Q&ARandom -10

Question Number 1 of 40
The nurse understands that during the "tension building" phase of a violent relationship, when the batterer
makes unreasonable demands, the battered victim may experience feelings of

A) Anger
B) Helplessness
C) Calm
D) Explosive

The correct answer is B: Helplessness The battered individual internalizes appropriate anger at the
batterer’s unfairness and instead feels depressed with a sense of helplessness, when the partner explodes
in spite of best efforts to please the batterer

Question Number 2 of 40
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the
nurse anticipate?

A) Bronchial breath sounds in outer lung fields

B) Decreased tactile fremitus
C) Hacking, nonproductive cough
D) Hyperresonance of areas of consolidation

The correct answer is A: Bronchial breath sounds in outer lung fields

Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits
bronchial breath sounds to outer lung fields.

Question Number 3 of 40
When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse
know about the offspring of a normal father and a carrier mother?

A) It is likely that all sons are affected

B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier

The correct answer is D: There is a 25% chance a daughter will be a carrier

Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and
carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25%
chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a
normal male.

Question Number 4 of 40
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and
carbohydrates is recommended. The nurse informs the child and family that the most important reason for
this diet is to

A) Promote healing and strengthen the immune system

B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs
The correct answer is D: Spare protein catabolism to meet metabolic needs

Because of the burn injury, the child has increased metabolism and catabolism. By providing a high
carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue

Question Number 5 of 40
A school nurse is advising a class of unwed pregnant high school students. What is the most important
action they can perform to deliver a healthy child?

A) Maintain good nutrition

B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep

The correct answer is A: Maintaining good nutrition

Nurses can serve a pivotal role in providing nutritional education and case management interventions.
Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens
need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain
between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.

Question Number 6 of 40
A parent has numerous questions regarding normal growth and development of a 10 month-old infant.
Which of the following parameters is of most concern to the nurse?

A) 50% increase in birth weight

B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen

The correct answer is A: 50% increase in birth weight Birth weight should be doubled at 6 months of age,
tripled at 1 year, and quadrupled by 18 months.

Question Number 7 of 40
A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that
the most likely cause of the HSV-1 infection in this client is

A) Immunosuppression
B) Emotional stress
C) Unprotected sexual activities
D) Contact with saliva

The correct answer is A: Immunosuppression The decreased immunity leads to frequent

secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result
in HSV-1. However they are not the most likely cause in clients with HIV.

Question Number 8 of 40
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her
hospital gown only. What is the rationale for this nursing intervention?

A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) So the client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing

The correct answer is D: To reduce the tendency of the client to hide objects under his or her clothing

The client may conceal weights on their body to increase weight gain.

Question Number 9 of 40
The nurse is caring for a post-op colostomy client. The client begins to cry saying, "I'll never be attractive
again with this ugly red thing." What should be the first action by the nurse?
 A) Arrange a consultation with a sex therapist
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care
D) Determine the client's understanding of her colostomy
The correct answer is D: Determine the client''s understanding of her colostomy

One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However,
the specific concern of the client needs to be assessed before specific suggestions for dealing with the
sexual concerns are given.

Question Number 10 of 40
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for
this client?
".
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support
Your response was "A".

The correct answer is B: Looking different from their peers

Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant,
the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term
and involves bracing and/or surgery

Question Number 11 of 40
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse
observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of
pink frothy sputum. The first action of the nurse would be which of the following?

A) Call the health care provider

B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen

The correct answer is D: Administer oxygen

When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation.
Starting oxygen is a priority.

Question Number 12 of 40
Which of the following nursing assessments indicate immediate discontinuance of an antipsychotic
medication?

A) Involuntary rhythmic stereotypic movements and tongue protrusion

B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension

The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension

Hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of NMS
(neuroleptic malignant syndrome

Question Number 13 of 40
A 3 year-old child is treated in the emergency department after ingestion of 1ounce of a liquid narcotic. What
action should the nurse do first?

A) Provide the ordered humidified oxygen via mask

B) Suction the mouth and the nose
 C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids

tthe correct answer is C: Check the mouth and radial pulse

The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation;
then stabilize the client. The other nursing actions will follow.

Question Number 14 of 40
The nurse has been assigned to these clients in the emergency room. Which client would the nurse go
check first?

A) Viral pneumonia with atelectasis

B) Spontaneous pneumothorax with a respiratory rate of 38
C) Tension pneumothorax with slight tracheal deviation to the right
D) Acute asthma with episodes of bronchospasm

The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right

Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal
shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the
side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension,
pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest

Question Number 15 of 40
The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new
behavior, how should the nurse explain the child's actions to the parents?

A) The ethical sense and feelings of justice are developing

B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts
The correct answer is A: The ethical sense and feelings of justice are developing The child is developing a
sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and
responsibilities. They also do what is right because of parental direction or to avoid punishment.
Question Number 16 of 40
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being
improved by hemodialysis?

A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia

The correct answer is A: Low hemoglobin Although hemodialysis improves or corrects electrolyte
imbalances it has not effect on improving anemia.

Question Number 17 of 40
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about
home care for the child. Which of the following information is appropriate for the nurse to include?
".
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house
The correct answer is A: Allow the child to continue their normal activities

Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable
adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help develop normal
breathing patterns.
Question Number 18 of 40
A schizophrenic client talks animatedly but the staff are unable to understand what the client is
communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome
for this client’s care will be

A) Expresses feelings appropriately through verbal interactions

B) Accurately interprets events and behaviors of others
C) Demonstrates improved social relationships
D) Engages in meaningful and understandable verbal communication

The correct answer is D: Engages in meaningful and understandable verbal communication

Data support impaired verbal communication deficit. The outcome must be related to the diagnosis and
supporting data. No data is presented related to feelings or to thinking processes

Question Number 19 of 40
The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would
the nurse anticipate finding?

A) Large volume of urinary output with each voiding

B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated

The correct answer is C: Frequent urination Clients with Benign Prostatic Hypertrophy have overflow
incontinence with frequent urination in small amounts day and night

Question Number 19 of 40
The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would
the nurse anticipate finding?

A) Large volume of urinary output with each voiding

B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated

The correct answer is C: Frequent urination Clients with Benign Prostatic Hypertrophy have overflow
incontinence with frequent urination in small amounts day and night

Question Number 20 of 40
Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old
client?

A) An accurate measurement of intake is not reliable

B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day

The correct answer is C: A serving size at this age is about 2 tablespoons

In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding
this, the nurse can assess adequacy of intake.

Question Number 21 of 40
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which
stomal diversion poses the highest risk for skin breakdown

A) Ileostomy
 B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy
The correct answer is A: Ileostomy

Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in
several hours. Because of the caustic nature of this stoma output adequate peristomal skin protection must
be delivered to prevent skin breakdown.

Question Number 22 of 40
During seizure activity which observation is the priority to enhance further direction of treatment?

A) Observe the sequence or types of movement

B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs

The correct answer is A: Observe the sequence or types of movement.

It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis
and subsequent treatment often rests solely on the seizure description.

Question Number 23 of 40
The nurse is teaching a client who has a hip prostheses following total hip replacement. Which of the
following should be included in the instructions for home care?

A) Avoid climbing stairs for 3 months

B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross legs

The correct answer is D: Do not cross legs Hip flexion should not exceed 60 degrees

Question Number 24 of 40
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most
important in this situation?

A) Glucose level of 120

B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates

The correct answer is C: Long term steroid usage Steroid dependency tends to delay wound healing. If the
client also smokes, the risk is increased.

Question Number 25 of 40
The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding
would the nurse expect?

A) Pelvic tip downward

B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp

The correct answer is D: Characteristic limp

Developmental dysplasia produces a characteristic limp in children who are walking.

Question Number 26 of 40
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
 A) Autistic
B) Ecopraxic
C) Echolalic
D) Catatonic

The correct answer is C: Echolalic Echolalic - repeating words heard.

Question Number 27 of 40
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse
should emphasize that a priority for their child is to

A) Avoid overheating during physical activities

B) Maintain normal activity with some restrictions
C) Be cautious of others with viruses or temperatures
D) Maintain routine immunizations
Your response was "A".

The correct answer is A: Avoid overheating

Fluid loss caused by overheating and dehydration can trigger a crisis

Question Number 28 of 40
Which of the following statements describes what the nurse must know in order to provide anticipatory
guidance to parents of a toddler about readiness for toilet training?

A) The child learns voluntary sphincter control through repetition

B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect

The correct answer is B: Myelination of the spinal cord is completed by this age

Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the
spinal cord, sometime between the ages of 18 to 24 months of age.

Question Number 29 of 40
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question,
"Where do babies come from?" What is the nurse's best response to the parent?

A) "When a child asks a question, give a simple answer."

B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."

The correct answer is A: "When a child asks a question, give a simple answer."

During discussions related to sexuality, honesty is very important. However, honesty does not mean
imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1
answer. When they are ready, they will ask about the other pieces.

Question Number 30 of 40
At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a
month. What is the nurse's best response?

A) "This is normal at this time of day."

B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"

The correct answer is B: "How long has this been occurring?"

Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may
occur due to infectious, anatomical and/or physiological reasons.

Question Number 31 of 40
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the
following instructions is appropriate for the nurse to teach the parents?

A) Report a persistent cough to the health care provider

B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort

The correct answer is A: Report a persistent cough to the health care provider Persistent coughing should
be reported to the health care provider as this may indicate bleeding.

Question Number 32 of 40
The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first
child in either family with this disease, and ask about the risk to future children. What is the best response by
the nurse?
".
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease

The correct answer is B: 1 in 4 risk for each child to have the disease

Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be
carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy,
there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of
having neither the trait or the disease

Question Number 33 of 40
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus
from a 1 piece drainable ostomy pouch. Which is the correct intervention?

A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch

The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be expelled

The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to
obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the
flatus and dose the bottom of the pouch.

Question Number 34 of 40
A client is unconscious following a tonic-clonic seizure. What should the nurse do first?

A) Check the pulse

B) Administer Valium
C) Place the client in a side-lying position
D) Place a tongue blade in the mouth

The correct answer is C: Place the client in a side-lying position

Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if
vomiting occurs.
Question Number 35 of 40
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his
mother's lap. Which of the following should the nurse do first?

A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears

The correct answer is C: Auscultate heart and lungs The nurse should auscultate the heart and lungs
during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may
follow in any order.

Question Number 36 of 40
The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the
measurements, the nurse finds that they are approximately the same. What action should the nurse take?

A) Notify the health care provider

B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings

The correct answer is D: Record these normal findings

The question is D. The rate of increase in head circumference slows by the end of infancy, and the head
circumference is usually equal to chest circumference at 1 to 2 years of age

Question Number 37 of 40
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food
they can add to the diet?

A) Vegetables
B) Cereal
C) Fruit
D) Meats

The correct answer is B: Cereal Cereal is usually introduced first because it is well tolerated, easy to digest,
and contains iron.

Question Number 38 of 40
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse
should also instruct the client's family to

A) Avoid smoking near the client

B) Turn off oxygen during meals
C) Adjust the liter flow to 10 as needed
D) Remind the client to keep mouth closed

The correct answer is A: Avoid smoking near the client

Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment

Question Number 39 of 40
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to
unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by

A) Requiring the client to mop the floor

 B) Restricting the client’s fluids throughout the day
C) Withholding privileges each time the voiding occurs
D) Toileting the client more frequently with supervision

The correct answer is D: Toileting the client more frequently with supervision With altered thought
processes the most appropriate nursing approach to alter the behavior is by attending to the physical need

Question Number 40 of 40
A nurse who travels with an agency is uncertain about what tasks can be performed when working in a
different state. It would be best for the nurse to check which resource?

A) The state nurse practice act in which the assignment is made

B) With a nurse colleague who has worked in that state 2 years ago
C) The policies and procedures of the assigned agency in that state
D) The Nursing Social Policy Statement within the United States

The correct answer is A: The state nurse practice act in which the assignment is made

The state nurse practice act is the governing document of what can be done in the assigned state.