One morning the nurse overhears Elma, who is admitted with BPD, having an argument with her mother, When suppertime, Elma is very angry with the nurse and complains nurse must say something bad to her mother about her performance in ward. What the defense mechanism Elma is using?

• A.Dissociation       
• B.Denial             
• C.Projection         
• D.Splitting

The client asks when he can stop taking the eye medication for his chronic open-angle glaucoma. Which would be the nurse's best response?

• A. "You can stop using the eye drops when your vision improves. " 
• B. "You Need to use the eye drops only when you has symptoms. " 
• C. "You can discontinue the eye drops after 2 months of normal eye examinations. " 
• D. "You must use the eye medication for the rest of his life. "

The multidisciplinary team decides to employ a behavior modification approach to a young female's problem with anorexia nervosa. A planned nursing intervention that would follow this approach would he to

• A.Have client role play interactions with her parents   
• B.Provide client with a high-calorie, high-protein diet   
• C.Restrict the client to her room until she gains 2 pounds   
• D.Force the client to talk about her favorite foods for 1 hour a day

A client with hypotonic labor dysfunction is receiving oxytoein augmentation. Her contractions become more frequent and intense. Dilation progresses to 8 cm, but the fetal head remains at station +1. The nurse notes a soft bulge just above the symphysis. Which of the following actions is best?

• A. Re-evaluate the fetal presentation.
• B. Change the client's position.
• C. Offer a narcotic analgesic.
• D. Help the client urinate.

A 2-month-old neonate with diarrhea and vomiting has been receiving IV fluids for the past 24 hours. The specific gravity of the neonate's urine is 1.012. What should the nurse do next?

• A. Check the neonate's blood pressure. 
• B. Check the specific gravity again as soon as possible. 
• C. Notify the physician. 
• D. Continue the ordered IV flow rate.

A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms?

• A. The opportunity to verbalize memories of trauma to a sympathetic listener. 
• B. Family support. 
• C. Prescribed medications taken as ordered. 
• D. Alcoholics Anonymous (AA) meetings.

The nurse is assessing a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is

• A. congenital deformity. 
• B. age. 
• C. trauma. 
• D. obesity.

An elderly client's family tells the nurse that the client has suffered some memory loss in the last few years. They say that the client is sensitive about not being able to remember and tries to cover up this loss to avoid embarrassment. When attempting to increase the client's self-esteem, the nurse should try to avoid discussing events that require memory of the client's

• A.Married           
• B.Work years       
• C.Recent days       
• D.Young adulthood

The nurse is performing wound care. Which of the following practices violates surgical asepsis?

• A. Holding sterile objects above the waist. 
• B. Considering a 1" (2.5 cm) edge around the sterile field as being contaminated. 
• C. Pouring solution onto a sterile field cloth. 
• D. Opening the outermost flap of a sterile package away from the body.

A 20-year-old mother of a premature newborn smoked cigarettes during her pregnancy. Her son is a client in a neonatal intensive care unit and has a diagnosis of acute respiratory distress syndrome. Because the mother is Roman Catholic, which nursing intervention would be most appropriate for the nurse to discuss with her?

• A. Baptism of the infant.
• B. Circumcision of the infant.
• C. Last rites for the infant.
• D. Sacraments of the sick for the mother.

The nurse is caring for a client with late-stage Alzheimer's disease. The client's wife tells the nurse that the client has become very dependent. The client's wife feels guilty if she takes any time for herself because the client cries out for her. The nurse should develop which outcome to assist the client's wife?

• A. The caregiver learns to explain to the client why she needs time for herself. 
• B. The caregiver distinguishes obligations she must fulfill from those that can be controlled or limited. 
• C. The caregiver leaves the client at home alone for short periods of time to encourage independence. 
• D. The caregiver avoids asking other family members to help for fear of imposing on them.

A mother whose daughter is killed in a school bus accident tells the nurse that her daughter was just getting over the chickenpox and did not want to go to school, but she insisted that she go. The mother cries bitterly and says her child's death is her fault. The nurse should realize that perceiving a death as preventable would most often influence the grieving process in that:

• A.The loss may be easier to understand and to accept   
• B.Bereavement may be of greater intensity and duration   
• C.The grieving process may progress to a psychiatric illness   
• D.It causes the mourner to experience a pathologic grief reaction

Which one is not right about personality disorder?

• A.Multiple personality disorder is distinct and separate personalities within the same person   
• B.People with personality disorder often experience child abuse or traumatic   
• C.Only the symptoms of personality disorder represent the person's stable characteristics and social functioning, he can be diagnosed personality disorder   
• D.Paranoid and antisocial personality disorders are more commonly diagnosed in women than men

Which of the following activities should a 2-year-old child to be able to do?

• A. Build a tower of eight cubes. 
• B. Point out a picture. 
• C. Wash and dry his hands. 
• D. Remove a garment.

When planning care for a 7-year-old boy with Down syndrome, the nurse should

• A. plan interventions at the developmental level of a 7-year-old child because that is the child's age. 
• B. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays. 
• C. assess the child's current developmental level and plan care accordingly. 
• D. direct all teaching to the parents because the child can't understand.

A primigravida in labor for 13 hours clenches her fists, tightens her muscles, and screams during every contraction. Her reaction to labor seems exaggerated compared to the contraction pattern recording from the electronic fetal monitor (EFM). What's the nurse's best response?

• A. Explain to the client that the EFM shows mild contractions, so she should just relax and let the contractions work. 
• B. Take over as her coach because her husband isn't helping her properly. 
• C. Ignore her reactions, realizing that this is her first time in labor and her reactions will soon match the intensity of contractions shown on the EFM. 
• D. Palpate her abdomen to determine the intensity of labor contractions as they're taking place.

During the first 3 months, which hormone is responsible for maintaining pregnancy?

• A. Human chorionic gonadotropin (HCG). 
• B. Progesterone. 
• C. Estrogen. 
• D. Relaxin.

The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying.

• A. "Now isn't a good time to begin dieting because you are eating for two. " 
• B. "Let's explore your feelings further. " 
• C. " Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems. " 
• D. "The prenatal vitamins should ensure the baby gets all the necessary nutrients. "

The client with a head injury receives mannitol (Osmitrol) during surgery to help decrease intracranial pressure. Which of the following nursing observations would most likely indicate that the drug is having the desired effect?

• A. Urine output increases. 
• B. Pulse rate decreases. 
• C. Blood pressure decreases. 
• D. Muscular relaxation increases.

A client is prescribed 1000 mL of an antibiotic solution to be given over 6 hours. What would be the flow rate? The infusion set administers 15 gtts/mL.

• A. 28 gtts/min. 
• B. 35 gtts/min. 
• C. 42 gtts/min. 
• D. 45 gtts/min.

Drugs to treat acute anxiety are prescribed to a client hospitalized for an acute myocardial infarction. The client is reluctant to take anti-anxiety drugs. The nurse suspects that the client is holding the drugs under his tongue and disposing of them after she has left the room. What should the nurse do first?

• A. Report her suspicions to the client's physician. 
• B. Talk to the client about his attitude toward the medications. 
• C. Search the client's room for evidence of the medications. 
• D. Tell the client that his behavior must stop for his own well-being.

A 10-year-old girl visits the clinic for a checkup before entering school. The child's mother questions the nurse about what to expect of her daughter's growth and development at this stage. Which response is most appropriate?

• A. "Her physical development will be rapid at this stage, and rapid development will continue from now on. " 
• B. "She'll become more independent and won't require parental supervision. " 
• C. "Don't anticipate any changes at this stage in her growth and development. " 
• D. "Friends will be very important to her, and she'll develop an interest in the opposite sex. "

A client with thyroid cancer undergoes a thyroidectomy. After surgery, the client develops peripheral numbness and tingling and muscle twitching and spasms. The nurse should expect to administer

• A. thyroid supplements. 
• B. antispasmodics. 
• C. barbiturates. 
• D. IV calcium.

Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip?

• A. Gastric gavage. 
• B. Intravenous fluids. 
• C. Rubber-tipped medicine dropper. 
• D. Bottle with a lamb's nipple.

The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

• A. Heparin sodium (Hep-Lock). 
• B. Dexamethasone (Deeadron). 
• C. Methyldopa (Aldomet). 
• D. Phenytoin (Dilantin).

Which client has the highest risk of ovarian cancer?

• A. 30-year-old woman taking oral contraceptive pills. 
• B. 45-year-old woman who has never been pregnant. 
• C. 40-year-old woman with three children. 
• D. 36-year-old woman who had her first child at age 22.

A pregnant client with premature rupture of the membranes has had contractions every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring. The nurse discusses with the client about preterm labor symptoms. Which of the following statements made by the client indicates that she needs further instruction?

• A. "I should report contractions that occur every 10 minutes in 1 hour. " 
• B. "I should lie in bed on my left side if contractions begin. " 
• C. "I should call the doctor if my contractions occur every hour for 6 hours. " 
• D. "If I start having contractions, I should empty my bladder. "

After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?

• A. Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact). 
• B. Parents' active participation in child's physical or emotional care. 
• C. Parents' failure to use available support systems or agencies to assist in coping. 
• D. Evidence of adaptation to parental role changes.

A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. Which of the following should be the nurse's overall goal of care?

• A. To help the client perform self-care activities. 
• B. To help the client function effectively in her environment. 
• C. To help control the client's symptoms. 
• D. To help the client participate in group therapy.

A client who was found huddled in her apartment by the police is admitted to the clinic. The client stares toward one corner of the room and seems to be responding to something not visible to others. She appears hyperalert and scared. Which of the following conclusion by the nurse is most appropriate according to the situation?

• A. Nothing is wrong because the client isn't a threat to society. 
• B. The client is malingering. 
• C. The client may be hallucinating. 
• D. The client is suicidal.

When developing a teaching plan for the family of a child with seizures, which of the following would the nurse include when discussing pharmacologic treatment?

• A. Medication is adjusted independently when side effects occur. 
• B. Abrupt cessation of the medication must be avoided. 
• C. Dosages will be decreased as the child grows older. 
• D. Medication therapy is necessary for the rest of the child's life.

A client who is breast-feeding has a temperature of 102°F (38.9℃) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the client's breast engorgement?

• A. Applying frozen cabbage leaves to the breasts. 
• B. Encouraging the client to shower with her back to the water. 
• C. Encouraging the client to nurse her baby frequently. 
• D. Applying a breast binder to support the breasts.

After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?

• A. Arm and leg weakness. 
• B. Absence of the gag reflex. 
• C. Difficulty swallowing. 
• D. Inability to speak clearly.

A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care?

• A. Assessing the client's temperature every 8 hours. 
• B. Placing the client in respiratory isolation. 
• C. Monitoring the client's fluid intake and output. 
• D. Wearing gloves during all client contact.

An 20-month-old with acquired immunodeficiency syndrome (AIDS) is seen in the clinic for health maintenance. Which of the following vaccines would the nurse anticipate administering to this toddler?

• A. Diphtheria-tetanus-acellular pertussis. 
• B. Varicella. 
• C. Measles, mumps, and rubella. 
• D. Hemophilus influenza.

An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation?

• A. Ask the parents not to visit the child until he has adjusted to the new environment. 
• B. Ask the physician to explain to the child why he needs to stay in the health care facility. 
• C. Explain to the child that he must act like an adult while he's in the facility. 
• D. Have the parents stay with the child and participate in his care.

The client complains a continuous bladder irrigation after a transurethral resection. Which of the following is the major goal of nursing interventions related to the irrigation?

• A. Recognize signs of prostate cancer. 
• B. Perform activities of daily living. 
• C. Maintain catheter patency. 
• D. Reduce incisional bleeding.

Conditions necessary for the development of a positive sense of self-esteem include

• A. consistent limits. 
• B. critical environment. 
• C. inconsistent boundaries. 
• D. physical discipline.

During a routine follow-up examination, the nurse updates the client's medication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease?

• A. Antidiabetic agents, administered orally. 
• B. Nonsteroidal anti-inflammatory drugs (NSAIDs). 
• C. Beta-adrenergic blockers. 
• D. Contraceptive agents, administered orally.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

• A. Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT). 
• B. Platelet count, blood glucose levels, and white blood cell (WBC) count. 
• C. Thrombin time, calcium levels, and potassium levels. 
• D. Fibrinogen level, WBC count, and platelet count.

Which toy would be most appropriate for a 3-year-old?

• A. A bicycle. 
• B. A puzzle with large pieces. 
• C. A pull toy. 
• D. A computer game.

The nurse is teaching a new mental health aide. For which of the following clients is setting limits most important?

• A. A depressed client. 
• B. A manic client. 
• C. A suicidal client. 
• D. An anxious client.

A multigravida at 36 weeks' gestation visits the emergency department because her boyfriend has beaten her severely. What should the nurse do first?

• A. Contact the authorities. 
• B. Ensure the client's safety. 
• C. Identify a support person. 
• D. Photograph the client's injuries.

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

• A. Avoiding the use of recreational drugs and alcohol. 
• B. Refraining from telling anyone about the diagnosis. 
• C. Following safer-sex practices. 
• D. Telling potential sex partners about the diagnosis, as required by law.

The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?

• A. Hypoglycemia. 
• B. Crackles. 
• C. Bradycardia. 
• D. Hyperkalemia.

Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should

• A. keep the client warm. 
• B. maintain room temperature at 78°F (25.6℃). 
• C. keep the client uncovered. 
• D. match the room temperature with the client's body temperature.

If none of the following bed positions is contraindicated, which position would be preferred for the client with hypovolemic shock?

• A. Supine. 
• B. Semi-Fowler's. 
• C. Trendelenburg's. 
• D. Supine with the legs elevated 15 degrees.

A hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take?

• A. Note the complaints as usual adverse effects. 
• B. Withhold the next dose of medication. 
• C. Administer an analgesic, as needed and as prescribed. 
• D. Help the client relax.