. Learning relaxation techniques
B. Limiting alcohol use
C. Eating smaller meals
D. Avoiding passive smoke
Answer: A. Learning relaxation techniques
118. The nurse is caring for 2 children who have had surgical repair of congenital heart
defects. For which defect is it a priority to assess for findings of heart conduction
disturbance?
A. Arterial septal defect
B. Patent ductus arteriosus
C. Aortic stenosis
D. Ventricular septal defect
Answer: D. Ventricular septal defect
119. Clients with mitral stenosis would likely manifest findings associated with congestion in
the
A. Pulmonary circulation
B. Descending aorta
C. Superior vena cava
D. Bundle of His
Answer: A. Pulmonary circulation
120. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women
in the group. Which information is a priority for these women?
A. Low tar cigarettes are less harmful during pregnancy
B. There is a relationship between smoking and low birth weight
C. The placenta serves as a barrier to nicotine
D. Moderate smoking is effective in weight control
Answer: B. There is a relationship between smoking and low birth weight
121. What is the best way for the nurse to accomplish a health history on a 14 year-old client?
A. Have the mother present to verify information
B. Allow an opportunity for the teen to express feelings
C. Use the same type of language as the adolescent
D. Focus the discussion of risk factors in the peer group
Answer: B. Allow an opportunity for the teen to express feelings
122. What principle of HIV disease should the nurse keep in mind when planning care for a
newborn who was infected in utero?
A. The disease will incubate longer and progress more slowly in this infant
B. The infant is very susceptible to infections
C. Growth and development patterns will proceed at a normal rate
D. Careful monitoring of renal function is indicated
Answer: B. The infant is very susceptible to infections
123. While planning care for a preschool aged child, the nurse understands developmental
needs. Which of the following would be of the most concern to the nurse?
A. Playing imaginatively
B. Expressing shame
C. Identifying with family
D. Exploring the playroom
Answer: B. Expressing shame
124. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of
bipolar illness. When planning client teaching, what is most important to emphasize to the
client?
A. Maintain a low sodium diet
B. Take a diuretic with lithium
C. Come in for evaluation of serum lithium levels every 1-3 months
D. Have blood lithium levels drawn during the summer months
Answer: D. Have blood lithium levels drawn during the summer months
125. While teaching a client about their medications, the client asks how long it will take
before the effects of lithium take place. What is the best response of the nurse?
A. Immediately
B. Several days
C. 2 weeks
D. 1 month
Answer: C. 2 weeks
126. The nursing intervention that best describes treatment to deal with the behaviors of
clients with personality disorders include
A. Pointing out inconsistencies in speech patterns to correct thought disorders
B. Accepting client and the client's behavior unconditionally
C. Encouraging dependency in order to develop ego controls
D. Consistent limit-setting enforced 24 hours per day
Review Information:
Answer: D. Consistent limit-setting enforced 24 hours per day
127. Following a cocaine high, the user commonly experiences an extremely unpleasant
feeling called
A. Craving
B. Crashing
C. Outward bound
D. Nodding out
Answer: B. Crashing
128. The nurse asks a client with a history of alcoholism about the client’s drinking behavior.
The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps me
to relax." The client is using which defense mechanism?
A. Denial
B. Projection
C. Intellectualization
D. Rationalization
Answer: D. Rationalization
129. One reason that domestic violence remains extensively undetected is
A. Few battered victims seek medical care
B. There is typically a series of minor, vague complaints
C. Expenses due to police and court costs are prohibitive
D. Very little knowledge is currently known about batterers and battering relationships
Answer: B. There is typically a series of minor, vague complaints
130. A client develops volume overload from an IV that has infused too rapidly. What
assessment would the nurse expect to find?
A. S3 heart sound
B. Thready pulse
C. Flattened neck veins
D. Hypoventilation
Answer: A. Auscultation of an
131. The nurse is caring for a client with end stage renal disease. What action should the
nurse take to assess for patency in a fistula used for haemodialysis?
A. Observe for edema proximal to the site
B. Irrigate with 5 mls of 0.9% Normal Saline
C. Palpate for a thrill over the fistula
D. Check color and warmth in the extremity
Answer: C. Palpate for a thrill over the fistula
132. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per
dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 2040
mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug
administration, what should the nurse do next?
A. Give the medication as ordered
B. Call the health care provider to clarify the dose
C. Recognize that antibiotics are over-prescribed
D. Hold the medication as the dosage is too low
Answer: A. Give the medication as ordered
133. The nurse is participating in a community health fair. As part of the assessments, the
nurse should conduct a mental status examination when
A. An individual displays restlessness
B. There are obvious signs of depression
C. Conducting any health assessment
D. The resident reports memory lapses
Answer: C. Conducting any health assessment
134. The nurse is caring for a 12 year-old with an acute illness. Which of the following
indicates the nurse understands common sibling reactions to hospitalization?
A. Younger siblings adapt very well
B. Visitation is helpful for both
C. The siblings may enjoy privacy
D. Those cared for at home cope better
Answer: B. Visitation is helpful for both
135. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home
from school because of a rash. The child had been seen the day before by the health care
provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most
appropriate action by the nurse?
A. Tell the parents to bring the child to the clinic for further evaluation
B. Refer the school officials to printed materials about this viral illness
C. Inform the teacher that the child is receiving antibiotics for the rash
D. Explain that this rash is not contagious and does not require isolation
Answer: D. Explain that this rash is not contagious and does not require isolation
136. When making a home visit to a client with chronic pyelonephritis, which nursing action
has the highest priority?
A. Follow-up on lab values before the visit
B. Observe client findings for the effectiveness of antibiotics
C. Ask for a log of urinary output
D. As for the log of the oral intake
Answer: C. Ask for a log of urinary output
137. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After
discussing the defect with the parents, the nurse should expect that
A. Circumcision can be performed at any time
B. Initial repair is delayed until ages 6-8
C. Post-operative appearance will be normal
D. Surgery will be performed in stages
Answer: D. Surgery will be performed in stages
138. The nurse is assessing a client on admission to a community mental health center. The
client discloses that she has been thinking about ending her life. The nurse's best response
would be
A. "Do you want to discuss this with your pastor?"
B. "We will help you deal with those thoughts."
C. "Is your life so terrible that you want to end it?"
D. "Have you thought about how you would do it?"
Answer: D. "Have you thought about how you would do it?"
139. The nursing care plan for a client with decreased adrenal function should include
A. Encouraging activity
B. Placing client in reverse isolation
C. Limiting visitors
D. Measures to prevent constipation
Answer: C. Limiting visitors
140. The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
A. Cough and deep breathe every 2 hours
B. Place the client in contact isolation
C. Provide a diet high in protein
D. Institute seizure precautions
Answer: A. Cough and deep breathe every 2 hours
141. Which of the following conditions assessed by the nurse would contraindicate the use of
benztropine (Cogentin)?
A. Neuromalignant syndrome
B. Acute extrapyramidal syndrome
C. Glaucoma, prostatic hypertrophy
D. Parkinson's disease, atypical tremors
Answer: C. Glaucoma, prostatic hypertrophy
142. The nurse is caring for a client in the coronary care unit. The display on the cardiac
monitor indicates ventricular fibrillation. What should the nurse do first?
A. Perform defibrillation
B. Administer epinephrine as ordered
C. Assess for presence of pulse
D. Institute CPR
Answer: C. Assess for presence of pulse
143. During the use of an interpreter to teach a client about a procedure to do in the home the
nurse should take which approach?
A. Speak directly to the interpreter while presenting information and use pauses for questions
B. Talk to the interpreter in advance and leave the client and interpreter alone
C. Include a family member and direct communications to that person
D. Face the client while presenting the information as the interpreter talks in the native
language
Answer: D. Face the client while presenting the information as the interpreter talks in the
native language .
144. A client is in her third month of her first pregnancy. During the interview, she tells the
nurse that she has several sex partners and is unsure of the identity of the baby's father. Which
of the following nursing interventions is a priority?
A. Counsel the woman to consent to HIV screening
B. Perform tests for sexually transmitted diseases
C. Discuss her high risk for cervical cancer
D. Refer the client to a family planning clinic
Answer: A. Counsel the woman to consent to HIV screening
145. A client is discharged following hospitalization for congestive heart failure. The nurse
teaching the family suggests they encourage the client to rest frequently in which of the
following positions?
A. High Fowler's
B. Supine
C. Left lateral
D. Low Fowler's
Answer: A. High Fowler''s
146. A nurse who is evaluating a mentally retarded 2 year-old in a clinic should stress which
goal when talking to the child's mother?
A. Teaching the child self care skills
B. Preparing for independent toileting
C. Promoting the child's optimal development
D. Helping the family decide on long term care
Answer: C. Promoting the child’s optimal development
147. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the
client with nutrition needs, the nurse should
A. Offer small meals of high calorie soft food
B. Assist the client to sit in a chair for meals
C. Provide additional servings of fruits and raw vegetables
D. Encourage the client to eat fish, liver and chicken
Answer: A. Offer small meals of high calorie soft food
148. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart
disease. Which of these is most likely to be seen with this diagnosis?
A. Several otitis media episodes in the last year
B. Weight and height in 10th percentile since birth
C. Takes frequent rest periods while playing
D. Changing food preferences and dislikes
Answer: C. Takes frequent rest periods while playing
149. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is
A. Urinary output of 30 ml per hour
B. No complaints of thirst
C. Increased hematocrit
D. Good skin turgor around burn
Answer: A. Urinary output of 30 ml per hour
150. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have
chalky white-to-yellowish staining with pitting of the enamel. Which of the following
conditions would most likely explain these findings?
A. Ingestion of tetracycline
B. Excessive fluoride intake
C. Oral iron therapy
D. Poor dental hygiene
Answer: B. Excessive fluoride intake
151. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which
of these cases of childhood poisoning would the nurse suggest that parents have the child
drink orange juice?
A. An 18 month-old who ate an undetermined amount of crystal drain cleaner
B. A 14 month-old who chewed 2 leaves of a philodendron plant
C. A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D. A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
Answer: A. An 18 month-old who ate an undetermined amount of crystal drain cleaner
152. Which of these is an example of a variation in the newborn resulting from the presence
of maternal hormones?
A. Engorgement of the breasts
B. Mongolian spots
C. Edema of the scrotum
D. Lanugo
Answer: A. Engorgement of the breasts
153. A 2 month-old child has had a cleft lip repair. The selection of which restraint would
require no further action by the charge nurse?
A. Elbow
B. Mummy
C. Jacket
D. Clove hitch
Answer: A. Elbow
154. A client treated for depression tells the nurse at the mental health clinic that he recently
purchased a handgun because he is thinking about suicide. The first nursing action should be
to
A. Notify the health care provider immediately
B. Suggest in-patient psychiatric care
C. Respect the client's confidential disclosure
D. Phone the family to warn them of the risk
Answer: A. Notify the health care provider immediately
155. A client has just been admitted with portal hypertension. Which nursing diagnosis would
be a priority in planning care?
A. Altered nutrition: less than body requirements
B. Potential complication hemorrhage
C. Ineffective individual coping
D. Fluid volume excess
Answer: B. Potential complication hemorrhage
156. While planning care for a 2 year-old hospitalized child, which situation would the nurse
expect to most likely affect the behavior?
A. Strange bed and surroundings
B. Separation from parents
C. Presence of other toddlers
D. Unfamiliar toys and games
Answer: B. Separation from parents
157. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A. Direct sunlight
B. Foods containing tyramine
C. Foods fermented with yeast
D. Canned citrus fruit drinks
Answer: A. Avoid direct sunlight
158. The initial response by the nurse to a delusional client who refuses to eat because of a
belief that the food is poisoned is
A. "You think that someone wants to poison you?"
B. "Why do you think the food is poisoned?"
C. "These feelings are a symptom of your illness."
D. "You’re safe here. I won’t let anyone poison you."
Answer: A. "You think that someone wants to poison you?"
159. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing
nursing assistants in the care of the client, the nurse should emphasize that
A. The client should remain on bed rest in a semi-Fowler's position
B. The client should alternate ambulation with bed rest with legs elevated
C. The client may ambulate and sit in chair as tolerated
D. The client may ambulate as tolerated and remain in semi-Fowler position in bed
Answer: B. The client should alternate ambulation with bed rest with legs elevated
160. The nurse is performing physical assessments on adolescents. When would the nurse
anticipate that females experience growth spurts?
A. About 2 years earlier than males
B. About the same time as males
C. Just prior to the onset of puberty
D. That increase height by 4 inches each year
Answer: A. About 2 years earlier than males
