I.

NLE PRACTICE TEST III

1. A client is admitted with Wernicke's encephalopathy. The nurse anticipates

that the first physician's order will include:

a. Ordering an MRI
b. Administering a steroid medication, such as Decadron
c. Giving thiamine 100 mg IM STAT
d. Ordering an EEG

2. Which of the following statements, if made by a four year old child whose
brother just died of cancer, would be age-appropriate?

a. "I know i will never see my mother again."

b. "I'm glad my mother isn't crying anymore."
c. "I can't wait to go get pizza with my brother."
d. "i know where my brother is buried."

3. A patient who has AIzheimer's disease is told by the nurse to brush his
teeth. He shouts angrily, "Tomato soup!" Which of the following actions by
the nurse would be correct?

a. Focusing on the emotional reaction

b. Clarifying the meaning of his statement
c. Giving him step-by-step directions
d. Doing the procedure for him

4. A nurse should teach a patient who is taking chlorpromazine (Thorazine)

to avoid:

a. Exposure to the sun

b. Swimming in a chlorinated pool
c. Drinking fluids high in sodium
d. Eating foods such as chocolate and aged cheese

5. In caring for a psychotic patient who is experiencing hallucinations, which

of the following interventions is considered critical?

a. Setting fewer limits in order to allow for more expressions of feeling

b. Maintaining constant observation.
c. Providing more frequent opportunities for interaction with others.
d. Constantly negating the patient's hallucinatory Ideations.

6. A 22-year-old client is being admitted with a diagnosis of brief psychotic

disorder. Two weeks ago, his girlfriend broke off their engagement and
cancelled the wedding. Given the Diagnosis and Statistical Manual of Mental
Disorders, edition, text' revised (DSM-IV-TR) criteria for this disorder the
nurse expects to find which of the following data during the interview with
the client?

a. Current treatment for pneumonia

b. Regular use of alcohol and marijuana
c. Evidence of delusions and hallucinations
d. A history of chronic depression

7. A set of monozygotic twins who are 23 years old have begun attending
groups at mental health center. One twin is diagnosed with schizophrenia.
Her twin has no diagnoses but has been experiencing significant anxiety since
becoming engaged. In counseling the engaged twin, it would be crucial to
include which of the following facts?

a. Her future children will be at risk for developing schizophrenia

b. She may have a predisposition for schizophrenia
c. One of her parents may develop schizophrenia later in life
d. It is unlikely that she wil! develop schizophrenia, at her age

8. A client tells the nurse that her co-workers are sabotaging the computer.
When the nurse asks questions, the client becomes argumentative. This
behavior shows personality traits associated with which of the following
personality disorders?

a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal

9. Which of the following types of behavior is expected from a client

diagnosed with paranoid personality disorder?

a. Eccentric
b. Exploitative
c. Hypersensitive
d. Seductive

10. A nurse is reviewing the serum laboratory test results for a client with
sickle cell anemia. The nurse finding that which of the following values is
elevated?

a. Hemoglobin F
b. Hemoglobin S
c. Hemoglobin C
d. Hemoglobin a

11. A parent with a daughter with bulimia nervosa asks a nurse, "How can
my child have an eating disorder when she isn't underweight?" Which of the
following responses is best?

a. "A person with bulimia nervosa can maintain a normal weight."

b. It's hard to face this type of problem in a person you love."
c. "At first there is no weight loss; it comes later In the disease."
d. "This is a serious problem even though there is no weight loss."

12. A nurse is assessing an adolescent girl recently diagnosed with an eating

disorder and symptoms of bulimia nervosa. Which of the following findings is
expected based on laboratory test results?

a. Hypocalcemia
b. Hypoglycemia
c. Hypokalemia
d. Hypophosphatemia

13. Which of the following complications of bulimia nervosa Is life

threatening?

a. Amenorrhea
b. Bradycardia
c. Electrolyte Imbalance
d. Yellow skin

14. A nurse is talking to a client with bulimia nervosa about the complications
of Laxative abuse. Which of the following complications should be included?

a. Loss of taste
b. Swollen glands
c. Dental problems
d. Malabsorption of nutrients

15. A nurse is assessing a client to determine the distress experienced after

binge eating. Which of the following symptoms are typical after bingeing?

a. Ageusia
b. Headache
c. Pain
d. Sore throat

16. Which of the following difficulties are frequently found in families with a
member who has bulimia nervosa?

a. Mental Illness
b. Multiple losses
c. Chronic anxiety
d. Substance abuse

17. A client with anorexia nervosa tells a nurse, "My parents never hug me or
say I've done anything right." Which of the following Interventions is the
best to use with this family?

a. Teach the family principles of assertive behavior.

b. Discuss the difficulties the family has in social situations.
c. Help the family convey a positive attitude toward the client.
d. Explore the family's ability to express affection appropriately.

18. A client with anorexia nervosa tells a nurse she always feels fat. Which of
the following interventions is the best for this client?

a. Talk about how important the client is.

b. Encourage her to look at herself in a mirror.
c. Address the dynamics of the disorder.
d. Talk about how she's different from her peers.

Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days
following a hypophysectomy for a pituitary tumor. She is alert, oriented, and
eager to return to her job as an executive to the hospital director. She is alert,
oriented and eager to return to her job as an executive assistant to the hospital
director. She calls the nurse to her room to express her concern about the
frequency of urination she is experiencing, as well as the feeling of weakness that
began this morning.

19. The most likely cause of her chief complaint this morning is

a. A decrease in postoperative stress causing polyuria

b. The onset of diabetes mellitus, an unusual complication
c. An expected result of the removal of the pituitary gland
d. A frequent complication of the hypophysectomy

20. Following hypophysectomy, patients require extensive teaching regarding

this major alteration in their lifestyle

a. Abnormal distribution of body hair

b. Lifetime dependency on hormone replacement
c. The need to drink many fluids to replace those lost
d. The need to undergo repeat surgical procedures
21. The Glasgow coma scale is used to .evaluate the level of consciousness in
the neurological and neurological patients. The three assessment factors
included in this scale are:

a. pupil size, response to pain, motor responses

b. Pupil size, verbal response, motor response
c. Eye opening, verbal response, motor response
d. Eye opening, response to pain, motor response

J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle
accident in which he sustained multiple trauma including a ruptured spleen,
myocardial contusion, fractured pelvis, and fractured right femur. He had a mild
contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84,
respirations 12, and temperature 99 F orally.

22. The nurse will monitor J.E. for the following signs and symptoms:

a. Change in the levei of consciousness, tachypnea, tachycardia, petechiae

b. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
c. Loss of consciousness, bradycardia, petechiae, and severe leg pain
d. Change in leve! of consciousness, bradycardia, chest pain and oliguria

23. Appropriate nursing interventions for J.E. would be

a. Skin care and position q2h and prn; maintain alignment of extremities;
respiratory exercises
b. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for
intermittent positive pressure breathing therapy
c. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises,
and intermittent positive pressure breathing q2h
d. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use
pressure relief devices

Ms. J., a 34-year old white female, is admitted via the emergency room
complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea.
She is a diabetic who been managed at 30 U NPH insulin every AM and a 1200-
calorie ADA diet. Her glucose in ER 700 mg/dL. Regular insulin 30 U was given
and a repeat glucose were drawn. Results were not avaiIable upon transfer to the
unit.

24. Given the above Information, which nursing activities should be highest
priority?

a. Monitoring vita i signs

b. Obtaining blood glucose results
c. Assessing neurological status
d. Assessing pedai pulses and feet

25. The nurse received the lab results from the blood sample drawn in ER.
Her glucose is now-100. However, her WBC count is 25,000 mm3. What
conclusion can the nurse draw basing on this information?

a. Lab results are within normal limits, no action Is necessary

b. Her diabetes is out of control
c. insulin administration increase WBC count
d. Infection has increased her insulin needs

26. Later that evening, Ms. J's abdominal pain increased in intensity. A
diagnosis of appendicitis is made and Ms. J is scheduled for surgery in the
morning. The physician has written the following orders:

-NPO after midnight

-At 6 AM start-ari iV of D5W to be'infused at 250 ml/hr
-15 U NPH insulin at 6AM
-Draw FBS prior to initiating iV fluids

The statement that best describe the rationale for these orders Is:

a. To provide calories to offset the patient being NPO

b. To prevent a hypoglycemic reaction
c. To prevent a fluid volume deficit
d. To assist with the body's response to stress

27. When ambulating a client following surgical removal of a protruded

intervertebral lurnbar disc, the nurse would do which of the following?

a. Maintain proper body alignment

b. Administer anaigesia after walking
c. Provide a cane for support
d. Immobilize the head and neck

28. Which of the following point scores on the post anesthesia chart, indicates
that the client has fulfilled minimal criteria for discharge from the PACU?

a. One point In each of the five areas .for a total score of 5.

b. One point in at least three areas" respiratory, circulatory, and consciousness -
for a total of 3
c. A total score for the five areas of 7 or.above.
d. Two points each in each of the five areas for a total score of 10.

29. Which of the following statements would be the nurse's response to a

famiiy member asking questions about a client's transient ischemic attack
(TIA)?

a. "I think you should ask the doctor. Would you like me to cail him for you?"
b. " The blood supply to the brain has decreased causing permanent brain
damage."
c. "It Is a temporary interruption in the blood flow to the brain."
d. "TIA means a transient ischemic attack."

30. While receiving radiation therapy for the treatment of breast cancer, a
client complains of dysphagia and skin texture changes, at the radiation site.
Which of the following instructions would be most appropriate to suggest to
minimize the risk of complications, and promote healing?

a. Wash the radiation site vigorously with soap and water to remove dead cells.
b. Eat a diet high in protein and calories to optimize tissue repair.
c. Apply coo! compresses to the radiation site to reduce edema,
d. Drink warm fluids throughout the day to relieve discomfort in swallowing.

31. A client using an over-the counter nasal decongestant spray reports

unrelieved and worsening nasal congestion. The nurse should instruct the
client to do which of the following?

a. Switch to a stronger dosage of the medication.

b. Discontinue the medication for a few weeks
c. Use the spray more frequently
d. Combine the spray with an oral decongestant.

32. Following a thyroidectomy, the client experiences.hemorrhage. The nurse

would prepare for which of the following emergency Interventions?

a. intravenous administration of calcium

b. insertion of an oral airway
c. Creation of a tracheostomy
d. Intravenous administration of thyroid hormone

33. After a client signs the form, giving informed consent for surgery and the
physician leaves the room, the client asks the nurse, "When will this hotel
bring me some food?" After confirming that the client is confused, which of
the following would be the nurse's priority action?

a. Reporting that the consent has been obtained from a confused client.
b. Teaching preoperative moving, coughing, and deep-breathing,exercises.
c. Inserting a bladder catheter to urine output.
d. Administering preoperative medication immediately ,
34. At 16 weeks gestation, no fetal heart rate was detected during assessment
of a pregnant patient. An ultrasound confirmed a hydatidiform molar
pregnancy. Which of the following actions should the nurse tell the patient to
expect during her one-year follow-up?

a. Multiple serum chorionic gonadotropin levels will be drawn

b. An Intrauterine device will be used to decrease vaginal bleeding
c. Pregnancy will be restricted for another year
d. Oral contraceptives will not be prescribed because they will increase the risk' of
cancer

35. Thirty minutes after the nurse removes a nasogastric tube that has been
In place for seven days, the patient experiences epistaxis (nosebleed). Which
of the following nursing actions is most appropriate to control the bleeding?

a. Apply pressure by pinching the anterior portion of the for five to ten minutes
b. Place the patient in a sitting position with the neck hyperextended
c. Pack the nostrils with gauze and keep the gauze in piace for four to five days
d. Apply ice compresses to the patient's forehead and back of the neck

36. The staff nurse calls a physician regarding an order to administer digoxin
(Lanoxin) to a patient with a pulse of 55 and a serum potassium levei of 2.9
mEq/L The physician says to give the medication, as ordered .The staff
nurse's best response would be

a. "I'll give the medication but you wiil still be responsbIe if anything happens to
the patient."
b. "I will not give this medication."
c. '"I think we should discuss this with the nursing supervisor."
d. "I'm sorry, but if you want the medication given, you will have to give it
yourself."

37. During the night, shift report, the charge nurse learns that an elderly
patient has become very confused and is shouting obscenities and undressing
himself. Which of the following actions is the most appropriate Initial
nursing response?

a. Restrain the patient with a Posey jacket

b. Medicate the patient with haloperidol (Haldol) as ordered.
c. Notify the physician
d. Complete a nursing assessment of the patient

38. When a woman is 10weeks pregnant which of the following hematology

test results would need further Investigation?

a. Hemoglobin level of 9 mg/dL

b. white blood cell count of 15,000/cu mm
c. platelet count of 200,000/cu mm
d. red blood cell count of 4,200,000/ cu mm

39. Which of the following techniques would a nurse use when interviewing a
94-year-old patient?

a. Using a low-pitched voice

b. Enunciating each word .slowly
c. Varying voice intonations
d. Reinforcing the words with pictures .

40. A patient who is receiving total parenteral nutrition has an elevated blood
glucose level and is to be administered intravenous insulin. Which of the
following types of insulin should a nurse has available?

a. Isophane insulin (NPH)

b. Regular insulin (Humulin R)
c. Insulin zinc suspension (Lente)
d. Semi-Lente Insulin (Semiterd)

41. A nurse is taking history from a patient who has just been admitted to the
hospital with an acute myocardia! infarction. Which of the following
questions would be most important for the nurse to ask?

a. "At what time did the pain start?"

b. "When did you eat your last meal?"
c. "Have you experienced a pounding headache?"
d. "Did you feel fluttering in your chest"

42. An infant who weighs 11 lbs. is to receive 750 mg of an antibiotic in a 24-

hour period. The liquid antibiotic comes in a concentration of 125 mg/5ml. If
the antibiotic were to be given three times each day. how many ml would the
nurse administer with each dose?

a. 2
b. 5
c. 6.25
d. 10

43. Spasm of the neck muscles developed in a patient who is taking

phenothiazine (Nemazine). Which of the following medications should the
nurse administer?

a. Vistaril)
b. Acetaminophen (Tyienol)
c. Acetylsalicylic acid (Aspirin)
d. Benztropine mesyiate (Cogentin)

Mr. Anthony Malailinelii is a 54-year old truck driver. He is admitted for possible
gastric ulcer, He is a heavy smoker.

44. When discussing his smoking habits with Mr. Martinelli. the nurse should
advise him to:

a. Smoke low-tar, filter cigarettes

b. Smoke cigars instead
c. Smoke only right after meals
d. Chew gum Instead

45. As the nurse preparing Ivlr. Martinelii for gastric analysis. You should
know which of the following Is not.correct concerning this test

a. The patient Is fasting 12 hours prior to test

b. Gastric contents are aspirated via a tube
c. Smoking for 8 hours prior to test is not allowed
d. Various position changes are necessary during the test

46. Mr. Martinelli had an Hgb of 9.8. You would not find which of the
following assessments in a patient with severe anemia?

a. Pallor
b. Cold sensitivity
c. Fatigue
d. Dyspnea only on exertion

47. When you report on duty, your team leader tells you that Mr. MartineHi
accidentally received 1000 ml of fluids in 2 hours and that you are to be alert
for signs of circulatory overload. Which of the following signs would not be
likely to occur?

a. moist gurgling respirations

b. Weak, slow pulse
c. Distended neck veins
d. Dyspnea and coughing

48. A new staff nurse is on an orientation tour with the head nurse. A client
approaches her and says, "I don't belong here. Please try to get me out." The
staff nurse's best response would be:

a. "What would you do if you were out of the hospital?"

b. "I am a. new staff member, and I'm on a tour. I'll come back and talk with you
later."
c. "I think you should talk to the head nurse about that.'
d. "I can't do anything about that."

49. A 50 year-old male client has a history of many hospitalizations for

schizophrenic disorder. He has been on long-term phenothiazines
(Thorazine), 400 mg/day. The nurse assessing this client observes that he
demonstrates a shuffling gait, drooling and exhibits generaj dystonic
symptoms.. From these symptoms and his history, the nurse concludes that
the client has developed:

a. Tardive dyskinesia
b. Parkinsonism
c. Dystonia
d. Akathisia

50. A client with antisocial personality disorder tells a nurse "Life has been
full of problems since childhood." Which of the following situations or
conditions would the nurse explore in the assessment?

a. Birth defects
b. Distracted easily
c. Hypoactive behavior
d. Substance abuse

51. A client with antisocial personality disorder is trying to manipulate the

healthcare team. Which of the following strategies is important for the staff
to use?

a. Focus on how to teach the client more effective behaviors for meeting basic
needs.
b. Help the client verbalize underlying feelings of hopelessness and learn coping
skills.
c. Remain calm and don't emotionally respond to the client's manipulative
actions.
d. Help the client eliminate the intense desire to have everything in life turn out
perfectly.

52. A client with antisocial personality disorder is beginning to practice

several socially acceptable behaviors in the group setting. Which of the
following
outcomes will result from this change?

a. Fewer panic attacks

b. Acceptance of reality
c. Improved self-esteem
d. decreased physical symptoms

53. Which of the following discharge instructions would be most accurate to

provide to a female client who has suffered a spinal cord injury at the C4
level?

a. After a spinal cord injury, women usually remain fertile; therefore, you may
consider contraception if you don't want to become pregnant.
b. After a spinal cord injury, women usually are unable to conceive a child.
c. Sexual intercourse shouldn't be different for you.
d. After a spinal cord injury, menstruation usually stops.

54.A client with chronic obstructive pulmonary disease (COPD) tells the
nurse, "I no longer have enough energy to make love to my husband." Which
of the following nursing interventions would be most appropriate?

a. Refer the couple to a sex therapist.

b. Advise the woman to seek a gynecologic consult
c. Suggest methods and measures that facilitate sexual activity.
d. Tell the client, "if you talk this over with your husband, he will understand.

55. A cllent tells the nurse she is having her menstrual period every 2 weeks
and it lasts for 1 week. Which of the following conditions is best defined by
this menstrual pattern?

a. Amenorrhea
b. Dyspareunia
d. menororrhagia
d. metrorrhagia

56. A nurse has just been told by a. physician that an order has been written
to administer an iron injection to an adult client. The nurse plans to
administer the medication In which of the following locations?

a. In the gluteal muscle using Z-track technique

b. In the deltoid muscle using an air lock
c. In the subcutaneous fesue of the abdomen
d. in the anterior lateral thigh using a 5/8 inch needle '

57. A 59-year-old patient with a diagnosis of delirium is admitted to the

hospital. To evaluate the cause of a patient's delirium, blood is sent to the
laboratory for analysis. The results are as follows: M,a+ 1.56, Cr 100. K4' 4.0,
C0221, BUN 86, glucose 100. Based on these laboratory result, the nurse
should record which of the following nursing diagnoses on the patient's care.
plan?
a. Alteration in patterns of urinary elimination.
b. Fluid volume deficit
c. Nutritional deficit: less than body requirements
d. Self-care deficit: feeding

58. The nurse knows that gender Is part of one's identity. Which of the
following events signifies when gender is first ascribed?

a. A baby is born
b. A child attends school
c. A child receives sex-specific toys
d. A child receives sex-specific clothing