Q&A RANDOM #9

Question Number 1 of 40
A client is in her third month of her first pregnancy. During the
interview, she tells the nurse that she has several sex partners and is
unsure of the identity of the baby's father. Which of the following
nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic
The correct answer is A: Counsel the woman to consent to HIV screening
The client''s behavior places her at high risk for HIV. Testing is the first step.
If the woman is HIV positive, the earlier treatment begins, the better the
outcome.
Question Number 2 of 40
A 16 month-old child has just been admitted to the hospital. As the
nurse assigned to this child enters the hospital room for the first time,
the toddler runs to the mother, clings to her and begins to cry. What
would be the initial action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention
The correct answer is B: Explain that this behavior is expected
During normal development, fear of strangers becomes prominent beginning
around age 6-8 months. Such behaviors include clinging to parent, crying,
and turning away from the stranger. These fears/behaviors extend into the
toddler period and may persist into preschool.
Question Number 3 of 40
While planning care for a 2 year-old hospitalized child, which situation
would the nurse expect to most likely affect the behavior?
A)
Strange bed and surroundings
B)
Separation from parents
C)
Presence of other toddlers
D)
Unfamiliar toys and games
The correct answer is B: Separation from parents
Separation anxiety if most evident from 6 months to 30 months of age. It is
the greatest stress imposed on a toddler by hospitalization. If separation is

avoided, young children have a tremendous capacity to withstand other

stress.
Question Number 4 of 40
While explaining an illness to a 10 year-old, what should the nurse
keep in mind about the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
Interpretation of events originate from their own
C)
perspective
D) Conclusions are based on previous experiences
The correct answer is B: Think logically in organizing facts
The child in the concrete operations stage, according to Piaget, is capable of
mature thought when allowed to manipulate and organize objects.
Question Number 5 of 40
The nurse has just admitted a client with severe depression. From
which focus should the nurse identify a priority nursing diagnosis?
A)
Nutrition
B)
Elimination
C)
Activity
D)
Safety
The correct answer is D: Safety
Safety is a priority of care for the depressed client. Precautions to prevent
suicide must be a part of the plan.
Question Number 6 of 40
Which playroom activities should the nurse organize for a small group
of 7 year-old hospitalized children?
A)
Sports and games with rules
B)
Finger paints and water play
C)
"Dress-up" clothes and props
D)
Chess and television programs
The correct answer is A: Sports and games with rules
The purpose of play for the 7 year-old is cooperation. Rules are very
important. Logical reasoning and social skills are developed through play.
Question Number 7 of 40
A client is discharged following hospitalization for congestive heart
failure. The nurse teaching the family suggests they encourage the
client to rest frequently in which of the following positions?

A)
High Fowler's
B)
Supine
C)
Left lateral
D)
Low Fowler's
The correct answer is A: High Fowler''s
Sitting in a chair or resting in a bed in high Fowler''s position decreases the
cardiac workload and facilitates breathing.
Question Number 8 of 40
The nurse is caring for a 10 year-old on admission to the burn unit.
One assessment parameter that will indicate that the child has
adequate fluid replacement is
A)
Urinary output of 30 ml per hour
B)
No complaints of thirst
C)
Increased hematocrit
D) Good skin turgor around burn
The correct answer is A: Urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest
overload.
Question Number 9 of 40
During the use of an interpreter to teach a client about a procedure to
do in the home the nurse should take which approach?
Speak directly to the interpreter while presenting
information and use pauses for questions
Talk to the interpreter in advance and leave the client and
B)
interpreter alone
Include a family member and direct communications to that
C)
person
Face the client while presenting the information as the
D)
interpreter talks in the native language
The correct answer is D: Face the client while presenting the information as
the interpreter talks in the native language
Communication is the cornerstone of an effective teaching plan, especially
when the nurse and client do not share the same cultural heritage. Even if
the nurse uses an interpreter, it is critical that the nurse use conversational
style and spacing, personal space, eye contact, touch, and orientation to
time strategies that are acceptable to the client. Therefore, face the client
and present the information to the client, allow the interpreter to translate
the content. Facing the client allows non-verbal communication to take place
between the client and nurse.
A)

Question Number 10 of 40

The nurse is performing physical assessments on adolescents. When

would the nurse anticipate that females experience growth spurts?
A) About 2 years earlier than males
B) About the same time as males
C) Just prior to the onset of puberty
D) That increase height by 4 inches each year
The correct answer is A: About 2 years earlier than males
Normally, females in their teen age years experience a growth spurt about 2
years earlier than their male peers.
Question Number 11 of 40
A 2 month-old child has had a cleft lip repair by a student nurse. The
selection of which restraint would require no further action by the
charge nurse?
A)
Elbow
B)
Mummy
C)
Jacket
D)
Clove hitch
The correct answer is A: Elbow
The elbow restraint will prevent the child from touching the surgical site
without hindering movement of other parts of the body.
Question Number 12 of 40
A client has developed thrombophlebitis of the left leg. Which nursing
intervention should be given the highest priority?
A)
Elevate leg on 2 pillows
B)
Apply support stockings
C)
Apply warm compresses
D)
Maintain complete bed rest
The correct answer is A: Elevate leg on 2 pillows
The first goal of nonpharmacologic interventions is to minimize edema of the
affected extremity by leg elevation.
Question Number 13 of 40
Which of these is an example of a variation in the newborn resulting
from the presence of maternal hormones?
A)
B)
C)
D)
The correct answer

Engorgement of the breasts

Mongolian spots
Edema of the scrotum
Lanugo
is A: Engorgement of the breasts

Breast engorgement occurs in both sexes as a result of the withdrawal of

maternal hormones.
Question Number 14 of 40
The nurse is assigned to a newly delivered woman with HIV/AIDS. The
student asks the nurse about how it is determined that a person has
AIDS other than a positive HIV test. The nurse responds
A) "The complaints of at least 3 common findings."
B) "The absence of any opportunistic infection."
C) "CD4 lymphocyte count is less than 200."
D) "Developmental delays in children."
The correct answer is C: "CD4 lymphocyte count is less than 200."
CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for
Disease Control defined AIDS as having a positive HIV plus one of these
the presence of an opportunistic infection or a CD4 lymphocyte count of less
than 200.
Question Number 15 of 40
The nursing care plan for a client with decreased adrenal function
should include
A) Encouraging activity
B) Placing client in reverse isolation
C) Limiting visitors
D) Measures to prevent constipation
The correct answer is C: Limiting visitors
Any exertion, either physical or emotional, places additional stress on the
adrenal glands which could precipitate an addisonian crisis. The plan of care
should protect this client from the physical and emotional exertion of
visitors.
Question Number 16 of 40
The nurse is planning care for a client with pneumococcal pneumonia.
Which of the following would be most effective in removing respiratory
secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
C) Maintaining bed rest with bathroom privileges
D) Performing chest physiotherapy twice a day
The correct answer is B: Increasing oral fluid intake to 3000 cc per day
Secretion removal is enhanced with adequate hydration which thins and
liquefies secretions.
Question Number 17 of 40

While assessing a client in an outpatient facility with a panic disorder,

the nurse completes a thorough health history and physical exam.
Which finding is most significant for this client?
A)
Compulsive behavior
B)
Sense of impending doom
C)
Fear of flying
D)
Predictable episodes
The correct answer is B: Sense of impending doom
The feeling of overwhelming and uncontrollable doom is characteristic of a
panic attack.
Question Number 18 of 40
The nurse is reviewing a depressed client's history from an earlier
admission. Documentation of anhedonia is noted. The nurse
understands that this finding refers to
A) Reports of difficulty falling and staying asleep
B) Expression of persistent suicidal thoughts
C) Lack of enjoyment in usual pleasures
D) Reduced senses of taste and smell
The correct answer is C: Lack of enjoyment in usual pleasures
Lack of enjoyment in usual pleasures defines this term.
Question Number 19 of 40
The nurse is caring for a client in the coronary care unit. The display
on the cardiac monitor indicates ventricular fibrillation. What should
the nurse do first?
A) Perform defibrillation
B) Administer epinephrine as ordered
C) Assess for presence of pulse
D) Institute CPR
The correct answer is C: Assess for presence of pulse
Artifact can mimic ventricular fibrillation on a cardiac monitor. If the client is
truly in ventricular fibrillation, no pulse will be present. The standard of care
is to verify the monitor display with an assessment of the clients pulse.
Question Number 20 of 40
A nurse who is evaluating a mentally retarded 2 year-old in a clinic
should stress which goal when talking to the child's mother?
A)
B)
C)
D)

Teaching the child self care skills

Preparing for independent toileting
Promoting the child's optimal development
Helping the family decide on long term care

The correct answer is C: Promoting the child''s optimal development

The primary goal of nursing care for a mentally retarded child is to promote
the child''s optimum development.