RENR PRACTICE TEST 11

1. A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the
following statements by the client DOES NOT indicate an understanding of safe management?
A. “I will clean the pins twice a day.”
B. “I will use a separate cotton swab for each pin.”
C. “I will report loosening of the pins to my doctor.”
D. “I will move my leg by lifting the device in the middle.”

2. A nurse is assessing a client who has a casted compound fracture of the right forearm. Which of the following
findings is an early indication of neurovascular compromise?
A. Paresthesia
B. Pulselessness
C. Paralysis
D. Pallor

3. A nurse is completing an assessment of a client who had an external fixation device applied 2 hr ago for a
fracture of the left tibia and fibula. Which of the following findings DOES NOT indicate compartment
syndrome?
A. Intense pain when the left foot is passively moved
B. Edematous left toes compared to the right
C. Hard, swollen muscle in the left leg
D. Burning and tingling of the distal left foot

4. A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which
of the following information should the nurse include in the teaching?
A. Antibiotic therapy should continue for 3 months.
B. Relief of pain indicates the infection is eradicated.
C. Contact precautions are used during wound care.
D. Dressing changes are performed using aseptic technique.

5. A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the
following immobilization devices should the nurse anticipate in the plan of care?
A. Skeletal traction
B. Buck’s traction
C. Halo traction
D. Gardner-Wells traction

An 18 year old mother brought her 6 months old infant to the clinic for a checkup. She also brought her 3 year
old son.

6. In assessing the abdomen of the 6 month old child, inspection and auscultation precede percussion and
palpation because
a. Percussion and palpation may stop peristalsis
b. Palpation and auscultation distress the child
c. Percussion and palpation may disturb bowel sounds
d. Percussion and palpation are not usually done on a child

7. the mother states that her 3 year old child does not seem to talk as well as her neighbour’s daughter, who is
the same age. The nurse’s BEST reply would be
a. “Your child should be evaluated”
b. “All children develop at their own speed”
c. “What is the neighbor’s child’s speech like?”
d. “You should focus on improving your child’s speech”

8. The three year old is protesting bedtime. Which of the following suggestions should the nurse include in a
teaching session with the mother?
a. “He is spoiled”
b. “ he needs to be evaluated”
 c. “put him to bed at the regular time”
d. “bring him into bed with you until he falls asleep

9. The three year old child is beginning to tell tales and lies. The nurse should suggest to the child’s mother that
the child
a. Is showing insecurity
b. Is making conversation
c. Is old enough to tell fact from fiction
d. Should be punished whenever this happens

10. Which of the following statements by the mother would indicates to the nurse that this three year old is
achieving the normal developmental milestones?
a. “he accepts limits”
b. “he shares his toys”
c. “he dresses himself”
d. “he helps with chores”
___________________________________________________________________

11. A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following clinical
manifestations should the nurse LEAST expect to find?
A. Heberden’s nodes
B. Small body frame
C. Enlarged joint size
D. Limp when walking

12. A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the
following information should the nurse NOT include in the information?
A. Apply heat to joints to alleviate pain.
B. Ice inflamed joints following activity.
C. Install an elevated toilet seat.
D. Take tub baths.

13. A nurse is providing information about capsaicin (Capsin) cream to a client who reports continuous knee
pain from osteoarthritis. Which of the following information should the nurse include in the discussion?
A. Continuous pain relief is provided.
B. Inspect for skin irritation and cuts prior to application.
C. Cover the area with tight bandages after application.
D. Apply the medication every 2 hr during the day.

14. A nurse is preparing a client who is to receive hyaluronic acid (Synvisc) injection for osteoarthritis. Which
of the following statements by the nurse is appropriate?
A. “Hyaluronic acid is currently approved for shoulder joint inflammation.”
B. “Report an allergy to shellfish before receiving hyaluronic acid.”
C. “Hyaluronic acid is a natural joint replacement fluid.”
D. “Hyaluronic acid is made from the combs of chickens.”

15. A nurse is providing educational information on glucosamine to a group of clients at a health fair. Which of
the following should the nurse include in the teaching?
A. It decreases the amount of synovial fluid produced in the joints.
B. The medication aids in the rebuilding of cartilage.
C. A prescription is required for this medication.
D. This medication is injected into the joint to decrease joint pain.

16. A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory
findings should the nurse anticipate reviewing to confirm this diagnosis?
A. Potassium hydroxide (KOH)
B. Culture and sensitivity
C. Tzanck smear report (A Tzanck smear report confirms if a skin lesion is viral in origin.)
D. Biopsy
17. A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection.
All of the following are actions the nurse should take EXCEPT?
A. Scrape the site with a wooden tongue depressor.
B. Puncture the crusted area with a sterile needle.
C. Place cotton-tipped applicator in culturette tube.
D. Place culturette tube in ice.

18. A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of
the following information should the nurse include in the teaching?
i. Bathe with antibacterial soap.( To reduce bacterial count on the skin)
ii. Apply antibacterial topical medication to the crusted exudate.
iii. Apply warm compresses to the affected area.
iv. Cover affected area with snug fitting clothing.
A. i, ii, iii
B. i and iii
C. ii and iii
D. iii only

19. A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. Which of the
following client statements indicates a need for further teaching?
A. “I can expect redness around the site for 3 days.”
B. “I will call my doctor if I have a fever.”
C. “I should apply an antibiotic ointment to the area.”
D. “I will make a return appointment in 7 days for removal of my sutures.”

The client should report redness, pain, drainage, or warmth at the biopsy site to
the provider.

20. A nurse is providing teaching to a client about a new prescription for clotrimazole (Lotrimin). Which of the
following should the nurse include in the teaching?
A. “It reduces the discomfort of a herpetic infection.”
B. “This is a cream to treat a bacterial infection.”
C. “Apply the topical medication for up to 2 weeks.”
D. “Allow the area to remain moist before applying.”

21. A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild
psoriasis. Which of the following should the nurse NOT include in the information?
A. Apply an occlusive dressing after application.
B. Apply three to four times per day.
C. Wear gloves after application to lesions on the hands.
D. Avoid applying in skin folds.

Corticosteroid cream is applied twice daily to prevent development of local and

22. A nurse is teaching a client who has a history of psoriasis about photo chemotherapy and ultraviolet light
(PUVA) treatments. Which of the following should the nurse include in the teaching?
A. Apply coal tar before each treatment.
B. Administer a psoralen medication before the treatment.
C. Use this treatment every evening.
D. Remove the scales gently following each treatment.

23. A nurse is educating a female client on the use of calcipotriene (Dovonex) topical medication for the
treatment of psoriasis. Which of the following information should the nurse NOT include?
A. Recommended for facial lesions.
B. Expect a stinging sensation upon application.
C. Apply to the scalp.
D. Obtain a pregnancy test.
24. A nurse is providing teaching to a client who has a prescription for methotrexate (Trexall) for severe
psoriasis. Which of the following information should the nurse include?
A. Drink a glass of wine daily.
B. Monitor for evidence of infection.
C. Monitor kidney function tests regularly.
D. Expect increased bruising.

25. A nurse is assessing a client who has seborrheic keratosis on the forehead and nose. Which of the following
manifestations should the nurse expect to find?
i. Waxy appearance of the lesions
ii. Black, rough lesions
iii. Pruritus of the lesions
iv. Wartlike surface of the lesions
A. i, ii iii
B. i, ii, iv
C. i, iii, iv
D. ii, iii, iv

26. A nurse working in a provider’s office is assessing a client who has severe sunburn. Which of the following
is the proper classification of this burn?
A. Superficial
B. Superficial partial-thickness
C. Deep partial-thickness
D. Full-thickness

27. A nurse is caring for a client who has sustained burns to 35% of his total body surface area. Of this total,
20% are full-thickness burns on the arms, face, neck, and shoulders. The client’s voice is hoarse, and he has a
brassy cough. These findings are indicative of which of the following?
A. Pulmonary edema
B. Bacterial pneumonia
C. Inhalation injury
D. Carbon monoxide poisoning

28. A nurse is caring for a client who was admitted 24 hr ago with deep partial-thickness and full-thickness
burns to 40% of his body. Which of the following are expected findings in this client?
A. Hypertension
B. Bradycardia
C. Hyperkalemia
D. Decreased hematocrit
Hyperkalemia, hyponatremia

29. A nurse is preparing to administer fentanyl (Sublimaze) to a client who was admitted 24 hr ago with deep
partial-thickness and full-thickness burns over 60% of his body. The nurse should plan to use which of the
following routes to administer the medication?
A. Subcutaneous
B. Intramuscular
C. Intravenous
D. Transdermal

30. A nurse is planning care for a client who has burn injuries. Which of the following interventions should be
included in the plan of care?
A. Use standard precautions when performing wound care.
B. Encourage fresh vegetables in the diet.
C. Increase fat intake.
D. Instruct client to consume 3,000 calories daily.

31. A client asks a nurse why the provider bases his medication regimen on his HbA1c instead of his log of
morning fasting blood glucose results. Which of the following is an appropriate response by the nurse?
A. “HbA1c measures how well insulin is regulating your blood glucose between meals.”
B. “HbA1c indicates how well your blood glucose has been regulated over the past 3 months.”
C. “A test of HbA1c is the first test to determine if an individual has diabetes.”
D. “A test of HbA1c determines if the dosage of insulin needs to be adjusted.”

32. A nurse is reviewing the laboratory findings of a client who has suspected hyperthyroidism. An elevation of
which of the following supports this diagnosis?
A. Triiodothyronine (T3)
B. Vanillylmandelic acid (VMA)
C. Adrenocorticotropic hormone (ACTH)
D. Glycosylated hemoglobin (HbA1c)

33. A nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which of the following laboratory findings should the nurse anticipate?
i. Low serum sodium
ii. High serum potassium
iii. High urine sodium
iv. Increased urine-specific gravity
A. i and ii
B. i, ii and iii
C. i, iii and iv
D. iii and iv

34. A nurse is caring for a client who has primary adrenal insufficiency. Which of the following findings should
the nurse anticipate after an IV injection of ACTH 1.0 mg?
A. Decrease in serum plasma cortisol
B. Elevated fasting serum blood glucose
C. Decrease in serum sodium
D. Increase in urinary output

35. A nurse is providing teaching to a client who is scheduled for a phentolamine blocking test. This test
supports a diagnosis for which of the following disorders?
A. Addison’s disease
B. Diabetes mellitus
C. Cushing’s disease
D. Pheochromocytoma

36. A nurse is caring for a client who has primary diabetes insipidus. Which of the following manifestations
should the nurse LEAST expects to find?
A. Serum sodium of 155 mEq/L
B. Fatigue
C. Serum osmolality of 250 mOsm/L
D. Polyuria

37. A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory
findings should the nurse anticipate?
A. Absence of glucose
B. Decreased specific gravity
C. Presence of ketones
D. Presence of red blood cells

38. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of
the following findings should the nurse expect?
A. Decreased serum sodium
B. Urine specific gravity 1.001
C. Polyuria
D. Increased thirst

39. A nurse is assessing a client who has SIADH. Which of the following findings indicate the client is
experiencing a complication?
A. Decreased central venous pressure (CVP)
B. Increased urine output
C. Distended neck veins
D. Extreme thirst

40. A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the
following statements by the client requires further teaching?
A. “I can drink up to 2 quarts of fluid a day.”
B. “I should expect to urinate frequently at night.”
C. “I may experience headaches.”
D. “I may experience a dry mouth.”
Excessive thirst is a manifestation of DI. Consumption of 4 to 30 L per day can be expected, and fluid
intake should not be limited.

41. A nurse in a provider’s office is reviewing the health record of a client who is being evaluated for Graves’
disease. Which of the following is an expected laboratory finding for this client?
A. Decreased thyrotropin receptor antibodies
B. Decreased thyroid stimulating hormone
C. Decreased free thyroxine index
D. Decreased triiodothyronine

42. A nurse is reviewing the clinical manifestations of hyperthyroidism with a client. Which of the following
findings should the nurse include?
A. Dry skin
B. Heat intolerance
C. Constipation
D. Bradycardia
Hyperthyroidism increases the client's metabolism. Therefore, heat intolerance, palpitations, and weight
loss are expected findings.
43. A nurse is providing instructions to a client who has Graves’ disease and has a new prescription for
propranolol (Inderal). Which of the following information should the nurse include?
A. An adverse effect of this medication is jaundice.
B. Take your pulse before each dose.
C. The purpose of this medication is to decrease production of thyroid hormone.
D. You should stop taking this medication if you have a sore throat.

44. A nurse is preparing to receive a client from the High Dependency Unit who is postoperative following a
thyroidectomy. Which of the following equipment is NOT necessary?
A. Suction equipment
B. Humidified air
C. Flashlight
D. Tracheostomy tray

45. A nurse in a provider’s office is planning care for a client who has a new diagnosis of Graves’ disease and a
new prescription for methimazole (Tapazole). Which of the following should the nurse NOT include in the plan
of care?
A. Monitor CBC.
B. Monitor triiodothyronine (T3).
C. Inform the client that the medication should not be taken for more than 3 months.
D. Advise the client to take the medication at the same time every day.

46. A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following
findings are indicative of thyroid crisis?
A. Hypothermia
B. Tremors
C. Abdominal pain
D. Mental confusion
Excessive levels of thyroid hormone can cause a client to experience tremors.
When thyroid crisis occurs, the client can experience G.I. conditions, such as vomiting, diarrhea, and abd
pain. 
Excessive thyroid hormone levels can cause the client to experience mental confusion.
47. A nurse in a provider’s office is reviewing the laboratory findings of a client who is being evaluated for
primary hypothyroidism. Which of the following laboratory findings is expected for a client who has
this condition?
A. Serum T4 10 mcg/dL
B. Serum T3 200 ng/dL
C. Hematocrit 34%
D. Serum cholesterol 180 mg/Dl
Hematocrit of 34% indicates anemia, which is an expected result for a client who has
hypothyroidism.

48. A nurse is collecting an admission history from a female client who has hypothyroidism. Which of the
following findings is the LEAST expected with this condition?
A. Menorrhagia
B. Dry skin
C. Increased libido
D. Hoarseness

49. A nurse is reinforcing teaching with a client who has been prescribed levothyroxine (Synthroid) to treat
hypothyroidism. Which of the following should the nurse NOT include in the teaching?
A. Weight gain is expected while taking this medication.
B. Medication should not be discontinued without the advice of the provider.
C. Follow-up serum TSH levels should be obtained.
D. Take the medication on an empty stomach.

50. A nurse in an intensive care unit is admitting a client who has myxedema coma. Which of the following
should the nurse anticipate in caring for this client?
i. Observe cardiac monitor for inverted T wave.
ii. Observe for evidence of urinary tract infection.
iii. Initiate IV fluids using 0.9% sodium chloride.
iv. Expect a prescription for levothyroxine (Synthroid) IV bolus.
A. i, ii, iii
B. i, iii, iv
C. i, ii, iv
D. i, ii, iii, iv

A 28 year old primigravida is making her first visit to the antenatal clinic at 13 weeks gestation. Her last normal
menstrual period (LNMP) was on the 28th September, 2009.

51. The patient expected date of delivery (EDD) is

52. The following represents weight in pounds that this patient is expected to gain during her pregnancy?
a. 15 – 20 lbs
b. 20 – 25 lbs
c. 25 – 30 lbs
d. 30 – 35 lbs

53. The patient’s appoint schedule to attend clinic over the next 3 months should be
a. Weekly
b. Two weekly
c. Four weekly
d. Six weekly

54. A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse
expects which finding on inspection and palpation of this patient?
a. 1+ edema of the feet and ankles bilaterally
 b. The circumference of the right leg is larger than the left leg
c. Patchy petechiae and purpura of the lower extremities
d. Cool feet with capillary refill of toes greater than 3 seconds

55. How is the first heart sound (S1) created?

56. Which communication technique is used more in crisis intervention than traditional counseling?
a. Role modeling
b. Giving direction
c. Information giving
d. Empathic listening

57. Which situation demonstrates the use of primary care related to crisis intervention?
a. Implementing suicide precautions for a patient with depression.
b. Teaching stress reduction techniques to a beginning student nurse.
c. Assessing coping strategies used by a patient who has attempted suicide.
d. Referring a patient with schizophrenia to a partial hospitalization program.

58. A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention
strategies that focus on:
a. supporting emotional security and reestablishing equilibrium.
b. offering long-term resolution of issues precipitating the crisis.
c. promoting growth of the individual.
d. providing legal assistance.

59. After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance.
What type of crisis has occurred?
a. Reactive
b. Situational
c. Maturational
d. Adventitious
Maturational crises occur when a person arrives at a new stage of development and finds that old coping
styles are ineffective but has not yet developed new strategies. Situational crises arise from sources
external to the individual, such as divorce and job loss. No classification called reactive crisis exists.
Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent
crimes disrupt coping styles
60. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was
prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What common
side effects should the nurse validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose

61. A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication
management. The patient repeatedly says, I don’t like taking pills. Which treatment strategy should the nurse
discuss with the health care provider?
a. Use of a long-acting antipsychotic injections
b. Addition of a benzodiazepine, such as lorazepam (Ativan)
c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil)
d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

62. A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the
patient may be hallucinating?
a. Aloofness, haughtiness, suspicion
b. Darting eyes, tilted head, mumbling to self
c. Elevated mood, hyperactivity, distractibility
d. Performing rituals, avoiding open places

63. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with
schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and
has hypertension. Which drug should the nurse advocate?
a. clozapine (Clozaril)
b. ziprasidone (Geodon)
c. olanzapine (Zyprexa)
d. aripiprazole (Abilify)

64. The elderly spouse of a 74-year-old male client states that she has noticed that her husband doesn’t
remember as well as he used to. She explains that he has been putting on his coat before his shirt, and that he
can never get their checkbook to balance as it did in the past. The client is exhibiting signs and symptoms
typical of:
a. Vascular dementia
b. Alzheimer’s disease
c. Acute delirium
d. Aging

65. The affective losses of Alzheimer’s disease refer to losses noticed in the individuals:
a. Personality
b. Thought processes
c. Ability to make and carry out plans
d. Self-care
Affective losses result in personality changes in the individual with Alzheimer’s disease. Thought processes
and self-care do not relate to the individual’s personality, and the ability to make and carry out plans is
referred to as cognitive loss.

66. The nurse manager plays a unique role in institutional management in that the nurse manager:
a. Encourages shared decision making.
b. Models professional nursing behavior.
c. Interprets healthcare trends and their impact on revenues.
d. Coordinates care and allocates resources.

67. For those family members who desire to care at home for loved ones who have been given a diagnosis of
Alzheimer’s disease, it is important for the nurse to ensure that the family is aware of which caregiver skills and
responsibilities will be necessary. What is one of the responsibilities of the caregiver during the middle stage of
the disease?
a. Helping the loved one with memory and communication problems
b. Providing a stable, routine environment
c. Providing complete assistance with physical care
d. Adapting to the changing personality and behavior of the loved one
The middle stage is when personality changes begin to occur. It is difficult for the family to see the loss of their
loved one’s personality. Helping with memory and communication problems and providing a stable, routine
environment occur in the early stage, and complete assistance with physical care is typically a responsibility of the
caregiver during the severe stage.
68. Decisions about a terminally ill clients remaining time belong to the:
a. Person
b. Family members
c. Medical care team
d. Spiritual advisor
In a “good death,” a person controls his or her own destiny.

69. Two nurses on a psychiatric unit come from different backgrounds and have graduated from different
universities. They are given a set of new orders from the unit manager. Each nurse displays different emotions
in response to the orders. Nurse A indicates that the new orders include too many changes; Nurse B disagrees
and verbally indicates why. This step in the process is which of the following in Thomas Stages of Conflict?
a. Frustration
b. Conceptualization
c. Action
d. Outcomes
Thomas’ Stages of Conflict include conceptualization, which involves different ideas and emphasis on what
is important or not or about what should occur.

70. The father of three young children dies. The wife expresses how worried she is about how to raise the
children on her own without the support of her husband. She finds herself crying and living through each day
without accomplishing anything. In which grieving stage is this behavior typically experienced?
a. Denial
b. Depression and identification
c. Acceptance and recovery
d. Yearning
ANS: D This is the second stage of grieving, in which the person longs for the deceased and feels overwhelmed
by the loss. Denial is the first stage of grieving, when the person is in shock and rejects the loss of another;
depression and identification is the third stage of grieving, characterized by depressed feelings followed by a
period of sharing memories and seeking support from others; and acceptance and recovery is the phase of the
grieving process during which individuals begin to focus their energies toward the living and their lives begin to
stabilize

71. Three years after the loss of her husband of 35 years, the wife has a full-time job but finds that she cannot
sleep well at night, has frequent mood changes, and attends the couple’s night out with friends that she and her
husband attended. Upon seeking counseling, she discovers that she is exhibiting symptoms of:
a. Bereavement-related depression
b. Complicated grief
c. Anticipatory grief
d. Caregiver grief

B
These are characteristic symptoms of complicated grief in which an individual experiences persistent
yearning for the deceased person without signs of depression. Bereavement-related depression refers to
depression following a loss that consumes every aspect of a person’s life; anticipatory grief refers to grief
felt in anticipation of a loss; and caregiver grief refers to grief felt by health care providers.

72. The nurse is caring for a female client with a diagnosis of severe bipolar disorder. Out of many treatment
methods, the one treatment that the client and the team have found to be most effective is the medication
lithium. The client voices concern about her future with this diagnosis.
Which nurse response best represents the concept of hope?
a. You need to take your lithium unless you want to relapse.
b. You are doing so well that there is nothing you can’t do if you put your mind to it.
c. You are doing very well since we found that lithium helps. You should do well as long as you continue your
therapy and medication.
d. A lot of people are much worse off than you are, so you should be thankful that you are doing as well as you
are.
C
This option is realistic and provides hope without providing false hope. Stating that the client will relapse if
she discontinues medication suggests that the nurse is threatening the client, which provides no hope.
Telling the client that “there is nothing that you can’t do” may be providing false hope. Reminding the client
that others are worse off is disregarding the client’s feelings.

73. A male client with schizophrenia has lost his job and home and has been living in a homeless shelter. He
voluntarily admits himself into a mental health treatment facility. The clients current living situation and lack of
a job at this time likely will contribute to his having difficulty with which dimension of hope?
a. Affective
b. Contextual
c. Temporal
d. Affiliative
ANS: B Although all the dimensions of hope listed in these options may be difficult for this client, the
dimension that is representative of the living and job situation for this client is contextual, because this refers to
inadequate physical, financial, and emotional resources.

74. A female client with obsessive-compulsive disorder is undergoing treatment in an outpatient setting and is
attending group therapy sessions. She is working on controlling the compulsion of touching her head three times
every time she talks. To maintain the therapeutic relationship established with the client, by which action can
the nurse show acceptance?
a. Ignoring the compulsion during the group therapy session and talking with the client privately about the
behavior
b. Asking the group to remind the client every time she touches her head to help her consciously stop the
compulsion
c. Pointing out the compulsion to the group each time the client exhibits the behavior
d. Asking the client to stop talking during the group session until she has learned to control her compulsion
ANS: A Ignoring the behavior in group therapy shows acceptance of the behavior because the nurse does not
embarrass the client in front of the group. Talking with her privately shows compassion for the client. Asking
the group to remind the client of the compulsion and pointing out the compulsion to the group could belittle the
client. Asking the client to stop talking would defeat the purpose of the support of belonging to a therapeutic
group

75. The characteristic of genuineness helps in establishing a therapeutic relationship with a client. Which nurse
response is the best example of a display of genuineness to a client who is going through a difficult divorce?
a. I know exactly how you feel. My husband and I divorced 2 years ago because of his infidelity.
b. Divorcing my husband was the best thing I ever did.
c. I have friends who have gone through a divorce. It must be difficult for you.
d. I am sorry that you have to go through this difficult time.
ANS: C This response shows the client sincerity and honesty, which are components of being genuine. The
nurse should not offer too much personal information, such as providing information about her own divorce.
When the nurse says that she is sorry that the client is experiencing the difficult time, it is an example of a
sympathetic response
76. During the preparation phase of a therapeutic relationship with a client, what is the main task to be
completed by the nurse?
a. To establish with the client the purpose of the relationship
b. To gather and review all possible information regarding the client
c. To build trust with the client
d. To obtain agreement from the client to work in conjunction with the nurse

B
The main task during the preparation phase is to gather and review all possible information regarding the
client; this can be accomplished by obtaining data from past and current medical records and from the
client’s significant others. The other options are tasks that occur during the orientation phase.

77. When should the nurse begin preparations for the termination phase of a therapeutic relationship?
a. During the orientation phase
b. Prior to the last meeting
c. During the last meeting
d. After all goals have been met

ANS: B Preparing for termination of the relationship should begin prior to the last meeting to allow for review
of whether goals have been met and to prepare for client independence. The orientation phase is too early in the
relationship to prepare for termination, and the last meeting is too late. Unfortunately, not all goals are always
met, so preparing for termination of the relationship after goals have been met may not be a possibility

78. The nurse is preparing an adult male client, who has been successfully treated for a social phobia, for the
termination phase of the therapeutic relationship. During their last meeting, the client told the nurse that he
noticed he has developed a nervous habit that started a few days ago of checking his door at home several times
a day to be sure it is locked. This client is exhibiting the client response to termination known as:
a. Continuation
b. Regression
c. Withdrawal
d. Confabulation
ANS:A
Continuation sometimes occurs when a client is fearful of ending the therapeutic relationship. This response is
characterized by a client’s trying to continue the relationship by bringing up new problems or having the
caregiver solve his problems. Regression and withdrawal are also client responses to termination, but they do
not fit the description in this situation. Confabulation is not a response to termination. It refers to the making up
of answers by a client who is experiencing a memory loss

79. When a caregiver becomes a role model for a client during a therapeutic relationship, the caregiver is
functioning in the role of:
a. Teacher
b. Therapist
c. Technician
d. Change agent
ANS:D
Serving as a role model is one of the many functions of a change agent. The role of a change agent also
includes promoting a climate of anticipation of positive change for the client and serving as a socializing
agent. The other options are roles of the caregiver, but role model is not included in those roles.

80. The turnover rate for RNs in the ICU is high. You discuss this situation with existing staff and you find out
that because of the rapid turnover, new staff are frequently required to assume full responsibilities soon into the
position and before training is completed. In considering approaches that will reduce turnover rates, the staff
and you decide to implement:
a. An employee recognition program.
b. Coaching for new staff.
c. A new performance appraisal system.
d. A committed orientation and training program
ANS:   D
Retention of new nursing personnel begins on the day of their hire. This includes an effective, appropriate
orientation and training program, which has a measurable impact on reducing turnover

81. Why is it important to avoid killing off normal flora with antibacterial drugs?
a. Normal flora can help provide protection against the development of pathogenic infections.
b. Normal flora result in opportunistic infections while other bacteria result in pathogenic infections.
c. When normal flora are not present, the immune system is suppressed, increasing the risk for infection.
d. When normal flora are not present, the immune system is overactive, increasing the risk for autoimmune
diseases.
ANS: A
Normal flora are the non pathogenic bacteria that are always present on skin mucus membrane and in digestive
tracts. They provide protection by crowding out pathogenic orgaism and preventing them from entering the
body
82. The biggest challenge in the recruitment of staff is:
a. Finding well-qualified candidates who can function well within your particular work culture.
b. Recruiting individuals with the appropriate qualifications and experience.
c. Screening out candidates who are unable to function well within a team.
d. Determining if candidates have had previous negative experiences in a work environment
Finding well-qualified candidates who can function well within your particular work culture. Finding well-qualified
candidates who can function well within your particular work culture.

83. What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
a. Guide the child to the floor if the child is standing, and then go for help.
b. Move objects out of the child’s immediate area.
c. Stick a padded tongue blade between the child’s teeth.
d. Manually restrain the child.
ANS:   B
During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

84. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would
the nurse expect to assess after a generalized tonic-clonic seizure?
a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiety

ANS:   B
Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time
(postictal lethargy) and then return to full consciousness.

85. What would the nurse include when creating a teaching plan that includes the long-term administration of
phenytoin (Dilantin)?
a. The medication should be given on an empty stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularly to prevent hyperplasia.
d. Blood pressure should be closely monitored

ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently
causes drowsiness and should be given with meals at the same time each day.
.

86. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits
jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed

ANS: C
Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of
muscles jerky and uncoordinated.

87. Which assessment finding in a child with meningitis should be reported immediately?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
ANS: A
Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported
immediately because they could indicate increased intracranial pressure

88. The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A).
What might this indicate?
a. Bleeding from the surgical site
b. Pain at the incision area
c. Sore throat from postnasal drip
d. Potential vomiting
ANS: A
Hemorrhage is the most common postoperative complication. Blood trickling down the back of the child's
throat could cause frequent swallowing.

89. What is the best choice for fluid replacement that the nurse can offer a child who has just had a
tonsillectomy?
a. A popsicle
b. Chocolate milk
c. Orange juice
d. Cola drink
ANS: A
Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as
natural juices. A Popsicle is usually well-tolerated
90. When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the
nurse immediately report?
a. Respiration rate decrease from 40 to 32 breaths/min
b. Heart rate decrease from 110 to 100 beats/min
c. Quiet chest from previous assessment of wheezing
d. Oxygen saturation of 90%
ANS: C
A "quiet chest" after assessment of wheezing indicates occlusion of air pathways and impending
respiratory arrest. All other options are within normal range for infants undergoing oxygen administration

91. Which of the following statements describes the purpose of the nursing process?
a. Process of documentation designed to decrease liability
b. Process designed to maximize reimbursement potential
c. A sophisticated time-management strategy
d. Process used to identify and solve patient problems
ANS:   D

A
Although proper documentation is part of the nursing process, it is a problem-solving process, not a
documentation process.
B
The nursing process is not used with reimbursement potential in mind.
C
The nursing process is not a time-management strategy.
D
The purpose of the nursing process is to identify and solve patient problems.
92. A researcher working for Google collects data on fair treatment in the workplace. He attempts to attach one
of the raw data forms to a message to himself, so that he can finish the data analysis at home that evening, but
accidentally sends it to another employee who had provided data for the study. The two employees,
coincidentally, have an identical opinion about fair treatment in the workplace. This best describes an example
of a violation of which of the following human rights?
a. Confidentiality
b. Fair treatment
c. Protection from harm
d. None of these no ethical violation occurred, because the two subjects share a point of view.
ANS:   A
Confidentiality is the researcher’s management of private information shared by a subject that must not be
shared with others without the authorization of the subject. In the example, sending one research subject the
raw data of a different subject is a direct breach of confidentiality. A breach in confidentiality can occur
when a researcher, by accident or direct action, allows an unauthorized person to gain access to raw study
data. The right to fair treatment is based on the ethical principle of justice. This principle holds that each
person should be treated fairly and should receive what he or she is due or owed. The right to protection
from discomfort and harm is based on the ethical principle of beneficence, which holds that one should do
good and, above all, do no harm.

93. The nurse observes a patient lying rigidly in bed and taking shallow breaths. The patient reports a pain score
of 4 out of 5 and says, My leg hurts. The nurse determines that the objective and subjective data are
a. incongruent and require more assessment.
b. insufficient to make any conclusions.
c. congruent and support that the patient is in pain.
d. unclear; the nurse needs to talk to the patients family for more information.
ANS:   C

A
The statement and behaviors observed indicate that the patient is experiencing pain.
B
One can make a conclusion because there is sufficient information available.
C
The patient states he/she is in pain and the rigid positioning and shallow breathing are behaviors found
when individuals experience pain.
D
The subjective nature of pain requires obtaining the information from the patient if at all possible. The
family can be an excellent source of information if the patient is unable to cooperate with the nurse's
assessment.

94. A nursing manager wants the unit staff to become more involved in research. The staff nurses say they are
not qualified to conduct research. Which response by the manager is best?
a. You need a basic understanding of the research process because you should be good consumers of research.
b. At the staff nurse level, you can assist with clinical studies by doing data collection.
c. A baccalaureate-prepared nurse should be able to design simple studies.
d. If we all work on this together, we can design and implement good research studies
ANS:   A
A
Nurses at all levels of basic preparation become consumers of research when they enter practice, so they
need a good understanding of the process.
B
Staff nurses might be asked to assist in data collection, but this option does not fully explain why they
should be involved in research.
C
The masters-prepared nurse should be able to design replication studies.
D
Without the educational background that prepares a nurse to conduct research, even a team effort will
probably not yield high quality studies.

95. The nurse forgets to give the patient a dose of antibiotic. Later in the shift, the patient goes into cardiac
arrest and dies. What element is lacking to support malpractice?
a. Duty of care
b. Breach of duty
c. Specific injury
d. Proximate cause
ANS:   D

A
There is nothing to support that the nurse did not assume the duty of care of the patient.
B
Although the nurse breached her duty by not administering the antibiotic, there also has to be support that
this action caused the injury.
C
Although one might claim injury (cardiac arrest and death), the link to the nurse's action is not supported.
D
There is no support that failing to administer the antibiotic caused the cardiac arrest and death.

96. The nurse assists the patient with a bath in the morning because the patient has a cast on one hand and an
intravenous line in the other. The nurse could be basing care on the philosophy of
a. Henderson.
b. Nightingale.
c. Roy.
d. Watson
ANS:   A

A
Henderson identified 14 basic needs as a general focus for patient care. She proposed that these needs
shaped the fundamental elements of nursing care. One of these needs is to keep the body clean, and the
nurse is assisting the patient to meet this need because the patient is unable to perform the function alone.
B
Nightingale believed that the health of patients was related to their environment. She recognized the
importance of clean air and water, adequate ventilation and sunlight, a balanced diet, and cleanliness.
C
Roy focused on the individual as a biopsychosocial adaptive system and described nursing as a humanistic
discipline that emphasized the person's adaptive abilities.
D
Watson's carative factors guide nurses who use transpersonal caring in practice. She believes that nurses
have the responsibility for creating and maintaining an environment supporting human caring while
recognizing and providing for patients' primary human requirements

97. The nurse adjusts the patient’s room to allow the patient to see the sunlight out the window and checks the
patient’s diet tray to ensure a balanced diet. The nurse could be basing care on the philosophy of
a. Henderson.
b. Nightingale.
c. Roy.
d. Watson
ANS:   B

A
Henderson identified 14 basic needs as a general focus for patient care. She proposed that these needs
shaped the fundamental elements of nursing care.
B
Nightingale believed that the health of patients was related to their environment. She recognized the
importance of clean air and water, adequate ventilation and sunlight, a balanced diet, and cleanliness.
C
Roy focused on the individual as a biopsychosocial adaptive system and described nursing as a humanistic
discipline that emphasized the person's adaptive abilities.
D
Watson's carative factors guide nurses who use transpersonal caring in practice. She believes that nurses
have the responsibility for creating and maintaining an environment supporting human caring while
recognizing and providing for patients' primary human requirements

98. The nurse is caring for a postoperative patient who is unable to feed himself and complete basic activities of
daily living. The nurse does catheter care and changes the surgical dressing, as well as assisting with feeding
and hygiene. The nurse could be basing care on the conceptual model of
a. Johnson.
b. King.
c. Orem.
d. Roy.

99. Peplau’s theory focuses on the therapeutic relationship as the key to successful nursing intervention. Which
of the following is correct about Peplau’s theory?
a. It is a grand theory that demonstrates that defining nursing was more important than application to practice.
b. Her theory developed from her work with oncology patients.
c. The theory describes six key nursing roles that are flexibly used, depending on the practice setting.
d. Her theory describes nursing roles as mother, technician, salesman, scholar, and advocate.
ANS:   C

A
Most nursing theorists develop midrange theories that are applicable to practice or education.
B
Peplau's work was with psychiatric patients.
C
Peplau's theory focuses on the therapeutic relationship between the nurse and patient. The nurse's role is
one of six that may change with the situation or practice setting.
D
Peplau described the roles of nurse as counselor, resource, teacher, technical expert, surrogate, and leader.

100. A nurse practitioner caring for a diabetic patient thinks the patient could gain better control of the diabetes
if the patient lost weight. After assessing the patient’s perception of weight loss, role, stresses, and support
systems, the nurse and patient establish the goal of losing 5 pounds in a month. The nurse could be basing care
on the conceptual model of
a. Johnson.
b. King.
c. Orem.
d. Roy.
ANS:   B

A
Johnson's model describes the person as a behavioral system that is an organized and integrated whole of
seven distinct behavioral subsystems. According to Johnson, nursing is an activity that helps the person
achieve and maintain an optimal state of health through the manipulation and regulation of the
environment.
B
King focused on goal attainment for and by the patient. King's interacting systems form a framework to
view whole persons in their family and social contexts.
C
Orem's model focuses on the patient's self-care capacities and the process of designing nursing actions to
meet the patient's self-care needs. The nurse prescribes and regulates the nursing system on the basis of
the patient's self-care deficit, which is the extent to which the patient is incapable of providing effective
self-care.
D
Roy focused on the individual as a biopsychosocial adaptive system and described nursing as a humanistic
discipline that emphasizes the person's adaptive abilities.