1.

Which of the following disorders is characterized by joint inflammation that is usually accompanied by pain and frequently accompanied by changes in structure? a. Synovitis b. Arthritis c. Bursitis d. Tendinitis 2. Which term refers to the expectoration of blood from the respiratory tract? a. A hemorrhage b. Hematopoiesis c. Hemoptysis d. Hemopexis 3. Which term describes lack of coordination in performing planned, purposeful movements, resulting from a neurologic deficit? a. Apraxia b. Ataxia c. Fasciculation d. Myokymia 4. An elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2) indicates that the patient has: a. Hypernatremia b. Hypocalcemia c. Hypoxemia d. Hypercapnia 5. The latest laboratory values indicate that the patient has thrombocytopenia. The combining form penia means:

a. Rupture b. Deficiency c. Formation d. Stupor 6. A patient is admitted to the hospital with a urine specific gravity of 1.030, a temperature of 102F (38.9 C), and flushed, dry skin. Based on these data, the nurse writes which of the following nursing diagnoses? a. Potential for impaired skin integrity b. Fluid volume deficit related to fever c. Potential for fluid volume deficit caused by fever d. Altered cardiopulmonary tissue perfusion related to fluid excess 7. The guidelines for writing an appropriate nursing diagnosis include all of the following except: a. State the diagnosis in terms of a problem, not a need b. Use nursing terminology to describe the patients response c. Use statements that assist in planning independent nursing interventions d. Use medical terminology to describe the probable cause of the patients response 8. Based on a physicians order for oxygen by nasal catheter at 3 liters/ minute, an appropriate nursing order would be: a. Cover the tip of the catheter with a water-soluble lubricant before insertion. b. Measure the length of the catheter from the tip of the patients nose to the tip of the earlobe before insertion c. Add sterile distilled water to the humidification container, as needed d. All of the above 9. A nurse observes a dazed and apparently confused co-worker taking two diazepam (Valium) tablets by mouth as the co-worker is about to pour medications. What should the nurse do?

a. Call the head nurse immediately before the co-worker pours and administers the medications b. Pour the medications for the co-worker while she goes for a cup of coffee c. Report the co-worker to hospital security because she may be addicted to drugs d. Watch the co-worker closely and report the incident to the head nurse at the end of the day. 10. A nurse manager notices that one of the staff nurses is always 15 to 20 minutes late. When the nurse manager discusses the problem with her, the nurse says that she has been late because her sons nursery school does not open until 7 am. The nurse manager should respond by telling her to: a. Ask one of the night nurses to cover for her b. See if a neighbor can take the child to school c. Find out if other schools open earlier d. Find some way to solve the problem and be on time 11. A nurse has just moved to a new state, where she has accepted employment in a hospitalbased hemodialysis unit. She needs information about her specific duties in caring for hemodialysis patients. She will find this information in: a. Policy statements set by the National Kidney Foundation b. The states nurse practice act c. Medicare and Medicaid regulations d. The hospitals procedure manual 12. Which of the following is an example of nursing malpractice? a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus

d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor 13. Therapeutic communication is a significant aspect of patient care. Which of the following statements most clearly defines this concept? a. Therapeutic communication conveys feelings of warmth, acceptance, and empathy from the nurse to the patient in a nonjudgmental atmosphere b. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals c. Therapeutic communication is the assessment component of the nursing process, in which the nurse gathers health history information from the patients perspective d. Therapeutic communication is an interactional process in which the nurse purposefully reviews and assesses the conversation and its potential outcomes 14. Many factors can become barriers to communication. In which of the following situations would communication least likely be hindered? a. Mr. S., a 30-year-old Vietnamese immigrant, is admitted to the hospital with a fractured tibia; he speaks limited English b. Ms. M., age 58 and unmarried, is admitted to the hospital for breast surgery c. Mrs. R, age 26, is admitted to the hospital for a scheduled cesarean section; this is her first admission d. Mr. G., age 78, arrives at the hospital by ambulance after suffering a stroke at home 15. The assessment component of the nursing process requires effective communication to elicit a complete, relevant history from the patient and to identify patient problems. What role does communication play in the other areas of the nursing process? a. In the planning phase, effective therapeutic communication helps to establish nursing care priorities and patient-oriented goals b. During the implementation phase, communication skills allow the nurse to assess the patients response to planned interventions c. During the evaluation phase, effective communication allows the nurse to find out from the patient if he is responding to treatment or if changes in treatment are necessary d. All of the above

16. All of the following would be considered objective assessment data for a patient admitted with diabetes mellitus except: a. + 2 urine glucose level; negative urine acetone level b. Chemstrip reading of 240 mg/dl c. Patient complaints of polydipsia d. Serum glucose level of 263 mg/dl 17. Which of the following statements about bowel sounds is accurate? a. Peristalsis causes bowel sounds b. Rapid, high-pitched, hyperactive bowel sounds indicate increased peristalsis c. Decreased bowel sounds can be a symptom of paralytic ileus d. All of the above 18. Independent nursing intervention commonly used for immobilized patients include all of the following except: a. Active or passive ROM exercises, body repositioning, and activities of daily living (ADLs) as tolerated b. Deep-breathing and coughing exercises with change of position every 2 hours c. Diaphragmatic and abdominal breathing exercises and increased hydration d. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy 19. Independent nursing interventions commonly used for patients with pressure ulcers include: a. Changing the patients position regularly to minimize pressure b. Applying a drying agent such as an antacid to decrease moisture at the ulcer site c. Debriding the ulcer to remove necrotic tissue, which can impede healing d. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated 20. A female patient has gained 24 lb after being admitted to the hospital. Im such a horse; I just cant stand myself like this, she tells the nurse. After assessing the patient, the nurse

writes the following nursing diagnosis: Body image disturbance. To arrive at this diagnosis, the nurse should include which of the following assessment findings? a. The patients perception of her body before the hospitalization and weight gain b. The significance the patient places on these changes c. The patients feelings about her body d. All of the above 21. Stressors cause the release of the mineralocorticoid aldosterone, which regulates sodium absorption and potassium excretion in the renal tubules, resulting in: a. The need for supplemental potassium b. The need for a low-sodium (500-mg) diet c. The conservation of water and maintenance of blood volume d. Increased diuresis 22. In planning the care of a patient who is exposed to multiple stressors such as separation from loved ones, anxiety about impending surgery, and concern about potential complications or death, the nurse must: a. Use both a structured and an unstructured format when interviewing the patient b. Know the stressors affecting the patient c. Develop the expected outcomes for each nursing diagnosis written for this patient d. All of the above 23. An accurate method of calculating the daily urine output of an incontinent patient wearing pads or diapers is to: a. Estimate the urine output b. Count the number of urine saturated pads c. Weigh a dry pad and each urine saturated pad and use a conversion calibration to calculate the urine output d. Weigh all the urine-saturated pads together and use a conversion calibration to calculate the urine output

24. A fashion model is admitted via the emergency room with facial and chest burns. Her hospital stay includes 10 days in the intensive care unit and 5 days on the regular hospital unit. The patient has not been eating or sleeping and refuses to perform her activities of daily living (ADLs). She refuses to work with speech and physical therapists. Which of the following nursing diagnoses might appears on the patients current care plan? a. Potential for noncompliance: Self-harm related to disturbed body image b. Self-care deficit related to knowledge deficit and disturbed body image c. Disturbance in self-concept: Personal identifying related to self-esteem d. Disturbance in self-concept related to altered thought process 25. White the nurse is providing a patients personal hygiene, she observes that his skin is excessively dry. During this procedure the patient tells her that he is very thirsty. An appropriate nursing diagnosis would be: a. Potential for impaired skin integrity related to altered gland function b. Potential for impaired skin integrity related to dehydration c. Impaired skin integrity relate to dehydration d. Impaired skin integrity related to altered circulation

1. Answer B. Arthritis is characterized by joint inflammation that is usually accompanied by pain and frequently accompanied by changes in structure. Synovitis is the inflammation of the synovial membrane, typically resulting from a traumatic injury or an aseptic wound. Bursitis is the inflammation of a bursa, typically one located between a bony prominence and a muscle or tendon. Tendinitis is the inflammation of tendon. 2. Answer C. Hemoptysis is the expectoration of blood from the respiratory tract. A hemorrhage is abnormal internal or external bleeding. Hematopoiesis is blood cell formation. Hemopexis is blood coagulation. 3. Answer B. Ataxia is lack of coordination in performing planned, purposeful movements, typically resulting from a neurologic deficit. Apraxia is the inability to perform purposeful movements even though no neuromuscular deficit exists. Fasciculations are fine twitching movements. Myokymia is a transient, spontaneous movement that occurs in muscle groups after strenuous exercise. 4. Answer D. Hypercapnia is an elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2). Hypernatremia is an elevated level of sodium in venous blood (more than 145 mEq/liter). Hypocalcemia is a decreased level of calcium in venous blood (less than 9 mg/dl). Hypoxemia is a reduced level of oxygen in arterial blood (less than 80 mm Hg while breathing room air). 5. Answer B. The combining form penia means deficiency, as in thrombocytopenia (deficiency in the number of circulating blood plates). Rrhexis is a combining form meaning rupture, as in enterorrhexis (rupture of the intestine). Plast is a combining form meaning formation, as in rhino-plasty (formation of a nose using plastic surgery). Narco is a combining form meaning stupor, as in narcolepsy (a condition marked by recurrent attacks of drowsiness and sleep). 6. Answer B. Fluid volume deficit related to fever is the appropriate nursing diagnosis based on this assessment. Potential for impaired skin integrity states a possible patient response. Potential for fluid volume deficit caused by fever implies a cause-and-effect relationship, which a nursing diagnosis should never do. Altered cardiopulmonary tissue perfusion related to fluid excess is an incorrect diagnosis based on a misinterpretation of the data. 7. Answer D. A nursing diagnosis is a statement about a patients actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never a part of the nursing diagnosis. An appropriate nursing diagnosis would be ineffective breathing pattern related to chest pain rather than ineffective breathing pattern caused by angina. 8. Answer D. A water-soluble lubricant must be applied to the tip of the catheter to decrease friction and the risk of injury to the patients nasal mucosa. (If petrolatum or mineral oil were applied to the catheter and then aspirated, the patient could develop a lipoid pneumonia) The

distance from the tip of the nose to the tip of the earlobe is the approximate distance from the point of insertion to the oropharynx. Sterile distilled water must be used to humidity the oxygen because oxygen administered by itself is a dry gas that can irritate the mucosa. 9. Answer A. Patient safety is the major concern in this situation. According to the International Council of Nurses Code for Nurses: The nurse [should] take appropriate action to safeguard the individual when his or her care is endangered by a co-worker or any other person. In this case, talking with the head nurse immediately would be the best way to safeguard the patients safety. The nurse isnt necessarily an addict, she may be abusing a prescription medication. 10. Answer D. It is the staff nurses responsibility to be on time. The nurse manager should not assume a responsibility that belongs to the nurse. 11. Answer D. Although Medicare and Medicaid regulations and suggestions made by such groups as the National Kidney Foundation may serve as guidelines, a hospitals procedure manual details how the nurse should perform her specific duties. A states nurse practice act defines the scope of practice within that state, but not the specifics for each area of practice. 12. Answer A. The three elements necessary to establishes nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or healing pad to a patient without a physicians order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. 13. Answer B. Therapeutic communication is a two way, deliberative interaction between the patient and nurse in which they establish mutually acceptable, achievable goals of care. Before the patient can feel comfortable discussing his problems, however, and atmosphere of trust and acceptance must be established. 14. Answer C. Many variables affect patient nurse communication, including the patients cultural beliefs, experiences with hospitalization, age, emotional needs, and problems with speech, hearing, or comprehension. A patient admitted to the hospital for the first time for a scheduled cesarean section is probably anxious, but she had time to plan for the procedure, does not bring negative experiences from previous hospitalizations, and in most cases looks forward to the birth. 15. Answer D. Therapeutic communication is a fundamental component at all phases of the nursing process. In the planning phase, it allows the patient and nurse to formulate mutually acceptable and patient-oriented goals, which are the basis for developing an individualized care plan. In the implementation phase, effective communication is necessary for teaching the patient, motivating him to achieve goals, and assessing patient outcomes. Finally, in the

evaluation phase, it is required to determine how well the patient has responded to interventions. 16. Answer C. Objective data are those which can be measured, like glucose levels. A complaint of polydipsia is subjective information obtained from the patient. 17. Answer D. Peristalsis is the muscular, rhythmic movement in the bowel wall that pushes food along the digestive tract distally. Increased bowel motility is indicated by rapid, highpitched, hyperactive bowel sounds. Decreased bowel sounds, caused by decreased bowel motility, can be the initial sign of paralytic ileus (adynamic intestinal obstruction resulting from the lack of peristalsis), a common occurrence following abdominal surgery. 18. Answer D. The use of a tilt table for weight-beating exercises, parenteral nutrition, and vitamin therapy are not independent nursing interventions because they require a physicians order. Unless specifically contraindicated, the independent nursing interventions listed in A, B, and C may be part of the nursing care plan for an immobilized patient. 19. Answer A. Independent nursing interventions for a patient with pressure ulcers commonly include changing his position several times each day to avoid pressure to any part of his body, especially the involved area. Drying agents, which are prescribed by a physician, are contraindicated because wounds need moisture to heal. Whirlpool therapy and chemical debridement must be prescribed, and surgical debridement is done by the physician. 20. Answer D. All of the choices will help the nurse determine the extent of the problem. For example, asking how the patient felt about her body before hospitalization will help the nurse determine whether the disturbed body image is a crisis brought on by the weight gain or a long-standing problem. Asking what the change means to her will reveal whether she feels she has control over what is happening or believes the change is permanent. Body image is also related to how we think we compare to others or whether others find us attractive. 21. Answer C. Because aldosterone regulates the bodys sodium and potassium levels, it acts as an adaptive mechanism in maintaining blood volume and conserving water. Supplemental potassium usually is given to a patient with a low serum potassium level or one who is receiving a diuretic or other medication such as digoxin that has a mild diuretic effect. A low-sodium diet is usually prescribed for a patient with a high serum sodium level, as in congestive heart failure (CHF), hypertension, or prolonged episodes of edema. Diuresis is increased naturally when a healthy patient increases his intake of fluids, especially those containing caffeine. Patients receiving diuretics also experience increased diuresis. 22. Answer D. Interviewing the patient in both a structured and an unstructured format is an important part of the initial nursing assessment. The structured format uses questions that require a yea-or-no answer to help the nurse obtain information; the unstructured format uses open-ended questions that allow the patient to express himself more fully. The interview helps the nurse and patient identify the stressors and develop appropriate outcomes.

23. Answer C. Calculating the difference in weight between a dry pad and a urine saturated pad using conversion calibration will provide an accurate measure of urine output. For example, if the difference between the dry pad and the urine-saturated pad is 200 g, the urine output would be 200 ml (1g = 1 ml). The other methods will provide only an estimate of urine output. 24. Answer C. Disturbances in self-concept may manifest themselves as signs and symptoms of depression, such as changes in sleep patterns, eating habits, and energy levels. The other nursing diagnoses are not supported by the given situation. 25. Answer C. An appropriate nursing diagnosis for a patient with excessively dry skin is Impaired skin integrity (actual not potential) in this case, related to dehydration because the patient complains of thirst. Altered circulation is not usually an etiologic factor for dry skin.

1. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? a. Decreased plasma drug levels b. Sensory deficits c. Lack of family support d. History of Tourette syndrome 2. When examining a patient with abdominal pain the nurse in charge should assess: a. Any quadrant first b. The symptomatic quadrant first c. The symptomatic quadrant last d. The symptomatic quadrant either second or third 3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? a. Vital signs b. Laboratory test result c. Patients description of pain d. Electrocardiographic (ECG) waveforms 4. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? a. A palpable radial pulse b. A palpable ulnar pulse c. Cool, pale fingers d. Pink nail beds 5. Which of the following planes divides the body longitudinally into anterior and posterior regions? a. Frontal plane b. Sagittal plane c. Midsagittal plane d. Transverse plane 6. A female patient with a terminal illness is in denial. Indicators of denial include: a. Shock dismay b. Numbness c. Stoicism d. Preparatory grief 7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? a. Position the head of the bed flat b. Helps the patient dangle the legs c. Stands behind the patient d. Places the chair facing away from the bed

8. A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? a. Asking frequently if the patient understands the instruction b. Asking an interpreter to replay the instructions to the patient. c. Writing out the instructions and having a family member read them to the patient d. Demonstrating the procedure and having the patient return the demonstration 9. Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patients medication drawer. What should the nurse in charge do? a. Discard the syringe to avoid a medication error b. Obtain a label for the syringe from the pharmacy c. Use the syringe because it looks like it contains the same medication the nurse was prepared to give d. Call the day nurse to verify the contents of the syringe 10. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects? a. Faster drug clearance b. Aging-related physiological changes c. Increased amount of neurons d. Enhanced blood flow to the GI tract 11. A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? a. Manager b. Educator c. Caregiver d. Patient advocate 12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patients anxiety? a. Everything will be fine. Dont worry. b. Read this manual and then ask me any questions you may have. c. Why dont you listen to the radio? d. Lets talk about whats bothering you. 13. a. b. c. d. A scrub nurse in the operating room has which responsibility? Positioning the patient Assisting with gowning and gloving Handling surgical instruments to the surgeon Applying surgical drapes

14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do? a. Leave the medication at the patients bedside b. Tell the patient to be sure to take the medication. And then leave it at the bedside c. Return shortly to the patients room and remain there until the patient takes the medication d. Wait for the patient to return to bed, and then leave the medication at the bedside 15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose? a. ml b. ml c. ml d. 1 ml 16. The nurse in charge measures a patients temperature at 102 degrees F. what is the equivalent Centigrade temperature? a. 39 degrees C b. 47 degrees C c. 38.9 degrees C d. 40.1 degrees C 17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? a. Red blood cell count b. Sputum culture c. Total hemoglobin d. Arterial blood gas (ABG) analysis 18. The nurse uses a stethoscope to auscultate a male patients chest. Which statement about a stethoscope with a bell and diaphragm is true? a. The bell detects high-pitched sounds best b. The diaphragm detects high-pitched sounds best c. The bell detects thrills best d. The diaphragm detects low-pitched sounds best 19. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? a. Within 1 month b. Within 3 months c. Within 6 months d. Within 12 months 20. Which human element considered by the nurse in charge during assessment can affect drug administration?

a. The patients ability to recover b. The patients occupational hazards c. The patients socioeconomic status d. The patients cognitive abilities 21. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Passive prevention 22. a. b. c. d. What does the nurse in charge do when making a surgical bed? Leaves the bed in the high position when finished Places the pillow at the head of the bed Rolls the patient to the far side of the bed Tucks the top sheet and blanket under the bottom of the bed

23. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give? a. 2 ml b. 1 ml c. ml d. ml 24. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? a. Prolonged half-life b. Poor absorption c. Potential for drug dependence d. Potential for hepatotoxicity 25. a. b. c. d. Which nursing action is essential when providing continuous enteral feeding? Elevating the head of the bed Positioning the patient on the left side Warming the formula before administering it Hanging a full days worth of formula at one time

26. When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the: a. Top of the tongue b. Roof of the mouth c. Floor of the mouth d. Inside of the cheek

27. Which action by the nurse in charge is essential when cleaning the area around a JacksonPratt wound drain? a. Cleaning from the center outward in a circular motion b. Removing the drain before cleaning the skin c. Cleaning briskly around the site with alcohol d. Wearing sterile gloves and a mask 28. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of: a. 15 drop per minute b. 21 drop per minute c. 32 drop per minute d. 125 drops per minute 29. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock? a. Restlessness b. Pale, warm, dry skin c. Heart rate of 110 beats/minute d. Urine output of 30 ml/hour 30. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult? a. Radial b. Brachial c. Femoral d. Carotid

 Answer B. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patients knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention. Answer C. The nurse should systematically assess all areas of the abdomen, if time and the patients condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment. Answer C. Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patients opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data. Answer C. A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings. Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions. Answer A. Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depressiona later stage of grief. Answer B. After placing the patient in high Fowlers position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed. Answer D. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately. Answer A. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error. Answer B. Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases. Answer B. When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patients wishes known to the doctor. Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the

patient some control over an anxiety-inducing situation. Because the other options ignore the patients feeling and block communication, they would not reduce anxiety. Answer C. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies. Answer C. The nurse should return shortly to the patients room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patients bedside unless specifically requested to do so. Answer C. The nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ml Answer C. To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees 32) x 5/9 C degrees = (102 32) 5/9 + 70 x 5/9 38.9 degrees C Answer D. All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patients oxygenation status. Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best. Answer C. In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written. Answer D. The nurse must consider the patients cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patients ability to recover, occupational hazards, and socioeconomic status do not affect drug administration. Answer A. Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others activities without doing anything themselves. Answer A. When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed,

the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed. Answer C. The nurse should give ml of the drug. The dosage is calculated as follows: 250 mg/X=500 mg/1 ml 500x=250 X=1/2 ml Answer C. Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver. Answer A. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patients intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours. Answer C. The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek. Answer A. The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary. Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 ml/minute To find the number of drops/minute: 2.1 ml/X gtts = 1 ml/15 gtts X = 32 gtts/minute, or 32 drops/minute Answer A. Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious,

nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits. Answer D. During a rapid assessment, the nurses first priority is to check the patients vital functions by assessing his airway, breathing, and circulation. To check a patients circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patients circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.

Psytchiatric

1. Which statement describes how elderly clients react to medication? a. At increased risk for adverse reactions b. Tolerate medication better because theyre less active c. Metabolize medications quickly d. All of the above 2. Nursing interventions for a male client taking central nervous system (CNS) stimulants include monitoring the client for which condition? a. Hyperpyrexia, slow pulse, and weight gain b. Tachycardia, weight loss, and mood swings c. Hypotension, weight gain, and listlessness d. All of the above 3. The charge nurse in an acute care setting assigns to a male client, whos on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered: a. Poor nursing practice because a registered nurse should work with this client b. Reasonable nursing practice because one-to-one supervision requires the total attention of a staff member c. Outside the responsibility of an aide d. Illegal to delegate to an aide 4. Whats a nurse most important role in caring for an adult client with a mental disorder? a. To offer advice b. To know how to solve the clients problem c. To establish trust and rapport d. To set limits with the client

5. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of: a. Structured limit setting b. A supportive environment c. Abuse and neglect d. Direction and attention 6. The nurse in-charge is displaying assertive behavior when she: a. Says whats on her mind at the expense of others b. Expresses an air of superiority c. Avoids unpleasant situations and circumstances d. Stands up for her rights while respecting the rights of others. 7. In a group therapy setting, one male member is very demanding, repeatedly interrupting others and taking most of the group time. The nurses best response would be: a. Will you briefly summarize your point because others need time also? b. Your behavior is obnoxious and drains the group. c. To ignore the behavior and allow him vent d. Im so frustrated with your behavior 8. The nurse is aware that the primary indication for the use of electroconvulsive therapy (ECT) is: a. Severe agitation b. Antisocial behavior c. Noncompliance with treatment d. Major depression with psychotic features 9. Two nurses are discussing a female clients condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which act?

a. Assault b. Battery c. Neglect d. Breach of confidentiality 10. A nurse at a substance abuse center answers the phone. A probation officer asks if the male client is in treatment. The nurse responds, No, the client youre looking for isnt here. Which statement best describes the nurses response? a. Correct because she didnt give out information about the client b. A violation of confidentiality because she informed the officer that the client wasnt there c. A breach of the principle of veracity because the nurse is misleading the officer d. Illegal because shes withholding information from law enforcement agents. 11. The employer of a female client on the psychiatric unit calls the nursing station inquiring about the clients progress. The nurse doesnt know if consent has been given by the client to allow the staff to give information out to caller on the phone. Which response by the nurse would be best? a. Im not permitted to discuss her progress. b. Ill give you the name and telephone number of her physician. c. Ill have her call you. d. I cant confirm whether your employee is a client here. 12. A voluntary male client in a health care facility decided to leave the unit before treatment is complete. To detain the client, the nurse refuses to return his personal effects. This is an example of: a. False imprisonment b. Limit setting c. Slander d. Violation of confidentiality

13. Which statement is guideline to help nurses avoid liability? a. Follow every physicians order b. Do what the client desires even though you may disagree c. Practice within the scope of the Nurse Practice Act d. Obtain malpractice insurance

14. A nurse places a male client in full leather restraints. How often must the nurse check the clients circulation? a. Once per hour b. Once per 8-hour shift c. Every 15 minutes d. Every 2 hours 15. Which clinical condition meets the criteria for involuntary commitment? a. A single parent who leaves her minor children unattended and stays out all night drinking b. A person who lives alone and has schizophrenia with delusions of persecution c. A man who threatens to kill his wife d. A person with depression who says hes tired of living but doesnt have a suicide plan 16. An adult client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes hes being poisoned. The nurse should respond by taking which action? a. Administering the medication by injection b. Omitting the dose and trying again the next day c. Crushing the medication and putting it in his food d. Consulting with the physician about a care plan

17. A nurse is working with a female dying client and his family. Which communication technique is most important to use? a. Reflection b. Interpretation c. Clarification d. Active listening 18. A male client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as: a. An increased response to a medication b. A diminished response to a drug so that more is required to achieve the same effect c. An allergic reaction to a medication d. An ability to take the same drug for extended periods of time. 19. The nurse is aware that the goal of crisis intervention is: a. To solve the clients problems for him b. Psychological resolution of the immediate crisis c. To establish a means for long-term therapy d. To provide a means for admission to an acute care facility 20. A male client in a group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, You look angry. The nurse is using which technique? a. A broad opening statement b. Reassurance c. Clarifying d. Making observations 21. A male patient with antisocial personality disorder smokes where it is prohibited and refuses to follow other unit and hospital rules. The patient gets others to do the laundry and other

personal chores, splits the staff, and will work only with certain nurses. The plan of care for this patient should focus primarily on: a. A consistently enforcing unit rules and hospital policy b. Isolating the patient to decrease contact with easily manipulated patients c. Engaging in power struggles with the patient to minimize manipulative behavior d. Using behavior modification to decrease negative behavior by using negative reinforcement 22. The nurse knows that the doctor in charge has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid? a. Has a more predictable onset of action b. Produces fewer anticholinergic effects c. Produces fewer drug infections d. Has a longer duration of action 23. A male patient receiving fluphenazine (Prolixen) therapy develops pseudoparkinsonism. The doctor is likely to prescribe which drug to control this extrapyramidal effect? a. Phenytoin (Dilantin) b. Amantadine (Symmetrel) c. Benztropine (Cogentin) d. Diphenhydramine 24. During a panic attack, a male patient runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The patient is pale, with the mouth wide open and eyebrows raised. What should the nurse do first? a. Assist the patient to breath deeply into a paper bag b. Orient the patient to person, place and time c. Set limits for acting out delusional behaviors d. Administer an I.M. anxiolytic agent

25. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband says he grew up in a household where his father frequently abused both his mother and him. When interviewing with this couple, the nurse in charge knows they are at risk for repeated violence because the husband: a. Has only moderate impulse control b. Denies feelings of jealousy or possessiveness c. Has learned violence as an acceptable behavior d. Feels secure in his relationship with his wife 26. What occurs during the working phase of the nurse-patient relationship? a. The nurse assesses the patients needs and develops a plan of care b. The nurse and patient together evaluate and modify the goals of the relationship c. The nurse and patient discuss their feelings about terminating the relationship d. The nurse and patient explore each others expectations of the relationship 27. When caring for a male adolescent patient diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adult. In an adolescent, signs and symptoms of depression are likely to include: a. Helplessness, hopelessness, hypersomnolence, and anorexia b. Truancy, a change of friends, social withdrawal, and oppositional behavior c. Curfew breaking, stealing from family members, truancy, and oppositional behavior d. Hypersomnolence, obsession with body image, and valuing of peers opinion. 28. During the admission assessment, a male patient with a panic disorder begins to hyperventilate and says, Im going to die if I dont get out of here right now! What is the nurses best response? a. Just calm down. Youre getting overly anxious. b. What do you think is causing your panic attack? c. You can rest alone in your room until you feel better. d. Youre having panic attack. Ill stay here with you.

29. In a female patient with a conversion disorder who reports blindness, ophthalmologic examinations reveal that no organic disorder is causing progressive vision loss. The most likely source of this patients blindness is: a. A family history of major depression b. Having been forced to watch a loved ones torture c. Noncompliance with a psychotropic medication regimen d. Daily use of antianxiety agents and alcoholic beverages 30. A busy attorney with a successful law practice is admitted to an acute care facility with epigastric pain. Since admission, the patient has called the nurse 15 minutes with one request or another. This patient is exhibiting: a. Repression b. Somatization c. Regression d. Conversion

View Questions i. Answer A. As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse reactions. Level of activity typically doesnt affect a persons reaction to medication. Elderly clients typically need lower doses, not higher. Answer B. Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression. Answer B. A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isnt illegal to delegate observation to an aide. Answer C. Its extremely important that the nurse establish trust and rapport. The nurse shouldnt offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important as developing trust and rapport. Answer C. Abuse and neglect lead to poor self-concept and role confusion, which are the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive environment, and direction and attention. Answer C. The basic element of assertive behavior includes the ability to express feelings and thoughts while respecting the rights of others. Doing so at the expense of others and expressing superiority are aggressive behaviors, and avoiding unpleasant situation is a form of passive behavior. Answer A. Asking the client to summarize his point redirects the clients to focus his comments and allows him to make his point. Telling the client that his behavior is obnoxious is judgmental, and ignoring the behavior doesnt help facilitate communication. Expressing frustration focuses more on the nurse than on the clients need. Answer D. ECT is indicated for major depression. ECT isnt indicated severe agitation, antisocial behavior, or treatment noncompliance. Answer D. Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do whats deemed reasonable in a situation. Answer B. The nurse violated confidentiality by informing the officer that the client wasnt in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the clients confidentiality. Because its unknown in this question whether the client is actually in treatment, it cant be concluded that the nurse is misleading the officer because her statement may be truthful. Information can be legally withheld when a court order isnt in place. Answer D. The nurses release of information to the clients employer without the clients consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the clients employment; therefore, its better to maintain confidentiality and refrain from disclosing any information about the client, including whether shes a client in the hospital.

ii. iii.

iv.

v.

vi.

vii.

viii. ix.

x.

xi.

xii.

xiii.

xiv.

xv.

xvi.

xvii.

xviii.

xix.

xx.

xxi.

Answer A. Confining a voluntary client against his will be considered false imprisonment. Limit setting is a therapeutic technique used to achieve a desired behavior, and wouldnt involve confining a voluntary client. Slander is oral defamation of character. The nurse hasnt given out any information about the client, so confidentiality hasnt been violated. Answer C. The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. Physicians may not be aware of guidelines for nurses and may inadvertently delegate inappropriate treatment of practice for the nurse. The client doesnt know standards of care and isnt responsible for the nurses actions. Insurance wont prevent a liability suit, but only assist the nurse if a suit would be filed. Answer C. Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isnt often enough and could result is permanent damage to the clients extremities. Answer C. One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others, such as a man who threatens to kill his wife. A parent might have a child removed from the home because of neglect, but that doesnt meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and dont require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself. Answer D. To determine care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself of others, medications cant be forced on a client. A dose shouldnt be omitted without first checking with the physician. Intentionally deceiving of misleading a client violates the therapeutic relationship. Answer D. When working with a dying patient and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false interference or putting the client on the defensive. Answer B. Tolerance occurs when the body requires higher doses of substances, such alcohol, opioids, or benzodiazepines, to achieve desired effect. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune response to a particular drug or class of drugs. A client may be able to take, or tolerate, the same drug for an extended period; however this isnt the definition of developing tolerance. Answer B. The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, neither is the goal of crisis intervention. Answer D. The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesnt give feedback to the client. The nurse didnt reassure the client or ask him to explain his actions (clarifying). Answer A. Firmness and consistency regarding rules are the hallmarks of a plan of care for a patient with a personality disorder. Isolation is inappropriate and would violate the patients rights. Power struggles should be avoided because the patient may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and patient manipulation.

xxii. xxiii.

xxiv.

xxv.

xxvi.

xxvii.

xxviii.

xxix.

xxx.

Answer A. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablet is unpredictable. Answer B. An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism, diphenhydramine or benztropine may be used to control other extrapyramidal effects. Answer A. Physiological needs, particularly breathing, are the first priorities during a panic attack. Having the patient breathe deeply into a paper bag corrects hyperventilation; restoring a normal breathing pattern should relieve the patients other symptoms. Orientation usually is unnecessary because most patients respond to external control and reduce stimulation. During a panic attack, the patient is not likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but is not the first priority. Answer C. Family violence usually is a learned behavior begets violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships. Answer B. The therapeutic nurse-patient relationship consists of four phases: preinteraction, introduction or orientation, working and termination. During the working phase, the nurse and patient together evaluate and refine the goals established during the orientation phase, in addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the patient, formulating a contract, exploring feelings, and establishing expectation about relationship. During the termination phase, the nurse prepares the patient for separation and explores feelings about the end of the relationship. Answer B. In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, it usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. Adolescents normally display hypersomnelence, and obsession with body image, and valuing of peers opinions. Answer D. During a panic attack, the nurses best approach is to orient the patient to what is happening and provide reassurance that the patient will not be left alone. The anxiety level is likely to increase and the panic attack is likely to continueif the patient is told to calm down (as in option A), asked the reasons for the attack (as in option B), or left alone (as in option C). Answer B. Conversion disorder, or hysterical neurosis, is characterized by alteration or loss of physical function with no physiological basis; the patients symptoms result from psychological conflict. For example, a patient may report blindness after having observed a distressing act. None of the other opinions causes conversion disorder. Answer C. The patient is exhibiting the defense mechanism of regressiona return to behavior characteristic of an earlier developmental level. Dependent, attentiongetting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety. 1. Which of the following medications would the nurse in-charge expect the doctor to order to reverse a dystonic reaction?

a. Procholorperazine (Compazine) b. Diphenhydramine (Benadryl) c. Haloperidol (Haldol) d. Midazolam (Versed) 2. While pacing in the hall, a female patient with paranoid schizophrenia runs to the nurse and says, Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul! how should the nurse respond? a. Im a nurse, Im not poisoning you. Its against the nursing code of ethics. b. Im a nurse, and youre a patient in the hospital. Im not going to harm you. c. Im not poisoning you. And how could I possibly steal your soul? d. I sense anger, Are you feeling angry today? 3. After completing chemical detoxification and a 12-step program to treat crack addiction, a male patient is being prepared for discharge. Which remark by the patient indicates a realistic view of the future? a. Im never going to use crack again. b. I know what I have to do. I have to limit my crack use. c. Im going to take 1 day at a time. Im not making any promises. d. I cant touch crack again, but I sure could use a drink. Ive earned it. 4. The nurse formulates a nursing diagnosis of impaired verbal communication for a male patient with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate? a. Helping the patient to participate in social interactions b. Establishing a one-on-one relationship with the patient c. Establishing alternative forms of communication d. Allowing the patient to decide when he wants to participate in verbal communication with you

5. A female patient with obsessive-compulsive disorder tells the nurse that he must check the lock on his apartment door 25 times before leaving for an appointment. The nurse knows that this behavior represents the patients attempt to: a. Call attention to himself b. Control his thoughts c. Maintain the safety of his home d. Reduce anxiety 6. A patient, age 42, is admitted for surgical biopsy of a suspicious lump in her left breast. When the nurse comes to her surgery, she is tearfully finishing a letter to her children. She tells the nurse, I want to leave this for my children in case anything goes wrong today. Which response by the nurse would be most therapeutic? a. In case anything goes wrong? What are your thoughts and feelings right now? b. I cant understand that youre nervous, but this is really a minor procedure. Youll be back in your room before you know it. c. Try to take a few deep breaths and relax. I have some medication that will help. d. Im sure your children know how much you love them. Youll be able to talk to them on the phone in a few hours. 7. Which nursing intervention is most important when restraining a violent male patient? a. Reviewing hospital policy regarding how long the patient can be restrained b. Preparing a p.r.n. dose of the patients psychotropic medication c. Checking that the restraints have been applied correctly d. Asking if the patient needs to use the bathroom or is thirsty 8. How soon after chlorpromazine administration should the nurse in charge expect to see a patients delusion thoughts and hallucinations eliminated? a. Several minutes b. Several hours c. Several days

d. Several weeks 9. Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used: a. For a maximum of 2 hours b. As necessary to control the patient c. If the patient poses a present danger to self or others d. Only with the patients consent 10. A female patient has been severely depressed since her husband died 6 months ago. Her doctor prescribes amitriptyline hydrochloride (Elavil), 50 mg P.O. daily. Before administering amitriptyline, the nurse reviews the patients medical history. Which preexisting condition would require cautions use of this drug? a. Hiatal hernia b. Hypernatremia c. Hepatic disease xxxi. d. Hypokalemia xxxii. 11. The physician orders a new medication for a male client with generalized anxiety disorder. During medication teaching, which statement or question by the nurse would be most appropriate? xxxiii. a. Take this medication. It will reduce your anxiety. xxxiv. b. Do you have any concern about taking the medication? xxxv. c. Trust us. This medication has helped many people. We wouldnt have you take it if it were dangerous. xxxvi. d. How can we help you if you wont cooperate? xxxvii. 12. The nurse is aware that the Hormonal effects of the antipsychotic medications include which of the following? xxxviii. a. Retrograde ejaculation and gynecomastia xxxix. b. Dysmenorrhea and increased vaginal bleeding xl. c. Polydipsia and dysmenorrheal xli. d. Akinesia and dysphasia xlii. 13. The nurse is caring for a female client in the manic phase of bipolar disorder whos ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate? xliii. a. Expressing feeling of anxiety xliv. b. Displaying anger, shouting, and banging the table xlv. c. Withdrawing from the nurse in silence xlvi. d. Rationalizing the termination, saying that everything comes to an end

xlvii. 14. The nurse is caring for a male client with schizophrenia. Which outcome is the least desirable? xlviii. a. The client spends more time by himself xlix. b. The client doesnt engage in delusional thinking l. c. The client doesnt harm himself or others li. d. The client demonstrates the ability to meet his own self-care needs lii. 15. The nurse is assigned to care for a recently admitted female client who has attempted suicide. What should the nurse do? liii. a. Search the clients belongings and room carefully for items that could be used to attempt suicide liv. b. Express trust that the client wont cause self-harm while in the facility lv. c. Respect the clients privacy by not searching any belongings lvi. d. Remind all staff members to check on the client frequently lvii. 16. A male client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as what defense mechanism? lviii. a. Rationalization lix. b. Repression lx. c. Displacement lxi. d. Suppression lxii. 17. Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resembles those used for: lxiii. a. Physical therapy lxiv. b. Neurologic examination lxv. c. General anesthesia lxvi. d. Cardiac stress testing lxvii. 18. Nursing care for a male client with schizophrenia must be based on valid psychiatric and nursing theories. The nurses interpersonal communication with the client and specific nursing intervention must be: lxviii. a. Clearly identified with boundaries and specifically defined roles lxix. b. Warn and non threatening lxx. c. Centered on clearly defined limits and expression of empathy lxxi. d. Flexible enough for the nurse to adjust the care plan as the situation warrants lxxii. 19. Before eating a meal, a female client with obsessive-compulsive disorder (OCD) must wash his hands for 18 minutes, comb his hair 444 strokes, and switch the bathroom lights 44 times. What is the most appropriate goal of care for this client? lxxiii. a. Omit one unacceptable behavior each day lxxiv. b. Increase the clients acceptance of therapeutic drug use lxxv. c. Allow ample time for the client to complete all rituals before each meal lxxvi. d. Systematically decrease the number of repetitions of rituals and the amount of time spent performing them. lxxvii. 20. A male client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client? lxxviii. a. Chlorpromazine (Thorazine) lxxix. b. Imipramine (Tofranil) lxxx. c. Lithium carbonate (Lithane)

lxxxi. d. Fluphenazine decanoate (Prolixin Decanoate) lxxxii. 21. A 23-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective individual coping? lxxxiii. a. In ability to make choices and decisions without advice lxxxiv. b. Showing interest only in solitary activities lxxxv. c. Avoiding developing relationship lxxxvi. d. Recurrent self-destructive behavior with history of depression lxxxvii. 22. During the mental status examination, a female client may be asked to explain such proverbs as Dont cry over spilled milk. The purpose is to evaluate the clients ability to think: lxxxviii. a. Rationally lxxxix. b. Concretely xc. c. Abstractly xci. d. Tangentially xcii. 23. After an upsetting divorce, a male client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client? xciii. a. Hopelessness related to recent divorce xciv. b. Ineffective coping related to inadequate stress management xcv. c. Spiritual distress related to conflicting thoughts about suicide and sin xcvi. d. Risk for self-directed-violence related to planning to commit suicide with a handgun xcvii. 24. A 25-year-old man reports losing his sight in both eyes. Hes diagnosed as having conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client? xcviii. a. Not focusing on his blindness xcix. b. Providing self-care for him c. c. Telling him that his blindness isnt real ci. d. Teaching eye exercises to strengthen his eyes cii. 25. In group therapy, a male client angrily speaks up and responds to a peer, Youre always whining and Im getting tired of listening to you! Here is the worlds smallest violin playing for you. Which role is the client playing? ciii. a. Blocker civ. b. Monopolizer cv. c. Recognition seeker cvi. d. Aggressor cvii. 26. A nurse places a female client in full leather restraints. How often must the nurse check the clients circulation? cviii. a. Once per hour cix. b. Once per shift cx. c. Every 10 to 15 minutes cxi. d. Every 2 hours cxii. 27. When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem? cxiii. a. The injury isnt consistent with the history of the childs age cxiv. b. The mother and father tell different stories regarding what happened cxv. c. The family is poor

cxvi. d. The parents are argumentative and demanding with emergency department personnel cxvii. 28. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of: cxviii. a. Structured limit setting cxix. b. Supportive environment cxx. c. Abuse and neglect cxxi. d. Direction and attention cxxii. 29. When monitoring a male client recently admitted for treatment of cocaine addiction, the nurse notes sudden increase in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: cxxiii. a. Norepinephrine (Levophed) and lidocaine (Xylocaine) cxxiv. b. Nifedipine (Procardia) and lidocaine cxxv. c. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc) cxxvi. d. Nifedipine and nitroglycerin cxxvii. 30. Conditions necessary for the development of a positive sense of self-esteem include: cxxviii. a. Consistent limits cxxix. b. Critical environment cxxx. c. Inconsistent boundaries cxxxi. d. Physical discipline

1. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? a. Endometritis b. Endometriosis c. Salpingitis d. Pelvic thrombophlebitis 2. A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? a. The ultrasound will help to locate the placenta b. The ultrasound identifies blood flow through the umbilical cord c. The test will determine where to insert the needle d. The ultrasound locates a pool of amniotic fluid 3. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy? a. Calcium gluconate b. Protamine sulfate c. Methylegonovine (Methergine) d. Nitrofurantoin (macrodantin) 4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? a. Turn the neonate every 6 hours b. Encourage the mother to discontinue breast-feeding c. Notify the physician if the skin becomes bronze in color d. Check the vital signs every 2 to 4 hours

5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? a. Back b. Abdomen c. Fundus d. Perineum 6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: a. Nausea and vomiting can be decreased if I eat a few crackers before arising b. If I start to leak colostrum, I should cleanse my nipples with soap and water c. If I have a vaginal discharge, I should wear nylon underwear d. Leg cramps can be alleviated if I put an ice pack on the area 7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartal psychological adaptation that the client would be in would be termed which of the following? a. Taking in b. Letting go c. Taking hold d. Resolution 8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? a. Activity limited to bed rest b. Platelet infusion c. Immediate cesarean delivery

d. Labor induction with oxytocin 9. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? a. Feeding the neonate a maximum of 5 minutes per side on the first day b. Wearing a supportive brassiere with nipple shields c. Breast-feeding the neonate at frequent intervals d. Decreasing fluid intake for the first 24 to 48 hours 10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? a. Startle reflex b. Babinski reflex c. Grasping reflex d. Tonic neck reflex 11. A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: a. Tailor sitting b. Leg lifting c. Shoulder circling d. Squatting exercises 12. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? a. Notify the neonates pediatrician immediately b. Check the diaper and circumcision again in 30 minutes c. Secure the diaper tightly to apply pressure on the site

d. Apply gently pressure to the site with a sterile gauze pad 13. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with abruption placenta? a. Excessive vaginal bleeding b. Rigid, boardlike abdomen c. Titanic uterine contractions d. Premature rupture of membranes 14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurses most appropriate action? a. Note the fetal heart rate patterns b. Notify the physician immediately c. Administer oxygen at 6 liters by mask d. Have the client pant-blow during the contractions 15. A client tells the nurse, I think my baby likes to hear me talk to him. When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? a. High-pitched speech with tonal variations b. Low-pitched speech with a sameness of tone c. Cooing sounds rather than words d. Repeated stimulation with loud sounds 16. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? a. Active phase b. Latent phase c. Expulsive phase

d. Transitional phase 17. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond? a. Yes, it produces no adverse effect. b. No, it can initiate premature uterine contractions. c. No, it can promote sodium retention. d. No, it can lead to increased absorption of fat-soluble vitamins. 18. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient? a. Knowledge deficit b. Fluid volume deficit c. Anticipatory grieving d. Pain 19. Immediately after a delivery, the nurse-midwife assesses the neonates head for signs of molding. Which factors determine the type of molding? a. Fetal body flexion or extension b. Maternal age, body frame, and weight c. Maternal and paternal ethnic backgrounds d. Maternal parity and gravidity 20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? a. The membranes must rupture b. The fetus must be at 0 station c. The cervix must be dilated fully d. The patient must receive anesthesia

21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense: a. Around the pelvic girdle b. Around the pelvic girdle and in the upper arms c. Around the pelvic girdle and at the perineum d. At the perineum 22. A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the patients risk for: a. Endometriosis b. Female hypogonadism c. Premenstrual syndrome d. Tubal or ectopic pregnancy 23. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? a. Proteinuria, headaches, vaginal bleeding b. Headaches, double vision, vaginal bleeding c. Proteinuria, headaches, double vision d. Proteinuria, double vision, uterine contractions 24. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patients fluid intake and output closely during oxytocin administration? a. Oxytoxin causes water intoxication b. Oxytocin causes excessive thirst c. Oxytoxin is toxic to the kidneys d. Oxytoxin has a diuretic effect

25. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? a. Low room humidity b. Cold weight scale c. Cools incubator walls d. Cool room temperature 26. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? a. Decreased peristalsis b. Increase heart rate c. Dry mucous membranes d. Nausea and Vomiting 27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? a. Active phase b. Complete phase c. Latent phase d. Transitional phase 28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: a. Apply warm compresses to her nipples just before feedings b. Lubricate her nipples with expressed milk before feeding c. Dry her nipples with a soft towel after feedings d. Apply soap directly to her nipples, and then rinse 29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time?

a. Between 10 and 12 weeks gestation b. Between 16 and 20 weeks gestation c. Between 21 and 23 weeks gestation d. Between 24 and 26 weeks gestation 30. Normal lochial findings in the first 24 hours post-delivery include: a. Bright red blood b. Large clots or tissue fragments c. A foul odor d. The complete absence of lochia

1. Answer A. Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes. 2. Answer B. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. 3. Answer B. Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications cause by heparin overdose. 4. Answer D. While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. 5. Answer D. A bilateral pudental block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudental block anesthesia is adequate for episiotomy and its repair. 6. Answer A. Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. 7. Answer C. Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

8. Answer A. Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the clients bleeding. 9. Answer C. Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonates and mothers needs. 10. Answer A. The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months. 11. Answer A. Tailor sitting is an excellent exercise that helps to strengthen the clients back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. 12. Answer D. If bleeding occurs after circumcision, the nurse should first apply gently pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. 13. Answer B. The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. 14. Answer B. The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation, unless cephalopelvic disproportion exists. 15. Answer A. Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than about 55 decibels. 16. Answer D. The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active phase extends form 4 to 7 cm; it is moderate for the patient. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta. 17. Answer B. Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased. 18. Answer B. If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

19. Answer A. Fetal attitudethe overall degree of body flexion or extensiondetermines the type of molding in the head a neonate. Molding is not influence by maternal age, body frame, weight, parity, or gravidity or by maternal and paternal ethnic backgrounds. 20. Answer A. Internal EFM can be applied only after the patients membranes have ruptures, when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. although the patient may receive anesthesia, it is not required before application of an internal EFM device. 21. Answer A.During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum. Upper arm pain is not common during ant stage of labor. 22. Answer D. Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome are not associated with progestin-only oral contraceptives. 23. Answer C. A patient with pregnancy-induced hypertension complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions are not associated with pregnancy-induces hypertension. 24. Answer A. The nurse should monitor fluid intake and output because prolonged oxytoxin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results form the work of labor and limited oral fluid intakenot oxytoxin. Oxytoxin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect. 25. Answer C. Common source of radiant heat loss includes cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss. 26. Answer D. Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase. 27. Answer D. The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 to 6 hours; it is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

28. Answer B. Measures that help relieve nipple soreness in a breast-feeding patient include lubrication the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples. 29. Answer B. A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. 30. Answer A. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.