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1. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

• Call security for assistance and prepare to sedate the client.
• Tell the client to calm down and ask him if he would like to play cards.
• Tell the client that if he continues his behavior he will be punished.
• Leave the client alone until he calms down.

2. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate?

• The treatment plan is not effective; the patient requires a larger dose of lithium.
• This is a normal response to lithium therapy; the patient should continue with the current treatment plan.
• This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior.
• The treatment plan is not effective; the patient requires an antidepressant

3. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

• Chronic fatigue syndrome
• Normal aging
• Sundowning
• Delusions

4. A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?

• The client is experiencing an auditory hallucination.
• The client is having a delusion of grandeur.
• The client is experiencing paranoid delusions.
• The client is intoxicated.

5. To provide effective feedback to a client, the nurse will focus on:

• The present and not the past.
• Making inferences of the behaviors observed.
• Providing solutions to the client.
• The client.

6. Nurses who seek to enhance their cultural-competency skills and apply sensitivity toward others are committed to which professional nursing value?

• Autonomy
• Strong commitment to service
• Belief in the dignity and worth of each person
• Commitment to education

7. Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process?

• "We've discussed past coping skills. Let's see if these coping skills can be effective now."
• "Please tell me in your own words what brought you to the hospital."
• "This new approach worked for you. Keep it up."
• "I notice that you seem to be responding to voices that I do not hear."

8. The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

• Blood pressure of 126/80
• Blood glucose of 110mg/dL
• Heart rate of 60bpm
• Respiratory rate of 30 per minute

9. The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:

• Apply a tourniquet to the client’s arm.
• Administer an anticonvulsant medication.
• Ask the client if he is allergic to shell fish.
• Apply a blood pressure cuff to the arm.

10. The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

• Application of a short inclusive spica cast
• Stabilization with a plaster-of-Paris cast
• Surgery with Kirschner wire implantation
• A gauze dressing only

11. Linda, 70 years old, has recently been diagnosed with Type 2 Diabetes. You have devised a care plan to meet her nutritional needs. However, you have noted that she has poorly fitting dentures. Which of the following is the least likely risk to the service user?

• Malnutrition
• Hyperglycemia
• Dehydration
• Hypoglycemia

12. Which therapeutic communication technique is being used in this nurse­ client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?"

• Reflecting
• Making observations
• Formulating a plan of action
• Giving recognition

13. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

• Tire easily
• Grow normally
• Need more calories
• Be more susceptible to viral infections

14. A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

• Hib titer
• Mumps vaccine
• Hepatitis B vaccine
• MMR

15. A client has been voluntarily admitted to the hospital. The nurse knows that which of the following statements is inconsistent with this type of hospitalization?

• The client retains all of his or her rights
• the client has a right to leave if not a danger to self or others
• the client can sign a written request for discharge
• the client cannot be released without medical advice

16. A patient with a history of schizophrenia is admitted to the acute psychiatric care unit. He mutters to himself as the nurse attempts to take a history and yells, “I don’t want to answer any more questions! There are too many voices in this room!” Which of the following assessment questions should the nurse ask NEXT?

• “Are the voices telling you to do things?
• “Do you feel as though you want to harm yourself or anyone else?”
• “Who else is talking in this room? It’s just you and me.
• “I don’t hear any other voices

17. The nurse is caring fora client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

• Hematuria
• Muscle spasms
• Dizziness
• Nausea

18. The five-year-old is being tested for enterobiasis (pinworms). Which symptom isassociated with enterobiasis?

• Rectal itching
• Nausea
• Oral ulcerations
• Scalp itching

19. You were a new nurse in a geriatric ward. The son of one of your patients discussed that he has noticed his mother is not being treated well in the ward, and that she looks very dehydrated and malnourished. How do you deal with the scenario?

• Do not do anything, because it is not much of a concern
• Discuss the case with a colleague
• Report this to your supervisor
• Make a decision not to intervene - it will be dealt with by management

20. A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening?

• S
• O
• L
• E
• R

21. The nurse is interacting with a client and observes the client’s eyes moving from side to side prior to answering a question. The nurse interprets this behavior as:

• The client being bored with the interaction.
• The client processing auditory information.
• The client engaging in intrapersonal communication.
• The client responding to auditory hallucinations

22. Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following?

• The age of the child
• The child’s weight
• The developmental level of the child
• The IQ of the child

23. The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

• Agnosia
• Apraxia
• Anomia
• Aphasia

24. The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the patient’s family to use which of the following approaches when speaking to the patient?

• Raise your voice until the patient is able to hear you.
• Face the patient and speak quickly using a high voice.
• Face the patient and speak slowly using a slightly lowered voice.
• Use facial expressions and speak as you would formally

25. To maintain Bryant’s traction, the nurse must make certain that the child’s:

• Hips are resting on the bed, with the legs suspended at a right angle to the bed
• Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
• Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
• Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

26. The nurse is discussing meal planning with the mother of a two-year-old. Which of the following statements, if made by the mother, would require a need for further instruction?

• “It is okay to give my child white grape juice for breakfast.”
• “My child can have a grilled cheese sandwich for lunch.”
• “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
• “For a snack, my child can have ice cream.”

27. A client comes to the local clinic complaining that sometimes his heart pounds and he has trouble sleeping. The physical exam is normal. The nurse learns that the client has recently started a new job with expanded responsibilities and is worried about succeeding. Which of the following responses by the nurse is BEST?

• “Have you talked to your family about your concerns?
• You appear to have concerns about your ability to do your job
• “You could benefit from counseling.
• “It’s normal to feel anxious when starting a new job.”

28. The nonverbal communication that expresses emotion is:

• Body positioning.
• Eye contact
• Cultural artifacts.
• Facial expressions.

29. Which of the following are barriers to effective communication?

• Cultural differences
• Unfamiliar accents
• Overly technical language and terminology
• Hearing problems
• All the above

30. Which therapeutic communication technique is being used in this nurse­client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian."

• Restatement
• Offering general leads
• Focusing
• Accepting

31. The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a "general lead"?

• "Do you know why you are here?”
• "Are you feeling depressed or anxious?"
• "Yes, I see. Go on."
• "Can you chronologically order the events that led to your admission?"

32. What is the purpose of a nurse providing appropriate feedback?

• To give the client good advice
• To advise the client on appropriate behaviors
• To evaluate the client's behavior
• To give the client critical information

33. A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?

• Placing mirrors in several locations in the home
• Placing a picture of herself in her bedroom
• Placing simple signs to indicate the location of the bedroom, bathroom, and so on
• Alternating healthcare workers to prevent boredom

34. An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anaesthesia and narcotic administration, the nurse should:

• Administer oxygen via nasal cannula.
• Have narcan (naloxane) available.
• Prepare to administer blood products.
• Prepare to do cardio resuscitation.

35. A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?

• Colorful crib mobile
• Hand-held electronic games
• Cars in a plastic container
• 30-piece jigsaw puzzle

36. According to Argyle (1988), when two people communicate what percentage of what is communicated is actually in the words spoken?

• 90%
• 50%
• 23%
• 7%

37. The toddler is admitted with cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

• Tire easily
• Grow normally
• Need more calories
• Be more susceptible to viral infections

38. The best size cathlon for administration of a blood transfusion to a six- year-old is:

• 18 gauge
• 19 gauge
• 22 gauge
• 20 gauge

39. The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?

• Pain at the site
• Warm fingers
• Pulses rapid
• Paresthesia of the fingers

40. The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

• Lack of exercise
• Hormonal disturbances
• Lack of calcium
• Genetic predisposition

41. According to the therapeutic communication theory, what criteria must be met for successful communication?

• The communication needs to be efficient, appropriate, flexible, and include feedback.
• The individuals communicating with each other must share a similar perception of the conversation.
• The communication must be intrapersonal, interpersonal, group, or societal in nature.
• Nonverbal communication is consistent with verbal communication

42. The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

• Tell the mother to wash the face with soap and apply powder.
• Tell her that 30% of newborns have a rash that will go away by one month of life.
• Report the rash to the doctor immediately.
• Ask the mother if anyone else in the family has had a rash in the last six months.

43. During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns?

• "Don't worry. Everything will be alright."
• "You appear uptight."
• "I notice you have bitten your nails to the quick."
• "You are jumping to conclusions."

44. An 86 year old male with senile dementia has been physically abused & neglected for the past two years by his live in caregiver . He has since moved & is living with his son & daughter-in-law. Which response by the client’s son would cause the nurse great concern?

• “ How can we obtain reliable help to assist us in taking care of Dad? We can’t do it alone.”
• “ Dad used to beat us kids all the time . I wonder if he remembered that when it happened to him?”
• “I’m not sure how to deal with Dad’s constant repetition of words.”
• “I plan to ask my sister & brother to help my wife & me with Dad on the weekends.”

45. Which of the following tasks is crucial in therapeutic communication?

• Listening attentively to a service user’s story
• Assessment of signs and symptoms
• Documenting an incident report
• All of the other answers

46. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

• Check the bowel sounds.
• Assess the blood pressure.
• Offer pain medication.
• Check for swelling.

47. A home care nurse performs a home safety assessment & discovers that a client is using a space heater to heather apartment. which of the following instructions would the nurse provide to the client regarding the use of the space heater.

• A space heater shouldnot be used in an apartment
• Space heater to be placed at least 3 feet from anything that can burn
• The space heater should be placed in the hallway at night
• The space heater should be kept at a low setting at all times

48. The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

• The client has traveled out of the country in the last six months.
• The client’s parents are skilled stained-glass artists.
• The client lives in a house built in 1990.
• The client has several brothers and sisters.

49. When caring for clients with psychiatric diagnoses, the nurse recalls that the purpose of psychiatric diagnoses or psychiatric labeling is to:

• Identify those individuals in need of more specialized care.
• Identify those individuals who are at risk for harming others.
• Enable the client’s treatment team to plan appropriate and comprehensive care.
• Define the nursing care for individuals with similar diagnoses.

50. A nurse obtains an order from a physician to restraint a client by using a jacket restraint. The nurse instructs nursing assistant to apply the restraint. Which of the following would indicate inappropriate application of the restraint by the nursing assistant.

• A safety knot in the restraint straps
• Restraint straps that are safely secured to the side rails
• The jacket restraint secured such that two fingers can slide easily between the restraints & the client skin
• Jacket restraint straps that do no tighten when force is applied against them