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C H A P T E R 3 T H R E E
Practice Exam 3 and
Rationales
1. A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suici- dal client has difficulty:
❍ A. Expressing feelings of low self-worth
❍ B. Discussing remorse and guilt for actions
❍ C. Displaying dependence on others
❍ D. Expressing anger toward others
2. A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
❍ A. Pear
❍ B. Apple
❍ C. Orange
❍ D. Banana
3. The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:
❍ A. Maintain the client in a semi-Fowler’s position with the
head and neck supported by pillows
❍ B. Encourage the client to turn her head side to side, to
promote drainage of oral secretions
❍ C. Maintain the client in a supine position with sandbags
placed on either side of the head and neck
❍ D. Encourage the client to cough and breathe deeply
every 2 hours, with the neck in a flexed position
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(^146) Chapter 3
4. A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
❍ A. Dairy products
❍ B. Carbonated beverages
❍ C. Refined sugars
❍ D. Luncheon meats
5. A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial per- sonality disorder. In reviewing the client’s record, the nurse could expect to find:
❍ A. A history of consistent employment
❍ B. A below-average intelligence
❍ C. A history of cruelty to animals
❍ D. An expression of remorse for his actions
6. The licensed vocational nurse may not assume the primary care for a client:
❍ A. In the fourth stage of labor
❍ B. Two days post-appendectomy
❍ C. With a venous access device
❍ D. With bipolar disorder
7. The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
❍ A. Administering pain medication
❍ B. Checking the adequacy of urinary output
❍ C. Requesting a daily complete blood count
❍ D. Obtaining a blood glucose by finger stick
8. The nurse is teaching a group of parents about gross motor devel- opment of the toddler. Which behavior is an example of the nor- mal gross motor skill of a toddler?
❍ A. She can pull a toy behind her.
❍ B. She can copy a horizontal line.
❍ C. She can build a tower of eight blocks.
❍ D. She can broad-jump.
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(^148) Chapter 3
14. An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:
❍ A. Assigning a nursing assistant to sit with him until he
falls asleep
❍ B. Allowing the client to room with another elderly client
❍ C. Administering a bedtime sedative
❍ D. Leaving a nightlight on during the evening and night
shifts
15. Which of the following is a common complaint of the client with end-stage renal failure?
❍ A. Weight loss
❍ B. Itching
❍ C. Ringing in the ears
❍ D. Bruising
16. Which of the following medication orders needs further clarification?
❍ A. Darvocet 65mg PO q 4–6 hrs. PRN
❍ B. Nembutal 100mg PO at bedtime
❍ C. Coumadin 10mg PO
❍ D. Estrace 2mg PO q day
17. The best diet for the client with Meniere’s syndrome is one that is:
❍ A. High in fiber
❍ B. Low in sodium
❍ C. High in iodine
❍ D. Low in fiber
18. Which of the following findings is associated with right-sided heart failure?
❍ A. Shortness of breath
❍ B. Nocturnal polyuria
❍ C. Daytime oliguria
❍ D. Crackles in the lungs
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Practice Exam 3 and Rationales^149
19. An 8-year-old admitted with an upper-respiratory infection has an order for O 2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
❍ A. Place the probe on the child’s abdomen
❍ B. Recalibrate the oximeter at the beginning of each shift
❍ C. Apply the probe and wait 15 minutes before obtaining
a reading
❍ D. Place the probe on the child’s finger
20. An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:
❍ A. Administer the medication using a nipple
❍ B. Administer the medication using the calibrated drop-
per in the bottle
❍ C. Administer the medication using a plastic baby spoon
❍ D. Administer the medication in a baby bottle with 1oz. of
water
21. The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for the nurse to make?
❍ A. “You will be given medicine to relax you during the
treatment.”
❍ B. “The treatment will produce a controlled grand mal
seizure.”
❍ C. “The treatment might produce nausea and headache.”
❍ D. “You can expect to be sleepy and confused for a time
after the treatment.”
22. Which of the following skin lesions is associated with Lyme’s dis- ease?
❍ A. Bull’s eye rash
❍ B. Papular crusts
❍ C. Bullae
❍ D. Plaques
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Practice Exam 3 and Rationales^151
28. An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
❍ A. Strep throat
❍ B. Epiglottitis
❍ C. Laryngotracheobronchitis
❍ D. Bronchiolitis
29. Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
❍ A. Offer the baby sterile water between feedings of for-
mula
❍ B. Apply an emollient to the baby’s skin to prevent drying
❍ C. Wear a gown, gloves, and a mask while caring for the
infant
❍ D. Place the baby on enteric isolation
30. A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
❍ A. Weighing the client after she eats
❍ B. Having a staff member remain with her for 1 hour
after she eats
❍ C. Placing high-protein foods in the center of the client’s
plate
❍ D. Providing the client with child-size utensils
31. According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is:
❍ A. Trust
❍ B. Initiative
❍ C. Independence
❍ D. Industry
32. The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
❍ A. Tinnitus
❍ B. Nausea
❍ C. Ataxia
❍ D. Hypotension
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(^152) Chapter 3
33. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
❍ A. The mottled appearance of the trunk
❍ B. The presence of conjunctival hemorrhages
❍ C. Cyanosis of the hands and feet
❍ D. Respiratory rate of 20–28 per minute
34. A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
❍ A. Periorbital edema
❍ B. Tenseness of the anterior fontanel
❍ C. Positive Babinski reflex
❍ D. Negative scarf sign
35. A client with a bowel resection and anastamosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suc- tion is working properly?
❍ A. The client’s abdomen is soft.
❍ B. The client is able to swallow.
❍ C. The client has active bowel sounds.
❍ D. The client’s abdominal dressing is dry and intact.
36. The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associ- ated with hypoglycemia?
❍ A. Tremulousness
❍ B. Slow pulse
❍ C. Nausea
❍ D. Flushed skin
37. Which of the following symptoms is associated with exacerbation of multiple sclerosis?
❍ A. Anorexia
❍ B. Seizures
❍ C. Diplopia
❍ D. Insomnia
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(^154) Chapter 3
43. The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should:
❍ A. Encourage the client to drink extra fluids
❍ B. Request a low-protein diet for the client
❍ C. Bathe the client using only mild soap and water
❍ D. Provide additional warmth for swollen, inflamed joints
44. The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
❍ A. Antabuse (disulfiram)
❍ B. Romazicon (flumazenil)
❍ C. Dolophine (methodone)
❍ D. Ativan (lorazepam)
45. A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
❍ A. 8 a.m.
❍ B. 10 a.m.
❍ C. 3 p.m.
❍ D. 5 a.m.
46. The licensed practical nurse is assisting the charge nurse in plan- ning care for a client with a detached retina. Which of the follow- ing nursing diagnoses should receive priority?
❍ A. Alteration in comfort
❍ B. Alteration in mobility
❍ C. Alteration in skin integrity
❍ D. Alteration in O 2 perfusion
47. The primary purpose for using a CPM machine for the client with a total knee repair is to help:
❍ A. Prevent contractures
❍ B. Promote flexion of the artificial joint
❍ C. Decrease the pain associated with early ambulation
❍ D. Alleviate lactic acid production in the leg muscles
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Practice Exam 3 and Rationales^155
48. Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
❍ A. Obeying adults is seen as correct behavior.
❍ B. Showing respect for parents is seen as important.
❍ C. Pleasing others is viewed as good behavior.
❍ D. Behavior is determined by consequences.
49. A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
❍ A. Determine whether the ear infection has affected her
hearing
❍ B. Make sure that she has taken all the antibiotic
❍ C. Document that the infection has completely cleared
❍ D. Obtain a new prescription in case the infection recurs
50. A factory worker is brought to the nurse’s office after a metal frag- ment enters his right eye. The nurse should:
❍ A. Cover the right eye with a sterile 4× 4
❍ B. Attempt to remove the metal with a cotton-tipped
applicator
❍ C. Flush the eye for 10 minutes with running water
❍ D. Cover both eyes and transport the client to the ER
51. The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
❍ A. Nephritis
❍ B. Cardiomegaly
❍ C. Desquamation
❍ D. Meningitis
52. Which diet is associated with an increased risk of colorectal cancer?
❍ A. Low protein, complex carbohydrates
❍ B. High protein, simple carbohydrates
❍ C. High fat, refined carbohydrates
❍ D. Low carbohydrates, complex proteins
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Practice Exam 3 and Rationales^157
58. A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
❍ A. Uses an electric blanket at night
❍ B. Dresses in extra layers of clothing
❍ C. Applies a heating pad to her feet
❍ D. Takes a hot bath morning and evening
59. A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
❍ A. A family history of laryngeal cancer
❍ B. Chronic inhalation of noxious fumes
❍ C. Frequent straining of the vocal cords
❍ D. A history of alcohol and tobacco use
60. The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious ane- mia from other types of anemia?
❍ A. Difficulty in breathing after exertion
❍ B. Numbness and tingling in the extremities
❍ C. A faster-than-usual heart rate
❍ D. Feelings of lightheadedness
61. The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
❍ A. Speak using words that rhyme
❍ B. Repeat words or phrases used by others
❍ C. Include irrelevant details in conversation
❍ D. Make up new words with new meanings
62. Which early morning activity helps to reduce the symptoms asso- ciated with rheumatoid arthritis?
❍ A. Brushing the teeth
❍ B. Drinking a glass of juice
❍ C. Drinking a cup of coffee
❍ D. Brushing the hair
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(^158) Chapter 3
63. A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
❍ A. 14 pounds
❍ B. 18 pounds
❍ C. 25 pounds
❍ D. 30 pounds
64. A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
❍ A. Tossed salad with oil and vinegar dressing
❍ B. Baked potato with sour cream and chives
❍ C. Cream of tomato soup and crackers
❍ D. Mixed fruit and yogurt
65. A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?
❍ A. Increased urinary output
❍ B. Stabilized weight
❍ C. Improved appetite
❍ D. Increased pedal edema
66. Which play activity is best suited to the gross motor skills of the toddler?
❍ A. Coloring book and crayons
❍ B. Ball
❍ C. Building cubes
❍ D. Swing set
67. The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
❍ A. Constipation
❍ B. Urinary retention
❍ C. Diarrhea
❍ D. Confusion
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(^160) Chapter 3
73. A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:
❍ A. Slow pulse rate, weight loss, diarrhea, and cardiac fail-
ure
❍ B. Weight gain, lethargy, slowed speech, and decreased
respiratory rate
❍ C. Rapid pulse, constipation, and bulging eyes
❍ D. Decreased body temperature, weight loss, and
increased respirations
74. Which statement describes the contagious stage of varicella?
❍ A. The contagious stage is 1 day before the onset of the
rash until the appearance of vesicles.
❍ B. The contagious stage lasts during the vesicular and
crusting stages of the lesions.
❍ C. The contagious stage is from the onset of the rash
until the rash disappears.
❍ D. The contagious stage is 1 day before the onset of the
rash until all the lesions are crusted.
75. A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:
❍ A. A religious experience
❍ B. A stressful event
❍ C. Low self-esteem
❍ D. Overwhelming anxiety
76. The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
❍ A. Reluctance to swallow
❍ B. Drooling of blood-tinged saliva
❍ C. An axillary temperature of 99°F
❍ D. Respiratory stridor
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Practice Exam 3 and Rationales^161
77. The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
❍ A. Skips a meal
❍ B. Rests in recumbent position
❍ C. Eats a meal
❍ D. Sits upright after eating
78. Which of the following meal selections is appropriate for the client with celiac disease?
❍ A. Toast, jam, and apple juice
❍ B. Peanut butter cookies and milk
❍ C. Rice Krispies bar and milk
❍ D. Cheese pizza and Kool-Aid
79. A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
❍ A. The client complains of blurred vision.
❍ B. The client complains of increased thirst and increased
urination.
❍ C. The client complains of increased weight gain over the
past year.
❍ D. The client complains of changes in taste.
80. A 2-month-old infant has just received her first Tetramune injec- tion. The nurse should tell the mother that the immunization:
❍ A. Will need to be repeated when the child is 4 years
of age
❍ B. Is given to determine whether the child is susceptible
to pertussis
❍ C. Is one of a series of injections that protects against
dpt and Hib
❍ D. Is a one-time injection that protects against MMR and
varicella
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Practice Exam 3 and Rationales^163
86. A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
❍ A. Apply a lanolin-based lotion to the skin
❍ B. Wash the skin with water and pat dry
❍ C. Cover the area with a petroleum gauze
❍ D. Apply an occlusive dressing to the site
87. A client with a laryngectomy returns from surgery with a nasogas- tric tube in place. The primary reason for placement of the naso- gastric tube is to:
❍ A. Prevent swelling and dysphagia
❍ B. Decompress the stomach via suction
❍ C. Prevent contamination of the suture line
❍ D. Promote healing of the oral mucosa
88. The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
❍ A. Speaking and writing
❍ B. Comprehending spoken words
❍ C. Carrying out purposeful motor activity
❍ D. Recognizing and using an object correctly
89. A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
❍ A. Just before sun exposure
❍ B. 5 minutes before sun exposure
❍ C. 15 minutes before sun exposure
❍ D. 30 minutes before sun exposure
90. A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications pro- duces a/an:
❍ A. Agonist effect
❍ B. Synergistic effect
❍ C. Antagonist effect
❍ D. Excitatory effect
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91. Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
❍ A. Record the pulse rate and administer the medication
❍ B. Administer the medication and monitor the heart rate
❍ C. Withhold the medication and notify the doctor
❍ D. Withhold the medication until the heart rate increases
92. What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
❍ A. Solid foods should not be given until the extrusion
reflex disappears, at 8–10 months of age.
❍ B. Solid foods should be introduced one at a time, with
4- to 7-day intervals.
❍ C. Solid foods can be mixed in a bottle or infant feeder to
make feeding easier.
❍ D. Solid foods should begin with fruits and vegetables.
93. A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
❍ A. Withholding all morning medications
❍ B. Ordering a CBC and CPK
❍ C. Administering prescribed anti-Parkinsonian medication
❍ D. Transferring the client to a medical unit
94. A client with human immunodeficiency syndrome has gastroin- testinal symptoms, including diarrhea. The nurse should teach the client to avoid:
❍ A. Calcium-rich foods
❍ B. Canned or frozen vegetables
❍ C. Processed meat
❍ D. Raw fruits and vegetables
95. A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
❍ A. Abdominal pain and anorexia
❍ B. Fatigue and bruising
❍ C. Bleeding and pallor
❍ D. Petechiae and mucosal ulcers
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