When an adolescent female client with the diagnosis of anorexia nervosa starts to discuss food and eating, the nurse should plan to

• A.Tell her gently but firmly to direct all discussion of food to the dietitian   
• B.Use her current interest in food to encourage her to increase her intake   
• C.Listen closely to determine her favorite foods and secure these foods for her   
• D.Let her talk about food as long as she wants, but limit discussion about her eating

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. "

A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following should the nurse include in the teaching plan?

• A. It will be necessary for the client to take potassium supplements to prevent hypokalemia. 
• B. The client should use a soft toothbrush and floss teeth daily. 
• C. The use of phenytoin can lead to the development of diabetes. 
• D. It is appropriate to substitute various brands of phenytoin as long as the dosage is the same.

Positive symptoms of schizophrenia include which of the following?

• A. Waxy flexibility, alogia, and apathy. 
• B. Flat affect, avolition, and anhedonia. 
• C. Hallucinations, delusions, and disorganized thinking. 
• D. Somatic delusions, echolalia, and a flat affect.

One-year-old Susan, the second child to have sickle cell disease in a family of five children, is admitted to the hospital with sickle cell crisis. When preparing the plan of care for her, which of the following treatments would the nurse most likely expect to include in the plan?

• A. Intravenous fluid therapy. 
• B. Fast-acting anticoagulant therapy. 
• C. Parenteral iron therapy. 
• D. Exchange transfusion.

A client is prescribed Gentamycin (Garamycin) IV to treat infection. It is important to monitor the client for the development of which of the following side effects from the medication?

• A. Ascites. 
• B. Confusion. 
• C. Ototoxicity. 
• D. Cardiac dysrhythmias.

Which of the following is NOT a contributory factor to thermoregulation in the preterm neonate?

• A. Immature central nervous system (CNS). 
• B. Large skin surface area. 
• C. Lack of subcutaneous (SC) and brown fat. 
• D. Tendency toward capillary fragility.

The nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would be

• A. getting the client out of bed and into a chair for 30 minutes, twice daily. 
• B. avoiding repositioning the client if he's comfortable. 
• C. repositioning the client on alternate sides at least every 2 hours. 
• D. positioning the client with the greatest pressure at the bony prominence.

The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths per minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means

• A. frequent bowel sounds. 
• B. heart rate greater than 100 beats/minute 
• C. hyperventilation.
• D. respiratory rate greater than 20 breaths/minute

When a client experiences a loss of vibratory sense on examination, this indicates

• A. injury to the cranial nerves. 
• B. injury to the peripheral nerves. 
• C. intact cranial nerves. 
• D. intact peripheral nerves.

Mrs. Cray, an African American, is admitted to the hospital after sustaining a hip fracture. She is 5 ft. , 4 inches tall and weighs 96 lbs. She has five children and has used estrogen replacement therapies for 10 years. She told the nurse that she "just stepped forward and fell. " The results of her bone density tests indicate she has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman?

• A. Her long-term use of estrogen.
• B. Her weight.
• C. Her family.
• D. Her race.

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 6-year-old girl has been hospitalized with rheumatic fever for 4 weeks. Her symptoms have gradually subsided, and she's now ready for discharge. Which of the following plans for her health care is most important for her future well-being?

• A. Arrange for her to return to school as soon as possible to promote psychosocial development. 
• B. Encourage her to engage in unrestricted physical activity to regain physical strength. 
• C. Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever. 
• D. Maintain seizure precautions, as central nervous system involvement may persist for several months.

The nurse is administering magnesium sulfate to a client with preeclampsia. The nurse explains to the client that this drug is given for which of the following reason?

• A. To prevent seizures. 
• B. To reduce blood pressure. 
• C. To slow the process of labor. 
• D. To increase diuresis.

At an outpatient clinic, a client asks the nurse how she can prepare for pregnancy. Which of the following responses by the nurse would be best?

• A. "Begin an iron supplement of 100 mg daily. " 
• B. "Supplement your diet with 400 meg of folio acid. " 
• C. "Avoid raw eggs and cats until conception. " 
• D. "Receive immunization against toxoplasmosis. "

The nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by

• A. genetic dysfunction.
• B. upper and lower motor neuron lesions. 
• C. decreased conduction of impulses in an upper motor neuron lesion. 
• D. a lower motor neuron lesion.

A 15-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include which of the following?

• A. Violence on television. 
• B. Passive parents. 
• C. An internal locus of control. 
• D. A single-parent family.

A client who has been admitted to the emergency room is restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances?

• A. Hypokalemia. 
• B. Hypercalcemia. 
• C. Hypomagnesemia. 
• D. Hypernatremia.

What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior?

• A. Ineffective coping.
• B. Imbalanced nutrition: Less than body requirements.
• C. Imbalaneed nutrition: More than body requirements.
• D. Interrupted family processes.

A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost?

• A. 1 pound. 
• B. 3 pounds. 
• C. 5 pounds. 
• D. 7 pounds.

From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis?

• A. Incisional pain. 
• B. Nausea. 
• C. Progressive ambulation. 
• D. Maintenance of a semi-Fowler's position.

A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take?

• A. Assume he's anxious about discharge, and administer pain medication. 
• B. Assess the surgical site and affected extremity. 
• C. Reassure the client that pain is a direct result of increased activity. 
• D. Suspect a wound infection, and monitor the client's temperature and vital signs.

Which of the following would not be an indication of placental detachment?

• A. An abrupt lengthening of the cord. 
• B. An increase in the number of contractions. 
• C. Relaxation of the uterus. 
• D. Increased vaginal bleeding.

Many clients on the eating disorders unit have been admitted for anorexia nervosa. The signs and symptoms that would be most specific for this diagnosis are

• A.Slow pulse, 10% weight loss, and alopecia   
• B.Compulsive behaviors, excessive fears, and nausea   
• C.Excessive activity, memory lapses, and an increased pulse   
• D.Excessive weight loss, amenorrhea, and abdominal distention

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for

• A. hypoglycemia. 
• B. fluid volume excess. 
• C. aspiration. 
• D. constipation.

The nurse plans to teach a client who is receiving radiation therapy how to care for his skin at home. Which of the following should be included in the nurse's instructions?

• A. "Apply a heating pad to the area to relieve pain. " 
• B. "Keep the area covered when you go outdoors. " 
• C. "You may use deodorant soap if you wish to cleanse the area. " 
• D. "Put baby oil on the area after each treatment to keep it from getting dry. "

A client hospitalized with a pneumothorax has the following arterial blood gas (ABG) analysis: pH, 7.19; partial pressure of arterial carbon dioxide (PaCO₂), 63 mmHg; and , 22 mEq/L. A chest tube was inserted and oxygen administered at 4 L/min by nasal cannula. One hour after the initiation of treatment, ABG analysis reveals: pH, 7.28; PaCO₂, 52 mmHg; and , 22 mEq/L. This change in ABG analysis indicates

• A. respiratory alkalosis. 
• B. impending respiratory arrest. 
• C. the need for intubation. 
• D. improved respiratory status.

A 20-year-old woman has just been diagnosed with Crohn's disease. She has lost 10 lb (4.5kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?

• A. Let the client eat as desired during hospitalization. 
• B. Weigh the client daily. 
• C. Ask the client to list what she eats during a typical day. 
• D. Place the client on I＆O status and draw blood for electrolyte levels.

After teaching the mother about tests performed to monitor the success of the infant's treatment for congenital hypothyroidism, the nurse would determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of which of the following?

• A. Blood electrolyte levels. 
• B. Metabolic rate. 
• C. Muscular coordination. 
• D. Bone age.

The nurse is assessing an 8-month-old during a wellness checkup. Which of the following is a normal developmental task for an infant this age?

• A. Sitting without support. 
• B. Saying two words. 
• C. Feeding himself with a spoon. 
• D. Playing patty-cake.

In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's 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 to vent. 
• D. "I'm so frustrated with your behavior. "

When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?

• A. "The pain lasted for about 45 minutes. " 
• B. "The pain resolved after I ate a sandwich. " 
• C. "The pain worsened when I took a deep breath. " 
• D. "The pain occurred while I was mowing the lawn. "

For a client with bulimia, which assessment is least important in the care plan?

• A. Observe the client after eating for 1 hour. 
• B. Note the client's intake. 
• C. Note changes in appetite. 
• D. Note changes in respiratory rate.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

• A. 9%. 
• B. 18%. 
• C. 27%. 
• D. 36%.

For a client with a head injury whose neck has been stabilized, the preferred bed position is

• A. Trendelenburg's. 
• B. 30-degree head elevation. 
• C. flat. 
• D. side-lying.

During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurse take?

• A. Allow him to continue to scratch inside the cast with a pencil. 
• B. Give him a sterile metal object to use for scratching instead of the pencil. 
• C. Encourage him to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists. 
• D. Obtain an order for a sedative, such as diazepam (Valium), to prevent him from scratching.

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.

Which of the following is the most important aspect of nursing care in the postpartum period?

• A. Supporting the mother's ability to successfully feed and care for her neonate. 
• B. Providing group discussions on infant care. 
• C. Monitoring the normal progression of lochia. 
• D. Involving the family in the teaching.

To assess the client's dorsalis pedis pulse, the nurse should palpate the

• A. medial surface of the ankle. 
• B. lateral surface of the ankle. 
• C. ventral aspect of the top of the foot. 
• D. medial aspect of the dorsum of the foot.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. What should the nurse do first?

• A. Auscultate for bowel sounds. 
• B. Palpate the abdomen. 
• C. Change the client's position. 
• D. Insert a rectal tube.

The child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

• A. To obtain a heart rate that isn't affected by medication. 
• B. To eliminate interference from the jerky movements of chorea. 
• C. To ensure that the child can't consciously raise or lower the heart rate. 
• D. To compensate for the effects of activity on the heart rate.

A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client's arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

• A. Prepare to assist with ventilation. 
• B. Monitor the client's heart rhythm. 
• C. Prepare to begin gastric lavage. 
• D. Obtain urine for drug screening.

The client was admitted with severe head injury resulting from a motor vehicle accident. The client is presently unconscious. To facilitate rehabilitation when the client's condition allows, the nurse should

• A. maintain limbs in the position of function. 
• B. apply restraints to arms and legs to control spasms.
• C. exercise just the arms as the legs maintain their tone longer. 
• D. notify physical therapy as soon as the physician orders passive range of motion.

The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP) ?

• A. Suction the airway every hour and as needed. 
• B. Elevate the head of the bed 15 to 30 degrees. 
• C. Turn the client and change his position every 2 hours. 
• D. Maintain a well-lit room.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?

• A. Breech position. 
• B. Late decelerations. 
• C. Entrance into the second stage of labor. 
• D. Multiple gestation.

Which of the following is not a contributing factor to unstable blood sugars in the neonate?

• A. Prematurity. 
• B. Respiratory distress. 
• C. Postdated infant. 
• D. Cesarean delivery.

Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

• A. Having the client take rapid, shallow breaths to decrease pain. 
• B. Having the client lay on the left side while coughing and deep breathing. 
• C. Teaching the client to use a folded blanket or pillow to splint the incision. 
• D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.

A client is experiencing an early postpartum hemorrhage. Which action is inappropriate?

• A. Inserting an indwelIing urinary catheter. 
• B. Fundal massage. 
• C. Administration of oxytoxics. 
• D. Pad count.

A client returns from a myelogram, for which an iodized oil (Pantopaque) was used. Which one of the following nursing measures would be included in his care?

• A. Bed rest with bathroom privileges. 
• B. Restricted fluid intake. 
• C. Head of the bed elevated 45 degrees. 
• D. Assessment of lower extremity movement and sensation.