Question 1. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
1. All lesions crusted
2. Elevated temperature
3. Rhinorrhea and coryza
4. Presence of vesicles
Looking for answers(s):1
Explanation: The correct answer is All lesions crusted The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.
Question 2. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
1. "I understand that a glass of wine with dinner is healthy."
2. "Beer is not really hard alcohol, so I guess I can drink some."
3. "If I drink, my baby may be harmed before I know I am pregnant."
4. "Drinking with meals reduces the effects of alcohol."
Looking for answers(s):3
Explanation: The correct answer is "If I drink, my baby may be harmed before I know I am pregnant." Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.
Question 3. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
1. Observe the child's behavior on at least 2 occasions
2. Consult with the teacher about how to control impulsivity
3. Compile a history of behavior patterns and developmental accomplishments
4. Compare the child's behavior with classic signs and symptoms
Looking for answers(s):3
Explanation: The correct answer is Compile a history of behavior patterns and developmental accomplishments A complete behavioral, and developmental history plays an important role in determining the diagnosis.
Question 4. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
1. Increased 10% in height
2. 2 deciduous teeth
3. Tripled the birth weight
4. Head > chest circumference
Looking for answers(s):3
Explanation: The correct answer is Tripled the birth weight The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.
Question 5. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?
1. Jumping rope
2. Tying shoelaces
3. Riding a tricycle
4. Playing hopscotch
Looking for answers(s):3
Explanation: The correct answer is Riding a tricycle Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.
Question 6. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
1. Promote verbal and nonverbal communication with both the client and the interpreter
2. Speak only a few sentences at a time and then pause for a few moments
3. Plan that the encounter will take more time than if the client spoke English
4. Ask the client to speak slowly and to look at the person spoken to
Looking for answers(s):1
Explanation: The correct answer is Promote verbal and nonverbal communication with both the client and the interpreter The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues
Question 7. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
1. Skin irritation
2. Drug tolerance
3. Severe headaches
4. Postural hypotension
Looking for answers(s):2
Explanation: The correct answer is Drug tolerance Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
Question 8. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
1. I noticed a little lump a little above the belly button.
2. The baby seems hungry all the time.
3. Mild vomiting that progressed to vomiting shooting across the room.
4. Irritation and spitting up immediately after feedings.
Looking for answers(s):3
Explanation: The correct answer is Mild emesis progressing to projectile vomiting Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings.
Question 9. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?
1. Discuss with the mother sharing parenting responsibilities
2. Set time aside to get the mother to express her feelings and concerns
3. Arrange for the parents to attend infant care classes
4. Talk with the father and help him accept the wife's decision
Looking for answers(s):2
Explanation: The correct answer is Set time aside to get the mother to express her feelings and concerns. Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed.
Question 10. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with
1. Recreational and social needs
2. Feelings of anger
3. Life’s stressors
4. Issues of guilt and disappointment
Looking for answers(s):3
Explanation: The correct answer is Life’s stressors Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings.
Question 11. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
1. "Touching the abdomen could cause cancer cells to spread."
2. "Examining the area would cause difficulty to the child."
3. "Pushing on the stomach might lead to the spread of infection."
4. "Placing any pressure on the abdomen may cause an abnormal experience."
Looking for answers(s):1
Explanation: The correct answer is "Touching the abdomen could cause cancer cells to spread." Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.
Question 12. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating
1. "I will increase sodium and fluids and restrict potassium."
2. "I will increase potassium and sodium and restrict fluids."
3. "I will increase sodium, potassium and fluids."
4. "I will increase fluids and restrict sodium and potassium."
Looking for answers(s):1
Explanation: The correct answer is "I will increase sodium and fluids and restrict potassium." The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.
Question 13. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
1. Cooing
2. Imitation of sounds
3. Throaty sounds
4. Laughter
Looking for answers(s):2
Explanation: The correct answer is Imitation of Sounds Imitation of sounds such as "da-da" is expected at this time.
Question 14. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
1. Provides a more precise blood glucose value than self-monitoring
2. Is performed to detect complications of diabetes
3. Measures circulating levels of insulin
4. Reflects an average blood sugar for several months
Looking for answers(s):4
Explanation: The correct answer is Reflects an average blood sugar for several months Glycosolated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 3-4 months and is used to monitor client adherence to the therapeutic regimen.
Question 15. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
1. "Do you want to take this pretty red medicine?"
2. "You will feel better if you take your medicine."
3. "This is your medicine, and you must take it all right now."
4. "Would you like to take your medicine from a spoon or a cup?"
Looking for answers(s):4
Explanation: The correct answer is "Would you like to take your medicine from a spoon or a cup?" At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.
Question 16. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
1. Temperature of 102 degrees Fahrenheit
2. Pulse rate of 98 beats per minute
3. Respiratory rate of 32
4. Blood pressure of 90/50
Looking for answers(s):3
Explanation: The correct answer is Respiratory rate of 32 Clients with deep vein thrombosis are at risk for the development of pulmonary embolism. The most common symptoms are tachypnea, dyspnea, and chest pain.
Question 17. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
1. Acceptance of the pregnancy
2. Acceptance of the termination of the pregnancy
3. Acceptance of the fetus as a separate and unique being
4. Satisfactory resolution of fears related to giving birth
Looking for answers(s):1
Explanation: The correct answer is Acceptance of the pregnancy During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.
Question 18. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
1. High in carbohydrates and proteins
2. Low in carbohydrates and proteins
3. High in carbohydrates, low in proteins
4. Low in carbohydrates, high in proteins
Looking for answers(s):1
Explanation: The correct answer is High in carbohydrates and proteins Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.
Question 19. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?
1. Leave the room and return five minutes later and give the medicine
2. Explain to the child that the medicine must be taken now
3. Give the medication to the father and ask him to give it
4. Mix the medication with ice cream or applesauce
Looking for answers(s):1
Explanation: The correct answer is Leave the room and return five minutes later and give the medicine Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.
Question 20. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
1. Septicemia
2. Dehydration
3. Hypokalemia
4. Hypercalcemia
Looking for answers(s):2
Explanation: The correct answer is Dehydration Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.
Question 21. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
1. Separation anxiety
2. Fear of pain
3. Loss of control
4. Bodily injury
Looking for answers(s):1
Explanation: The correct answer is Separation anxiety While a toddler will experience all of the stresses, separation from parents is the major stressor.
Question 22. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?
1. "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings."
2. "At your next AA meeting discuss the possibility of limited drinking with your sponsor."
3. "A recovering person needs to get in touch with their feelings. Do you want a drink?"
4. "A recovering person cannot return to drinking without starting the addiction process over."
Looking for answers(s):4
Explanation: The correct answer is "The recovering person cannot return to drinking without starting the addiction process over." Recovery is total abstinence from all drugs.
Question 23. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
1. Take the client's vital signs
2. Place the client in a sitting position with legs dangling
3. Contact the health care provider
4. Administer the PRN antianxiety agent
Looking for answers(s):2
Explanation: The correct answer is Place the client in a sitting position with legs dangling Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.
Question 24. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily
1. Psychological
2. Physical
3. Biological
4. Social-cultural
Looking for answers(s):1
Explanation: The correct answer is Psychological With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that produces craving and compulsive use.
Question 25. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
1. History of obesity
2. Prescribed use of an MAO inhibitor
3. Diagnosis of vascular disease
4. Takes antacids frequently
Looking for answers(s):2
Explanation: The correct answer is Prescribed use of an MAO inhibitor SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
Question 26. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
1. Dress the child warmly to avoid chilling
2. Keep the child away from other children for the duration of the rash
3. Clean the affected areas with tepid water and detergent
4. Wrap the child's hand in mittens or socks to prevent scratching
Looking for answers(s):4
Explanation: The correct answer is Wrap the child''s hand in mittens or socks to prevent scratching A toddler with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possible a secondary infection.
Question 27. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?
1. Pack the nose and ears with sterile gauze
2. Apply pressure to the injury site
3. Apply bulky, loose dressing to nose and ears
4. Apply an ice pack to the back of the neck
Looking for answers(s):3
Explanation: The correct answer is Apply bulky, loose dressing to nose and ears. Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.
Question 28. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
1. Eat foods high in sodium increases sputum liquefaction
2. Use oxygen during meals improves gas exchange
3. Perform exercise after respiratory therapy enhances appetite
4. Cleanse the mouth of dried secretions reduces risk of infection
Looking for answers(s):2
Explanation: The correct answer is Use oxygen during meals improves gas exchange Clients with emphysema breathe easier when using oxygen while eating.
Question 29. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?
1. "I should position my baby completely facing me with my baby's mouth in front of my nipple."
2. "The baby should latch onto the nipple and areola areas."
3. "There may be times that I will need to manually express milk."
4. "I can switch to a bottle if I need to take a break from breast feeding."
Looking for answers(s):4
Explanation: The correct answer is I can switch to a bottle if I need to take a break from breast feeding. Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.
Question 30. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by
1. Seeking medical help for the victim's injuries
2. Minimizing the episode and underestimating the victim’s injuries
3. Contacting a close friend and asking for help
4. Being very remorseful and assisting the victim with medical care
Looking for answers(s):2
Explanation: The correct answer is Minimizing the episode and underestimating the victim’s injuries Many abusers lack an understanding of the effect of their behavior on the victim and use excessive minimization and denial.
Question 31. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?
1. Report the behavior to the charge nurse
2. Talk with the client to find out about the preferred herbal preparation
3. Contact the client's health care provider
4. Explain the importance of the medication to the client
Looking for answers(s):2
Explanation: The correct answer is Talk with the client to find out about the preferred herbal preparation Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health-care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death".
Question 32. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?
1. Retractions in the intercostal tissues of the thorax
2. Chest pain aggravated by respiratory movement
3. Cyanosis and mottling of the skin
4. Rapid, shallow respirations
Looking for answers(s):1
Explanation: The correct answer is Retractions in the soft tissues of the thorax Slight intercostal retractions are normal. However in disease states, especially in severe airway obstruction, retractions become extreme.
Question 33. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
1. Massage legs frequently
2. Frequent turning
3. Moisten skin with lotions
4. Apply moist heat to reddened areas
Looking for answers(s):2
Explanation: The correct answer is Frequent turning Frequent turning will prevent skin breakdown.
Question 34. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?
1. Allow the infant to drink the liquid from a medicine cup
2. Administer the medication with a syringe next to the tongue
3. Mix the medication with the infant's formula in the bottle
4. Hold the child upright and administer the medicine by spoon
Looking for answers(s):2
Explanation: The correct answer is Administer the medication with a syringe next to the tongue Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.
Question 35. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
1. Measure head circumference
2. Place in airborne isolation
3. Provide passive range of motion
4. Provide an over-the-crib protective top
Looking for answers(s):1
Explanation: The correct answer is Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.
Question 36. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
1. May drink as much milk as desired
2. Can have milk mixed with other foods
3. Will benefit from fat-free cow's milk
4. Should be limited to 3-4 cups of milk daily
Looking for answers(s):4
Explanation: The correct answer is Should be limited to three to four cups of milk daily More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.
Question 37. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
1. Instruct the client to breathe into a paper bag
2. Place the client in a high Fowler's position
3. Assist the client with pursed lip breathing
4. Administer oxygen at 6L/minute via nasal cannula
Looking for answers(s):3
Explanation: The correct answer is Assist the client with pursed lip breathing Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration
Question 38. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
1. Cardizem SR tablet (diltiazem)
2. Lanoxin liquid
3. Os-cal tablet (calcium carbonate)
4. Tylenol liquid (acetaminophen)
Looking for answers(s):1
Explanation: The correct answer is Cardizem SR tablet (diltiazem) Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.
Question 39. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have
1. Scrotal discoloration
2. Sustained painful erection
3. Inability to achieve erection
4. Heaviness in the affected testicle
Looking for answers(s):4
Explanation: The correct answer is Heaviness in the affected testicle The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.
Question 40. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
1. Age 40 years
2. Lactose intolerance
3. Family history of breast cancer
4. Uses cocaine on weekends
Looking for answers(s):4
Explanation: The correct answer is Uses cocaine on weekends Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.
Question 41. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
1. Heart rate
2. Muscle tone
3. Cry
4. Color
Looking for answers(s):4
Explanation: The correct answer is Color Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.
Question 42. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
1. Touring the coronary intensive unit
2. Mailing a video tape to the home
3. Assessing the client's learning style
4. Administering a written pre-test
Looking for answers(s):3
Explanation: The correct answer is Assessing the client''s learning style As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.
Question 43. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?
1. "My partner's breathing rate is usually below 12."
2. "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
3. "It seems our sex life is nonexistant over the past 6 months."
4. "In the morning and evening I hear complaints that reading is next to impossible from blurred print."
Looking for answers(s):2
Explanation: The correct answer is "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.
Question 44. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
1. Change in body image
2. An unfamiliar environment
3. Perceived loss of control
4. Guilt over being hospitalized
Looking for answers(s):3
Explanation: The correct answer is Perceived loss of control For school age children, major fears are loss of control and separation from friends/peers.
Question 45. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
1. A transparent film dressing
2. Wet dressing with debridement granules
3. Wet to dry with hydrogen peroxide
4. Moist saline dressing
Looking for answers(s):4
Explanation: The correct answer is D: Moist saline dressing This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.
Question 46. The nurse, assisting in applying a cast to a client with a broken arm, knows that
1. The cast material should be dipped several times into the warm water
2. The cast should be covered until it dries
3. The wet cast should be handled with the palms of hands
4. The casted extremity should be placed on a cloth-covered surface
Looking for answers(s):3
Explanation: The correct answer is The wet cast should be handled with the palms of hands Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.
Question 47. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?
1. It measures a child’s intelligence.
2. It assesses a child's development.
3. It evaluates psychological responses.
4. It helps to determine problems.
Looking for answers(s):2
Explanation: The correct answer is It assesses a child''s development. The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.
Question 48. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is
1. Avoid alcohol use during this time
2. Observe the client for hypotension
3. Abrupt discontinuation of the drug
4. Assess for mild physical symptoms
Looking for answers(s):1
Explanation: The correct answer is Avoid alcohol use during this time Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided
Question 49. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
1. 14 minutes
2. 10 minutes
3. 15 minutes
4. 9 minutes
Looking for answers(s):3
Explanation: The correct answer is 15 minutes Frequency is the time from the beginning of one contraction to the beginning of the next contraction.
Question 50. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
1. With acceptance and views the victim’s comment as an indication that their marriage is in trouble
2. With fear of rejection causing increased rage toward the victim
3. With a new commitment to seek counseling to assist with their marital problems
4. With relief, and welcomes the separation as a means to have some personal time
Looking for answers(s):2
Explanation: The correct answer is With fear of rejection causing increased rage toward the victim. The fear of rejection and loss only serve to increase the batterer’s rage at his partner.
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