Q A Random - 13

Question Number 1 of 40
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?
The correct response is "B".
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
Your response was "A". The correct answer is B: Imitation of Sounds Imitation of sounds such as "da-da" is expected at
this time
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?
The correct response is "A".
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
Your response was "C". The correct answer is A: Leave the room and return five minutes later and give the medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in
order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back
later is another episode to the toddler.
Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
The correct response is "C".
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.
Your response was "C". The correct answer is C: Mild emesis progressing to projectile vomiting Mild regurgitation or
emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding.
The other findings are present, though not initial findings.
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
Your response was "B". The correct answer is B: Decreased colloidal osmotic pressure in the capillaries The increased
glomerular permeability to protein causes a decrease in serum albumin which results in decreased colloidal osmotic
pressure
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
Your response was "B". The correct answer is C: Bilirubin In the laboratory data provided, the only elevated level expected
is bilirubin. Additional liver function tests will confirm the diagnosis
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
Your response was "B". The correct answer is C: Assessing the client''s learning style As with any anticipatory teaching,
assess the client''s level of knowledge and learning style first.
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
Your response was "C". The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-
evaluation Evaluation process of the nursing process focuses on the client''s status, progress toward goal achievement
and ongoing re-evaluation of the plan of care.
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 nonexistant over the past 6 months."
D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."
Your response was "B". The correct answer is B: "I find the mood swings and the change from a calm person to being
angry all the time hard to deal with." The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in
this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate
behavior.
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?
The correct response is "D".
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.
Your response was "B". The correct answer is D: I can switch to a bottle if I need to take a break from breast feeding.
Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose.
Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple
weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a
bottle during the learning stage of breast feeding.
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
Your response was "B". The correct answer is C: Flight of ideas Flight of ideas - defines nearly continuous flow of speech,
jumping from 1 topic to another.
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
Your response was "B". The correct answer is C: Compile a history of behavior patterns and developmental
accomplishments A complete behavioral, and developmental history plays an important role in determining the diagnosis.
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
Your response was "C". The correct answer is D: Should be limited to three to four cups of milk daily More than 32 ounces
of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients
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
Your response was "C". The correct answer is C: Life’s stressors Alcohol is used by some people to manage anxiety and
stress. The overall intent is to decrease negative feelings and increase positive feelings
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
Your response was "B". The correct answer is A: Retractions in the soft tissues of the thorax Slight intercostal retractions
are normal. However in disease states, especially in severe airway obstruction, retractions becomes extreme
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
Your response was "B". The correct answer is A: Measure head circumference In meningitis, assessment of neurological
signs should be done frequently. Head circumference is measured because subdural effusions and obstructive
hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and
crib top applied to bed on admission to the unit.
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
Your response was "A". The correct answer is D: Uses cocaine on weekends Binge use of cocaine can be just as harmful
to the breast fed newborn as regular use.
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
Your response was "B". The correct answer is B: Dehydration Clinical findings dehydration include lethargy, irritability, dry
skin, and increased pulse.
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?"
Your response was "C". The correct answer is D: "Would you like to take your medicine from a spoon or a cup?" At 3
years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will
allow the child to express an opinion and have some control.
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 favorite toy to the hospital
Your response was "B". The correct answer is B: Explain the surgery 1 week prior to the procedure A 5 year-old can
understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day"
surgeries and do not require an overnight stay.
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.
Your response was "A". The correct answer is B: It assesses a child''s development. The Denver Developmental Test II is
a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross
motor development. A child experiences the fun of play during the test.
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 recovering person has to be very careful not to lose control, therefore, confine your drinking just at family
A)
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."
Your response was "A". The correct answer is D: "The recovering person cannot return to drinking without starting the
addiction process over." Recovery is total abstinence from all drugs.
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
Your response was "B". The correct answer is B: With fear of rejection causing increased rage toward the victim The fear
of rejection and loss only serve to increase the batterer’s rage at his partner.
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
Your response was "A". The correct answer is C: Tripled the birth weight The infant usually triples his birth weight by the
end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have
approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of
age, head and chest circumferences are approximately equal
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 antianxiety agent
Your response was "C". The correct answer is B: Place the client in a sitting position with legs dangling Place the client in
a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and
minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to
contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.
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
Your response was "D". The correct answer is A: High in carbohydrates and proteins Provide a high-energy diet by
increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic
enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and
lack of abdominal pain.
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
Your response was "A". The correct answer is D: Thiocyanate Thiocyanate levels rise with the metabolism if nitroprusside
and can cause cyanide toxicity.
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
Your response was "B". The correct answer is C: The wet cast should be handled with the palms of hands Handle cast
with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on
the cast.
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
Your response was "B". The correct answer is B: Set time aside to get the mother to express her feelings and concerns
Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural
influences may also be revealed.
A nurse is doing preconceptual 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."
Your response was "C". The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women
considering a pregnancy should not drink.
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
Your response was "B". The correct answer is A: Review the medications the client is receiving Antibiotics and
medications containing sorbital may induce diarrhea
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
Your response was "C". The correct answer is C: 15 minutes Frequency is the time from the beginning of one contraction
to the beginning of the next contraction.
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
Your response was "C". The correct answer is B: Ask the client what foods are acceptable Many Hispanic women
subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the
client or family.
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
Your response was "B". The correct answer is C: Riding a tricycle Coordination is gained through large muscle use. A
child of 3 has the ability to ride a tricycle.
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
Your response was "C". The correct answer is B: Tissue hypoxia When the hemoglobin falls sufficiently to produce clinical
manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the
blood.
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
Your response was "B". The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching A toddler
with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin
lesions, thereby causing new lesions and possible a secondary infection.
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
Your response was "B". The correct answer is B: Use oxygen during meals improves gas exchange Clients with
emphysema breathe easier when using oxygen while eating
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
Your response was "B".
The correct answer is B: Use oxygen during meals improves gas exchange Clients with emphysema breathe easier when
using oxygen while eating.
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
Your response was "A". The correct answer is D: Moist saline dressing This wound is a stage III pressure ulcer. The
wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue
to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.
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
Your response was "B". The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alchohol intake

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