NurseLabs QnA#2
NurseLabs QnA#2
NurseLabs QnA#2
1. A 28-year-old male has been found wandering around in a confusing pattern. The
male is sweaty and pale. Which of the following tests is most likely to be
performed first?
A. Blood sugar check
B. CT scan
C. Blood cultures
2. A mother is inquiring about her child’s ability to potty train. Which of the following
factors is the most important aspect of toilet training?
Correct Answer: C. The overall mental and physical abilities of the child.
Age is not the greatest factor in potty training. The overall mental and physical abilities
of the child are the most important factor.
Option A: Readiness for toilet training varies with every age of the child.
Option B: A child who can follow simple instructions may start toilet training.
However, it is not considered the most important factor.
Option D: Positive reinforcement is a great tool for toilet training, yet, it may not
be the most important one.
3. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her
child drank for 20 minutes. Which of the following is the most important instruction the
nurse can give the parent?
B. Gluteus minimus
C. Vastus lateralis
D. Vastus medialis
Correct Answer: D. Ask the father who is in the room the child’s name.
In this case, you can determine the name of the child by the father’s statement. You
should not withhold the medication from the child after identification.
Option A: Contacting the provider is unnecessary and may take time. A pediatric
patient must have folks with them inside the room, so asking the child’s folks
would be the most appropriate intervention.
Option B: The child may have not yet developed his writing abilities. Some
children are able to write their names at age 4, but some typically developing
children still aren’t ready until well into age.
Option C: Asking a coworker would be inappropriate and against the patient’s
confidentiality.
7. A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of
the following diet modifications is not recommended?
A. A diet high in grains
B. Hyperglycemia
C. Hypoglycemia
D. Diabetic ketoacidosis
A. Bowel perforation
B. Viral Gastroenteritis
C. Colon cancer
D. Diverticulitis
10. A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the
following laboratory tests assesses coagulation? Select all that apply.
B. Prothrombin time
C. Platelet count
D. Hemoglobin
Correct Answer: A, B, & C
Prothrombin time, partial thromboplastin time, and platelet count are all included in
coagulation studies.
Option A: The partial thromboplastin time (PTT; also known as activated partial
thromboplastin time (aPTT)) is a screening test that helps evaluate a person’s
ability to appropriately form blood clots. It measures the number of seconds it
takes for a clot to form in a sample of blood after substances (reagents) are
added.
Option B: Prothrombin time (PT) is a blood test that measures how long it takes
blood to clot. A prothrombin time test can be used to check for bleeding
problems. PT is also used to check whether medicine to prevent blood clots is
working.
Option C: Platelets, also called thrombocytes, are tiny fragments of cells that are
essential for normal blood clotting. They are formed from very large cells called
megakaryocytes in the bone marrow and are released into the blood to circulate.
The platelet count is a test that determines the number of platelets in a sample of
blood.
Option D: The hemoglobin level, though important information prior to an
invasive procedure such as liver biopsy, does not assess coagulation.
11. A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the
following is the most likely route of transmission?
B. Contaminated food
C. Blood transfusion
C. Asymptomatic diverticulosis
13. A physician has diagnosed acute gastritis in a clinic patient. Which of the following
medications would be contraindicated for this patient?
B. Calcium carbonate
C. Clarithromycin (Biaxin)
D. Furosemide (Lasix)
14. The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of
the following information is important to communicate?
A. The patient must maintain a low-calorie diet.
15. A patient admitted to the hospital with myocardial infarction develops severe
pulmonary edema. Which of the following symptoms should the nurse expect the
patient to exhibit?
B. Stridor
C. Bradycardia
D. Air hunger
Correct Answer: D. Air hunger
Patients with pulmonary edema experience air hunger, anxiety, and agitation. Symptoms
may also include coughing up blood or bloody froth; difficulty breathing when lying
down (orthopnea); feeling of “air hunger” or “drowning” (this feeling is called
“paroxysmal nocturnal dyspnea” if it causes you to wake up 1 to 2 hours after falling
asleep and struggle to catch your breath).
Option A: Physical findings in patients with pulmonary edema are notable for
tachypnea and tachycardia. Patients may be sitting upright, they may
demonstrate air hunger, and they may become agitated and confused. Patients
usually appear anxious and diaphoretic.
Option B: Auscultation of the lungs usually reveals fine, crepitant rales, but
rhonchi or wheezes may also be present. Rales are usually heard at the bases first;
as the condition worsens, they progress to the apices.
Option C: Cardiovascular findings are usually notable for S3, accentuation of the
pulmonic component of S2, and jugular venous distention. Auscultation of
murmurs can help in the diagnosis of acute valvular disorders manifesting with
pulmonary edema.
16. A nurse caring for several patients in the cardiac unit is told that one is scheduled for
implantation of an automatic internal cardioverter-defibrillator. Which of the following
patients is most likely to have this procedure?
A. A patient admitted for myocardial infarction without cardiac muscle damage.
17. A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected
lung cancer. Which of the following is a contraindication to the study for this patient?
A. The patient is allergic to shellfish.
18. A nurse calls a physician with the concern that a patient has developed a pulmonary
embolism. Which of the following symptoms has the nurse most likely observed?
C. The patient has developed a wet cough and the nurse hears crackles on
auscultation of the lungs.
Correct Answer: B. The patient suddenly complains of chest pain and shortness of
breath.
Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and
severe anxiety. The physician should be notified immediately. Clinical signs and
symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of
having pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest
pain or the presence of risk factors for pulmonary embolism—must undergo diagnostic
tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is
confirmed.
Option A: The patient may present atypical symptoms based on risk factors, such
as delirium or a decreasing level of consciousness.
Option B: The diagnosis of pulmonary embolism should be sought actively in
patients with respiratory symptoms UNEXPLAINED by an alternative diagnosis;
symptoms may include productive cough and wheezing.
Option D: A patient with fever, chills, and loss of appetite may be developing
pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of patients;
however, a temperature higher than 39.5°C (103.1º) F is not from a pulmonary
embolism.
19. A patient comes to the emergency department with abdominal pain. Work-up
reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the
following actions should the nurse expect?
A. The patient will be admitted to the medicine unit for observation and medication.
B. The patient will be admitted to the day surgery unit for sclerotherapy.
C. The patient will be admitted to the surgical unit and resection will be scheduled.
Correct Answer: C. The patient will be admitted to the surgical unit and resection
will be scheduled.
A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and
should be resected as soon as possible. No other appropriate treatment options
currently exist.
Option A: Admitting the patient for observation will be a delay and may result in
the rupture of the aneurysm. Immediate surgery is the only recommended
management.
Option B: Sclerotherapy, in which a solution is injected into a vein, causing it to
collapse, scar, and fade, remains the primary treatment for the small-vessel
varicose disease of the lower extremities.
Option D: The patient should not be discharged because the abdominal
aneurysm may rupture at any time and place the patient’s life at risk.
20. A patient with leukemia is receiving chemotherapy that is known to depress bone
marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter.
Which of the following actions related specifically to the platelet count should be
included in the nursing care plan?
A. Monitor for fever every 4 hours.
D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct Answer: D. Check for signs of bleeding, including examination of urine and
stool for blood.
A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt
the initiation of bleeding precautions, including monitoring urine and stool for evidence
of bleeding.
Option A: According to three retrospective case reviews of childhood leukemia
(in which 75% to 100% of the cases were acute lymphoblastic leukemia), common
presenting signs and symptoms include fever (17% to 77%), lethargy (12% to
39%), and bleeding (10% to 45%).
Option B: Requiring protective clothing is indicated to prevent infection if white
blood cells are decreased. Protective garments consisting of gloves,
chemotherapy gowns, eye protection e.g.; goggles, N95 respirator, and shoe
covers will be worn according to the task being performed with a
Chemotherapy/Biotherapy agent or excreta of a patient who has received a
Chemotherapy/Biotherapy agent within the last 48 hours.
Option C: Transfusion of red cells is indicated for severe anemia. Blood
transfusions represent one of the most important forms of supportive care for
patients with leukemia. Cancer is the major cause of transfusion. One-third of
transfused patients have a malignant disease, with acute leukemia being the
malignancy in a large part of them.
21. A nurse in the emergency department is observing a 4-year-old child for signs of
increased intracranial pressure after a fall from a bicycle, resulting in head trauma.
Which of the following signs or symptoms would be cause for concern?
B. Repeated vomiting
C. Signs of sleepiness at 10 PM
D. Inability to read short words from a distance of 18 inches
22. A nonimmunized child appears at the clinic with a visible rash. Which of the
following observations indicates the child may have rubeola (measles)?
A. Small blue-white spots are visible on the oral mucosa.
23. A child is seen in the emergency department for scarlet fever. Which of the following
descriptions of scarlet fever is not correct?
A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
24. A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an
allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is
prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the
following best describes the prescribed drug dose?
25. The mother of a 2-month-old infant brings the child to the clinic for a well-baby
check. She is concerned because she feels only one testis in the scrotal sac. Which of the
following statements about the undescended testis is the most accurate?
26. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which
of the following statements most accurately describes this stage?
A. The tumor is less than 3 cm. in size and requires no chemotherapy.
B. The tumor did not extend beyond the kidney and was completely resected.
C. The tumor extended beyond the kidney but was completely resected.
D. The tumor has spread into the abdominal cavity and cannot be resected.
Correct Answer: C. The tumor extended beyond the kidney but was completely
resected.
The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is
limited to the kidney and completely resected; stage II, the tumor extends beyond the
kidney but is completely resected; stage III, the residual non-hematogenous tumor is
confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread
beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
Option A: The mass is solid at presentation and usually >10 cm.
Option B: This option describes stage 1, wherein the tumor is limited to the
kidney and completely resected.
Option D: In stage IV, hematogenous metastasis has occurred with spread
beyond the abdomen.
27. A teen patient is admitted to the hospital by his physician who suspects a diagnosis
of acute glomerulonephritis. Which of the following findings is consistent with this
diagnosis? Select all that apply.
A. Urine specific gravity of 1.040
D. Generalized edema
Correct Answer: A, B, & C
Acute glomerulonephritis is characterized by high urine specific gravity related to
oliguria as well as dark “tea-colored” urine caused by large amounts of red blood cells.
Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and RBC casts
are present.
Option B: Functional changes include proteinuria, hematuria, reduction in GFR
(ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The
decreased GFR and avid distal nephron salt and water retention result in the
expansion of intravascular volume, edema, and, frequently, systemic
hypertension.
Option C: This is a universal finding, even if it is microscopic. Gross hematuria is
reported in 30% of pediatric patients, often manifesting as smoky-, coffee-, or
cola-colored urine.
Option D: There is periorbital edema, but generalized edema is seen in nephrotic
syndrome, not acute glomerulonephritis. Most often, the patient is a boy, aged 2-
14 years, who suddenly develop puffiness of the eyelids and facial edema in the
setting of a post-streptococcal infection.
28. Which of the following conditions most commonly causes acute glomerulonephritis?
D. Nephrotic syndrome.
Correct Answer: B. Prior infection with group A Streptococcus within the past 10-
14 days.
Acute glomerulonephritis is most commonly caused by the immune response to a prior
upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine, and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
Option A: No congenital condition predisposes to glomerulonephritis.
Noninfectious causes of acute GN may be divided into primary renal diseases,
systemic diseases, and miscellaneous conditions or agents.
Option C: Viruses may cause acute glomerulonephritis but rarely.
Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B virus
(HBV), rubella, rickettsiae (as in scrub typhus), parvovirus B19, and mumps virus
are accepted as viral causes only if it can be documented that a recent group A
beta-hemolytic streptococcal infection did not occur. Acute GN has been
documented as a rare complication of hepatitis A.
Option D: Nephrotic syndrome does not cause acute glomerulonephritis. PSGN
usually develops 1-3 weeks after acute infection with specific nephritogenic
strains of group A beta-hemolytic streptococcus. The incidence of GN is
approximately 5-10% in persons with pharyngitis and 25% in those with skin
infections.
29. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age.
The scrotum is smaller than it was at birth, but the fluid is still visible on illumination.
Which of the following actions is the physician likely to recommend?
A. Massaging the groin area twice a day until the fluid is gone.
D. Keeping the infant in a flat, supine position until the fluid is gone.
30. A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of
any kind. Which of the following is the most likely explanation for these symptoms?
31. A patient in the cardiac unit is concerned about the risk factors associated with
atherosclerosis. Which of the following are hereditary risk factors for developing
atherosclerosis?
B. Overweight
C. Smoking
D. Age
34. A patient who has been diagnosed with the vasospastic disorder (Raynaud’s disease)
complains of cold and stiffness in the fingers. Which of the following descriptions is
most likely to fit the patient?
A. An adolescent male
B. An elderly woman
C. A young woman
D. An elderly man
Correct Answer: C. young woman.
Raynaud’s disease is most common in young women and is frequently associated with
rheumatologic disorders, such as lupus and rheumatoid arthritis. Vasospasm of the
arteries reduces blood flow to the fingers and toes. In people who have Raynaud’s, the
disorder usually affects the fingers. In about 40 percent of people who have Raynaud’s,
it affects the toes. Rarely, the disorder affects the nose, ears, nipples, and lips.
Option A: Primary Raynaud’s usually develops before the age of 30. In primary
Raynaud’s (also called Raynaud’s disease), the cause isn’t known. Primary
Raynaud’s are more common and tend to be less severe than secondary
Raynaud’s.
Option B: Secondary Raynaud’s usually develops after the age of 30. Secondary
Raynaud’s is caused by an underlying disease, condition, or other factors. This
type of Raynaud’s is often called Raynaud’s phenomenon.
Option D: Although anyone can develop the condition, Raynaud’s disease often
begins between the ages 15 to 30, but it mostly affects women. If one has
primary or secondary Raynaud’s, cold temperatures or stress can trigger
“Raynaud’s attacks.” During an attack, little or no blood flows to affected body
parts.
35. A 23-year-old patient in the 27th week of pregnancy has been hospitalized on
complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied
by chest pain. Which of the following conditions is the most likely cause of her
symptoms?
A. Myocardial infarction due to a history of atherosclerosis.
B. Cerebral hemorrhage.
37. An infant is brought to the clinic by his mother, who has noticed that he holds his
head in an unusual position and always faces to one side. Which of the following is
the most likely explanation?
A. Torticollis, with shortening of the sternocleidomastoid muscle.
B. Craniosynostosis, with premature closure of the cranial sutures.
Correct Answer: C. The student experiences pain in the inferior aspect of the knee.
Osgood-Schlatter disease occurs in adolescents in the rapid growth phase when the
infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain
and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly
caused by activities that require repeated use of the quadriceps, including track and
soccer.
Option A: Swimming is not a likely cause. OSD is a traction phenomenon
resulting from repetitive quadriceps contraction through the patellar tendon at its
insertion upon the skeletally immature tibial tubercle. This occurs in
preadolescence during a time when the tibial tubercle is susceptible to strain. The
pain associated will be localized to the tibial tubercle and occasionally the
patellar tendon itself.
Option B: The condition is usually self-limited, responding to ice, rest, and
analgesics. OSD is a self-limiting condition. In a study by Krause et al, 90% of
patients treated with conservative care were relieved of all of their symptoms
approximately 1 year after the onset of symptoms. [3] After skeletal maturity,
patients may continue to have problems kneeling. This typically is due to
tenderness over an unfused tibial tubercle ossicle or a bursa that may require
resection.
Option D: Continued participation will worsen the condition and the symptoms.
The onset of OSD is usually gradual, with patients commonly complaining of pain
in the tibial tubercle and/or patellar tendon region after repetitive activities.
Typically, running or jumping activities that significantly stress the patellar tendon
insertion upon the tibial tubercle aggravate the patient’s symptoms.
39. The clinic nurse asks a 13-year-old female to bend forward at the waist with arms
hanging freely. Which of the following assessments is the nurse most likely conducting?
A. Spinal flexibility
B. Leg length disparity
D. Scoliosis
40. A clinic nurse interviews a parent who is suspected of abusing her child. Which of the
following characteristics is the nurse least likely to find in an abusing parent?
A. Low self-esteem
B. Unemployment
C. Self-blame for the injury to the child
D. Single status
41. A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who
has just been diagnosed with juvenile idiopathic arthritis. Which of the following
statements about the disease is most accurate?
42. A child is admitted to the hospital several days after stepping on a sharp object that
punctured her athletic shoe and entered the flesh of her foot. The physician is
concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the
following actions is done immediately before the antibiotic is started?
A. The admission orders are written.
44. A toddler has recently been diagnosed with cerebral palsy. Which of the following
information should the nurse provide to the parents? Select all that apply.
B. Cerebral palsy is caused by injury to the upper motor neurons and results in
motor dysfunction, as well as possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no
additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health
care issues.
45. A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The
parents are receiving genetic counseling prior to planning another pregnancy. Which of
the following statements includes the most accurate information?
C. Procedure that compresses plaque against the wall of the diseased coronary
artery to improve blood flow.
D. Non-invasive radiographic examination of the heart.
Correct Answer: C. Procedure that compresses plaque against the wall of the
diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is
performed during a cardiac catheterization. Aorta coronary bypass graft is the surgical
procedure to repair a diseased coronary artery.
Option A: Coronary artery bypass grafting is the surgical repair of a diseased
coronary artery.
Option B: Angioplasty does not involve the placement of an internal cardiac
defibrillator. An internal cardiac defibrillator is needed if the client has ventricular
tachycardia or ventricular fibrillation because they detect and stop abnormal
heartbeats or arrhythmias.
Option D: PTCA is not a radiographic examination of the heart.
47. A newborn has been diagnosed with hypothyroidism. In discussing the condition and
treatment with the family, the nurse should emphasize:
A. Re-orientation to reality
B. Elimination of symptoms
49. A 19-year-old client is paralyzed in a car accident. Which statement used by the
client would indicate to the nurse that the client was using the mechanism of
“suppression”?
C. “It’s the other entire guy’s fault! He was going too fast.”
50. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation
indicates that the membranes were ruptured for 36 hours prior to delivery. What are the
priority nursing diagnoses at this time?
Altered tissue perfusion
Correct Answer: A. Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with the surface exposed to the air. Casts and
splints hold the bones in place while they heal. They also reduce pain, swelling, and
muscle spasm.
Option B: Heat lamps may cause burns in the skin inside the cast. Inspect the
skin around the cast. If the skin becomes red or raw around the cast, contact a
doctor.
Option C: Do not handle the cast until it is dry because it might still break. It
takes about one hour for fiberglass, and two to three days for plaster to become
hard enough to walk on. Some physicians will give a “cast shoe” to wear over a
walking cast. The cast shoe will help protect the bottom of the cast.
Option D: Turning the child would ensure equal drying of the cast at all sides.
Keep the cast dry. If the cast becomes wet, it can hurt the child’s skin. Do not try
to dry cast with something warm (i.e., a blow dryer) this may cause burns.
52. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the
client for this test, the nurse would:
A. Instruct the client to maintain a regular diet the day prior to the examination.
Correct Answer: C. Administer a laxative to the client the evening before the
examination
Bowel prep is important because it will allow greater visualization of the bladder and
ureters. Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast
material to evaluate the kidneys, ureters, and bladder and help diagnose blood in the
urine or pain in the side or lower back. An IVP may provide enough information to allow
the doctor to treat with medication and avoid surgery.
Option A: Eating and drinking the night before the exam should be avoided.
Option B: Restriction of fluids on the night before the exam should be
emphasized.
Option D: An intravenous pyelogram is an x-ray of the kidneys, ureters, and
urinary bladder that uses iodinated contrast material injected into veins.
53. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child,
the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s
response is based on an understanding that:
54. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea,
occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with
5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35
ml/hr. Which finding should be reported to the healthcare provider immediately?
A. 3 episodes of vomiting in 1 hour.
55. While caring for the client during the first hour after delivery, the nurse determines
that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first
action?
A. Check vital signs.
C. Offer a bedpan.
D. Check for perineal lacerations.
B. Limited adduction
C. Take the client to the day room and introduce her to the other clients.
D. Ask the nursing assistant to get the client’s vital signs and complete the
admission search.
Correct Answer: B. Introduce him/herself and accompany the client to the client’s
room.
Anxiety is triggered by change that threatens the individual’s sense of security. In
response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move
the client to a calmer, more secure/safe setting.
Option A: The client is still confused and fearful. Orientation should be
postponed until he is calm. They can deliver effective, safe care by assessing risk
and building a rapport with the patient during the admission process; utilizing
crisis prevention strategies, including appropriate medication administration,
environmental, psychobiological, counseling, and health teaching interventions;
and employing conflict resolution techniques.
Option C: The client should be taken to a calm environment with less stimuli so
he could feel safe and become calmer.
Option D: Taking the client’s vital signs while he is still fearful would further
aggravate his feelings of insecurity and fear. Utilizing the nursing process, the
nurse can provide effective therapeutic interventions to promote safety for both
the patient and the nurse.
59. During the admission assessment on a client with chronic bilateral glaucoma, which
statement by the client would the nurse anticipate since it is associated with this
problem?
60. A client with asthma has low pitched wheezes present in the final half of exhalation.
One hour later the client has high pitched wheezes extending throughout exhalation.
This change in assessment indicates to the nurse that the client:
D. Exhibits hyperventilation.
A. Alcoholic
B. Overconfident
D. Low self-esteem
Correct Answer: D. Low self-esteem
Batterers are usually physically or psychologically abused as children or have had
experiences of parental violence. Batterers are also manipulative, have low self-esteem,
and have a great need to exercise control or power-over partners.
Option A: Being an alcoholic predisposes an individual to be a domestic abuser.
To be perfectly clear, alcohol and alcoholism are never a sole trigger for, or cause
of, domestic abuse. Rather, they are compounding factors that could eventually
trigger intimate partner abuse in a violent individual.
Option B: Most domestic abusers have low self-confidence or self-esteem.
Basically, domestic violence offenders always feel the need to be in control of
their victims. The less in control an offender feels, the more they want to hurt
others.
Option C: Domestic abusers often vent out their frustrations on their partners or
children. Domestic abuse, often referred to as domestic violence or intimate
partner violence (IPV), is a pattern of behavior or behaviors used by one partner
to maintain power and control over another partner that they are in a
relationship with. Anyone, regardless of race, gender, sexual orientation, religion,
or age, can be a victim or perpetrator of domestic abuse. Abuse can be physical,
sexual, emotional, mental, social, and financial.
62. The nurse is caring for a client with a long leg cast. During discharge teaching about
appropriate exercises for the affected extremity, the nurse should recommend:
A. Isometric
B. Range of motion
C. Aerobic
D. Isotonic
63. 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.
64. 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?
66. While explaining an illness to a 10-year-old, what should the nurse keep in mind
about the cognitive development at this age?
B. Elimination
C. Activity
D. Safety
68. Which playroom activities should the nurse organize for a small group of 7-year-old
hospitalized children?
A. Sports and games with rules
A. High Fowler’s
B. Supine
C. Left lateral
D. Low Fowler’s
70. 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:
B. No complaints of thirst
C. Increased hematocrit
72. You are creating a teaching plan for a patient with newly diagnosed migraine
headaches. Which key items should be included in the teaching plan? Select all that
apply.
A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
73. The patient with migraine headaches has a seizure. After the seizure, which action
can you delegate to the nursing assistant?
A. Document the seizure
74. You are preparing to admit a patient with a seizure disorder. Which of the following
actions can you delegate to LPN/LVN?
A. Complete admission assessment
75. A nursing student is teaching a patient and family about epilepsy prior to the
patient’s discharge. For which statement should you intervene?
A. “You should avoid consumption of all forms of alcohol.”