An unconscious client has been admitted with a head injury. Which of the following nursing diagnoses would receive the greatest priority in the plan of care?
  A. Disturbed sensory perception related to decreased level of consciousness.
  B. Ineffective airway clearance related to inability to remove respiratory secretions.
  C. Impaired gas exchange related to shallow irregular breathing.
  D. Risk for injury related to disorientation and decreased level of consciousness.

Linda is a 19-year-old primipara who delivered a viable male neonate 2 hours ago. She has decided to breast-feed. Her 22-year-old husband supports her decision. She tells the nurse, "My mother breast-fed all of her children, but I'm going to need lots of help with breastfeeding. I'm worried that I won't be able to do this. " Which of the following should the nurse include when assessing the client?
 A. Determine the client's level of motivation to breast-feed.
 B. Perform a complete physical examination to determine her need for help.
 C. Assess her body-to-fat ratio and nutritional status before beginning breast-feeding.
 D. Ask the client if she has read any literature about breast-feeding.

A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following?
  A. Excess sugar causing reduced placental functioning.
  B. Insulin acting as a growth hormone on the fetus.
  C. Maternal dietary intake of high calories.
  D. Excess insulin reducing placental functioning.

A client with diverticulitis is treated as an outpatient with drug therapy. Which of the following medication would most probably be included in the drug therapy?
  A. Broad-spectrum antibiotics.
  B. Opioid analgesics.
  C. Tranquilizers.
  D. Laxatives.

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.

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. \

The nurse is instructing a client with angina about sublingual nitroglycerin. Which of the following points should be included?
 A. The shelf life of nitroglycerin is long, it keeps for up to 2 years.
 B. Store the tablets in a tight, light-resistant container.
 C. Use the tablets only when the pain is severe.
 D. The drug will cause increased urine output.

The physician has ordered Oxtriphyllin (Choledyl SA) 0.2 g. Available tablets of the medicine are 100 mg. How many tablets should be given?
 A. 0.5 tablets.
 B. 2.0 tablets.
 C. 2.5 tablets.
 D. 5.0 tablets.

Mr. Smith has had a cast applied to his arm as an outpatient in the emergency room. Which of the following home care instructions should the nurse advice for his cast care?
  A. Use a ruler to reach inside and scratch under the cast.
  B. Apply a heating pad to the arm for 24 hours after the injury.
  C. Use powder on the skin around the cast.
  D. Smell the cast for foul odors.

A client has been placed on levodopa to treat his Parkinson's disease. Which of the following is a common side effect of levodopa that the nurse should include in the client's teaching plan?
  A. Pancytopenia.
  B. Peptic ulcer.
  C. Orthostatic hypotension.
  D. Weight loss.

The mother of a new-born asks the nurse how often she should breastfeed her baby. Which of the following responses by the nurse would be best?
  A. "Newborns should breastfed at least every 3 hours during the day. "
  B. "Newborns should be fed when they cry. "
  C. "As long as the baby feeds four times a day, he will get enough. "
  D. "Newborns may breastfeed continuously until they stabilize. \

Mrs. S with preterm labor will be under Terbutaline (Brethine) therapy. Before beginning the therapy, which of the following assessments would be most important?
  A. Estimated fetal size.
  B. Maternal heart rate.
  C. Contraction intensity.
  D. Deep tendon reflexes.

Antipsyehotie medications may cause which of the following adverse effects?
  A. Increased production of insulin.
  B. Lower seizure threshold.
  C. Increased coagulation time.
  D. Increased risk of heart failure.

The nurse is evaluating a client's lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields?
  A. Vesicular.
  B. Bronchial.
  C. Bronchovesicular.
  D. Adventitious.

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.

When instructing the client with severe burns about proper nutrition, the nurse would encourage him to eat which of the following meals?
  A. Chicken breast, salad, iced tea.
  B. Roast beef sandwich, milkshake, cottage cheese.
  C. Hamburger, orange, coffee.
  D. Pasta salad, carrots, iced tea.

Mrs. Brown, who is breast-feeding, asks the nurse if she should supplement breast- feeding with formula feeding. The nurse bases the response on which of the following?
   A. Formula feeding should be avoided to prevent interfering with the breast milk supply.
  B. Primarily, water supplements should be used to prevent jaundice.
  C. Formula supplements can provide nutrients not found in breast milk.
  D. More vigorous sucking is needed for a bottle-feeding, so supplements should be avoided.

The client with a lumbar laminectomy asks to be turned onto his side. What should the nurse do?
  A. Inform the client that because of his laminectomy, he may only lie supine.
  B. Ask the client to help by using an overhead trapeze to turn himself.
  C. Turn the client's shoulders first, followed by his hips and legs.
  D. Get another nurse to help log roll the client into position.

A client has had a total gastrectomy for gastric cancer. Which one of the following is the most appropriate expected outcomes about nutrition?
  A. The client will learn to self-administer enteral feedings every 4 hours.
  B. The client will maintain adequate nutrition through oral or parenteral feedings.
  C. The client will regain any weight lost within 4 weeks of the surgical procedure.
  D. The client will eat three full meals a day without experiencing gastric complications.

A client with ulcerative colitis is chatting with the nurse. Which of the following statements indicates the client understands the lifestyle modifications he needs to make?
  A. "I will have to stop smoking. "
  B. "I can eat popcorn for an evening snack. "
  C. "I may have coffee with my meals. "
  D. "I am allowed to have alcohol as long as I only drink wine. \

The nurse has assisted a multigravida with a precipitous delivery of a viable neonate in a local grocery store. Because a precipitous delivery can lead to decreased uterine tone, which of the following nursing actions would help to prevent this complication?
  A. Place the neonate on the client's fundus.
  B. Place the mother in a supine position.
  C. Encourage the mother to breast-feed the infant.
  D. Massage the client's fundus continuously.

A client has had a cerebrovascular accident (CVA). Because the CVA affected the left side of the client's brain, the nurse should anticipate that the client would most likely experience
  A. dyslexia.
  B. apraxia.
  C. agnosia.
  D. expressive aphasia.

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.

While managing the separation anxiety during hospitalization for a two-year-old boy, which of the following suggestions would be most helpful to the parents?
  A. Tell the child the time they are leaving and returning.
  B. Bring the child's favorite toys from home.
  C. Leave while the child is sleeping.
  D. Keep the visit time short.

The nurse administers a preoperative intramuscular medication at the ventrogluteal site. The nurse will inject the medication into which muscle?
  A. Rectus femoris.
  B. Gluteus maximus.
  C. Gluteus minimus.
  D. Vastus lateralis.

Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalva's maneuver. Valsalva's maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure, and thrombi dislodgment. Which of the following actions would help prevent Valsalva's maneuver?
 A. Have the client drink fluids through a straw.
 B. Have the client avoid holding her breath during activity.
 C. Have the client assume a side-lying position.
 D. Have the client clench her teeth while moving in bed.

A mother of an ill child tells the nurse that her child "isn't eating well. " Which of the following strategies devised by the mother to help increase the child's intake is not appropriate?
  A. Asking the child to say why he is not eating.
  B. Telling the child he must eat or else he will not get better.
  C. Allowing the child to choose his meals from an acceptable list of foods.
  D. Letting the child to substitute items on his tray for other nutritious foods.

A primigravida at 28 weeks' gestation is admitted with a diagnosis of preterm labor. The client's contractions are occurring every 15 to 20 minutes, lasting 25 seconds. The membranes are intact. What should the nurse do?
  A. Request assistance from the neonatal resuscitation team.
  B. Place the client on bed rest on her left side.
  C. Obtain equipment for an amniotomy.
  D. Prepare terbutaline in an intravenous solution of normal saline.

The client delivers a viable male neonate who is given a score of 9 at 5 minutes on the Apgar rating system. The client asks the nurse what it means. The nurse interprets this finding as indicating that the neonate's physical condition is which of the following?
  A. Good.
  B. Fair.
  C. Poor.
  D. Critical.

An adolescent is admitted to the hospital for headaches. She approaches the nurse and confides that she is being sexually abused by a family friend. Which of the following would be the nurse's best initial response?
  A. "Can you tell me what happened?"
  B. "I believe you; you were right to tell me. "
  C. "Have you told your mother and father about this?"
  D. "Who else have you told about this?\

A patient who is admitted for treatment of an eating disorder displays controlling behaviors, takes responsibility for others' actions, and has difficulty identifying feelings. These manifestations suggest
  A. dependency.
  B. manipulation.
  C. learned helplessness.
  D. codependency.

In caring for the client with hepatitis B, which of the following situations would most likely expose the nurse to the virus?
  A. Contact with fecal material.
  B. A blood splash into the nurse's eyes.
  C. Disposing of syringes and needles without recapping.
  D. Touching the client's arm with ungloved hands while taking blood pressure.

Mr. Smith is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts and two episodes of hitting a coworker at the grocery store where he works. He is very anxious and tells the nurse, "I didn't mean to hit him. He made me so mad that I just couldn't help it. I hope I don't hit anyone here. " Which of the following is the nurse's best response?
   A. "It sounds like you were angry. When you feel angry here, talk to the staff about it instead of hitting. "
   B. "I'm sure you didn't mean to hit him and that it won't happen here. "
  C. "You'd better not hit anyone here, even if you do get mad. "
  D. "Tell me more about what happened. \

Which of the following measures would the nurse take into consider to help minimize joint pain in a child with rheumatic fever?
  A. Massaging the affected joints.
  B. Applying ice to the affected joints.
  C. Limiting movement of the affected joints.
  D. Encouraging progressive weight bearing.

Which of the following functions would the nurse expect to be unrelated to the placenta?
  A. Production of estrogen and progesterone.
  B. Detoxification of some drugs and chemicals.
  C. Exchange site for food, gases, and waste.
  D. Production of maternal antibodies.

The immobile adolescent with a recent fractured femur suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect?
  A. Atelectasis.
  B. Pneumonia.
  C. Pulmonary edema.
  D. Pulmonary emboli.

A parent group is discussing different types of punishment. The parents ask the nurse to discuss corporeal punishment. What would be the nurse's response?
  A. "Corporeal punishment does not physically harm the child. "
  B. "Corporeal punishment can result in children becoming accustomed to spanking. "
  C. "Corporeal punishment can be beneficial in teaching children what they should do. "
  D. "Corporeal punishment reinforces the idea that violence is not acceptable. \

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 (S. Ｃ. ) and brown fat.
  D. Tendency toward capillary fragility.

The nurse is preparing an elderly client to get out of bed on the first postoperative day after a total hip replacement. Which of the following activities would be most helpful to the client?
  A. Demonstrate the use of a walker with partial weight bearing.
  B. Explain to the client that she will be lifted out of bed to a chair.
  C. Reassure the client that she will be assisted to walk to the hall.
  D. Demonstrate the swing-through crutch-walking gait with limited weight hearing.

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 client takes prednisone for an acute exacerbation of her rheumatoid arthritis. The nurse teaches the client about how to take this drug. Which of the following statements by the client indicates that the education is effective?
   A. "I can stop taking the prednisone as soon as my joints feel better. "
   B. "It is important for me to increase my sodium intake while I am taking this medication. "
   C. "I should not be concerned if I lose a little weight while I take the prednisone. "
   D. "It is best if I take this medication with some food. \

Which of the following situations is more likely to predispose a client to postpartum hemorrhage?
  A. Birth of a 7 lb (3,175g) infant.
  B. Prolonged first stage of labor.
  C. Pregnancy-induced hypertension (PIH).
  D. Birth of twins.

The nurse is assessing an elderly client for dementia. Which of the following is a primary symptom of dementia?
   A. Neurosis.
   B. Loss of impulse control.
   C. Psychosis.
   D. Memory loss.

Nitroglycerin is also available in ointment or paste form. Before applying nitroglycerin ointment, what should the nurse do first?
  A. Cleanse the skin with alcohol where the ointment will be placed.
  B. Obtain the client's pulse rate and rhythm.
  C. Remove the ointment previously applied."
  D. Instruct the client to expect pain relief in the next 15 minutes.

A woman tells the nurse that her 6-year-old daughter has severe nosebleeds. Which of the following instructions should the nurse give this woman to manage nosebleeds?
  A. Help the child assume a comfortable position with her head tilted backward.
  B. Tilt the child's head backward and place firm pressure on the nose.
  C. Help the child lie on her stomach and collect the blood on a clean towel.
  D. Place the child in a sitting position with her neck bent forward and apply firm pressure on the nasal septum.

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.

The nurse is teaching the client how to use a cane. Which of the following statements is most inaccurate?
  A. The client should hold the cane on the involved side.
  B. The client should hold the cane close to his body.
  C. The stride length and the timing of each step should be equal.
  D. The nurse should stand behind the client to prevent falls.

A mother brings her 2-year-old adopted Korean child to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. What should the nurse do?
  A. Ask the mother in private how the bruise occurred.
  B. Notify social services of a case of possible child abuse.
  C. Question the mother about the family's discipline style.
  D. Do nothing concerning this finding.

To obtain a good monitor tracing on a client in labor, the mother lies on her back. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which of the following should be the nurse's first action?
  A. Reposition the client to her left side.
  B. Immediately take the client's blood pressure and call the physician.
  C. Start oxygen at 6 L via nasal cannula.
  D. Increase the IV fluids to correct the client's dehydration.

Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?
  A. Profuse vomiting.
  B. Cramping abdominal pain.
  C. Abdominal distention.
  D. High-pitched bowel sounds above the obstruction.

The nurse is caring a client in an acute care mental health program. The client refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. What should the nurse do?
  A. Crushing the medication and putting it in his food.
  B. Consulting with the physician about a plan of care.
  C. Administering the medication by injection.
  D. Omitting the dose and trying again the next day.

The nurse teaches the parents of a child being treated with antibiotics for an ear infection for a follow-up visit after the child completes the course of therapy. Which of the following statements by the parents indicates that they understand the reason for the follow-up visit?
  A. "Her hearing needs to be checked to see if the infection has done any damage. "
  B. "The doctor wants to make certain she has taken all the antibiotics. "
  C. "We need to make sure that her ear infection has completely cleared. "
  D. "She needs to get another prescription for second course of antibiotics. \

Sedative-hypnotic drugs are used to treat which of the following problems?
  A. Hallucinations and delusions.
  B. Anxiety and insomnia.
  C. Obsessive-compulsive disorder (OCD).
  D. Attention deficit hyperactivity disorder (ADHD).