Masters: McK & Willi

RENR REVIEW
Patrick Mckenzie
1. A client says to the nurse, Its over for me the whole thing is over. Which response
by the nurse would be therapeutic?
a. What do you mean, The whole thing is over?
b. Over? Well, that sounds pretty drastic to me. Lets discuss this in the strictest confidence.
c. Can you tell me more about why its over for you? Ill keep your thoughts strictly
confidential.
d. Lets talk more about your feeling that the whole thing is over for you. This is important,
and I may need to share your feelings with other staff members.

2. A home care nurse makes a visit to a client with a diagnosis of depression. The nurse
finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic
antidepressant lying near the client. What action must the nurse take immediately?
a. Inducing vomiting
b. Calling an ambulance
c. Administering syrup of ipecac
d. Counting the pills remaining in the bottle
3. A nurse has been closely observing a client who has been displaying aggressive behaviors
and notes that the clients aggressiveness is escalating. Which nursing intervention would
be least helpful to this client at this time?
a. Initiating confinement measures
b. Acknowledging the clients behavior
c. Assisting the client to an area that is quiet
d. Maintaining a safe distance with the client
4. An adolescent client says, Im just a burden to my folks. They wish Id never been born.
My dad told me he had to marry Mom because she got pregnant. Which response by the
nurse would be therapeutic?
a. Youre feeling that your folks didnt want you, but they chose to marry and have you.
b. You feel that you were a burden and not wanted? Lets talk with your parents to see
whether youre right.
c. Lets speak with your parents about what youve just told me. Lets ask whether you were
truly unwanted.
d. Sounds like your father was very inappropriate, but Im certain that he didnt mean that
you were a burden to him.

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5. A client tells the nurse, I am a queen. Im mean, and I gleam. The nurse recognizes this
as an example of:
a. Echolalia
b. Tangential speech
c. Clang associations
d. Loosened associations

6. A nursing instructor enters a classroom to begin class and finds two students yelling and
physically assaulting each other. Which intervention by the instructor would be most
appropriate?
a. Walking out of the classroom and asking the secretary to call security, then telling all of the
students to leave and go to the nursing laboratory
b. Getting the class to leave with her and sending everyone to the nursing laboratory, then
calling security to the classroom and reentering to observe what is happening with the two
students.
c. Telling the class, Take a break. Ill come and get you to restart class as soon as I can,
then closing the classroom door, refusing to let anyone else in, and asking a passing
instructor to get security
d. Telling the class to go to the nursing laboratory at once, then asking a student to tell the
nursing secretary to have security come to the classroom, and asking the students who are
fighting to stop fighting and take their seats

7. An acutely ill schizophrenic client says to the nurse, He keeps saying that he likes you,
and I keep telling him youre married, but he wont listen, and I think hes going to get
fresh with you. Once the nurse has determined that the client is hallucinating, which
response to the client would be most appropriate statement?
a. Try not to listen to the voices right now so that I can talk with you.
b. I think that you can help him stop his behavior if you concentrate.
c. Tell him I said to mind his ps and qs or Ill call the police on him.
d. I think that youre trying to share your own feelings toward me, but youre shy.
8. A client with major depression says to the nurse, I should have died. Ive always been a
failure. Which response by the nurse is therapeutic?
a. I see a lot of positive things in you.
b. You still have a great deal to live for.
c. Feeling like a failure is part of your illness.
d. Youve been feeling like a failure for some time now?

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9. A nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD).
Which of the following should be the nurse's primary focus?
a. Group therapy
b. Recreational therapy
c. Goals and objectives
d. The clients medical diagnosis

10. A nurse is preparing a plan of care for an older client with a diagnosis of depression. In
preparing the plan, the nurse recalls that:
a. Older clients do not commit suicide
b. Depression in an older person is never treatable
c. Depression in an older person will not cause physical manifestations
d. Indications of dementia may be present in an older client with depression
11. A client says to the nurse, Im worried about my husband. Hes talking about ending it
all since his law practice dropped off and his son by his late first wife died of a drug
overdose but hes too intelligent to hurt himself, isnt he? Which response by the
nurse is appropriate?
a. Yes, hes too intelligent to end it all.
b. Im not sure. I dont know him that well.
c. Most people who talk about ending it all are just looking for attention.
d. Your husband is displaying behaviors that indicate a risk for self-harm.

12. A nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health
unit. Which of the following characteristics is a hallmark of this disorder?
a. Social contacts are important.
b. The client is not concerned about food and meal planning.
c. Personal relationships tend to become more superficial and distant.
d. The client with anorexia will usually keep his or her weight near normal weight.

13. A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are
taken until the client can be admitted to the psychiatric unit. Which nursing intervention
does the nurse implement?
a. Placing the client in a private room and locking the clients closets and bathroom
b. Placing the client in a private room and removing all knives and glass from the clients
meal tray
c. Allowing the client to go out on pass as long as the client is accompanied by a responsible
adult
d. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping
an arms distance from the client at all times

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14. A client in a retirement center rings the night alarm and says to the nurse, Look at this
old man! He keeps breaking into my apartment! Youve got to get him to stay out of here
so I can sleep. Which statement by the nurse would be most therapeutic?
a. Why not just throw him out yourself and lock up once and for all?
b. Now, you know that youre always seeing things and people at night who arent there.
c. This must be very troubling to you, but I cant see the old man. Perhaps I could stay with
you for an hour or so while you try to rest.
d. Im sure youre very frightened right now. Do you recall my telling you that this is called
sundowner syndrome? Go to sleep and hell leave your apartment.

15. A client says to the nurse, Im really phobic about flying, so my husband and I always
drove or took the train everywhere. Now hes been offered a big job in Europe, and if I
dont get over this and fly with him, he says were done. Ill be left to bring up our three
children by myself. Which statement by the nurse would be therapeutic?
a. No problem. You can be hypnotized to sleep through your trip.
b. Im interested that it took his threat of leaving you to motivate you to seek help.
c. You seem more anxious and afraid of raising three children alone than of flying.
d. I can teach you strategies to help master your panic. An antianxiety medicine would also
help you.

16. A nurse is working with an older client who has been hospitalized and the clients family
to formulate a plan for discharge. In guiding the discussion with the client and family, the
nurse understands that most older persons prefer to live:
a. Alone
b. With their children
c. In long-term care facilities
d. Independently but close to their children
17. A nurse caring for a schizophrenic client is assessing the clients ability to control
distorted thought processes. Which of the following findings indicates a positive
outcome?
a. The client is able to identify when hallucinations or delusions are real.
b. The client can describe in detail the frequency and context of the hallucinatory and
delusional behavior.
c. The client can describe the hallucinations and delusions in detail and is able to interact with
others and share in their delusional systems.
d. The client can identify the recurrence of hallucinations, can refrain from responding to
them, and reports a significant decrease in the incidence of hallucinations.

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18. A nurse notices a paranoid stare during a conversation with a client. The client then
begins to fidget and gets up to pace around the room. Which of the following actions by
the nurse would be beneficial?
a. Allowing the client to pace
b. Escorting the client to a quiet room
c. Changing the conversation to a less threatening subject
d. Sharing the observation with the client and helping the client recognize and acknowledge
his or her feelings
19. An adolescent is returning home after an acute psychiatric hospitalization for a suicide
attempt. Which of the following strategies will be least effective in preparing the client
for discharge?
a. Encouraging the sharing of feelings
b. Suggesting that the clients mother quit her job
c. Identifying the familys strengths and weaknesses
d. Offering and providing the family options and resources
20. A nurse is providing information to a group of nursing staff members about caring for
suicidal clients. The nurse tells the group that:
a. Discussing suicide with a client is not harmful
b. Those clients who talk about suicide never actually try it
c. Depressed clients are the only people who commit suicide
d. When a person makes suicide threats, the only thing the person wants is attention

21. A 2-year-old child is a suspected victim of child abuse and the nurse is interviewing the
childs parent. Which statement by the parent indicates the possibility of child abuse?
a. My child cant be expected to learn everything at once.
b. I can expect my child to talk using some words at this age.
c. I expect my child to try doing some things without my help.
d. When I tell my child to do something, I dont expect to have to repeat myself.
22. A nurse is assigned to care for a client experiencing a crisis. What is the appropriate
initial nursing intervention for this client?
a. Providing authority and action
b. Displaying an attitude of detachment and efficiency
c. Providing hope and reassurance that the crisis is temporary
d. Demonstrating confidence in the clients ability to deal with the crisis

23. A nurse in the emergency department is helping care for a young female victim of sexual
assault. The clients physical assessment is complete, and physical evidence has been

Masters: McK & Willi

a.
b.
c.
d.

collected. The nurse notes that the client is withdrawn, confused, and, at times, physically
immobile. The nurse interprets these behaviors as:
Signs of depression
Normal reactions to a devastating event
Indicative of the need for hospital admission
Evidence that the client is at high risk for suicide

24. A nurse employed in an emergency department is assisting in caring for an adult client
who is a victim of family violence. Which priority instruction does the nurse include in
the discharge plan?
a. Calling the police
b. Self-defense classes
c. The locations of shelters
d. The importance of leaving the violent situation
25. A nurse observes that a client is pacing back and forth. The nurse asks the client how she
is feeling, and the client responds by telling the nurse that she feels out of control!
Which intervention is most appropriate initially to maintain a safe environment?
a. Restraining the client
b. Placing the client in seclusion
c. Continuing to monitor the client
d. Moving the client to a quiet room and talking about her feelings
26. A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted.
Which of the following interventions does the nurse implement?
a. Restricting visitors
b. Placing the client in a private room and locking the bathroom door
c. Removing perfume, shampoo, and other toiletries from the clients room
d. Placing flowers brought to the client in a small glass vase and putting them in the clients
room
27. A nurse is collecting data from a client in crisis and assessing the potential for self-harm.
Which of the following findings indicates that the client is at high risk for suicide?
a. The client is impulsive.
b. The client is disorganized.
c. The client has a history of suicide attempts.
d. The client has an immediate plan for a suicide attempt.

28. A schizophrenic client exhibits confused and unintelligible speech. Which nursing
statement would be most therapeutic?
a. Got it. The blinks are taking over the bumpers.
b. I cant understand what youre saying. You have to talk more clearly!
c. This morning you are participating in the tree-decorating ceremony for the unit.

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d. I cant understand you. Are you asking me to stay with you while you eat supper?
29. A 24-year-old schizophrenic client says, I was in college and suddenly I was hearing
voices telling me I was no good and that I should jump off the bridge by our college. My
parents came and got me when I called them. We thought that I had inadvertently taken
drugs at a party or something. My psychiatrist says that if I can improve, I can return to
college next semester. Which of the following guidelines does the nurse plan to
incorporate into teaching of the client and family about self-care on the clients return to
college?
a. Compliance with the treatment regimen, immediate reporting of any relapse signs,
avoidance of alcohol and drugs, and living a balanced lifestyle
b. Telling all friends about the illness so that they support the clients avoidance of alcohol
and drugs and help the client maintain a balanced lifestyle
c. Limiting college attendance to commuter status to maintain a supportive family group and
avoiding drugs, alcohol, and the strain of socialization
d. Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol
and drugs, and socialization with one supportive friend
30. A client who delivered a baby 4 months ago says, I keep thinking that this boy is some
sort of demon. All he does is cry. Its as if I cant feed him enough or satisfy him in any
way. My daughter never gave me this kind of trouble. I really cant stand it. Which
statement by the nurse is most important?
a. Have you been having any thoughts of hurting your baby?
b. Do you think that something physically wrong is causing your baby to cry?
c. Do you think that your baby cries so frequently because hes not getting enough
nourishment from breastfeeding?
d. You say that he doesnt seem to be satisfied. Do you feel that this is significantly different
from when your daughter was a baby?
31. A nurse working with a victim of rape in a clinic setting is developing a plan of care for
the client. Which short-term initial goal is most appropriate?
a. The client will care for her own physical wounds.
b. The client will verbalize her feelings about the event.
c. The client will identify an appropriate treatment plan.
d. The client will resolve feelings of fear and anxiety related to the rape trauma.

32. A schizophrenic client arrives for a scheduled appointment with the mental health nurse.
The nurse notes that the clients hygiene is poor and that the client is having difficulty
concentrating on what the nurse is saying and responding appropriately. Which nursing
intervention would be most appropriate?
a. Saying nothing and contacting the psychiatrist to sign a commitment order

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b. Saying, I notice that you dont seem to be caring for yourself. Are you taking your
medication?
c. Giving the client his antipsychotic medication and asking him to return in the morning for a
follow-up visit
d. Asking, Will you voluntarily admit yourself for a couple of days so that you can
straighten out your medicine and thinking?
33. A client who is experiencing suicidal thoughts says to the nurse, It just doesnt seem
worth it anymore. Why shouldnt I just end it all? Which of the following statements
should the nurse use to gather additional data from the client?
a. Did you sleep at all last night?
b. Tell me what you mean by that.
c. I know youve had a stressful night.
d. Im sure that your family is worried about you.
34. A nurse determines that a client whose son died in a car accident is at risk for self-harm.
Which intervention is most appropriate initially?
a. Making a no suicide contract with the client
b. Telling the client that anger should be suppressed
c. Providing a peaceful place for the client to meditate
d. Helping the client control expression of his feelings

35. A 30-year-old client says to the nurse, I want to die. I think about it a lot, but I dont
know how in the world to do it. On the basis of the clients statement, the nurse
determines that:
a. There is no suicide risk
b. There is a minimal suicide risk
c. Suicide has been attempted unsuccessfully
d. The risk for suicide exists and continued assessment is needed
36. A nurse plans outcomes for a client who is being treated for psychosis. Which of the
following steps would be included during the stable or discharge phase of treatment?
a. Evaluation of neurological status
b. Use of directive communications with the client
c. Administration of acute psychotropic medications
d. Keeping the client active with hobbies, exercise, and work

37. A client and her new-born infant have undergone human immunodeficiency virus (HIV)
testing, and the results for both clients are positive. The news is devastating, and the
mother is crying. What is the appropriate nursing action at this time?
a. Describe the stages of and treatments for HIV

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b. Listen quietly while the mother talks and cries

c. Discuss with the mother how she might have gotten HIV
d. Call an HIV counsellor and make an appointment for the woman

38. A nurse is trying to deescalate aggressive behaviour exhibited by a client with

schizophrenia. Which nursing action would be contraindicated in this situation?
a. Being assertive with the client
b. Negotiating options with the client
c. Maintaining a nonaggressive posture
d. Standing close to the client and telling the client that the behaviour is unacceptable
39. An alcoholic client says to the nurse, Im taking milk thistle, so I can drink all I want
and never get cirrhosis. Which statement by the nurse would be therapeutic?
a. Milk thistle aside, you still need to stop using alcohol. You have a severe drinking
problem.
b. If milk thistle is so effective, I wonder why the liquor industry isnt lobbying to put it in
alcohol?
c. Milk thistle is used in Europe this way, but research findings are limited, so Id stop
drinking if I had a problem like you do.
d. Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver
cell regeneration, but it cant prevent damage to other organs, like your brain.

40. A nurse sees a nursing assistant talking in an unusually loud voice to a client with
delirium. Which action should the nurse take?
a. Informing the client that everything is all right
b. Speaking to the nursing assistant immediately, while in the clients room, to solve the
problem
c. Explaining to the nursing assistant that yelling in the client's room is tolerated only if the
client is talking loudly
d. Determining that the client is safe, calmly asking the nursing assistant to join you outside
the room, and informing the nursing assistant of the observation

41. A homeless client with an antisocial disorder is brought to the emergency department by
the police after disturbing customers in a department store. The client says to the nurse, I
need to be hospitalized. Its getting cold out, and I need a warm bed. If you dont get me
into a hospital, Ill jump off a bridge. Which nursing intervention would be therapeutic?

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a. Sending the client to the psychiatric hospital intake center immediately for evaluation
b. Asking the police to pick the client up and arrest him for vagrancy, as they should have
done immediately
c. Discharging the client with a follow-up appointment for the next day and guaranteeing him
a hospital bed if he shows up
d. Sending the client to a shelter that will provide temporary housing if he signs a contract
agreeing not to attempt suicide
42. A nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the
clients discharge outcomes, the most positive outcome is that the client states that he or
she will:
a. Learn to play tennis
b. Take a painting class
c. Start an exercise program
d. Continue to attend Alcoholics Anonymous meetings
43. A client who has expressed suicidal ideation in the past says to the nurse, while shuffling
several documents in an effort to organize them, Well, Im feeling so much better now
since I got organized. My lawyer wrote my will and durable power of attorney. Which
response by the nurse is appropriate?
a. Good grief! You dont look organized to me.
b. Okay, what are you up to today? Your behavior is not appropriate.
c. You talk about getting organized. Are you thinking of killing yourself?
d. If you keep behaving like this, you know that Ill have to tell the doctor, and well have to
seclude you.
44. A client in halo traction says to the nurse, I cant get used to this contraption. I cant see
properly on the side, and I keep misjudging where everything is. Which response by the
nurse is therapeutic?
a. No one ever gets used to that thing! Its horrible.
b. If I were you, Id have had the surgery rather than suffer like this.
c. Halo traction involves many difficult adjustments. Practice scanning with your eyes after
standing up, before you move.
d. Why do you feel like this when you could have died of a broken neck? This is the way it
will be for several months. You need to accept it, dont you think?

45. A client with schizophrenia and his parents are meeting with the nurse. One of the young
mans parents says to the nurse, We were stunned when we learned that our son had
schizophrenia. He was no different than from his older brother when they were growing
up. Now hes had another relapse, and we cant understand why he stopped his
medication. Which response by the nurse is appropriate?

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a. Telling the parents, Medication noncompliance is the most frequent reason that people
with this diagnosis relapse.
b. Telling the parents, Well, its his decision to take his medicine, but its yours to have him
live with you if he stops the medication.
c. Asking the client, How can we help you to take your medicine or to tell us when youre
having problems so that your medication can be adjusted?
d. Saying to the parents, Your concerns are appropriate, but I wonder whether your son was
having trouble telling someone that he had concerns about his medication.
46. A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern
is of the highest priority?
a. Fear
b. Anxiety
c. Distorted body image
d. Risk for impaired breathing
47. A nurse brings a meal tray to a psychotic client in his hospital room. The client refuses
the meal and says, Im not eating any more poisoned food while Im vacationing here.
Im starting on a fast to stay healthy and alive. Which nursing intervention would be
most appropriate initially?
a. Taking the tray away and canceling all meals until further notice
b. Having the client eat with other clients in the community dining room
c. Eating some of the food from the clients tray to prove that it isnt poisoned
d. Telling the client that the psychiatrist will be called for a prescription for a tube feeding
48. A manic client who tends to be manipulative says angrily, You had better let me out of
here, or Im going to call my lawyer. My boss has good friends with the owners of this
tin-pot place you call a mind holism respite. Which statement by the nurse would be
most therapeutic?
a. When you can speak to me without yelling and being aggressive, Ill be happy to speak
with you.
b. Just get your anger out with me, because were not going to allow you be discharged until
you calm down.
c. Do threats and name-calling usually work for you? Do people tend to listen to you and do
as you order them to?
d. I know that you feel that youre doing your very best right now, but you are yelling. Take
some time out and some deep breaths, and Ill speak to you in half an hour.

49. A nurse is preparing a discharge plan for a client who has attempted suicide. The nurse
understands that the plan of care should focus on:
a. Follow-up appointments
b. Providing the hospital phone number

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c. Contracts and immediate available crisis resources

d. Encouraging the family to always be with the client
50. A client with a history of multiple somatic complaints involving several organ systems
has no evidence of organic pathologic conditions. It is important for the nurse planning
care for this client to understand that the client is afflicted with:
a. Paranoia
b. Depression
c. Schizophrenia
d. Somatization disorder
51. A client says to the nurse, I came in to see you because Ive been off my medication for
4 years but I feel as though I may be getting depressed again. Ive been despondent again
and thinking I should have ended it. Thats why Im here to get help. Which response by
the nurse would be therapeutic?
a. Well, you really have had a good long drug-free time, but it sounds as if the doctor needs
to reorder your medication at once.
b. If youve been able to be drug free all this time, you probably dont need to restart the
medicine. You probably just need some therapy to help you manage stress.
c. Well, its been more than 4 years, so youve done really well. Sounds like youre right
about getting depressed again, though. Can you tell me whats been happening with you
lately?
d. Well, its similar to when a client is battered things have to boil over before the police
can act so you need to be suicidal to get admitted to a hospital or hurt yourself before
the doctor can restart the medication.
52. A client brought to the emergency department by the police after being mugged is
extremely agitated, trembling and hyperventilating. What is the appropriate initial nursing
action?
a. Staying with the client
b. Teaching the client how to relax
c. Asking the client questions about the mugging
d. Allowing the client to be alone in a room at the end of the emergency department corridor,
where it is quiet

53. A student calls the campus crisis hotline and tells the nurse, I went out to a sorority party
last week and drank too much. Someone raped me, but when I told my folks about it, they

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a.
b.
c.
d.

acted like it was my fault. I feel so dirty and used. Which statement by the nurse would
be most therapeutic?
Would you come in to talk with me in the strictest confidence?
I believe that you can feel a lot better about yourself. Wont you come in to see me
tomorrow?
Parents always feel that their daughters could never be raped. I could talk to them for you,
if youll let me.
Youve had an awful experience, but its not your fault that it happened. Can you come in
and talk to me about it in more detail?

54. A schizophrenic client is admitted to the inpatient psychiatric unit. The client is
exhibiting clang associations, word salad, and loose associations. Which problem does
the nurse recognize that the client is experiencing?
a. Defensive coping
b. Inability to cope effectively
c. Sensory perception alterations
d. Inability to communicate effectively
55. A client arrives in the emergency department in a crisis state. The client demonstrates
signs of profound anxiety and is unable to focus on anything but the object of the crisis
and the impact on herself. The nurse plans to focus the initial assessment on:
a. Sources of support
b. The object of the crisis
c. The clients coping mechanisms
d. The physical condition of the client
56. A schizophrenic client says, Im away for the day ... but dont think we should play
or do we have feet of clay? Which alteration in the clients speech does the nurse
document?
a. Neologism
b. Word salad
c. Clang association
d. Associative looseness
57. A schizophrenic client in the psychiatric inpatient unit is yelling, The CIA is trying to
kill me. I know theyre plotting to kill me so they can overthrow the government. On the
basis of the clients statement, which clinical manifestation would the nurse document in
the client record?
a. Demonstrates paranoia
b. Exhibits ideas of reference
c. Evidence of persecutory delusions
d. Evidence of ideas of somatic delusions

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58. A client is severely injured, sustaining a full-thickness circumferential burn to the left leg,
after passing out as a result of drinking alcohol and falling into a fire while on a camping
trip. In report, the nurse is told that the client has just signed consent for amputation of
the limb and that the procedure is scheduled for tomorrow. While caring for the client, the
nurse notes that the client is upset and withdrawn. What is the most appropriate nursing
action at this time?
a. Reflecting back to the client that he appears upset
b. Letting the client have some time alone to grieve the impending loss of the limb
c. Reminding the client that the injury was a result of alcohol abuse and referring him for
counseling
d. Informing the physician of the clients depression and requesting medication to assist the
client in coping with the diagnosis
59. A heroin addict who overdoses on the drug is brought into the emergency department.
The client is having seizures, and the nurse notes that his pupils are dilated. Which of the
following interventions does the nurse anticipate that the emergency department
physician will prescribe?
a. Gastric lavage
b. Intravenous fluid
c. Naloxone (Narcan)
d. Ammonium chloride

60. The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the
school nurse that she is administering an over-the-counter (OTC) cough syrup to her son.
Which response by the nurse would be appropriate?
a. His cough could be a side effect of the Ritalin.
b. Your son should never take any medicine, even if its OTC.
c. You may administer a small amount of OTC cough syrup without a problem, but not for
more than 3 days.
d. I think that you should stop giving this medicine to your son until I can check its content
with the pharmacy.
61. A client with obsessive-compulsive disorder who continually cleans her room with paper
towels becomes enraged with her roommate for throwing the package of paper towels
into the waste basket, begins to yell, and slaps the roommate. Which of the following
actions would the nurse take first?
a. Restraining the client
b. Filling out an incident report
c. Removing both clients to safe locations
d. Calling the hospitals risk-management department

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62. A client who has twice attempted suicide says, If people would just leave me alone and
let me do what I want with my life, I could get on with what I want to do. Which
response should the nurse should give to the client?
a. Of course you cant be left alone to get on with what you want to do.
b. Okay, go ahead and do whatever you want to do. Human beings have free will.
c. Youve tried to end your life twice, yet you feel that everyone should let you do what you
want to do?
d. Sounds like youre angry with people for caring enough about you to try to keep you from
hurting yourself.
63. A schizophrenic client is seen seemingly talking to someone who isnt there. Which
nursing statement would be most therapeutic initially?
a. Today is my birthday. Would you like to go on an outing with my family?
b. You need to wash up and get ready to go to supper in the cafeteria with the other clients
now.
c. Ive noticed your eyes darting back and forth, and I wondered whether you might be
hearing voices.
d. You were telling me yesterday that your mother died last June of cancer. Can you tell me
more about that?
64. A client in a mental health unit gets into a fight with another client over the use of the
public telephone on the unit. The client is accused of making two telephone calls and
staying on the telephone for 1 hour. Which of the following interventions by the nurse
would be most therapeutic?
a. Taking telephone privileges away from both clients for the day and giving them time-outs
in their rooms
b. Saying to the clients, Okay, this is the last straw. Neither of you may use the telephone
until tomorrow, and then only with a nurse timing you.
c. Saying to the clients, Go to your rooms, both of you. I dont want to hear anything more
about the telephone on this unit for at least 2 hours.
d. Saying to the clients, You may each use the phone for 10 minutes. I will time the calls for
both of you. Do you both agree to abide by my decision?

65. An alcoholic client who has been admitted to the mental health unit states to the nurse,
The judge made me come in here. My blood alcohol level was only 0.20% when the cop
pulled me over in my car. Which statement by the nurse is most appropriate?
a. Did you ask the judge to clarify his decision to make you come here?

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b. This limit means that you had consumed enough alcohol to put you close to the legal
intoxication level. You were lucky because you just missed that level.
c. Well, the legal limit is much less than that, so you avoided a drunken driving charge by
coming here. Seems to me that the judge treated you pretty leniently by allowing you to
take refuge here. Dont you agree?
d. This level means that you consumed several drinks of alcohol and would be experiencing
depressed motor function of the brain. You would have been staggering and clumsy and
your judgment would have been impaired, but you seem to feel that the judge was
unreasonable for sending you here.
66. A nurse employed in a home care agency is assigned a recently widowed client. When the
nurse arrives at the clients home, the ordinarily immaculate house is in chaos and the
client is disheveled, with the odor of alcohol on his breath. Which of the following
statements by the nurse would be therapeutic?
a. I can see that this isnt a good time to visit.
b. You seem to be having a very difficult time.
c. Do you think your wife would want you to behave like this?
d. What are you doing? How much are you drinking, and how long has this been going on?
67. A client says to the nurse, I dont do anything right. Im such a loser. What is the
appropriate response?
a. Everything will get better.
b. You dont do anything right?
c. You do things right all the time.
d. You are not a loser; you are sick.
68. A client says to the nurse, Im going to die, and I wish my family would stop hoping for
a cure! I get so angry when they carry on like this! I'm the one whos dying. Which
response by the nurse would be most therapeutic?
a. Have you shared your feelings with your family?
b. Well, it sounds like youre being pretty pessimistic.
c. I think we should talk more about your anger with your family.
d. Youre feeling angry that your family continues to hope for you to be cured.

69. Which of the following steps should be included in the care of a 13-year-old hospitalized
child who has been abused?
a. Encouraging the child to avoid the abuser
b. Providing a caring environment that fosters the development of trust
c. Teaching the child to make intelligent choices when confronted with an abusive situation

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d. Having the child identify the abuser if that person should visit while the child is
hospitalized
70. A nurse is caring for a client who has been identified as a victim of physical abuse.
Which of the following actions is the priority as the nurse plans care for the client?
a. Notifying the caseworker of the situation
b. Adhering to mandatory abuse reporting laws
c. Removing the client from any immediate danger
d. Obtaining treatment for the abusing family member
71. A nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for
the client to come out of seclusion when the client states:
a. I need to go to the bathroom.
b. Im no longer a threat to myself or others.
c. I want to be alone for a while in my own room.
d. I cant breathe in here. The walls are closing in on me.
72. A nurse working in the emergency department is performing an initial assessment on a
client, and notes many physical injuries. The nurse suspects family-related violence.
Which of the following findings are specific to this type of violence?
a. The client lives in an assisted living facility.
b. The client is financially dependent on him or herself.
c. The client relies on neighbors and friends for transportation to and from appointments.
d. The client lives with one of their children and requires extensive assistance with activities
of daily living.
73. An adolescent client has graduated high school and is preparing to leave home to attend
college. The adolescent is distressed about this life change. The nurse plans to implement
crisis interventions, knowing that this situation is characteristic of:
a. A situational crisis
b. An individual crisis
c. A maturational crisis
d. An adventitious crisis

74. A moderately depressed client who was admitted to the mental health unit 2 days ago
suddenly begins smiling and reports that the crisis is over. The client says to the nurse,
Im finally cured. The nurse interprets this behavior as a cue to modify the treatment
plan by:
a. Suggesting a reduction of medication

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b. increased in-room activities

c. Increasing the level of suicide precautions
d. Allowing the client off-unit privileges as necessary
75. A male client reports difficulty concentrating, outbursts of anger, and a feeling of being
keyed up all the time and states that peer relations are poor. He then tells the nurse that
the symptoms started after his best friend was killed in the terrorist attack at the World
Trade Center. The nurse suspects that the client is experiencing:
a. Social phobia
b. Panic disorder
c. Posttraumatic stress disorder
d. Obsessive-compulsive disorder
76. A nurse performing a lethality assessment asks the client whether he is thinking of
suicide. Which statement by the client would be of most concern to the nurse?
a. No, I wasnt, but I am now, thanks to you.
b. I hadnt thought of that, but I can see that you are.
c. Of course not, but there are days when I think that I should be.
d. What is suicide going to do for me except get me excommunicated from the church?
77. A nurse working in a mental health unit reads a clients medical record and notes
documentation that the client has been experiencing flashbacks. The nurse interprets this
as a classic sign of:
a. Depression
b. Schizophrenia
c. Posttraumatic stress disorder
d. Obsessive-compulsive disorder
78. A client has just been admitted to the mental health unit with a diagnosis of obsessivecompulsive disorder. The nurse observes the client for compulsive behaviour involving
repetitive:
a. Fears
b. Actions
c. Thoughts
d. Delusions

79. A schizophrenic client attending a support group held by a clinic nurse says to the nurse
and the group, Ive been laid off from my job at the factory, and so have 300 other
people, so Ill have to get a new job. For now, theres unemployment. Which statement
by the nurse would be most therapeutic at this time?
a. It seems that the stock market is responsible for mass unemployment in our factory-based
city.

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b. Im sorry to hear that youve lost your job. Why not make an appointment to come in and
talk with me this week?
c. How do people feel about this loss of employment? Does anyone in the group who
experienced this have any advice?
d. Have other people in the group been feeling the job crunch this week? When changes like
this occur, its best to increase the number of your appointments with me for a short time.

80. A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug
overdose. The priority nursing intervention is to:
a. Remain with the client at all times
b. Request that a family member remain with the client at all times
c. Remove the clients clothing and dress the client in a hospital gown
d. Place the client in a seclusion room from which all potentially dangerous articles have been
removed
81. A psychiatric nurse is playing a card game with a client in the day room. The client states
to the nurse, "The voice in my head is telling me that you're cheating." Which of the
following responses by the nurse is therapeutic?
a. "I do not hear any voices. Has the voice said anything else?"
b. "Is the voice telling you to do anything?"
c. "It isn't possible for people to hear voices in their head."
d. "I don't believe that you are hearing voices."
82. A client in skeletal traction says to the nurse, I cant get any help with my care! I call
and call, but the nurses never answer my light. Last night one of them told me she had
other patients besides me! Im very sick, but the nurses dont care! Which response by
the nurse would be therapeutic?
a. You poor thing! Im so sorry this happened to you. That nurse should be reported!
b. I think youre being very impatient. The nurses work very hard and come as quickly as
they can.
c. Its hard to be in bed and have to ask for help. You call for a nurse who never seems to
come?
d. I can hear your anger. That nurse had no right to speak to you that way. I will report her
to the director. It wont happen again.

83. A mental health nurse is conducting the initial assessment of an obese client. The client
confides that she was sexually molested at age 7 and began putting on weight thereafter.
The nurse determines that the clients symptoms are compatible with a somatization
disorder and recalls that obesity for this client most likely represents:

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a. Satisfaction with self

b. A form of functional coping
c. Protection from the risk of intimacy
d. Long-term lack of compliance with weight programs
84. A nurse is caring for an older adult client who says, I don't want to talk with you
youre only a nurse. Ill wait for my doctor. Which of the following responses by the
nurse would be therapeutic?
a. Ill leave you now and call your physician.
b. So youre saying that you want to talk to your physician?
c. Im angry with the way youve dismissed me. I am your nurse!
d. Im assigned to work with you. Your doctor placed you in my hands.
85. Family members awaiting the outcome of a suicide attempt are tearful. Which response
by the nurse would be most therapeutic to the family at this time?
a. I can see that you are worried.
b. You have nothing to worry about.
c. You can see your loved one soon.
d. Everything possible is being done.
86. A woman is brought to the emergency department after an assault. She presents with
complaints of dizziness, dyspnea, visual disturbance, and motor tension with
hyperactivity. Which level of anxiety does the nurse recognize in the clients
presentation?
a. Mild
b. Panic
c. Severe
d. Moderate
87. A resident of a long-term care facility who has Alzheimers disease becomes agitated
when a group of children comes to sing and dance at the facility and tries to take one of
the children to her room. Which of the following pieces of information should the nurse
use when approaching the client about this behavior?
a. This resident is a dangerous individual.
b. Individuals with Alzheimers disease are likely to be child molesters.
c. This resident probably had an unfortunate experience while singing and dancing in his
own youth.
d. Individuals with Alzheimers disease have difficulty tolerating excessive stimulation and
changes in routine.
88. A nurse employed in a mental health unit is reviewing the work schedule. At what time
does the nurse expect that additional client safety precautions will be provided?
a. Day shift
b. Weekdays
c. Weekends
d. 7 to 10 a.m.

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89. A nurse is preparing to provide nursing unit information to a client who does not speak
English who is being admitted to the mental health unit. Which action is best for the
nurse to take to ensure that the client understands the information?
a. Asking a family member to translate for the client
b. Obtaining a hospital interpreter to communicate with the client
c. Asking a hospitalized client who speaks the same language as the client to translate
d. Providing the client with a pamphlet that explains the nursing unit information in the
clients language
90. A schizophrenic client says, I feel like Im rotting away inside and all of my organs are
rusting. Which type of delusion does the nurse identify in the clients statement?
a. Somatic
b. Jealousy
c. Persecution
d. Idea of reference
91. Which of the following clients is at the highest risk for suicide?
a. A 24-year-old man who is angry with his family
b. A 71-year-old man with mild depression and social withdrawal
c. A 75-year-old woman with severe depression and crippling arthritis
d. A 30-year-old newly divorced woman who has custody of her children
92. Which statement made by a client with anorexia nervosa would indicate to the nurse that
treatment has been effective?
a. I no longer have to lose weight.
b. I wont starve myself anymore.
c. Ill eat until I dont feel hungry.
d. I went out to lunch today with my cousin.

93. A nurse collects data from an older client and monitors him for signs of abuse. Which of
the following psychosocial factors does the nurse recognize as placing the client at risk
for abuse?
a. The client lives alone.
b. The client is independent.
c. The client shows signs and symptoms of depression.
d. The client is completely dependent on family members for food and medicine.

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94. A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong
with the organs of communication. The nurse plans care knowing that this condition is
referred to as:
a. Mutism
b. Verbigeration
c. Pressured speech
d. Poverty of speech
95. A schizophrenic client says to the nurse, I keep getting these thoughts and hearing
voices. They worry and consume me so that I cant always stop myself like my doctor
told me to. Which intervention would the nurse suggest as a distraction technique?
a. Pretend that youre on the phone and talk to the voices.
b. Have you tried to count back from 100 or listen to music?
c. The next time this happens, try telling the voices to go away.
d. Tell the voices that you will only listen to them just before you watch television at 8:30 in
the evening.
96. A furious and aggressive client is put in restraints and told that the restraints will be
removed once the she regains control. At which of the following times is removal of the
restraints by the nurse appropriate?
a. When medication that has been administered has taken effect
b. When the client apologizes and tells the nurse that it will never happen again
c. When the nurse explores with the client the reasons for the angry and aggressive behavior
d. When no acts of aggression are observed in the hour following the release of two
extremity restraints
97. A nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the
mental health unit observes the client for certain characteristic behaviors. What are they?
a. Hostility
b. Inflexibility
c. Adaptability
d. Extreme fear

98. A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and
states, My priest assaulted me when I was an altar boy, and my dad just found out. Hes
got a gun, and hes driving over to the church rectory. I dont know what to do. Which
response by the nurse is most appropriate initially?
a. How did your dad learn of your abuse by clergy?
b. Call the police immediately and then call the priest to warn him that your dad has a gun.
c. Call the priest immediately and tell him to lock the doors until the police arrive. Ill call
the police.
d. You will want to come in to see our psychiatrist with your father, but, for now, call the
police and tell them what happened.

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99. A client says to the nurse, Ive ruined my life. I left college with only a few credits to go.
I keep telling myself that Im going to make it as a writer, but Ill be a loser and a nothing
for the rest of my life. Which response by the nurse is therapeutic?
a. What are you saying? Sounds like you need to pull yourself together and go back to
school.
b. Having faith in yourself is one thing, but looking at your alternatives realistically is
another.
c. You seem to be saying that your choices are final and that youve lost any other
opportunities.
d. Sounds like you feel that things should come easy for you, unlike the rest of us, who work
for what we get.
100.
A postpartum client says to the nurse, Sometimes I hear voices telling me to kill
my baby to save her all the heartache Ive been through. Which statement by the nurse
would be most therapeutic?
a. The voices will disappear in a few weeks as your hormones stabilize.
b. This must be very distressing to you. Can you tell me more about the voices?
c. It is so good that you shared your feelings and thoughts with me. Im going to help you
get immediate attention for your voices.
d. You will want to tell the doctor about them when you visit him next week. He is very
interested in these voices and will want to help you with them.
Scenario I
Items 1-8
Mr Jay Sing was brought to the emergency room with history of SOB, with
generalized weakness; he has been experiencing drenching night sweats.
He complains of anorexia and notices significant weight loss. After a chest
x-ray a diagnosis of Tuberculosis was made.
101.
a.
b.
c.
d.

Which of the following is not a risk factor for Mr. Sing contracting TB
Consumption of milk
Living near a factory
Living in a crowded community
Contact with someone with TB

102.
During meal Mr. Sing states I am not used to looking like this. Which of
the meals on the food cart would be the most appropriate for the nurse to
serve him?
a. Chicken breast, pasta salad, mixed vegetables and fruit juice
b. Burger, canned fruits, mixed vegetables and water
c. Baked bean, sunshine rice, mixed vegetables and fruit juice
d. Roast beef, raw vegetables, mixed nuts

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103.
When taking Mr. Sings blood pressure, the nurse would take which of
the following precautions?
a. Mask, gloves, gown
b. Mask and gloves
c. Gloves only
d. Mask only
104.
After an education session with Mr. Sing, the nurse would be most
concerned if he made which of the following statement?
a. My medication will be long term
b. I will have to sleep in a separate room
c. I can still go to my football games on Sunday
d. I can take my mask of when I am alone in my room
105.
Mr Sing was prescribed Rifampin, Isoniazid and Streptomycin. The
nurse would recommend vitamin B6 if the client states which of the
following?
a. My urine and saliva appears orange
b. My stomach is upset when I take the medication
c. I used to feel when an insect crawls on me
d. My mouth has a very bitter taste
106.
Mr Sing is coughing thick yellow secretions. Which of the following
would be an effective nursing intervention
a. Instruct him to turn every two hours
b. Encourage oral fluids
c. Administer mucolytic
d. Encourage ambulation
107.
The nurse needs to prepare Mr. Sing for transfer to National Chest
Hospital. The nurses action would be considered safe if she:
a. Inform national Chest of the transfer
b. Transport the patient in a mask
c. Take the patient to the ambulance bay
d. Transport the patient in gloves, gown and mask
108.
Mr Sing is to return to the hospital for sputum culture. He would be
considered as still having active TB if the culture reveals which of the
following?
a. Pneumocystis carinii
b. Mycobacterium tuberculosis
c. Tubercles in the lung
d. Positive Tuberculin
Scenario 2
Items 9- 15

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A Two-year old boy was brought to the Accident and Emergency unit with
history of vomiting and abdominal pain. V/S T. 100.5F pulse 130 R 28.
Assessment revealed visible peristaltic wave across the abdomen a
medical diagnosis of pyloric stenosis was made and the child was
scheduled for surgery the next day.
109.
Which of the following is a cardinal sign of pyloric stenosis?
a. Olive shape mass in left upper quadrant
b. High fever
c. Non-projectile vomiting
d. Currant jelly stool
110.
The nurse would be considered negligent if she does which of the
following while providing care for this client?
a. Pull the cot rails up
b. Deep palpation of the abdomen
c. Passing and NG tube
d. Tell the mother surgery is a part of the treatment
111.
When preparing the child for surgery the nurse would
i.
Pass NG tube
ii.
Maintain NPO
iii.
Bowel enema
iv.
Measure amount of vomitus
a. I,iii
b. I, ii, iii, iv
c. I, ii
d. Ii, iv
112.
The manger on the unit realizes there is a shortage of staff, and as a
result the child might not be prepared for surgery on time. Which of the
following would be the most effective action by the ward manager to ensure
the client is prepared for surgery on time?
a. Reduce staff break time
b. Set time to accomplish task
c. Assess the experience of the staff
d. Prioritize tasks to be accomplish
113.
The child came back to the ward after surgery and shows signs of
drowsiness and difficulty arousing. What should the nurse do first?
a. Suction the patient
b. Place in a side lying position
c. Call the physician immediately
d. Assess the vital signs
114.
The doctor ordered gentamicin 20mgs tid. On hand is gentamicin
80mgs/2ml the nurse would give __________ml
a. O.5
b. 5
c. 4
d. 0.4

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115.
The child has IV fluid 400mls NS to go for 4hrs at a drip rate of
60drops/ml. the nurse would set the IV line at __________ gtt/min
a. 10
b. 101
c. 100
d. 112
116.
The risk factors for type 1 diabetes include all of the following except:
a. Diet
b. Genetic
c. Autoimmune
d. Environmental
117.
Risk factors for type 2 diabetes include all of the following except:
a. Advanced age
b. Obesity
c. Smoking
d. Physical inactivity
118.
Untreated diabetes may result in all of the following except:
a. Blindness
b. Cardiovascular disease
c. Kidney disease
d. tinnitus
119.
Excessive thirst and volume of very dilute urine may be symptoms of:
a. Urinary tract infection
b. Diabetes insipidus
c. Viral gastroenteritis
d. Hypoglycemia
120.
Untreated hyperglycemia may lead to all of the following complications
except:
a. Hyperosmolar syndrome
b Vitiligo
c. Diabetic ketoacidosis
d. Coma
121.
Which of the following measures does not help to prevent diabetes
complications?
a. Controlling blood glucose
b. Controlling blood pressure and blood lipids
c. Eliminating all carbohydrates from the diet
d. Prompt detection of diabetic eye and kidney disease
122.
Which of the following processes describe the bodys immunological
response a localized infection? There will be:
a. Normal respiration
b. Slight increase in heart rate
c. Impaired function of a body part

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d. an increase in temperature indicating that the bodys defense is low.

SCENARIO 3
Tony Hunt is a 19 year old college student who fell off a cliff and sustained
a head injury.
He was rushed to the local hospital some two miles away. Upon arrival at
the Accident
and Emergency Department. Mr. Hunt was unaware of his surroundings
and was unable
to respond appropriately to questions. His colleagues reported that after
his fall he
remained conscious and complained of a headache. On assessment his
vital signs were temperature 36:90C: pulse 80bpm: respiration 26bpm:
blood pressure 140/90 mmHg and
he showed signs of increased intracranial pressure.
Item 123

The prime reason for conducting an initial assessment of this client is to

A
convey a verbal report of his condition
B
influence the course of action to be taken
C
determine patients level of consciousness
D
provide up-to-date information to his friends
Item 124
Which of the following is the MOST important reason for recording baseline assessments on
client with head injury?
A
Provide evidence of continuity of care for legal purpose
B
To establish a standard of documentation of patients condition
C
Justify the utilization of the nursing process as a powerful instrument of care
D
Provide for comparison of patients condition and facilitate observation of
changes.
Item 125

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Which of the following respiratory assessments should be included to monitor for increased
intracranial pressure?
i
Arterial blood gases
ii
The rate and pattern of respiration
iii
Amount of secretion suctioned hourly
iv
The colour of skin and mucous membrane
A
i, ii, iii
B
i, ii, iv
C
i, iii, iv
D
ii, iii, iv
Item 126
Which of the following statements best define intracranial pressure?
A
Severe persistent headaches
B
Pressure in the cerebro-spinal fluid
C
Pressure exerted within the cerebral ventricular system
D
Severe headaches accomplished with an elevated blood pressure

Item 127
Which of the following results should be reported by the nurse about a client suspected of having
increased intra-cranial pressure?
i
Respiratory rate within the range of 20 per minute
ii
A pulse rate less than 50, or more than 100 beats per minute
iii
Systolic blood pressure less than 90mmHg, or more than 170 mmHg.
iv
Diastolic blood pressure of less than 50 mmHg, or more than 100 mmHg
A
B
C
D

i, ii, iii
i, ii, iv
i, iii, iv
ii, iii, iv

Item 128
In which position should this client be placed in order to prevent increased intra-cranial pressure?
A
B
C
D

Supine with the head of the bed completely flat.

On his left or right side and the head of the bed flat.
Supine with the head of the bed elevated 45 degrees
On his left or right side with the head of the bed elevated to 30 degrees.

Item 129
Which of the following drugs may be administered to this client to relieve him of cerebral
edema?

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A
B
C
D

Valium
Baralgin
Cortisone
Dexamethazone

Item 130
Which of the following is considered the MOST severe complication of head injury?
A
B
C
D

Severe hypertension
Tentorial herniation
Depression in respiration
Changes in pupillary reactions

Item 131
Which of the following should be included in a discharge plan for this client?
i
ii
iii
iv

Remain on bed rest with bathroom priviledges.

Keep all follow-up appointments with the surgeon.
Seek medical attention for dizziness or increasing headaches.
Resume normal physical activity as soon as possible, if he feels fit.
A
i, ii
B
i, iii
C
ii, iii
D
i, iv

132. Following a unilateral adrenalectomy, the nurse would assess for

hyperkalemia shown by which of the following?
A.
B.
C.
D.

Muscle weakness
Tremors
Diaphoresis
Constipation

133. Which outcome indicates that treatment of a male client with diabetes
insipidus has been effective?
A.
B.
C.
D.

Fluid intake is less than 2,500 ml/day.

Urine output measures more than 200 ml/hour.
Blood pressure is 90/50 mm Hg
The heart rate is 126 beats/minute.

134. A female client has a serum calcium level of 7.2 mg/dl. During the
physical examination,
assesses:
A.
B.
C.

Trousseaus sign.
Homans sign.
Hegars sign

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D.

Goodells sign.

135. When assessing a male client with pheochromocytoma, a tumor of the

adrenal medulla that secretes excessive catecholamine, the nurse is most
likely to detect:
A.
B.
C.
D.

a blood pressure of 130/70 mm Hg.

a blood glucose level of 130 mg/dl.
bradycardia
a blood pressure of 176/88 mm Hg.

136. During a class on exercise for diabetic clients, a female client asks the
nurse educator how often to exercise. The nurse educator advises the clients
to exercise how often to meet the goals of planned exercise?
A.
B.
C.
D.

At least once a week

At least three times a week
At least five times a week
Every day

137. The nurse is aware that the following is the most common cause of
hyperaldosteronism?
A.
B.
C.
D.

Excessive sodium intake

A pituitary adenoma
Deficient potassium intake
An adrenal adenoma

138. A male client with type 1 diabetes mellitus has a highly elevated
glycosylated hemoglobin (Hb) test result. In discussing the result with the
client, nurse Sharmaine would be most accurate in stating:
A.
B.
C.
D.

The test needs to be repeated following a 12-hour fast.

It looks like you arent following the prescribed diabetic diet.
It tells us about your sugar control for the last 3 months.
Your insulin regimen needs to be altered significantly.

139. A female adult client with a history of chronic hyperparathyroidism

admits to being noncompliant. Based on initial assessment findings, nurse
Julia formulates the nursing diagnosis of Risk for injury. To complete the
nursing diagnosis statement for this client, which related-to phrase should
the nurse add?
A.
Related to bone demineralization resulting in pathologic fractures
B.
Related to exhaustion secondary to an accelerated metabolic rate
C.
Related to edema and dry skin secondary to fluid infiltration into the
interstitial spaces
D.
Related to tetany secondary to a decreased serum calcium level

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140. When caring for a male client with diabetes insipidus, the nurse would
administer:
A.
B.
C.
D.

vasopressin (Pitressin Synthetic).

furosemide (Lasix).
regular insulin.
10% dextrose.

141. A male client is admitted for treatment of the syndrome of

inappropriate antidiuretic hormone (SIADH). Which nursing intervention is
appropriate?
A.
B.
C.
D.

Infusing I.V. fluids rapidly as ordered

Encouraging increased oral intake
Restricting fluids
Administering glucose-containing I.V. fluids as ordered

142. Nurse John is assigned to care for a postoperative male client who has
diabetes mellitus. During the assessment interview, the client reports that
hes impotent and says hes concerned about its effect on his marriage. In
planning this clients care, the most appropriate intervention would be to:
A.
Encourage the client to ask questions about personal sexuality.
B.
Provide time for privacy.
C.
Provide support for the spouse or significant other.
D.
Suggest referral to a sex counselor or other appropriate professional.
143. Early this morning, a female client had a subtotal thyroidectomy.
During evening rounds, nurse Tina assesses the client, who now has nausea,
a temperature of 105 F (40.5 C), tachycardia, and extreme restlessness.
What is the most likely cause of these signs?
A.
B.
C.
D.

Diabetic ketoacidosis
Thyroid crisis
Hypoglycemia
Tetany

144. An agitated, confused female client arrives in the emergency

department. Her history includes type 1 diabetes mellitus, hypertension, and
angina pectoris. Assessment reveals pallor, diaphoresis, headache, and
intense hunger. A stat blood glucose sample measures 42 mg/dl, and the
client is treated for an acute hypoglycemic reaction. After recovery, nurse Lily
teaches the client to treat hypoglycemia by ingesting:
A.
B.
C.

2 to 5 g of a simple carbohydrate.
10 to 15 g of a simple carbohydrate.
18 to 20 g of a simple carbohydrate.

Masters: McK & Willi

D.

25 to 30 g of a simple carbohydrate.

145. An incoherent female client with a history of hypothyroidism is brought

to the emergency department by the rescue squad. Physical and laboratory
findings reveal hypothermia, hypoventilation, respiratory acidosis,
bradycardia, hypotension, and nonpitting edema of the face and pretibial
area. Knowing that these findings suggest severe hypothyroidism, nurse
Libby prepares to take emergency action to prevent the potential
complication of:
A.
B.
C.
D.

Thyroid storm.
Cretinism
myxedema coma.
Hashimotos thyroiditis

146. A female client with hypothyroidism (myxedema) is receiving

levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans
recognize as an adverse drug effect?
A.
B.
C.
D.

Dysuria
Leg cramps
Tachycardia
Blurred vision

147. you are developing a teaching plan for a male client diagnosed with
diabetes insipidus. you should include information about which hormone
lacking in clients with diabetes insipidus?
A.
B.
C.
D.

antidiuretic hormone (ADH).

thyroid-stimulating hormone (TSH).
follicle-stimulating hormone (FSH).
luteinizing hormone (LH).

148. A 67-year-old male client has been complaining of sleeping more,

increased urination, anorexia, weakness, irritability, depression, and bone
pain that interferes with her going outdoors. Based on these assessment
findings, the nurse would suspect which of the following disorders?
A.
B.
C.
D.

Diabetes mellitus
Diabetes insipidus
Hypoparathyroidism
Hyperparathyroidism

149. a client, who weighs 210 lb (95 kg) and has been diagnosed with
hyperglycemia tells the nurse that her husband sleeps in another room
because her snoring keeps him awake. The nurse notices that she has large

Masters: McK & Willi

hands and a hoarse voice. Which of the following would the nurse suspect as
a possible cause of the clients hyperglycemia?
A.
B.
C.
D.

Acromegaly
Type 1 diabetes mellitus
Hypothyroidism
Deficient growth hormone

150. For a male client with hyperglycemia, which assessment finding best
supports a nursing diagnosis of Deficient fluid volume?
A.
B.
C.
D.

Distended neck veins

Increased urine osmolarity
Decreased serum sodium level
Cool, clammy skin

151. the Nurse is providing dietary instructions to a male client with

hypoglycemia. To control hypoglycemic episodes, the nurse should
recommend:
A.
Increasing saturated fat intake and fasting in the afternoon.
B.
Increasing intake of vitamins B and D and taking iron supplements.
C.
Eating a candy bar if light-headedness occurs.
D.
Consuming a low-carbohydrate, high-protein diet and avoiding fasting.

152. During preoperative teaching for a female client who will undergo
subtotal thyroidectomy, the nurse should include which statement?
A.
B.
C.
D.

The head of your bed must remain flat for 24 hours after surgery.
You should avoid deep breathing and coughing after surgery.
You wont be able to swallow for the first day or two.
You must avoid hyperextending your neck after surgery.

153. Nurse Oliver should expect a client with hypothyroidism to report

which health concerns?
A.
B.
C.
D.

Increased appetite and weight loss

Puffiness of the face and hands
Nervousness and tremors
Thyroid gland swelling

154. When caring for a female client with a history of hypoglycemia, nurse
Ruby should avoid administering a drug that may potentiate hypoglycemia.
Which drug fits this description?
A.
B.
C.

sulfisoxazole (Gantrisin)
mexiletine (Mexitil)
prednisone (Orasone)

Masters: McK & Willi

D.

lithium carbonate (Lithobid)

155. A male client with type 1 diabetes mellitus asks the nurse about taking
an oral antidiabetic agent. As the nurse you explain that these medications
are only effective if the client:
A.
prefers to take insulin orally.
B.
has type 2 diabetes
C.
has type 1 diabetes.
D.
is pregnant and has tiredness
156. A nurse is reviewing the history of a client who is suspected of having
glomerulonephritis. Which of the following would the nurse consider
significant?
a. History of hyperparathyroidism
b. History of osteoporosis
c. Recent history of streptococcal infection
d. Previous episode of acute pyelonephritis