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A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?
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A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training?
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Nurselab 2
RN
| Question | Answer |
|---|---|
| A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first? | A. Blood sugar check B. CT scan C. Blood cultures D. Arterial blood gases |
| A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training? | A. The age of the child B. The child’s ability to understand instruction. C. The overall mental and physical abilities of the child. D. Frequent attempts with positive reinforcement. |
| A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent? | A. This too shall pass. B. Take the child immediately to the ER C. Contact the Poison Control Center quickly D. Give the child syrup of ipeca |
| A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate? | A. Gluteus maximus B. Gluteus minimus C. Vastus lateralis D. Vastus medialis |
| A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do? | A. Contact the provider B. Ask the child to write their name on paper C. Ask a coworker about the identification of the child D. Ask the father who is in the room the child’s name |
| A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings? | A. Elevated serum calcium B. Low serum parathyroid hormone (PTH) C. Elevated serum vitamin D D. Low urine calcium |
| A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended? | A. A diet high in grains B. A diet with adequate caloric intake C. A high protein diet D. A restricted sodium diet |
| A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the | A. Anesthesia reaction B. Hyperglycemia C. Hypoglycemia D. Diabetic ketoacidosis |
| following is the most likely explanation for the patient’s symptoms? | |
| A nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concer | A. Bowel perforation B. Viral Gastroenteritis C. Colon cancer D. Diverticulitis |
| A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. | A. Partial thromboplastin time B. Prothrombin time C. Platelet count D. Hemoglobin |
| A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission? | A. Sexual contact with an infected partner B. Contaminated food C. Blood transfusion D. Illegal drug use |
| A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this? | A. A history of hepatitis C five years previously B. Cholecystitis requiring cholecystectomy one year previously C. Asymptomatic diverticulosis D. Crohn’s disease in remission |
| A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient? | A. Naproxen sodium (Naprosyn) B. Calcium carbonate C. Clarithromycin (Biaxin) D. Furosemide (Lasix) |
| The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? | A. The patient must maintain a low-calorie diet B. The patient must maintain a high protein/low carbohydrate diet. C. The patient should limit sweets and sugary drinks. D. The patient should limit fatty foods. |
| A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit? | A. Slow, deep respirations B. Stridor C. Bradycardia D. Air hunger |
| A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure? | A. A patient admitted for myocardial infarction without cardiac muscle damage. B. A postoperative coronary bypass patient, recovering on schedule. C. A patient with a history of ventricular tachycardia and syncopal episodes. D. A patient |
| with a history of atrial tachycardia and fatigue. | |
| A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient? | A. The patient is allergic to shellfish. B. The patient has a pacemaker. C. The patient suffers from claustrophobia. D. The patient takes antipsychotic medication. |
| A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? | A. The patient is somnolent with decreased response to the family. B. The patient suddenly complains of chest pain and shortness of breath. C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. |
| D. The patient has a fever, chills, and loss of appetite. | |
| A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? | A. The patient will be admitted to the medicine unit for observation and medication. B. The patient will be admitted to the day surgery unit for sclerotherapy. C. The patient will be admitted to the surgical unit and resection will be scheduled. |
| D. The patient will be discharged home to follow-up with his cardiologist in 24 hours. | |
| A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platete | A. Monitor for fever every 4 hours. B. Require visitors to wear respiratory masks and protective clothing. C. Consider transfusion of packed red blood cells. D. Check for signs of bleeding, including examination of urine and stool for blood |
| platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan? | |
| A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern? | A. Bulging anterior fontanel B. Repeated vomiting C. Signs of sleepiness at 10 PM D. Inability to read short words from a distance of 18 inches |
| A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)? | A. Small blue-white spots are visible on the oral mucosa. B. The rash begins on the trunk and spreads outward. C. There is low-grade fever. D. The lesions have a “teardrop-on-a-rose-petal” appearance. |
| A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? | A. Scarlet fever is caused by infection with group A Streptococcus bacteria. B. “Strawberry tongue” is a characteristic sign. C. Petechiae occur on the soft palate. D. The pharynx is red and swollen. |
| A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg | A. It is the correct dose B. The dose is too low C. The dose is too high D. The dose should be increased or decreased, depending on the symptoms |
| kg/day. Which of the following best describes the prescribed drug dose? | |
| The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate? | A. Normally, the testes are descended by birth. B. The infant will likely require surgical intervention. C. The infant probably has only one testis. D. Normally, the testes descend by one year of age. |
| A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage? | A. The tumor is less than 3 cm. in size and requires no chemotherapy. B. The tumor did not extend beyond the kidney and was completely resected. C. The tumor extended beyond the kidney but was completely resected. D. The tumor has spread into the |
| the abdominal cavity and cannot be resected. | |
| A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply. | A. Urine specific gravity of 1.040. B. Urine output of 350 ml in 24 hours. C. Brown (“tea-colored”) urine. D. Generalized edema. |
| Which of the following conditions most commonly causes acute glomerulonephritis? | A. A congenital condition leading to renal dysfunction. B. Prior infection with group A Streptococcus within the past 10-14 days. C. Viral infection of the glomeruli. D. Nephrotic syndrome. |
| An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend? | A. Massaging the groin area twice a day until the fluid is gone. B. Referral to a surgeon for repair. C. No treatment is necessary; the fluid is reabsorbing normally. D. Keeping the infant in a flat, supine position until the fluid is gone. |
| A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? | A. Inadequate tissue perfusion leading to nerve damage. B. Fluid overload leading to compression of nerve tissue. C. Sensation distortion due to psychiatric disturbance. D. Inflammation of the skin on the hands and feet. |
| A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis? | A. Family history of heart disease B. Overweight. C. Smoking. D. Age. |
| Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply: | A. It results when oxygen demand is greater than oxygen supply. B. It is characterized by pain that often occurs during rest. C. It is a result of tissue hypoxia. D. It is characterized by cramping and weakness. |
| E. It always affects the upper extremities. | |
| A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions? | A. Walk barefoot whenever possible. B. Use a heating pad to keep feet warm. C. Avoid crossing the legs. D. Use antibacterial ointment to treat skin lesions at risk of infection. |
| A patient who has been diagnosed with vasospastic disorder (Raynaud’s disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient? | A. An adolescent male B. An elderly woman C. A young woman D. An elderly man |
| A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms? | A. Myocardial infarction due to a history of atherosclerosis. B. Pulmonary embolism due to deep vein thrombosis (DVT). C. Anxiety attacks due to worries about her baby’s health. D. Congestive heart failure due to fluid overload. |
| Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant | A. Air embolus. B. Cerebral hemorrhage. C. Expansion of the clot. D. Resolution of the clot. |
| An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation? | A. Torticollis, with shortening of the sternocleidomastoid muscle. B. Craniosynostosis, with premature closure of the cranial sutures. C. Plagiocephaly, with flattening of one side of the head. D. Hydrocephalus, with increased head size. |
| An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct? | A. The condition was caused by the student’s competitive swimming schedule. B. The student will most likely require surgical intervention. C. The student experiences pain in the inferior aspect of the knee. |
| D. The student is trying to avoid participation in physical education. | |
| The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? | A. Spinal flexibility B. Leg length disparity C. Hypostatic blood pressure D. Scoliosis |
| A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent? | A. Low self-esteem B. Unemployment C. Self-blame for the injury to the child D. Single status |
| A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate? | A. The child has a poor chance of recovery without joint deformity. B. Most children progress to adult rheumatoid arthritis. C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. D. Physical activity should be minimized. |
| A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. | A. The admission orders are written. B. A blood culture is drawn. C. A complete blood count with differential is drawn. D. The parents arrive. |
| Which of the following actions is done immediately before the antibiotic is started? | |
| A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms? | A. Possible fracture of the tibia. B. Bruising of the gastrocnemius muscle. C. Possible fracture of the radius. D. No anatomic injury, the child wants his mother to carry him. |
| A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply. | A. Regular developmental screening is important to avoid secondary developmental delays. B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. |
| C. Developmental milestones may be slightly delayed but usually will require no additional intervention. D. Parent support groups are helpful for sharing strategies and managing health care issues. | |
| E. Therapies and surgical interventions can cure cerebral palsy. | |
| A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information? | A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease. B. Duchenne’s is an X-linked recessive disorder, so both daughters and sons have a 50% chance of d dx |
| C. Each child has a 1 in 4 (25%) chance of developing the disorder. D. Sons only have a 1 in 4 (25%) chance of developing the disorder. | |
| A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the | A. Surgical repair of a diseased coronary artery. B. Placement of an automatic internal cardiac defibrillator. C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow. |
| D. Non-invasive radiographic examination of the heart. | |
| A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize: | A. They can expect the child will be mentally retarded. B. Administration of thyroid hormone will prevent problems. C. This rare problem is always hereditary. D. Physical growth/development will be delayed. |
| A priority goal of involuntary hospitalization of the severely mentally ill client is | A. Re-orientation to reality B. Elimination of symptoms C. Protection from harm to self or others D. Return to independent functioning |
| A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”? | A. “I don’t remember anything about what happened to me.” B. “I’d rather not talk about it right now.” C. “It’s the other entire guy’s fault! He was going too fast.” D. “My mother is heartbroken about this.” |
| The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time? | A. Altered tissue perfusion B. Risk for fluid volume deficit C. High risk for hemorrhage D. Risk for infection |
| A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should: | A. Expose the cast to air and turn the child frequently. B. Use a heat lamp to reduce the drying time. C. Handle the cast with the abductor bar. D. Turn the child as little as possible. |
| A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would: | A. Instruct the client to maintain a regular diet the day prior to the examination. B. Restrict the client’s fluid intake 4 hours prior to the examination. C. Administer a laxative to the client the evening before the examination. |
| D. Inform the client that only 1 x-ray of his abdomen is necessary. | |
| Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that: | A. AGN is a streptococcal infection that involves the kidney tubules. B. The disease is easily transmissible in schools and camps. C. The illness is usually associated with chronic respiratory infections. |
| D. It is not “caught” but is a response to a previous B-hemolytic strep infection. | |
| The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mE | A. 3 episodes of vomiting in 1 hour. B. Periodic crying and irritability. C. Vigorous sucking on a pacifier. D. No measurable voiding in 4 hours. |
| mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately? | |
| While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action? | A. Check vital signs. B. Massage the fundus. C. Offer a bedpan. D. Check for perineal lacerations. |
| The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? | A. Unequal leg length B. Limited adduction C. Diminished femoral pulses D. Symmetrical gluteal folds |
| To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would: | A. Assist the client to use the bedside commode. B. Administer stool softeners every day as ordered. C. Administer antidysrhythmics prn as ordered. D. Maintain the client on strict bed rest. |
| On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to: | A. Give the client orientation materials and review the unit rules and regulations. B. Introduce him/her and accompany the client to the client’s room. |
| C. Take the client to the day room and introduce her to the other clients. D. Ask the nursing assistant to get the client’s vital signs and complete the admission search. | |
| During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? | A. “I have constant blurred vision.” B. “I can’t see on my left side.” C. “I have to turn my head to see my room.” D. “I have specks floating in my eyes.” |
| A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client: | A. Has increased airway obstruction. B. Has improved airway obstruction. C. Needs to be suctioned. D. Exhibits hyperventilation. |
| The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises fo affected extremity, the nurse should recommend: | A. Isometric B. Range of motion C. Aerobic D. Isotonic |
| A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority? | A. Counsel the woman to consent to HIV screening. B. Perform tests for sexually transmitted diseases. C. Discuss her high risk for cervical cancer. D. Refer the client to a family planning clinic. |
| A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse? | A. Arrange to change client care assignments. B. Explain that this behavior is expected. C. Discuss the appropriate use of “time-out”. D. Explain that the child needs extra attention. |
| While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? | A. Strange bed and surroundings. B. Separation from parents. C. Presence of other toddlers. D. Unfamiliar toys and games. |
| While explaining an illness to a 10-year-old, what should the nurse keep in mind about cognitive development at this age? | A. They are able to make simple associations of ideas. B. They are able to think logically in organizing facts. C. Interpretation of events originates from their own perspective. |
| D. Conclusions are based on previous experiences. | |
| The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? | A. Nutrition B. Elimination C. Activity D. Safety |
| Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children? | A. Sports and games with rules. B. Finger paints and water play. C. “Dress-up” clothes and props. D. Chess and television programs |
| A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? | A. High Fowler’s B. Supine C. Left lateral D. Low Fowler’s |
| The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is: | A. Urinary output of 30 ml per hour B. No complaints of thirst C. Increased hematocrit D. Good skin turgor around burn |
| What is the priority nursing diagnosis for a patient experiencing a migraine headache? | A. Acute pain related to biologic and chemical factors B. Anxiety related to change in or threat to health status C. Hopelessness related to deteriorating physiological condition D. Risk for Side effects related to medical therap |
| You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? Select all that apply. | A. Avoid foods that contain tyramine, such as alcohol and aged cheese. B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine. C. Abortive therapy is aimed at eliminating the pain during the aura. |
| D. A potential side effect of medications is rebound headache. E. Complementary therapies such as relaxation may be helpful. F. Continue taking estrogen as prescribed by your physician. | |
| The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant? | A. Document the seizure B. Perform neurologic checks C. Take the patient’s vital signs D. Restrain the patient for protection |
| You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? | A. Complete admission assessment. B. Set up oxygen and suction equipment. C. Place a padded tongue blade at the bedside. D. Pad the side rails before the patient arrives. |
| A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene? | A. “You should avoid consumption of all forms of alcohol.” B. “Wear your medical alert bracelet at all times.” C. “Protect your loved one’s airway during a seizure.” |
| D. “It’s OK to take over-the-counter medications.” Correct Answer: D. “It’s OK to take over-the-count |
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Faith111