Question 1To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose ofdeep palpation is to assess which of the following?Skin turgorHydrationOrgansQuestion 2A client is rought to the emergency department and the physician determines he hasgastrointestinal !"#$ leeding. #n planning for his care, which of the following would e first priority?assessment of vital signscomplete adominal e%aminationinsertion of a nasogastric tue and Hematest of emesisthorough investigation of precipitating eventsIncorrect. The answer isassessment of vital signsExplanation:The Correct answer is:assessment of vital signsVital sign assessment would be the priority nursing intervention. This would provide an indication of the amount ofblood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The otheranswers (b, c, and d) are important but not priority actions.Question 3&hen providing instructions to the adolescent regarding physical development of her ody, the '(should do all of the following )*+),T-iscuss the importance of avoiding social events in order to stay out of troule.)%plain that ody hair distriution increases and is normal.-iscuss that it is normal to gain weight during puerty.#nstruct on active seaceous and sweat glands.Correct. The answer isDiscuss the importance of avoiding social events in order to stay out of troule.Explanation:The Correct answer is:Discuss the importance of avoiding social events in order to stay out of troule.Socialiation is very important to teenagers and is a normal part of their development. The other answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding development.Question !The nurse is developing discharge plans for a ./0year0old client. The discharge plans indicate theclient will e discharged home with home health nursing care. The nurse provides the home healthagency with details regarding the needs of the patient. The nurse made which of the following to thehome health agency?A care plan.A referral.A transfer to another unit.A re1uest for at home physical therapy.Incorrect. The answer is" referral.Explanation:Correct answer:" referral! referral is recommending home care services or giving information to an home care service regarding the client and the client"s needs. Typically the sources of referral to a home care agency are family members, nurses, physicians, social wor#ers, discharge planners or therapists.Question #$hich of the following is the normal serum electrolyte level for magnesium%23 to 45. m)167.4.8 to 9.4 m)167.:./ to /.8 m)167.48/ to 4:3 m)167.Incorrect. The answer is1.3 to 2.1 mE$%&.Explanation:Correct answer:1.3 to 2.1 mE$%&Choice ! is the normal value for chloride. Choice C is the normal value for calcium and choice &, sodium.Question #$hich of the following is the normal serum electrolyte level for magnesium%23 to 45. m)167.4.8 to 9.4 m)167.:./ to /.8 m)167.48/ to 4:3 m)167.Incorrect. The answer is1.3 to 2.1 mE$%&.Explanation:Correct answer:1.3 to 2.1 mE$%&Choice ! is the normal value for chloride. Choice C is the normal value for calcium and choice &, sodium.Question 'The school nurse is approached y a mother who e%plains that her kindergarten child is constantlyscratching the perianal area and that the area is irritated. The '( understands thatshe shouldinstruct the mother to otain a rectal specimen y a tape test and that the mother should otain thespecimen when?After athing.&hen the child is put to ed.#n the morning, when the child awakens.After toileting.Incorrect. The answer isIn the morning( )hen the child a)a*ens.Explanation:The Correct answer is:in the morning( )hen the child a)a*ensVisualiation of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic e'amination. The best specimen is obtained as thechild awa#ens, before toileting or bathing.Question +A 950year0old patient is admitted to the hospital with respiratory failure. He;s intuated, giveno%ygen, and is coughing with copious secretions in his lungs. &hat should e done first?Suction the lungs+all his family+all for assistance in restraining the patient+heck his heart rate and lood pressureCorrect. The answer is,uction the lungsExplanation:-he correct ans)er is ". The first priority is to ma#e sure the client(s airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe.Question +A 950year0old patient is admitted to the hospital with respiratory failure. He;s intuated, giveno%ygen, and is coughing with copious secretions in his lungs. &hat should e done first?Suction the lungs+all his family+all for assistance in restraining the patient+heck his heart rate and lood pressureCorrect. The answer is,uction the lungsExplanation:-he correct ans)er is ". The first priority is to ma#e sure the client(s airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe.Question .A high school student is referred to the school nurse for suspected sustance ause. ures. &hich of the following solutions will the nurse use to dilute thismedication?(ormal saline !5.2?$ solution.-e%trose /? and half0normal saline !5.:/?$ solution.-e%trose /? solution.7actated ringer's solution.Correct. The answer is0ormal saline 12./34 solution.Explanation:The Correct answer is:normal saline 12./34 solution*henytoin (&ilantin) should be administered by in+ection into a large vein by intermittent intravenous infusion. ,ormal saline (-../) solution is the preferred solution. &e'trose should be avoided because of medication precipitation.Question 12$hich of the following terms corresponds with the phrase: a woman that is pregnant%0ctomomesis*lacenta previa1ravidaSpermatogoniaIncorrect. The answer is5ravidaExplanation:The correct answer is C. 1ravida is another word for pregnancy. Spermatogonia refers to male sperm cells.Question 114909: hours.8508. hours.8@0:3 hours.@902. hours.Question 13A woman is two months pregnant when her five0year0old child develops ruella. &hat is most likelyto e given to her?#mmune serum gloulin'ho"am'uella antito%in=='Incorrect. The answer isImmune serum gloulinExplanation:The correct answer is immune serum globulin. 2mmune serum globulin gives her a passive immunity and helps #eep her from developing rubella, which can have devastating effect on her unborn child. 334 is a live virus and is not given to pregnant women. 4ho1am prevents anti 4h antibody development. There is no such thing as rubella antito'in.Question 1!$hat is the normal value of urine potassium%56758 m9:;6< hr5=>75 m9:;6< hr6>75-- m9:;6< hr-.=75.8 m9:;6< hrIncorrect. The answer is2#6122 mE$%2! hrExplanation:Correct ans)er:2#6122 mE$%2! hrThe normal value for urine potassium is 6>75-- m9:;6< hrQuestion 1#Aefore applying a cord clamp, the nurse assesses the umilical cord for the presence of vessels. Thefindings that are often associated with genitourinary anormalities are what?one artery, one vein.two arteries, one vein.two veins, one artery.two veins, two arteries.Correct. The answer isone artery( one vein.Explanation:-he correct ans)er is one artery( one vein. Two arteries and one vein are present in a normal umbilical cord. The presence of one artery in the umbilical cord is associated with genitourinary abnormalities.Question 1'Bou are assigned to educated the nursing assistants regarding caring for the older adult. #t isimportant that the assistants understand that which of the following situations portrays ageism?Accepting differences among older adults.Advising older adults to forgo aggressive treatment.Allowing older adults to make decisions.#nforming the older adult of their rights.Incorrect. The answer is"dvising older adults to forgo aggressive treatment.Explanation:The Correct answer is:"dvising older adults to forgo aggressive treatment.!geism is a form of pre+udice in which older adults are stereotyped by characteristics found in only a few members of their group. ?undamental to ageism is the view that older persons are different from @me@ and will remain different from @me.@ The other answers (a, c, and d) identify supporting roles of the nurse for the older person.Question 1+&hen taking a dietary history from a newly admitted client, the nurse should rememer that whichof the following foods is a common allergen?readcarrotsorangesstrawerriesCorrect. The answer isstra)erriesExplanation:-he correct ans)er is stra)erries. Common food allergens include berries, peanuts, Arail nuts, cashews, shellfish, and eggs. Aread, carrots and oranges rarely cause allergic reactions.Question 1+&hen taking a dietary history from a newly admitted client, the nurse should rememer that whichof the following foods is a common allergen?readcarrotsorangesstrawerriesCorrect. The answer isstra)erriesExplanation:-he correct ans)er is stra)erries. Common food allergens include berries, peanuts, Arail nuts, cashews, shellfish, and eggs. Aread, carrots and oranges rarely cause allergic reactions.Question 1.A nurse who violates the civil rights of an individual may e committing what?A tort.(egligence.=alpractice.An unintentional tort.Incorrect. The answer is" tort.Explanation:Correct answer:" tort! tort is the process of violating civil law when dealing with an individual or an individual"s property. The types of torts are commission and omission. ?urther, negligence and malpractice are not the best choices as these deal withunintentional torts.Question 1/A patient with Addison's disease has een given an inade1uate steroid dosage.&hich of thefollowing are (OT symptoms the patient could e%perience?$eight gain.?atigue.$ea#ness.&iiness.Correct. The answer is7eight gain.Explanation:Correct answer:7eight gain $eight loss is more li#ely. Choices A, C, and & are often indicated. Question 1/A patient with Addison's disease has een given an inade1uate steroid dosage.&hich of thefollowing are (OT symptoms the patient could e%perience?$eight gain.?atigue.$ea#ness.&iiness.Correct. The answer is7eight gain.Explanation:Correct answer:7eight gain $eight loss is more li#ely. Choices A, C, and & are often indicated. Question 1/A patient with Addison's disease has een given an inade1uate steroid dosage.&hich of thefollowing are (OT symptoms the patient could e%perience?$eight gain.?atigue.$ea#ness.&iiness.Correct. The answer is7eight gain.Explanation:Correct answer:7eight gain $eight loss is more li#ely. Choices A, C, and & are often indicated. Question 22&hich of the following ehavior does (OT show improvement in a client with Osessive +ompulsive-isorder?Client uses Bwill powerC to stop rituals.4efrains from rituals during stress.Client uses Bthought stoppingC when obsessive thoughts occur.Client verbalies a relationship between stress and rituals.Incorrect. The answer isClient uses 8)ill po)er9 to stop rituals.Explanation:Correct answer:Client uses 8)ill po)er9 to stop ritualsThe client can employ appropriate intervention techni:ues and more about the disease process such as A, C and &. B$ill powerC alone will not be effective in dealing with 0bsessive Compulsive &isorder. Question 210f the following, which is the normal respirations range for an adult%5D76-6oral?Cetocona>ole.#sotretinoin.(ystatin.t ta*e >the pill> if I have gallladder disease.=Explanation:-he correct ans)er is =I can>t ta*e >the pill> if I have gallladder disease.= 0ral contraceptive is contraindicated in women with gallbladder disease and those who are heavy smo#ers. There is not an age specification. 3enstrual flow is decreased with the use of oral contraceptives.Question 2/&hich of the following clinical signs would the nurse e%pect to see in a child with respiratorydepression?Sleep apnea.#ncreased pulse rate.Shallow reathing.Instale angina.Correct. The answer is,hallo) reathing.Explanation:Correct answer:,hallo) reathing4espiratory depression is the breaths per minute that are less than 56 breaths per minute in a child who is two years of age and younger. 4espiratory depression is one of the complications associated with opioids (for e'amplemorphine, codeine, &emerol, 0'ycodone), which are a common analgesic given to client"s after surgery or to treat a severe in+ury. Children who e'perience respiration depression e'hibit clinical signs such as shallow breathing, sleepiness and small pupils.Question 32&hich of the following possile lood transfusion reactions is a rare, severe reaction in which thedonated lood type is not compatile with that of the patient?Allergic,one of theseGemolytic?ebrileIncorrect. The answer is?emolyticExplanation:The correct answer is C. Choice ! is usually due to a patient(s sensitivity to the plasma proteins of the donor(s blood. Choice & is a reaction caused by the incompatibility of leu#ocytes.Question 31A client is admitted to the health care facility with a diagnosis of a leeding gastric ulcer. The nursee%pects this client's stool to look like which of the following?+offee ground0like.+lay0colored.Alack and tarry.Aright .Correct. The answer is@lac* and tarry.Explanation:Correct answer:@lac* and tarryAlac#, tarry stools are a sign of bleeding high in the 12 tract, as from a gastric ulcer, and result from the action of digestive enymes in the blood. Vomitus associated with upper 12 tract bleeding is commonly described as coffee ground7li#e. Clay7colored stools are associated with biliary obstruction. Aright red stools indicate lower 12 tract bleeding.Question 32A client is scheduled to have a lood transfusion. The client asks the nurse, H&hat types of diseasesare transmitted through lood transfusions?H The nurse should respond that there is a low risk ofcontracting diseases through lood transfusions. However, a possile illness is which of the following?+ytomegalovirus.Hypertension.Sei>ure disorder.+ushing's disease.Correct. The answer isCytomegalovirus.Explanation:Correct answer:CytomegalovirusAlood borne diseases and diseases that are transmitted through a transfusion are Gepatitis A, Gepatitis C, G2V, Cytomegalovirus and 3alaria,to name a few. !lso, the nurse should assure the client that the transmission of these diseases is low since blood ban#s have rigorous screening procedures to test blood.Question 32A client is scheduled to have a lood transfusion. The client asks the nurse, H&hat types of diseasesare transmitted through lood transfusions?H The nurse should respond that there is a low risk ofcontracting diseases through lood transfusions. However, a possile illness is which of the following?+ytomegalovirus.Hypertension.Sei>ure disorder.+ushing's disease.Correct. The answer isCytomegalovirus.Explanation:Correct answer:CytomegalovirusAlood borne diseases and diseases that are transmitted through a transfusion are Gepatitis A, Gepatitis C, G2V, Cytomegalovirus and 3alaria,to name a few. !lso, the nurse should assure the client that the transmission of these diseases is low since blood ban#s have rigorous screening procedures to test blood.Question 33#n which of the following stages of reaction toward stress does a ody increase in hormone levels inorder to moili>e for a fight?Alarm.)%haustion.(one of these.'esistance.Incorrect. The answer is"larm.Explanation:Correct answer:"larm&uring the e'haustion stage, the body becomes @e'hausted@ because it did not positively respond to the stress. The body undergoes many physiological changes such as ta#ing more air into the lungs in order to prepare for fightor flight during the resistance stage.Question 3!#n a client with acute hepatitis, the nurse assesses the client's aspartate aminotransferase !AST$range on the laoratory test at /95 units. &hat should the nurse understand aout this test value?The AST is normal.The AST is decreased.The AST is elevated.The AST is stale.Correct. The answer is-he ",- is elevated.Explanation:Correct answer:-he ",- is elevated2n clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (!ST) is elevated. The normal range for this enyme in the blood is 5- to 6D units per liter. 2n clients with acute hepatitis, the enyme may be elevated four times above the normal range.Question 3#The nurse who teaches nutrition at a community center is asked Hhow much water does a personneed to drink dailyH. The nurse's est response would eGtwo 1uartstwo pintsone gallonfour cupsIncorrect. The answer ist)o $uartsExplanation:The correct answer is two :uarts. The average adult needs eight glasses, or two :uarts, of water per day. The remaining answer choices are not correct.Question 3#The nurse who teaches nutrition at a community center is asked Hhow much water does a personneed to drink dailyH. The nurse's est response would eGtwo 1uartstwo pintsone gallonfour cupsIncorrect. The answer ist)o $uartsExplanation:The correct answer is two :uarts. The average adult needs eight glasses, or two :uarts, of water per day. The remaining answer choices are not correct.Question 3'&hich of the following tasks can a registered nurse delegate to a nursing assistant in an acute mentalhealth setting?Assessing mental status on admission.+hecking for sharp oJects.Administering medication.-iscussing the treatment plan.Incorrect. The answer isChec*ing for sharp oAects.Explanation:Correct answer:Chec*ing for sharp oAects! nursing assistant may be assigned to search a client"s luggage or room for potentially harmful ob+ects, such as glass or sharp metal. ! mental status assessment should be conducted by the nurse on admission. !dministering medication cannot be delegated to an unlicensed person. ! nurse or physician must discuss the treatment plan withthe client.Question 3+The nurse oserves a child's nasal discharge. The discharge is clear in oth nasal cavities. Thedischarge most likely indicates what type of condition?noseleedupper respiratory infectionallergyforeign odyCorrect. The answer isallergyExplanation:The correct answer is allergy. ! child who has clear, watery discharge is associated with allergies. The remaining answer choices are not the best options as bloody discharge is indicative of a nosebleed or a trauma. 2tchy mucus containing discharge indicates an upper respiratory infection. 2f there is mucoid or purulent nasal discharge in one side of the nostrils, the child may have a foreign body lodged in the nostril.Question 3.A female client who complains of chest pain is admitted. The nurse can e%pect which of the followinglaoratory tests ordered y the physician to confirm a myocardial infarction diagnosis?creatine kinaseelectrocardiogramradionuclide imaginghemodynamic monitoringIncorrect. The answer iscreatine *inaseExplanation:The correct answer is creatine #inase. The physician orders laboratory tests and diagnostic tests to confirm a diagnosis of myocardial infarction. Creatine #inase is an enyme located in the cardiac muscle, brain and s#eletal muscle. !s this enyme rises, there is in+ury to the muscle cells. ?urther, the higher the serum CH, the more the muscle tissue that is damaged. 9lectrocardiogram, radionuclide imaging and hemodynamic monitoring are used to diagnosis a myocardial infarction. Gowever, these are diagnostic tests and not laboratory tests.Question 3/The nurse is providing reast cancer education at a community facility. The American +ancer Societyrecommends that women get mammogramsyearly after age :5after the irth of the first child and every 9 years thereafterafter the first menstrual period and annually thereafterevery 8 years etween ages 95 and :5 and annually thereafterCorrect. The answer isyearly after age !2Explanation:-he correct ans)er is yearly after age !2. The !merican Cancer Society recommends a mammogram yearly for women over age es this woman is using whatdefense mechanism?denialdisplacementrationali>ationcompensationIncorrect. The answer iscompensationExplanation:The correct answer is compensation. Compensation is covering a wea#ness with a more desirable trait or behavior, such as replacing the desire to have children with adopting a child. &enial is avoiding unwanted realities by refusing to ac#nowledge they e'ist, such as the woman who refuses to accept that she is unable to bear children. 4ationaliation is +ustifying behavior with faulty logic, such as the woman who uses drugs or alcohol and says that it is due to being unable to have children. &isplacement is discharging emotion from one person or ob+ectto another person or ob+ect, such as the woman who learns she cannot have children and goes home and argues with her husband.Question !2A client is admitted with tuerculosis. The client should e placed in which type of precaution asedisolation?-roplet.+ontact.,rotective.Airorne.Correct. The answer is"irorne.Explanation:Correct answer:"irorneThe nurse should use airborne precautions when caring for a client with #nown or suspected tuberculosis to reduce the spread of the tuberculosis. *recautions that are employed are private room that has its own hand washing station and bathroom, special ventalation system that is separate from the hospital wide ventilation system and providing mas#s for anyone entering the room to see the client.Question !3&hich clinical indicator is the nurse most likely to identify when e%ploring the history of a client withinsomnia?)nuresis.#rritaility.Sleep talking.Sleepwalking.Correct. The answer isIrritaility.Explanation:Correct answer:Irritaility2nsomnia is the inability to fall asleep or stay sleep. 2ndividuals who e'perience insomnia complain of unrefreshed sleep, daytime sleepiness, trouble concentrating, irritability, and wa#ing up several times at night.Question !3&hich clinical indicator is the nurse most likely to identify when e%ploring the history of a client withinsomnia?)nuresis.#rritaility.Sleep talking.Sleepwalking.Correct. The answer isIrritaility.Explanation:Correct answer:Irritaility2nsomnia is the inability to fall asleep or stay sleep. 2ndividuals who e'perience insomnia complain of unrefreshed sleep, daytime sleepiness, trouble concentrating, irritability, and wa#ing up several times at night.Question !!The physician prescries home o%ygen therapy for a client with pulmonary firosis. The nursecollaorates with the social worker assigned to the client aout arranging the home o%ygen therapy.&hich health team memer will e responsile for evaluating the client's knowledge of home o%ygenuse?home health nursephysicianhospital staff nursesocial workerIncorrect. The answer ishome health nurseExplanation:Correct answer home health nurse The home health nurse is responsible for evaluating the client"s #nowledge of home o'ygen use. The social wor#er is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in the home, so they cannot ade:uately evaluate the client"s #nowledge of home o'ygen use.Question !!The physician prescries home o%ygen therapy for a client with pulmonary firosis. The nursecollaorates with the social worker assigned to the client aout arranging the home o%ygen therapy.&hich health team memer will e responsile for evaluating the client's knowledge of home o%ygenuse?home health nursephysicianhospital staff nursesocial workerIncorrect. The answer ishome health nurseExplanation:Correct answer home health nurse The home health nurse is responsible for evaluating the client"s #nowledge of home o'ygen use. The social wor#er is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in the home, so they cannot ade:uately evaluate the client"s #nowledge of home o'ygen use.Question !#The normal lood glucose range is which of the following?.50455 mg6dl3504:5 mg6dl45504/5 mg6dl@50495 mg6dlCorrect. The answer is+26122 mg%dlExplanation:-he correct ans)er is D. !ny reading higher than 56D ml should prompt the nurse to chec# with the doctor for follow7up. Gowever, a recent ingestion of sugar or carbohydrates could cause a high reading.Question !'$hich is a ?!ES9 statement regarding the factors contributing to its development%2n most theories of schiophrenia, stress plays an essential role in triggering schiophrenic episodes.Some investigators suggest that communication disorders in parents and family memers may e a predisposing factor for schi>ophrenia.The dopamine hypothesis fits only some cases of schiophrenia.#n order for someone to e diagnosed with schi>ophrenia, they must show rain damage on a rain scan.Incorrect. The answer isIn order for someone to e diagnosed )ith schi;ophrenia( they must sho) rain damage on a rain scan.Explanation:Correct answer:In order for someone to e diagnosed )ith schi;ophrenia( they must sho) rain damage on a rain scan2t is becoming more clear ever day, the damage schiophrenia is doing to the brain, but researchers are nowhere near finding all of the answers. &ifferent researchers are still arguing over the conclusiveness of the data that does e'ist. 0ther scientists are trying to discover the cause of schiophrenia.Question !'$hich is a ?!ES9 statement regarding the factors contributing to its development%2n most theories of schiophrenia, stress plays an essential role in triggering schiophrenic episodes.Some investigators suggest that communication disorders in parents and family memers may e a predisposing factor for schi>ophrenia.The dopamine hypothesis fits only some cases of schiophrenia.#n order for someone to e diagnosed with schi>ophrenia, they must show rain damage on a rain scan.Incorrect. The answer isIn order for someone to e diagnosed )ith schi;ophrenia( they must sho) rain damage on a rain scan.Explanation:Correct answer:In order for someone to e diagnosed )ith schi;ophrenia( they must sho) rain damage on a rain scan2t is becoming more clear ever day, the damage schiophrenia is doing to the brain, but researchers are nowhere near finding all of the answers. &ifferent researchers are still arguing over the conclusiveness of the data that does e'ist. 0ther scientists are trying to discover the cause of schiophrenia.Question !+*ain has which of the following effects on respiratory rate%,one.&ecreases.2ncreases.ine.,henergan.(e%ium.Correct. The answer isEeglan.Explanation:Correct answer:EeglanChoice A is a brand name for *rochlorperaine. Choice C is a brand name for *romethaine and choice &, for 9somepraole 3agnesium.Question '/A white female client is admitted to an acute care facility with a diagnosis of stroke. Her historyreveals ronchial asthma, e%ogenous oesity, and iron deficiency anemia. &hich history finding is arisk factor for stroke?+aucasian race.0faire leadershipdemocratic leadershipsituational leadershipIncorrect. The answer isdemocratic leadershipExplanation:The Correct answer is:democratic leadership!utocratic leadership is focused and maintains strong control, ma#es decisions, and addresses all problems. The autocratic leader dominates and commands rather than see# suggestions or input. The laisse7faire leader assumes a passive, nondirective, and inactive approach and relin:uishes part or all of the leadership responsibilities to group members. The situational leader uses a combination approach based on the circumstances.Question +1&hat is the est way for a client with reoccurring kidney stones to prevent further kidneystones?2ncrease dairy inta#e.&ecrease fatty protein and carbohydrate inta#e.2ngest plenty of cranberry +uice.Ta#e vitamin & supplements.Incorrect. The answer isIngest plenty of cranerry Auice.Explanation:Correct answer:Ingest plenty of cranerry AuiceCranberry +uice increases the acidity of urine, which helps with the dissolving of #idney stones. $hile the other foods will add nutrients to the diet, they do not address the development of further #idney stones.Question +2The nurse is providing dietary teaching for the parents of a child with celiac disease. This child shouldavoid what?Kegetales.