Q&A RANDOM #10

Question Number 1 of 40
In providing care to a 14 year-old adolescent with scoliosis, which of
the following will be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support
The correct answer is B: Looking different from their peers
Conformity to peer influences peaks at around age 14. Since many persons
view any disability as deviant, the client will need help in learning how to
deal with reactions of others. Treatment of scoliosis is long-term and
involves bracing and/or surgery.
Question Number 2 of 40
The nurse is preparing to perform a physical examination on an 8
month-old who is sitting contentedly on his mother's lap. Which of the
following should the nurse do first?
A)
Elicit reflexes
B)
Measure height and weight
C)
Auscultate heart and lungs
D)
Examine the ears
The correct answer is C: Auscultate heart and lungs
The nurse should auscultate the heart and lungs during the first quiet
moment with the infant so as to be able to hear sounds clearly. Other
assessments may follow in any order.
Question Number 3 of 40
Which of these principles should the nurse apply when performing a
nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day
The correct answer is C: A serving size at this age is about 2 tablespoons
In children, a general guide to serving sizes is 1 tablespoon of solid food per
year of age. Understanding this, the nurse can assess adequacy of intake.
Question Number 4 of 40
The nurse is assessing a client with delayed wound healing. Which of
the following risk factors is most important in this situation?

A)
Glucose level of 120
B)
History of myocardial infarction
C)
Long term steroid usage
D) Diet high in carbohydrates
The correct answer is C: Long term steroid usage
Steroid dependency tends to delay wound healing. If the client also smokes,
the risk is increased.
Question Number 5 of 40
Which of the following nursing assessments indicate immediate
discontinuance of an antipsychotic medication?
Involuntary rhythmic stereotypic movements and tongue
protrusion
Cheek puffing, involuntary movements of extremities and
B)
trunk
C) Agitation, constant state of motion
Hyperpyrexia,
severe
muscle
rigidity,
malignant
D)
hypertension
The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant
hypertension
Hyperpyrexia, severe muscle rigidity, and malignant hypertension are
assessment signs indicative of NMS (neuroleptic malignant syndrome).
A)

Question Number 6 of 40
A client with HIV infection has a secondary herpes simplex type 1
(HSV-1) infection. The nurse knows that the most likely cause of the
HSV-1 infection in this client is
A)
Immunosuppression
B)
Emotional stress
C)
Unprotected sexual activities
D)
Contact with saliva
The correct answer is A: Immunosuppression
The decreased immunity leads to frequent secondary infections. Herpes
simplex virus type 1 is an opportunistic infection. The other options may
result in HSV-1. However they are not the most likely cause in clients with
HIV.
Question Number 7 of 40
The nurse measures the head and chest circumferences of a 20
month-old infant. After comparing the measurements, the nurse finds
that they are approximately the same. What action should the nurse
take?
A)

Notify the health care provider

B)
Palpate the anterior fontanel
C)
Feel the posterior fontanel
D)
Record these normal findings
The correct answer is D: Record these normal findings
The question is D. The rate of increase in head circumference slows by the
end of infancy, and the head circumference is usually equal to chest
circumference at 1 to 2 years of age.
Question Number 8 of 40
At a routine clinic visit, parents express concern that their 4 year-old is
wetting the bed several times a month. What is the nurse's best
response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"
The correct answer is B: "How long has this been occurring?"
Nighttime control should be present by this age, but may not occur until age
5. Involuntary voiding may occur due to infectious, anatomical and/or
physiological reasons.
Question Number 9 of 40
A client was admitted to the psychiatric unit after refusing to get out of
bed. In the hospital the client talks to unseen people and voids on the
floor. The nurse could best handle the problem of voiding on the floor
by
A) Requiring the client to mop the floor
B) Restricting the clients fluids throughout the day
C) Withholding privileges each time the voiding occurs
D) Toileting the client more frequently with supervision
The correct answer is D: Toileting the client more frequently with supervision
With altered thought processes the most appropriate nursing approach to
alter the behavior is by attending to the physical need.
Question Number 10 of 40
The nurse is caring for a client with a sigmoid colostomy who requests
assistance in removing the flatus from a 1 piece drainable ostomy
pouch. Which is the correct intervention?
Piercing the plastic of the ostomy pouch with a pin to vent
the flatus
Opening the bottom of the pouch, allowing the flatus to be
B)
expelled
C) Pulling the adhesive seal around the ostomy pouch to allow
A)

the flatus to escape

Assisting the client to ambulate to reduce the flatus in the
D)
pouch
The correct answer is B: Opening the bottom of the pouch, allowing the
flatus to be expelled
The only correct way to vent the flatus from a 1 piece drainable ostomy
pouch is to instruct the client to obtain privacy (the release of the flatus will
cause odor), and to open the bottom of the pouch, release the flatus and
dose the bottom of the pouch.
Question Number 11 of 40
The nurse is teaching parents of an infant about introduction of solid
food to their baby. What is the first food they can add to the diet?
A)
Vegetables
B)
Cereal
C)
Fruit
D)
Meats
The correct answer is B: Cereal
Cereal is usually introduced first because it is well tolerated, easy to digest,
and contains iron.
Question Number 12 of 40
When counseling parents of a child who has recently been diagnosed
with hemophilia, what must the nurse know about the offspring of a
normal father and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier
The correct answer is D: There is a 25% chance a daughter will be a carrier
Hemophilia A is a sex-linked recessive trait seen almost exclusively in males.
With a normal father and carrier mother, affected individuals are male.
There is a 25% chance of having an affected male, 25% chance of having a
carrier female, 25% chance of having a normal female and 25% chance of
having a normal male.
Question Number 13 of 40
When teaching a client with chronic obstructive pulmonary disease
about oxygen by cannula, the nurse should also instruct the client's
family to
A)
B)
C)

Avoid smoking near the client

Turn off oxygen during meals
Adjust the liter flow to 10 as needed

D) Remind the client to keep mouth closed

The correct answer is A: Avoid smoking near the client
Since oxygen supports combustion, there is a risk of fire if anyone smokes
near the oxygen equipment.
Question Number 14 of 40
The nurse is caring for a post-op colostomy client. The client begins to
cry saying, "I'll never be attractive again with this ugly red thing."
What should be the first action by the nurse?
A) Arrange a consultation with a sex therapist
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care
D) Determine the client's understanding of her colostomy
The correct answer is D: Determine the client''s understanding of her
colostomy
One of the greatest fears of colostomy clients is the fear that sexual intimacy
is no longer possible. However, the specific concern of the client needs to be
assessed before specific suggestions for dealing with the sexual concerns are
given.
Question Number 15 of 40
A schizophrenic client talks animatedly but the staff are unable to
understand what the client is communicating. The client is observed
mumbling to herself and speaking to the radio. A desirable outcome
for this clients care will be
Expresses
feelings
appropriately
through
verbal
interactions
B) Accurately interprets events and behaviors of others
C) Demonstrates improved social relationships
Engages in meaningful and understandable verbal
D)
communication
The correct answer is D: Engages in meaningful and understandable verbal
communication
Data support impaired verbal communication deficit. The outcome must be
related to the diagnosis and supporting data. No data is presented related to
feelings or to thinking processes.
A)

Question Number 16 of 40
A 7 year-old child is hospitalized following a major burn to the lower
extremities. A diet high in protein and carbohydrates is recommended.

The nurse informs the child and family that the most important reason
for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs
The correct answer is D: Spare protein catabolism to meet metabolic needs
Because of the burn injury, the child has increased metabolism and
catabolism. By providing a high carbohydrate diet, the breakdown of protein
for energy is avoided. Proteins are then used to restore tissue.
Question Number 17 of 40
The parents of a 7 year-old tell the nurse their child has started to
"tattle" on siblings. In interpreting this new behavior, how should the
nurse explain the child's actions to the parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts
The correct answer is A: The ethical sense and feelings of justice are
developing
The child is developing a sense of justice and a desire to do what is right. At
seven, the child is increasingly aware of family roles and responsibilities.
They also do what is right because of parental direction or to avoid
punishment.
Question Number 18 of 40
A school nurse is advising a class of unwed pregnant high school
students. What is the most important action they can perform to
deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep
The correct answer is A: Maintaining good nutrition
Nurses can serve a pivotal role in providing nutritional education and case
management interventions. Weight gain during pregnancy is one of the
strongest predictors of infant birth weight. Specifically, teens need to
increase their intake of protein, vitamins, and minerals including iron.
Pregnant teens who gain between 26 and 35 pounds have the lowest
incidence of low-birth-weight babies.
Question Number 19 of 40

A client continually repeats phrases that others have just said. The
nurse recognizes this behavior as
A)
Autistic
B)
Ecopraxic
C)
Echolalic
D)
Catatonic
The correct answer is C: Echolalic
Echolalic - repeating words heard.
Question Number 20 of 40
A client is admitted for hemodialysis. Which abnormal lab value would
the nurse anticipate not being improved by hemodialysis?
A)
Low hemoglobin
B)
Hypernatremia
C)
High serum creatinine
D)
Hyperkalemia
The correct answer is A: Low hemoglobin
Although hemodialysis improves or corrects electrolyte imbalances it has not
effect on improving anemia.