1. After a car accident, Jessy, age 10, is treated in the emergency department for a fractured clavicle and evaluated for a possible head injury. Alert and oriented, she keeps asking what will happen to her. Which nursing diagnosis is most appropriate?
a. Anxiety related to separation from parents and an unfamiliar environment
b. Hypothermia related to head injury
c. Interrupted family processes related to maturational crisis
d. Risk for infection related to sepsis
2. A male client, age 68, admitted for treatment of a colon tumor, asks the nurse, “Do I have cancer?” Which response by nurse Gemma would be best?
a. Most people your age develop some type of colon problem
b. Your physician can discuss this in more detail
c. You sound concerned about what is happening
d. You’ll have to have some tests before cancer can be ruled out
3. Myrna, age 17, rarely expresses feelings and usually remains passive. However, when angry, her face becomes flushed and her blood pressure rises to 170/100 mm Hg. Her parents are passive and easygoing. The adolescent may be using which defense mechanism to handle anger?
4. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective individual coping?
a. Inability to make choices and decisions without advice
b. Showing interest only in solitary activities
c. Avoiding developing relationships
d. Recurrent self-destructive behavior with history of depression
5. Cess is concerned because her breast-feeding infant wants to “nurse all the time.” Which of the following responses best indicates the normal newborn’s breast-feeding behavior?
a. Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings
b. Let me call the lactation consultant to make sure that your baby is feeding properly
c. Don’t worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction
d. It seems as if your baby is hungry. Why don’t you provide your baby with formula after the feeding to make sure he’s getting enough nourishment
6. To establish a good interview relationship with an adolescent, which of the following strategies is most appropriate?
a. Asking personal questions unrelated to the situation
b. Writing down everything the teen says
c. Asking open-ended questions
d. Discussing the nurse’s own thoughts and feelings about the situation
7. Which of the following factors would have the most influence on the outcome of a crisis situation?
b. Previous coping skills
d. Perception of the problem
8. A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which of the following interventions should nurse Kate implement?
a. Discuss the client’s concern with the husband
b. Refer the client to a psychiatrist
c. Invite a client with a similar experience to speak with the client
d. Refer the client to a sex therapist
9. A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells nurse Dennia, “I can’t keep up with my housework any more because I spend so much time caring for the baby.” The nurse should:
a. help the client break down large tasks into smaller ones
b. encourage the client to work faster
c. reassure the client that her feelings will soon pass
d. help the client accept her new role
10. During labor, a client greatly relies on her husband for support. They previously attended childbirth education classes, and now he’s working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple?
a. Ineffective family coping: Compromised related to labor
b. Readiness for enhanced family coping related to participation in pregnancy and delivery
c. Powerlessness related to pain
d. Ineffective role performance related to involvement with the pregnancy
11. Nurse Levy is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
a. Avoiding the use of recreational drugs and alcohol
b. Refraining from telling anyone about the diagnosis
c. Following safer-sex practices
d. Telling potential sex partners about the diagnosis, as required by law
12. During the initial admission process, a geriatric client seems confused. What is the most probable cause of this client’s confusion?
b. Altered long-term memory
c. Decreased level of consciousness (LOC)
d. Stress of an unfamiliar situation
13. Which is the most appropriate nursing diagnosis for a grieving family?
a. Interrupted family processes
c. Spiritual distress
d. Ineffective coping
14. During the mental status examination, a client may be asked to explain such proverbs as “Don’t cry over spilled milk.” The purpose is to evaluate the client’s ability to think:
15. During rounds, a client admitted with gross hematuria asks nurse Alma about the physician’s diagnosis. To facilitate effective communication, what should the nurse do?
a. Ask why the client is concerned about the diagnosis
b. Change the subject to something more pleasant
c. Provide privacy for the conversation
d. Give the client some good advice
16. Nurse Yvette refers a client with terminal cancer to a local hospice. What is the goal of this referral?
a. To provide support for the client and family in coping with terminal illness
b. To ensure that the client gets counseling regarding health care costs
c. To teach the client and family about cancer and its treatment
d. To help the client find appropriate treatment options
17. Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person’s conscious awareness?
18. A 15-year-old female with a urinary tract infection is admitted to the facility. She tells nurse Lauren she hopes that she’s pregnant. Which of the following would be the best response by the nurse?
a. Does your mother know about this?
b. Tell me what pregnancy would mean to you
c. Congratulations. Does the baby’s father know?
d. I hope you aren’t pregnant; you’re too young
19. A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
a. I’ll play card games with my friends
b. I’ll take a long trip to visit my aunt
c. I’ll bowl with my team after discharge
d. I’ll eat lunch in a restaurant every day
20. While in the facility, a client with obsessive-compulsive disorder saves all used medicine cups and paper cups and arranges them in elaborate sculptures in the room. At home, the client saves mail and magazines and makes elaborate paper sculptures from them. Which outcome would indicate successful treatment for this client?
a. The client throws away all disposable cups
b. The client is discharged and takes the cups home
c. The client keeps the cups in a bag in his room
d. The client goes home on pass and arranges magazines
21. The parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate?
a. Children of that age view death as temporary and reversible, which makes it hard to explain
b. Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth
c. At this developmental stage, children are afraid of death, so it’s best not to discuss it with them
d. At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it
22. A chronically ill school-age child is most vulnerable to which stressor?
a. Mutilation anxiety
b. Anticipatory grief
c. Anxiety over school absences
d. Fear of hospital procedures
23. A geriatric client with Alzheimer’s disease has been living with his grown child’s family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement?
a. It’s difficult dealing with Dad. It’s a thankless job
b. We had no idea this would be so difficult. It’s our cross to bear
c. Dad really seems to be making progress. We’re hoping he’ll be able to move back into his house soon
d. Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break
24. When developing a plan of care for a hospitalized child, nurse Pauleen knows that children in which age-group are most likely to view illness as a punishment for misdeeds?
b. Preschool age
c. School age
25. An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?
a. Encouraging the infant to hold a bottle
b. Keeping the infant on bed rest to conserve energy
c. Rotating caregivers to provide more stimulation
d. Maintaining a consistent, structured environment