While a client with hypertension is being assessed, he says to the nurse, "I really don't know why I'm here. I feel fine and haven't had any symptoms. " Which of the following would be the nurse's best response?
  A. "Symptoms of hypertension are often not present. "
  B. "Symptoms of hypertension signify a high risk of stroke. "
  C. "Symptoms of hypertension occur only with malignant hypertension. "
  D. "Symptoms of hypertension appear after irreversible kidney damage has occurred. \

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.

The client exhibits signs of sleep disturbance. Which intervention should the nurse try first?
  A. Administer sleeping medication before bedtime.
  B. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
  C. Ask the client each morning to describe the quality of sleep during the previous night.
  D. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.

A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?
  A. Provide an unstructured environment for the client.
  B. Rotate the nurses who are assigned to the client.
  C. Ignore the client's behaviors.
  D. Bend unit rules to meet the client's needs.

The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients?
  A. By their teeth.
  B. By body size and weight.
  C. By looking for Mallory-Weiss tears.
  D. The clients are indistinguishable upon physical examination.

The nurse is instructing an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions?
 A. "I will empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag. "
 B. "I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container. "
 C. "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container. "
 D. "I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container. \

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 with diabetes is explaining to the nurse how he cares for his feet at home. The nurse could judge from which of the following statements that the client needs further instruction on how to care for his feet properly?
  A. "I inspect my feet once a week for cuts and redness. "
  B. "I am not allowed to use a heating pad on my feet. "
  C. "It is important to dry my feet carefully after my bath. "
  D. "I should not go barefoot, even in my home. \

Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?
  A. Monitoring intake and output.
  B. Allowing the infant to rest undisturbed.
  C. Providing age-appropriate diversionary activities.
  D. Initiating oral feedings.

The nurse noticed that an 8-month-old child's posterior fontanel is slightly open. Which of the following should the nurse do next?
  A. Check the child's head circumference.
  B. Question the mother about the child's delivery.
  C. Schedule an X-ray of the child's head.
  D. Document this as a normal finding.

When developing a teaching plan for the mother of a child diagnosed with spastic cerebral palsy, which of the following descriptions would the nurse include?
  A. Wide-based gait and poor muscle coordination.
  B. Tremors and lack of active movement.
  C. Increased muscle tone and stretch reflexes.
  D. Slow, wormlike writhing movements.

Which of the following findings is suggestive of myocardial infarction (MI)?
  A. Below-normal erythrocyte sedimentation rate.
  B. Elevated white blood cell count.
  C. Elevated serum cholesterol value.
  D. Elevated creatine phosphokinase (CPK) value.

Mrs. Wilson, a primigravida, was admitted to the hospital at 12 weeks' gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse determines that the client is most likely experiencing which of the following types of abortion?
  A. Complete.
  B. Threatened.
  C. Inevitable.
  D. Missed.

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.

A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer which of the following medication?
  A. Ritodrine (Yutopar).
  B. Bromocriptine (Parlodel).
  C. Betamethasone (Celestone).
  D. Magnesium sulfate.

The client experiences a wound evisceration on day 2 after the abdominal hysterectomy. What should the nurse immediately do?
  A. Approximate the wound edges by applying strips of adhesive over the wound.
  B. Cover the exposed tissues with sterile dressings moistened with normal saline solution.
  C. Replace the abdominal contents into the wound carefully while wearing gloves.
  D. Apply a loose-fitting sterile abdominal binder over the wound.

While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid?
  A. Paralytic ileus.
  B. Gastric distention.
  C. Hiatal hernia.
  D. Gastrointestinal ulceration.

Which of the following serum electrolyte levels would the nurse expect to find in an infant with persistent vomiting?
  A. K⁺, 3.2 mEq/L; Cl^-, 92 mEq/L; Na⁺, 120 mEq/L.
  B. K⁺, 3.4 mEq/L; Cl^-, 120 mEq/L; Na⁺, 140 mEq/L.
  C. K⁺, 3.5 mEq/L; Cl^-, 90 mEq/L; Na⁺, 145 mEq/L.
  D. K⁺, 5.5 mEq/L; Cl^-, 110 mEq/L; Na⁺, 130 mEq/L.

A priority nursing diagnosis during the first 24 hours following an MI is
  A. Ineffective cardiac tissue perfusion.
  B. Risk for infection.
  C. Deficient fluid volume.
  D. Constipation.

The physician prescribes clomiphene citrate (Clomid) for a woman who has been having difficulty getting pregnant. When preparing the teaching plan for the client about this drug's potential side effects, which of the following would the nurse include in the teaching plan?
  A. Increase in fibrocystic breast disease.
  B. Increase in congenital anomalies.
  C. Multiple pregnancies.
  D. Increase in spontaneous abortions.

The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
  A. Presence of menses.
  B. Uterine enlargement.
  C. Breast sensitivity.
  D. Fetal heart tones.

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.

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his action?
  A. Somatic delusions.
  B. Waxy flexibility.
  C. Neologisms.
  D. Nihilistic delusions.

A client is taking chlorpropamide (Diabenese). Which of the following side effects should be nurse expect from the medication?
  A. Hypoglycemia.
  B. Oral candidiasis.
  C. Dumping syndrome.
  D. Extrapyramidal symptoms.

An agitated client demands to see his chart so that he can read what has been written about him. Which of the following statements is the nurse's best response in this situation?
 A. "I'm sorry the chart is the property of the facility. We don't permit clients to read them. "
 B. "You have the right to see your chart. Please discuss this with your primary care provider. "
 C. "You may see your chart after you're discharged. "
 D. "Please discuss this matter with your attorney. \

The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of the following?
  A. The client is responding to the antipsychotic.
  B. The client may be experiencing increased energy and is at an increased risk for suicide.
  C. The client is ready to be discharged from treatment.
  D. The client is experiencing a split personality.

When caring for an adolescent client diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include which of the following?
  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' opinions.

The nurse is assessing a client with an ileal conduit. She notes that the client's urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data?
  A. These findings are normal for the client.
  B. There is irritation of the stoma.
  C. The client is developing an infection of the urinary tract.
  D. The mucus is caused by elevated levels of glucose in the urine.

The nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client?
  A. The client has regular obsessions.
  B. Relaxation techniques and psychotherapy are necessary for cure.
  C. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder.
  D. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months.

Which of the following signs or symptoms would the nurse expect to see in a client with pancreatitis?
  A. Bradycardia.
  B. Hypertension.
  C. Decreased white blood cell count.
  D. Left upper quadrant abdominal pain.

Which of the following is an appropriate health promotion activity to reduce the incidence of osteoporosis?
   A. Teaching women to maintain adequate calcium intake.
   B. Teaching women how to administer pain medication safely.
   C. Avoiding estrogen replacement therapy when postmenopausal.
   D. Teaching women to increase caffeine intake as a preventive measure.

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response?
  A. "I can see you're upset. Why don't we discuss this with you at a later time when you're feeling better. "
  B. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again. "
  C. "Let me check with your physician and get you something that will help you relax. "
  D. "Pregnancy should be avoided until all of your testing is normal. \

Immediately after a spontaneous rupture of the membranes, the nurse observes a loop of umbilical cord protruding from the vagina. What should the nurse do first?
  A. Administer oxygen.
  B. Notify the physician.
  C. Document the deceleration.
  D. Elevate the hips on two pillows.

A 30-year-old primigravida tells the nurse that her hemorrhoids have become itchy and painful. The nurse instructs the client about relief measures. From which of the following statements by the client would the nurse suspect that the client needs further instructions?
   A. "I should sit in a warm sitz bath daily. "
   B. "I can use a topical ointment for relief. "
   C. "I should apply an ice pack at night. "
   D. "I should decrease my fluid intake. \

During a conversation with the client, the nurse observes the client shaking his leg and tapping his fingers on the table next to him. The nurse's best statement is.
  A. "I'll get you something to help you feel less anxious. "
  B. "I know that you feel anxious. Let's discuss something more pleasant. "
  C. "I see that you're anxious. I'll be back later when you're calmer. "
  D. "I noticed that your leg is shaking and you're tapping your fingers on the table. How are you feeling now?\

Which of the following is the nurse's goal in crisis intervention?
  A. To provide medication to sedate the client.
  B. To provide nondirective techniques such as free association.
  C. To provide problem-solving techniques and structured activities.
  D. To provide an insight-oriented analytic approach.

When caring for a client who has had a cesarean birth, which of the following nursing interventions is least appropriate?
  A. Removing the initial dressing for incision inspection.
  B. Monitoring pain status and providing necessary relief.
  C. Supporting self-esteem concerns about delivery.
  D. Assisting with parental neonate bonding.

In developing a plan of care for a client with rheumatoid arthritis, the nurse should consider that clients with rheumatoid arthritis should be positioned so as to
   A. prevent flexion deformities of the joints.
   B. decrease edema around the joints.
   C. promote maximum comfort.
   D. prevent venous stasis.

Which one of the following observation would the nurse evaluate as an expected outcome for a client who has undergone surgical repair of an inguinal hernia?
   A. The client will remain on a soft diet until the wound is healed.
   B. The client's voiding patterns will return to normal within 6 months after surgery.
   C. The client will use a cane for assistance with ambulation for 2 to 6 weeks after surgery.
   D. The client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks

The neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. The nurse should interpret this positive finding as which of the following?
  A. Stepping reflex.
  B. Plantar grasp.
  C. Galant reflex.
  D. Babinski sign.

The nurse is caring for a client with acute osteomyelitis in the right tibia. Which of the following measures is most appropriate when repositioning the client's leg?
  A. Hold the leg by the ankle when repositioning to avoid touching the tibia.
  B. Support the leg above and below the affected area when positioning.
  C. Have the client move the leg by himself to decrease pain.
  D. Apply warm moist compresses to the leg before repositioning.

A child with leukemia presents with peteehiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which of the following laboratory test results would the nurse correlate with these findings?
  A. Platelet count of 80×10³/mm³.
  B. Serum calcium level of 5 mg/dL.
  C. Fibrinogen level of 75 mg/dL.
  D. Partial thromboplastin time (PTT) of 38 seconds.

After staying several hours with her 10-year-old daughter who is admitted to the hospital with an asthmatic attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings would lead the nurse to make a nursing diagnosis of Anxiety related to respiratory distress?
  A. Complaints of an inability to get comfortable.
  B. Frequently requests for someone to stay in the room.
  C. Inability to remember his exact address.
  D. Verbalization of a feeling of tightness in his chest.

A client with cirrhosis should be encouraged to follow which of the following diet regime?
  A. High-calorie, restricted protein, low-sodium diet.
  B. Bland, low-protein, low-sodium diet.
  C. Well-balanced normal nutrients, low-sodium diet.
  D. High-protein, high-calorie, high-potassium diet.

The client with benign prostatic hypertrophy is prepared for admission to the hospital Which of the following information reported by the emergency room nurse would be most helpful to the nurse responsible for admitting the client?
  A. "A urine specimen was obtained from the client and sent to the laboratory for analysis. "
  B. "The client was catheterized, and 1100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory. "
  C. "The client is very cooperative. He is comfortable now that his bladder has been emptied. He had no ill effects from catheterization. "
  D. "The client was in the emergency room for 3 hours because of bladder distention. He is fine now but is being admitted as a possible candidate for surgery. \

Which of the following findings would indicate that the goals for total parenteral nutrition (TPN) are being achieved for the client?
  A. Serum glucose level of 96.
  B. Weight gain of 0.5 pounds/day.
  C. Urine negative for glucose.
  D. Serum potassium level of 4 mEq/L.

The nurse is making a plan of care for the child with juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising. Which of the following interventions would be included in the plan?
  A. Awakening the child once nightly to exercise the joints.
  B. Having the child sleep in a sleeping bag.
  C. Having the child sleep with the joints flexed.
  D. Increasing pain medication at bedtime.

A 34-year-old client is 34 weeks pregnant and is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which of the following nursing interventions should be of priority?
  A. Monitor the amount of vaginal blood loss.
  B. Allow the client to ambulate with assistance.
  C. Perform a vaginal examination to cheek for cervical dilation.
  D. Notify the physician for a fetal heart rate of 130 beats/minute.

The mother of a 4-year-old asks about dental care for her child. "I help brush her teeth every day and her teeth look healthy. When should I take her to see a dentist?" Which of the following responses would be most appropriate?
  A. "Because you help brush her teeth, there's no need to see a dentist right now. "
  B. "Ideally she should have seen a dentist already, but it's still not too late. "
  C. "Your child doesn't need to see the dentist until she starts school. "
  D. "A dental checkup is a good idea even if no problems are noticeable. \

A mother asks the nurse about how to manage her child's morning hyperglycemia. Which of the following would be most appropriate response by the nurse?
  A. Question the mother if her child has been avoiding sweets.
  B. Tell the mother that this is normal and to continue with the ordered doses.
  C. Ask the mother what her child's blood glucose levels have been for the last few days.
  D. Inform the mother that this is unusual and the child needs to be seen in the emergency room now.

When developing the postoperative plan of care for a child who is scheduled to have a tympanostomy tubes inserted into the right ear, which of the following interventions would the nurse identify to accomplish the goal of facilitating drainage?
  A. Applying warm compresses to the right ear.
  B. Applying a gauze dressing to the left ear.
  C. Applying an ice pack to the left ear.
  D. Positioning the child to lie on the right side.

The nurse is caring for a 35-year-old multipara who delivered a full-term infant by cesarean delivery because of a breech presentation. The nurse recognizes that which of the following events would be the most important contribution to preventing thromboembolism?
  A. Increasing oral fluid intake.
  B. Providing oxygen therapy.
  C. Encouraging frequent ambulation.
  D. Administering pain medications as needed.

A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. Which of the following should be the nurse's first action?
  A. Reassure the client and administer as-needed lorazepam (Ativan) IM.
  B. Administer as-needed dose of benztropine (Cogentin) by mouth as ordered.
  C. Administer as-needed dose of benztropine (Cogentin) IM as ordered.
  D. Administer as-needed dose of haloperidol (Haldol) by mouth.