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More NCLEX review questions
Topic Started: Dec 8 2009, 11:43 AM (25,537 Views)
Karmela
Wanderer
[ * ]
Nursing Bullets: Fundamentals of Nursing Reviewer Part II
Quote:
 
The second set of the ultimate review for Fundamentals of Nursing! It contains another set of bits of information (246 in total) to review you about the concepts of Fundamentals of Nursing. Perfect for those who will be taking the board exams!

Relax your mind, get it ready for information, now are you ready…?

Go!

1. After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings of skin assessment.

2. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation.

3. When percussing a patient’s chest for postural drainage, the nurse’s hands should be cupped.

4. When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength.

5. Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels.

6. When assessing respirations, the nurse should document their rate, rhythm, depth, and quality.

7. For a subcutaneous injection, the nurse should use a 5/8″ 25G needle.

8. The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time).

9. Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration.

10. After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results.

11. When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle), with the bevel up.

12. To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure.

13. The nurse should count an irregular pulse for 1 full minute.

14. A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus.

15. Prophylaxis is disease prevention.

16. Body alignment is achieved when body parts are in proper relation to their natural position.

17. Trust is the foundation of a nurse-patient relationship.

18. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls.

19. Malpractice is a professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another.

20. As a general rule, nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in abortions.

21. A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform.

22. States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws don’t apply to care provided in a health care facility.

23. A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.

24. A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal.

25. Although a patient’s health record, or chart, is the health care facility’s physical property, its contents belong to the patient.

26. Before a patient’s health record can be released to a third party, the patient or the patient’s legal guardian must give written consent.

27. Under the Controlled Substances Act, every dose of a controlled drug that’s dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally.

28. A nurse can’t perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician.

29. To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed.

30. In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns.

31. The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions.

32. Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.

33. In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex.

34. The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves.

35. To maintain package sterility, the nurse should open a wrapper’s top flap away from the body, open each side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body.

36. The nurse shouldn’t dry a patient’s ear canal or remove wax with a cotton-tipped applicator because it may force cerumen against the tympanic membrane.

37. A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises.

38. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential.
39. Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States.

40. Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence.

41. Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.

42. Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.

43. Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.

44. Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society.

45. Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI.

46. The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest.

47. The most important goal to include in a care plan is the patient’s goal.

48. Fruits are high in fiber and low in protein, and should be omitted from a low-residue diet.

49. The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals.

50. Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings.

51. The nurse should provide honest answers to the patient’s questions.

52. Milk shouldn’t be included in a clear liquid diet.

53. When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paramount.

54. The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland.

55. The three membranes that enclose the brain and spinal cord are the dura mater, pia mater, and arachnoid.

56. A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively.

57. Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for drugs.

58. The area around a stoma is cleaned with mild soap and water.

59. Vegetables have a high fiber content.

60. The nurse should use a tuberculin syringe to administer a subcutaneous injection of less than 1 ml.

61. For adults, subcutaneous injections require a 25G 1″ needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½” needle.

62. Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name.

63. To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion.

64. The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation.

65. If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure.

66. The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative.

67. If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma.

68. When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head.

69. The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patient’s condition.

70. Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.

71. The hearing aid that’s marked with a blue dot is for the left ear; the one with a red dot is for the right ear.

72. A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water.

73. The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid.

74. The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy.
75. The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown.

76. Heat is applied to promote vasodilation, which reduces pain caused by inflammation.

77. A sutured surgical incision is an example of healing by first intention (healing directly, without granulation).

78. Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered.
79. Keloid formation is an abnormality in healing that’s characterized by overgrowth of scar tissue at the wound site.

80. The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site.

81. An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter.

82. A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis.

83. When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection.

84. Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation.

85. To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.)

86. Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patient’s prognosis, and to feel that there is hope of recovery.

87. Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to.

88. A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient.

89. Target symptoms are those that the patient finds most distressing.

90. A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola.

91. For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal.

92. Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient.

93. Administering an I.M. injection against the patient’s will and without legal authority is battery.

94. An example of a third-party payer is an insurance company.

95. The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused × drip factor) ÷ time in minutes = drops/minute

96. On-call medication should be given within 5 minutes of the call.

97. Usually, the best method to determine a patient’s cultural or spiritual needs is to ask him.

98. An incident report or unusual occurrence report isn’t part of a patient’s record, but is an in-house document that’s used for the purpose of correcting the problem.

99. Critical pathways are a multidisciplinary guideline for patient care.

100. When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation.

101. The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern.

102. A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort.

103. For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that he’s “bored,” that he has “nothing to do,” or words to that effect.

104. The most appropriate nursing diagnosis for an individual who doesn’t speak English is Impaired verbal communication related to inability to speak dominant language (English).

105. The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him.

106. Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube.

107. To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac.

108. After administering eye ointment, the nurse should twist the medication tube to detach the ointment.

109. When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens.

110. Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement.

111. Listening is the most effective communication technique.

112. Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.

113. Process recording is a method of evaluating one’s communication effectiveness.

114. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.

115. When feeding an elderly patient, essential foods should be given first.

116. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.

117. Isometric exercises are performed on an extremity that’s in a cast.

118. A back rub is an example of the gate-control theory of pain.

119. Anything that’s located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is considered unsterile.

120. A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.

121. A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia.

122. Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.

123. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.

124. A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.

125. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.

126. Usually, patients who have the same infection and are in strict isolation can share a room.

127. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.

128. For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.

129. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning).

130. According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60).

131. When communicating with a hearing impaired patient, the nurse should face him.

132. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system.

133. Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C).

134. Milk is high in sodium and low in iron.

135. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge.

136. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.

137. When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.

138. Ethnocentrism is the universal belief that one’s way of life is superior to others.

139. When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.

140. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”

141. Prejudice is a hostile attitude toward individuals of a particular group.

142. Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.

143. Increased gastric motility interferes with the absorption of oral drugs.

144. The three phases of the therapeutic relationship are orientation, working, and termination.

145. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.

146. Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion.

147. When measuring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more than two-thirds the length of the extremity that’s used.

148. When administering a drug by Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the syringe because doing so could stain the skin.

149. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.

150. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.

151. When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasn’t confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.

152. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient.

153. Beneficence is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.

154. Nonmaleficence is the duty to do no harm.

155. Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.

156. A = Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.

157. B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.

158. C = Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.

159. D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.

160. E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.

161. When answering a question on an NCLEX examination, the basic rule is “assess before action.” The student should evaluate each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated.

162. Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.

163. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society.

164. Active euthanasia is actively helping a person to die.

165. Brain death is irreversible cessation of all brain function.

166. Passive euthanasia is stopping the therapy that’s sustaining life.

167. A third-party payer is an insurance company.

168. Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective.
169. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.

170. Voluntary euthanasia is actively helping a patient to die at the patient’s request.

171. Bananas, citrus fruits, and potatoes are good sources of potassium.

172. Good sources of magnesium include fish, nuts, and grains.

173. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.

174. Intrathecal injection is administering a drug through the spine.

175. When a patient asks a question or makes a statement that’s emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.

176. The steps of the trajectory-nursing model are as follows:
177. Step 1: Identifying the trajectory phase
178. Step 2: Identifying the problems and establishing goals
179. Step 3: Establishing a plan to meet the goals
180. Step 4: Identifying factors that facilitate or hinder attainment of the goals
181. Step 5: Implementing interventions
182. Step 6: Evaluating the effectiveness of the interventions

183. A Hindu patient is likely to request a vegetarian diet.

184. Pain threshold, or pain sensation, is the initial point at which a patient feels pain.

185. The difference between acute pain and chronic pain is its duration.

186. Referred pain is pain that’s felt at a site other than its origin.

187. Alleviating pain by performing a back massage is consistent with the gate control theory.

188. Romberg’s test is a test for balance or gait.

189. Pain seems more intense at night because the patient isn’t distracted by daily activities.

190. Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency.

191. No pork or pork products are allowed in a Muslim diet.

192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to increase the quality of life and the number of years of optimal health
194. Eliminate health disparities among different segments of the population.

195. A community nurse is serving as a patient’s advocate if she tells a malnourished patient to go to a meal program at a local park.

196. If a patient isn’t following his treatment plan, the nurse should first ask why.

197. Falls are the leading cause of injury in elderly people.

198. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.

199. Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.

200. Tertiary prevention is treatment to prevent long-term complications.

201. A patient indicates that he’s coming to terms with having a chronic disease when he says, “I’m never going to get any better.”

202. On noticing religious artifacts and literature on a patient’s night stand, a culturally aware nurse would ask the patient the meaning of the items.

203. A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient.

204. In an infant, the normal hemoglobin value is 12 g/dl.

205. The nitrogen balance estimates the difference between the intake and use of protein.

206. Most of the absorption of water occurs in the large intestine.

207. Most nutrients are absorbed in the small intestine.

208. When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”

209. A vegan diet should include an abundant supply of fiber.

210. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis.

211. First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.

212. To induce sleep, the first step is to minimize environmental stimuli.

213. Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions as well as the amount of strength required to move the patient.

214. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).

215. To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.

216. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow.

217. Vitamin C is needed for collagen production.

218. Only the patient can describe his pain accurately.

219. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.

220. Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.

221. An Asian American or European American typically places distance between himself and others when communicating.

222. The patient who believes in a scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery to cure illness.

223. Chronic illnesses occur in very young as well as middle-aged and very old people.

224. The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions.

225. Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization.

226. School health programs provide cost-effective health care for low-income families and those who have no health insurance.

227. Collegiality is the promotion of collaboration, development, and interdependence among members of a profession.

228. A change agent is an individual who recognizes a need for change or is selected to make a change within an established entity, such as a hospital.

229. The patients’ bill of rights was introduced by the American Hospital Association.

230. Abandonment is premature termination of treatment without the patient’s permission and without appropriate relief of symptoms.

231. Values clarification is a process that individuals use to prioritize their personal values.

232. Distributive justice is a principle that promotes equal treatment for all.

233. Milk and milk products, poultry, grains, and fish are good sources of phosphate.

234. The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails.

235. By the end of the orientation phase, the patient should begin to trust the nurse.

236. Falls in the elderly are likely to be caused by poor vision.

237. Barriers to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis.

238. The three elements that are necessary for a fire are heat, oxygen, and combustible material.

239. Sebaceous glands lubricate the skin.

240. To check for petechiae in a dark-skinned patient, the nurse should assess the oral mucosa.

241. To put on a sterile glove, the nurse should pick up the first glove at the folded border and adjust the fingers when both gloves are on.

242. To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection.

243. Treatment for a stage 1 ulcer on the heels includes heel protectors.

244. Seventh-Day Adventists are usually vegetarians.

245. Endorphins are morphine-like substances that produce a feeling of well-being.

246. Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.

credits to Mervilyn C. Pabustan

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Karmela
Wanderer
[ * ]
Online Nursing Practice Test/Exam about Cancer
Copied from:
http://www.nclexpinoy.com


36. The nurse on the oncology unit enters the room of the client with lung cancer. Which action is most appropriate for the nurse to do first?

a) check the client's IV infusion pump and IV fluid rate
b) take the client's blood pressure and pulse
c) assess the client's mental status
d) elevate the client's head of the bed

37. The nurse on the oncology unit is planning care for the client with colon cancer who is refusing a diagnostic test. Which action is most appropriate for the nurse to take first?

a) call the radiology department to let them know the client will not be going to take the test
b) speak with the client to determine the reason for refusing the test
c) inform the health care provider that the client is refusing the test
d) ask the client's spouse why the client is refusing the test

38. A nurse is admitting a 63-year old male reporting hemoptysis and weight loss. The nurse identifies that the highest priority risk factor for lung cancer for this client is:

a) family history of lung cancer
b) the client works in a chemical factory
c) the client lives in a coal mining area
d) the client uses chewing tobacco

39. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which of the following?

a) 2,000 cells/mm3
b) 5,800 cells/mm3
c) 8,400 cells/mm3
d) 11,500 cells/mm3

40. A nurse is caring for a child after removal of a brain tumor. The nurse assesses the child for which of the following signs that would indicate that brainstem involvement occurred during the surgical procedure?

a) inability to swallow
b) elevated temperature
c) altered hearing ability
d) orthostatic hypotension



ANSWERS AND RATIONALE

36) D
- the client with lung cancer experiences difficulty of breathing. Therefore, the first action by the nurse is to facilitate the client's breathing by elevating the head of the bed.

37) B
- the first nursing action when a client refuses a test or treatment is to assess the reason for refusal. Assessment is the first phase of the nursing process.

38) B
- the client who is exposed to chemicals for a long period of time is at highest risk to develop lung cancer.

39) A
- the normal white blood cell count ranges from 4,500 to 11,000/mm3. The client who is immunosuppressed has a decrease in the number of circulating white blood cells. The nurse implements neutropenic precautions when the client's values fall sufficiency below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. Options B, C, and D are normal values.

40) B
- Vital signs and neurological status are assessed frequently. Special attention is given to the child’s temperature, which may be elevated because of hypothalamic or brainstem involvement during surgery. A cooling blanket should be in place on the bed or readily available if the child becomes hyperthermic. Options A and C are related to functional deficits following surgery. Orthostatic hypotension is not a common clinical manifestation following brain surgery. An elevated blood pressure and widened pulse pressure may be associated with increased intracranial pressure, which is a complication following brain surgery.



41. The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which statement by a client indicates a need for further instructions?

a) I will avoid sun exposure after 3 pm
b) I will use sunscreen when participating in outdoor activities
c) I will wear a hat, opaque clothing, and sunglasses when in the sun
d) I will examine my body monthly for any lesions that may be suspicious

42. The client is undergoing radiation therapy to treat lung cancer. Following treatment, the nurse notes erythema on the client's chest and neck, and the client is complaining of pain at the radiation site. The nurse interprets this assessment data a(n):

a) allergic reaction to the radiation
b) superficial injury to tissue from the radiation
c) cutaneous reaction to products formed by the lysis of the neoplastic cells
d) ischemic injury, much like pressure ulcer formation. caused by pressure from the linear accelerator

43. The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cervical cancer. Which of the following, if identified by the client as a risk factor to cervical cancer, indicates a need for further teaching?

a) smoking
b) multiple sex partners
c) first intercourse after age 20
d) annual gynecological examinations

44. The client is diagnosed as having a bowel tumor and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy?

a) biopsy of tumor
b) abdominal ultrasound
c) magnetic resonance imaging
d) computed tomography scan

45. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which of the following would the nurse expect to note specifically in this disorder?

a) increased calcium level
b) increased white blood cells
c) decreased blood urea nitrogen level
d) decreased number of plasma cells in the bone marrow




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

41) A
- The client should be instructed to avoid sun exposure between the hours of 11 AM and 3 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions.

42) B
- Superficial injury from radiation can manifest with erythema (probably caused by capillary damage), hyperpigmentation (from stimulation of melanocytes), dry desquamation (caused by basal cell destruction), or moist desquamation (also caused by basal cell destruction). Moist desquamation is comparable to a second-degree burn in histology, appearance, and sensation.

43) C
- Risk factors for cervical cancer include human papillomavirus (HPV) infection, active and passive cigarette smoking, certain high-risk sexual activities (first intercourse before 17 years of age, multiple sex partners, or male partners with multiple sex partners). Screening via regular gynecological exams and Papanicolaou smear (Pap test) with treatment of precancerous abnormalities decrease the incidence and mortality of cervical cancer.

44) A
-A biopsy is done to determine whether a tumor is malignant or benign. Magnetic resonance imaging, computed tomography scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy.

45) A
- Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.



46. The nurse is instructing the client to perform a testicular self-examination. The nurse tells the client:

a) to examine the testicles while lying down
that the best time for the examination is after a shower
c) to gently feel the testicles with one finger to feel for a growth
d) that testicular self-examinations should be done at least every 6 months

47. The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care?

a) monitoring temperature
b) ambulation three times daily
c) monitoring the platelet count
d) monitoring for pathological fractures


48. The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count is normal if which of the following results were present?

a) 2000 to 5000 cells/mm3
b) 3000 to 8000 cells/mm3
c) 5000 to 10000 cells/mm3
d) 7000 to 15000 cells/mm3


49. The community health nurse is instructing a group of female clients about breast self-examination. The nurse instructs the clients to perform the examination:

a) at the onset of menstruation
b) every month during ovulation
c) weekly at the same time of day
d) 1 week after menstruation begins


50. The nurse is caring for a client who has undergone vaginal hysterectomy. The nurse avoids which of the following in the care of this client?

a) elevating the knee on the bed
b) assisting with range-of-motion leg exercises
c) removal of antiembolism stockings twice a day
d) checking placement of pneumatic compression boots




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

46) B
- The testicular-self examination is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

47) C
- Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Option A relates to monitoring for infection, particularly if leukopenia is present. Options B and D, although important in the plan of care, are not related directly to thrombocytopenia.

48) C
- The normal white blood cell count ranges from 5000 to 10,000 cells/mm3. Options A and B indicate low values. Option D indicates an elevated value.

49) D
- The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

50) A
- The client is at risk of deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Range-of-motion exercises, antiembolism stockings, and pneumatic compression boots are helpful. The nurse should avoid using the knee gatch in the bed, which inhibits venous return, thus placing the client more at risk for deep vein thrombosis or thrombophlebitis.



51. The client suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which pre-procedure instruction to the client?

a) eat a light breakfast only
b) maintain an NPO before the procedure
c) wear comfortable clothing and shoes for the procedure
d) drink six to eight glasses of water without voiding before the test

52. A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder?

a) altered red blood cell production
b) altered production of lymph nodes
c) malignant exacerbation in the number of leukocytes
d) malignant proliferation of plasma cells within the bone



53. The oncology nurse specialist provides an educational session to nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which of the following is a characteristic of the disease?

a) presence of Reed-Sternberg cells
b) occurs most often in the older client
c) prognosis depending on the stage of the disease
d) involvement of lymph nodes, spleen, and liver

54. The community health nurse conducts a health promotion program regarding testicular cancer to community members. The nurse determines that further information needs to be provided if a community member states that which of the following is a sign of testicular cancer?

a) alopecia
b) back pain
c) painless testicular swelling
d) heavy sensation in the scrotum

55. The client is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is:

a) dyspnea
b) diarrhea
c) sore throat
d) constipation




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

51) D
- A pelvic ultrasound requires the ingestion of large volumes of water just before the procedure. A full bladder is necessary so that it will be visualized as such and not mistaken for a possible pelvic growth. An abdominal ultrasound may require that the client abstain from food or fluid for several hours before the procedure. Option 3 is unrelated to this specific procedure.

52) D
- Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Options A and B are not characteristics of multiple myeloma. Option C describes the leukemic process.

53) B
- Hodgkin’s disease is a disorder of young adults. Options A, C, and D are characteristics of this disease.

54) A
- Alopecia is not an assessment finding in testicular cancer. Alopecia may occur, however, as a result of radiation or chemotherapy. Options B, C, and D are assessment findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

55) C
- In general, only the area in the treatment field is affected by the radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the larynx is most likely to experience a sore throat. Options B and D may occur with radiation to the gastrointestinal tract. Dyspnea may occur with lung involvement.



56. The nurse is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?

a) limit the time with the client to 1 hour per shift
b) do not allow pregnant women into the client's room
c) remove the dosimeter badge when entering the client's room
d) individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client

57. A cervical radiation implant is placed in the client for the treatment of cervical cancer. The nurse initiates what most appropriate activity order for this client?

a) bed rest
b) out of bed ad lib
c) out of bed in a chair only
d) ambulation to the bathroom only



58. The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to:

a) call the physician
b) reinsert the implant into the vagina immediately
c) pick up the implant with gloved hands and flush it down the toilet
d) pick up the implant with long-handled forceps and place it in a lead container

59. The nurse is caring for a client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plants to:

a) restrict all visitors
b) restrict fluid intake
c) teach the client and family about the need for hand hygiene
d) insert an indwelling urinary catheter to prevent skin breakdown

60. The nurse is reviewing the laboratory results of a client receiving chemotherapy whose platelet count is 10,000 cells/mm3. based on this laboratory value, the priority nursing assessment is which of the following?

a) assess skin turgor
b) assess temperature
c) assess bowel sounds
d) assess level of consciousness




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

56) B
- The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client’s room. Children younger than 16 years of age and pregnant women are not allowed in the client’s room.

57) A
- The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids turning the client on the side. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled.

58) D
- A lead container and long-handled forceps should be kept in the client’s room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. Options A, B, and C are inaccurate interventions.

59) C
- In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.

60) D
- A high risk of hemorrhage exists when the platelet count is less than 20,000 cells/mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000 cells/mm3. The client should be assessed for changes in level of consciousness, which may be an early indication of an intracranial hemorrhage. Option B is a priority nursing assessment when the white blood cell count is low and the client is at risk for an infection. Although options A and C are important to assess, they are not the priority in this situation.



61. The home health care nurse is caring for a client with cancer and the client is complaining of acute pain. The appropriate nursing assessment of the client's pain would include which of the following?

a) the client's pain rating
b) nonverbal cues from the client
c) the nurse's impression of the client's pain
d) pain relief after appropriate nursing intervention

62. The nurse is caring for a client who is a pelvic exenteration and the physician changes the client's diet from NPO status to clear liquids. The nurse makes which priority assessment before administering the diet?

a) bowel sounds
b) ability to ambulate
c) incision appearance
d) urine specific gravity



63. The client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

a) fatigue
b) weakness
c) weight gain
d) enlarged lymph nodes

64. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?

a) diarrhea
b) hypermenorrhea
c) abnormal bleeding
d) abdominal distention

65. The nurse is reviewing the complications of conization with a client who has microinvasive cervical cancer. Which complication, if identified by the client, indicates a need for further teaching?

a) infection
b) hemorrhage
c) cervical stenosis
d) ovarian perforation




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

61) A
- The client’s self-report is a critical component of pain assessment. The nurse should ask the client about the description of the pain and listen carefully to the client’s words used to describe the pain. The nurse’s impression of the client’s pain is not appropriate in determining the client’s level of pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. Assessing pain relief is an important measure, but this option is not related to the subject of the question.

62) A
- The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options B, C, and D are unrelated to the subject of the question.

63) D
- Hodgkin’s disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

64) D
- Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

65) D
- Conization procedure involves removal of a cone-shaped area of the cervix. Complications of the procedure include hemorrhage, infection, and cervical stenosis. Ovarian perforation is not a complication.



66.When assessing the laboratory results of the client with bladder cancer and bone metastasis, the nurse notes a calcium level of 12 mg/dl. The nurse recognizes that this is consistent with which oncological emergency?

a) hyperkalemia
b) hypercalemia
c) spinal cord compression
d) superior vena cava syndrome

67. The client reports to the nurse that when performing testicular self-examination, he found a lump the size and shape of a pea. The appropriate response to the client is which of the following?

a) lumps like that are normal, don't worry
b) let me know if it gets bigger next month
c) that could be cancer. I'll ask the doctor to examine you
d) that's important to report even though it might not be serious



68. The hospice nurse visits a client dying of ovarian cancer. During the visit, the client expresses that "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing?

a) anger
b) denial
c) bargaining
d) depression

69. The nurse is caring for a client following mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?

a) pain at the incisional site
b) arm edema on the operative side
c) sanguineous drainage in the Jackson-Pratt drain
d) complaints of decreased sensation near the operative side

70. The nurse is admitting a client with laryngeal cancer to the nursing unit. The nurse assesses for which most common risk factor for this type of cancer?

a) alcohol abuse
b) cigarette smoking
c) use of chewing tobacco
d) exposure to air pollutants





NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

66) B
- Hypercalcemia is a serum calcium level higher than 10 mg/dL, most often occurs in clients who have bone metastasis, and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream.

67) D
- Testicular cancer almost always occurs in only one testicle and is usually a pea-sized painless lump. The cancer is highly curable when found early. The finding should be reported to the physician.

68) C
- Denial, bargaining, anger, depression, and acceptance are recognized stages that a person facing a life-threatening illness experiences. Bargaining identifies a behavior in which the individual is willing to do anything to avoid loss or change prognosis or fate. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn. Anger also may be a first response to upsetting news and the predominant theme is “why me?” or the blaming of others.

69) B
- Arm edema on the operative side (lymphedema) is a complication following mastectomy and can occur immediately postoperatively or may occur months or even years after surgery. Options A, C and D are expected occurrences following mastectomy and do not indicate a complication.

70) B
- The most common risk factor associated with laryngeal cancer is cigarette smoking. Heavy alcohol use and the combined use of tobacco increase the risk. Another risk factor is exposure to environmental pollutants.


71. The female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing:

a) rupture of the bladder
b) the development of a vesicovaginal fistula
c) extreme stress caused by the diagnosis of cancer
d) altered personal sensation as the side effect of radiation therapy

72. The client with leukemia is receiving busulfan (Myleran) and allupurinol (Zyloprim) is prescribed for the client. The nurse tells the client that the purpose of the allupurinol is to prevent:

a) nausea
b) alopecia
c) vomiting
d) hyperuricemia



73. The client receiving chemotherapy is experiencing mucositis. The nurse advises the client to use which of the following as the best substance to rinse the mouth?

a) alcohol-based mouthwash
b) hydrogen peroxide mixture
c) lemon-flavored mouthwash
d) weak salt and bicarbonate mouth rinse

74. The community nurse is conducting a health promotion program and the topic of the discussion relates to the risk factors for gastric cancer. Which risk factor, if identified by a client, indicates a need for further discussion?

a) smoking
b) a high-fat diet
c) foods containing nitrates
d) a diet of smoked, highly salted, and spiced food

75. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. Which of the following is the appropriate nursing intervention?

a) notify the physician
b) measure abdominal girth
c) irrigate the nasogastric tube
d) continue to monitor the drainage




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

71) B
- A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina. The client’s complaint is not associated with options A, C, and D.

72) D
- Allopurinol decreases uric acid production and reduces uric acid concentrations in serum and urine. In the client receiving chemotherapy, uric acid levels increase as a result of the massive cell destruction that occurs from the chemotherapy. This medication prevents or treats hyperuricemia caused by chemotherapy. Allopurinol is not used to prevent alopecia, nausea, or vomiting.

73) D
- An acidic environment in the mouth is favorable for bacterial growth, particularly in an area already compromised from chemotherapy. Therefore, the client is advised to rinse the mouth before every meal and at bedtime with a weak salt and sodium bicarbonate mouth rinse. This lessens the growth of bacteria and limits plaque formation. The other substances are irritating to oral tissue. If hydrogen peroxide must be used because of severe plaque, it should be a weak solution because it dries the mucous membranes.

74) B
- A high-fat diet plays a role in the development of cancer of the pancreas. Options A, C, and D are risk factors related to gastric cancer.

75) D
- Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the physician at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific physician orders to do so.
Edited by Karmela, Jun 23 2011, 11:50 AM.
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NCLEX Review Questions on Cancer
From: http://www.nclexpinoy.com


76. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching related to colorectal cancer is necessary if the client identifies which of the following as an associated risk factor?

a) age younger than 50 years
b) history of colorectal polyps
c) family history of colorectal cancer
d) chronic inflammatory bowel disease

77. The nurse is performing an admission assessment on a client diagnosed with a right colon tumor. The nurse asks the client about which characteristic symptom of this type of tumor?

a) rectal bleeding
b) flat, ribbon-like stool
c) crampy, colicky abdominal pain
d) alternating constipation and diarrhea



78. The nurse is reviewing the preoperative orders of a client with a colon tumor who is scheduled for abdominal perineal resection and notes that the physician has prescribed neomycin (Mycifradin) for the client. The nurse determines that this medication has been prescribed primarily:

a) to prevent immune dysfunction
b) because the client has an infection
c) to decrease the bacteria in the bowel
d) because the client is allergic to penicillin

79. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

a) notify the physician
b) clamp the penrose drain
c) change the dressing as prescribed
d) remove and replace the perineal packing

80. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which of the following assessment findings indicates that the colostomy is beginning to function?

a) absent bowel sounds
b) the passage of flatus
c) the client's ability to tolerate food
d) bloody drainage from the colostomy




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

76) A
- Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.

77) C
- Vague abdominal discomfort or crampy, colicky abdominal pain is a characteristic symptom of a right colon tumor. Options A, B, and D are symptoms associated with left colon tumors.

78) C
- To reduce the risk of contamination at the time of surgery, the bowel is emptied and cleansed. Laxatives and enemas are given to empty the bowel. Intestinal anti-infectives such as neomycin or kanamycin (Kantrex) are administered to decrease the bacteria in the bowel.

79) C
- Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. The nurse does not need to notify the physician at this time. A Penrose drain should not be clamped because this action will cause the accumulation of drainage within the tissue. Penrose drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.

80) B
- Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.



81. The nurse is caring for a client following a radical neck dissection and creation of a tracheostomy performed for laryngeal cancer and is providing discharge instructions to the client. Which statement by the client indicates a need for further instructions?

a) I will protect the stoma from water
b) I need to keep powders and sprays away from the stoma
c) I need to use an air conditioner to provide cool air to assist in breathing
d) I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking

82. What is the purpose of cytoreductive ("debulking") surgery for ovarian cancer?

a) cancer control by reducing the size of the tumor
b) cancer prevention by removal of precancerous tissue
c) cancer cure by removing all gross and microscopic tumor cells
d) cancer rehabilitation by improving the appearance of a previously treated body part



83. Hormone therapy is prescribed as the mode of treatment for a client with prostate cancer. The nurse understands that the goal of this form of treatment is to:

a) increase testosterone levels
b) increase prostaglandin levels
c) limit the amount of circulating androgens
d) increase the amount of circulating androgens

84. The nurse is caring for a client with cancer of the prostate following a prostatectomy. The nurse provides discharge instructions to the client and tells the client to:

a) avoid driving the car for 1 week
b) restrict fluid intake to prevent incontinence
c) avoid lifting objects heavier than 20 lb for at least 6 weeks
d) notify the physician if small blood clots are noticed during urination

85. The oncology nurse is providing a teaching session to group of nursing students regarding the risks and causes of bladder cancer. Which statement by a student indicates a need for further teaching?

a) bladder cancer most often occurs in women
b) using cigarettes and coffee drinking can increase the risk
c) bladder cancer generally is seen in client older than 40
d) environmental health hazards have been attributed as a cause




NCLEX REVIEW QUESTIONS ON CANCER:
ANSWERS AND RATIONALE

81) C
- Air conditioners need to be avoided to protect from excessive coldness. A humidifier in the home should be used if excessive dryness is a problem. Options A, B, and D are appropriate interventions regarding stoma care following radical neck dissection and creation of a tracheotomy.

82) A
- Cytoreductive or “debulking” surgery may be used if a large tumor cannot be completely removed as is often the case with late-stage ovarian cancer (e.g., the tumor is attached to a vital organ or spread throughout the abdomen). When this occurs, as much tumor as possible is removed and adjuvant chemotherapy or radiation may be prescribed.

83) C
- Hormone therapy (androgen deprivation) is a mode of treatment for prostatic cancer. The goal is to limit the amount of circulating androgens because prostate cells depend on androgen for cellular maintenance. Deprivation of androgen often can lead to regression of disease and improvement of symptoms.

84) C
- Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A high daily fluid intake should be maintained to limit clot formation and prevent infection. Option C is an accurate discharge instruction following prostatectomy.

85) A
- The incidence of bladder cancer is greater in men than in women and affects the white population twice as often as blacks. Options B, C, and D are associated with the incidence of bladder cancer.



86. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common symptom of this type of cancer?

a) dysuria
b) hematuria
c) urgency on urination
d) frequency of urination

87. The nurse is caring for a client following intravesical instillation of an alkylating chemotherapeutic agent into the bladder for the treatment of bladder cancer. Following the instillation, the nurse should instruct the client to:

a) urinate immediately
b) maintain strict bed rest
c) change position every 15 minutes
d) retain the instillation fluid for 30 minutes



88. The nurse is assessing the stoma of a client following a ureterostomy. Which of the following should the nurse expect to note?

a) a dry stoma
b) a pale stoma
c) a dark-colored stoma
d) a red and moist stoma

89. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

a) placing cool compresses on the affected arm
b) elevating the affected arm on a pillow above heart level
c) avoiding arm exercises in the immediate postoperative period
d) maintaining an intravenous site below the antecubital area on the affected site

90. The nurse is preparing a client for a mammography. The nurse tells the client:

a ) that mammography takes about 1 hour
b) that there is no discomfort associated with the procedure
c) to maintain an NPO status on the day of the test
d) to avoid the use of deodorants, powders, or creams on the day of the test






NCLEX REVIEW QUESTIONS ON CANCER:
ANSWERS AND RATIONALE

86) B
- The most common symptom in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ.

87) C
- Normally, the medication is injected into the bladder through a urethral catheter, the catheter is clamped or removed, and the client is asked to retain the fluid for 2 hours. The client changes position every 15 to 30 minutes from side to side and from supine to prone or resumes all activity immediately. The client then voids and is instructed to drink water to flush the bladder.

88) D
- Following ureterostomy, the stoma should be red and moist. A pale stoma may indicate an inadequate amount of vascular supply. A dry stoma may indicate a body fluid deficit. Any sign of darkness or duskiness in the stoma may indicate a loss of vascular supply and must be reported immediately or necrosis can occur.

89) B
- Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring.

90) D
- Mammography takes about 15 to 30 minutes to complete. Some discomfort may be experienced because of the breast compression required to obtain a clear image. There is no reason to maintain an NPO status before the procedure. Option D is an accurate instruction.



91. A nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which of the following is an early sign of this oncological emergency?

a) cyanosis
b) arm edema
c) periorbital edema
d) mental status changes


92. A nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which of the following is a serious late sign of this oncological emergency?

a) headache
b) dysphagia
c) constipation
d) electrocardiographic changes



93. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of the greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed when the client states:

a) I should avoid blowing my nose
b) I may need a platelet transfusion if my platelet count is too low
c) I'm going to take aspirin for my headache as soon as I get home
I will count the number of pads and tampons I use when menstruating

94. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply

a) radiation
b) chemotherapy
c) increased fluid intake
d) serum sodium levels
e) decreased oral sodium intake
f) medication that is antagonistic to antidiuretic hormone


95. The client has undergone mastectomy. The nurse interprets that the client is making the best adjustment to the loss of the breast if which of the following behaviors is observed?

a ) participating in the care of the surgical drain
b) reading the postoperative care booklet
c) refusing to look at the wound
d) asking for pain medication when needed





NCLEX REVIEW QUESTIONS ON CANCER:
ANSWERS AND RATIONALE

91) C
- Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

92) D
- Hypercalcemia is a late manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.

93) C
- During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. Option C describes an incorrect statement by the client. Aspirin and nonsteroidal anti-inflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity, thus further teaching is needed. Options A, B, and D are correct statements by the client to prevent and monitor bleeding.

94) A, B, D, F
- Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.

95) A
- The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that would be in place for a short time after discharge. Asking for pain medication is also an action-oriented option, but it does not relate to acceptance of the loss of the breast. Reading the postoperative care booklet is useful, but is not the best of the options presented here. Refusing to look at the wound indicates no adaptation to the loss.



96. The client is preparing for discharge from the hospital after radical vulvectomy. The nurse plans to teach this client that which of the following activities is acceptable after discharge because it will no precipitate complications?

a) sexual activity
b) walking
c) sitting for lengthy periods
d) driving a car

97. The nurse has admitted a client to the clinical nursing unit following a modified right radical mastectomy for the treatment of breast cancer. The nurse plans to place the right arm in which of the following positions?

a) elevated above shoulder level
b) elevated on a pillow
c) level with the right atrium
d) dependent to the right atrium



98. The nurse instructs the client in breast self-examination (BSE). The nurse tells the client to lie down and to examine the left breast. The nurse instructs the client that while examining the left breast, she should place a pillow under the :

a) right shoulder
b) left shoulder
c) small of the back
d) right scapula

99. The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is:

a) 7 to 10 days after menses
b) just before menses begins
c) at ovulation time
d) at a specific day of the month and on that same day every month thereafter

100. The 32 y/o female client has a history of fibrocyctic disorder of the breasts. The nurse interviewing the client asks whether the breast lumps are more noticeable:

a) in the spring months
b) in the autumn
c) after menses
d) before menses




NCLEX REVIEW QUESTIONS ON CANCER:
ANSWERS AND RATIONALE


96) B
- The client should resume activity slowly, but walking is a beneficial activity. The client should know to rest when fatigued. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged standing or sitting. Sexual activity is prohibited for 4 to 6 weeks after surgery.

97) B
- The client’s operative arm should be positioned so that it is elevated on a pillow, and not exceeding shoulder elevation. This promotes optimal drainage from the limb, without impairing the circulation to the arm. If the arm is positioned flat (option C) or dependent (option D), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

98) B
- The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow would be placed under the left shoulder.

99) D
- If the client has had a hysterectomy or is no longer menstruating, the breast self-examination (BSE) should be performed on the same day every month. Options A and B are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.

100) D
- The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes.



101. The nurse is teaching the client who has had a laryngectomy for laryngeal cancer how to use an artificial larynx. The nurse tells the client to:

a) insert the device into the tracheostomy
b) hold the device alongside the neck
c) hold the device over the upper

102. A client is scheduled for a Papanicolaou (Pap) smear at the next scheduled clinic visit. The nurse provides instructions to the client regarding preparation for this test. The nurse tells the client that:

a) the test can be performed during menstruation
b) fluids are restricted on the day of the test
c) the test is painless
d) vaginal douching is required 2 hours before the test



103. The client has been hospitalized for a cervical implant. The implant is removed and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instructions?

a) cream may be used to relieve dryness or itching
b) foul-smelling vaginal discharge is a sign of an infection
c) sexual intercourse may be resumed after 7 to 10 months
d) some vaginal bleeding is expected for 1 to 3 months

104. The nurse teaches skin care to the client receiving external radiation therapy. Which of the following statements, if made by the client, would indicate the need for further instruction?

a) I will handle the area gently
b) I will avoid the use of deodorants
c) I will limit sun exposure to 1 hour daily
d) I will wear loose-fitting clothing

105. A community health nurse is preparing a poster for educational session for a group of women and will be discussing the risk factors associated with breast cancer. Select the risk factors for breast cancer that the nurse will list on the poster. Select all that apply.

a) family history of breast cancer
b) early menarche
c) early menopause
d) previous cancer of the breast, uterus, or ovaries
e) multiparity
f) high-dose radiation exposure to chest




NCLEX REVIEW QUESTIONS ON CANCER:
ANSWERS AND RATIONALE

101) B
- The artificial larynx is an electronic device that assists the client after laryngectomy to produce speech. There are two types—one is held at the side of the neck and the other is inserted into the mouth. The vibration produces a mechanical sounding speech that is monotone in quality but is intelligible.

102) C
- A Pap smear is usually painless. The test cannot be performed during menstruation. The client needs to be instructed to avoid douching for at least 24 hours prior to the test. There is no reason to restrict fluids on the day of the test.

103) B
- Foul-smelling vaginal discharge is expected and will occur for some time following removal of a cervical radiation implant. Options A, C and D are accurate discharge instructions.

104) C
- The client needs to be instructed to avoid exposure to the sun. Options A, B, and D are accurate measures in the care of a client receiving external radiation therapy.

105) A, B, D, F
- Risk factors for breast cancer include family history of breast cancer, age older than 40 years, early menarche, late menopause, or both, previous cancer of the breast, uterus, or ovaries, nulliparity or first child born after age 30 years, and high-dose radiation exposure to chest.


Edited by Karmela, Jun 23 2011, 11:52 AM.
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Karmela
Wanderer
[ * ]
NCLEX Review Questions on Cancer
From: http://www.nclexpinoy.com

106. A nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client who had a laryngectomy. Select all instructions that would be included in the list

a) avoid swimming and use care when showering
b) keep the humidity in the home low
c) avoid exposure to people with infections
d) restrict fluid intake
e) obtain a Medic-Alert bracelet
f) prevent debris from entering the stoma

107. A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse tells the client that:

a) the test may be painful
b) the dye injected may cause a warm, flushing sensation
c) fluids will be restricted following the test
d) the test takes approximately 2 hours



108. A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which food that is most likely to cause this taste for the client?

a) beef
b) potatoes
c) custard
d) cantaloupe

109. The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions regarding breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which of the following information should the nurse give the client?

a) it is not necessary to do BSE because you are postmenpausal
b) you are not at risk for breast cancer because you are in the postmenopausal phase
c) you need to perform BSE on the same day of every month
d) mammograms performed every 5 years are sufficient in the postmenopausal phase

110. A community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instructions?

a) TSE is performed once a month
b) TSE should be performed on the same day of each month
c) the scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand
d) it is best to do TSE first thing in the morning before a bath or shower





NCLEX REVIEW QUESTIONS ON CANCER:
ANSWERS AND RATIONALE

106) A, C, E, F
- The nurse would teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include to avoid swimming, use care when showering, avoid exposure to people with infections, prevent debris from entering the stoma, and obtain a Medic-Alert bracelet. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

107) B
- CT scanning causes no pain and can take 15 to 60 minutes to perform. The dye may cause a warm flushing sensation when injected. Fluids are encouraged following the procedure. If an iodine dye is used, the client should be asked about allergies to seafood or iodine.

108) A
- Chemotherapy may cause distortion of taste. Often, beef and pork are reported to taste bitter or metallic. The nurse can promote client nutrition by helping the client choose alternative sources of protein in the diet. Options B, C, and D are not likely to cause distortion of taste.

109) C
- Women who are in the postmenopausal phase are taught to do BSE on the same day of every month. Before menopause, woman should do the procedure 7 days after the start of the menstrual cycle when the breasts are less tender. Options A, B, and D are incorrect regarding breast cancer and BSE in a woman who is postmenopausal.

110) D
- TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after a warm shower or bath when the scrotum is most relaxed.
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Karmela
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NCLEX Review Questions on Cancer

Welcome to the NCLEX Review Questions on Cancer.

Enjoy answering and Good Luck.


Situation: Aling Nena is a 60 year old woman with a malignant tumor of the breast, who was admitted for modified radical mastectomy.

1. The physician has ordered 5 flourouracil, 700 mg IV once a week. When Aling Nena hears this, she says to the nurse, "Am I going to lose my hair?" Which is the best response by the nurse?


a) 5-flourouracil usually does nit cause loss of hair
b) hair loss can occur but a wig can be worn until your hair grows back
c) the physician will prescribe a medication to prevent this side effect from occurring
d) losing your hair is less traumatic than losing breast

2. Aling Nena is being assessed of her nutritional status. She weigh 100 lbs and is 5'8 ft. tall. Her assessment would include the following except:

a) a diet history
b) anthropometric measurements
c) food preferences
d) serum protein

3. Which nursing action would best attain the goal of providing and promoting coping for Aling Nena?

a) telling Aling Nena for her strengths and progress
b) planning experienced for her that are conclusive
c) helping her to identify her problems and solutions
d) giving her information on how to handle her problems


Try to read the latest type of cancer, it might be included in the exam --> Mesothelioma Cancer:http://www.online-mesothelioma-cancer.com/



NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

1) B
- the drug can cause alopecia or hair loss but the hair will grow back after treatment. The nurse can advise the patient to wear a wig or other head accessories for coverage. The patient should buy the wig before hair falls out.
5-fluoroucacil or 5-FU is an antineoplastic drug that used for the cancers of the colon, rectum, breast, stomach and pancreas.

The adverse side effects of this drug are:
Photosensitivity - advise to avoid prolonged exposure to sunlight and to use highly protective sunlight to prevent inflammatory erythematous dermatitis
advise patient she cannot get pregnant or breastfeed while under medication because of its toxic effect
advise patient to discontinue drug and report to physician if diarrhea occurs as it is a sign of toxicity
Mouth sores (stomatitis) - apply topical anesthetics for comfort, advise oral hygiene to prevent infection of the denuded oral mucosa
Nausea, vomiting, and anorexia - give antiemetic before administration
Leukopenia, anemia, agranulocytosis - avoid exposure to infection
Scaling of the skin, pruritus, desquamative rash of hands and feet, and nail changes - reversible after medication, can be treated with pyridoxine 50-150 mg for 7 days
Thrombocytopenia - avoid IM injections when platelet count goes below 50,000
if crystals form in the drug - redissolve by warming solution
do not use cloudy solution, do not refrigirate, protect from sunlight, discard unused portion after 1 hour
use plastic IV bags if to be infused by intravenous route as the drug is more stable in plastic than glass
2) C
- although inquiry about food preferences is history taking, it is not used in the standard nutritional status assessment of the patient.
The information gained during nutritional status assessment are:
Anthropometric measurements: height, weight, body mass index (BMI), circumferential measurements
Physical examination - clinical signs and symptoms such as pallor, dry skin, brittle hair, mouth sores
Diet history - 24 hours diet recall to assess the quality and quantity of food intake
Diagnostic tests: hemoglobin, hematocrit, transferring, serum protein, total lymphocyte count, nitrogen balance, d-xylose absorption test, creatinine excretion, serum levels
3) C


After you reviewed your answers through its rationale, you can now proceed to the next set of questions.



4. The nurse evaluates that zofran (ondansetron) is effective in a client undergoing chemotherapy if which of the following is observed?

a) urine output is 1,500 ml/day
b) the client can tolerate mechanically soft diet
c) the client's anxiety is relieved
d) the client was able to sleep

5. A client with cancer of the colon who is receiving chemotherapy tells a nurse that some foods on the metal tray taste bitter. The nurse would try ti limit which of the following foods that is most likely to cause this taste for the client?

a) cantaloupe
b) potatoes
c) beef
d) custard

6. A client suspected of having lung tumor is scheduled for a computerized tomography (CT) scan with dye injection. A nurse tells the client that

a) the test may be painful
b) the dye injected may cause a warm, flushing sensation
c) fluids will be restricted following the test
d) the test takes approximately 2 hours

7. Which of the following is a nursing responsibility for a client undergoing external radiation therapy?

a) wear gown, gloves and mask
b) observe time, distance, and shielding
c) provide the client adequate rest and schedule activity
d) place the client in isolation for few days

8. Who among these clients is at high risk to develop testicular cancer?

a) the client has undescended testes at birth
b) the client has human papilloma virus
c) the client has recurrent urinary tract infection
d) the client is uncircumcised

9. A nursing assistant is taking care of a patient who had undergone liver biopsy. When should the registered nurse intervene?

a) when the nursing assistant monitors the patient's vital signs every 15 minutes for the 1st two hours after the procedure
b) when the nursing assistant tells the patient to remain in bed for several hours
c) when the nursing assistant positions the patient on the left side
d) when the nursing assistant checks the biopsy site for bleeding

10. Which of the following is a risk factor to cancer of the colon?

a) diabetes mellitus
b) peptic ulcer
c) abdominal hernia
d) high fat, high calorie diet


NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

4) B
- zofran is antiemetic. The drug is effective if the client is no longer experiencing nausea and vomiting. Therefore, the client can already tolerate food.

5) C
- meat is perceived as bitter by clients with cancer

6) B
- iodinated contrast medium causes warm, flushing sensation as it is injected.

7) C
- fatigue is a side effect of external radiation therapy. Answers A, B, and D are practiced in internal radiation therapy.

8) A
- history of undescended testes at birth is strongly linked with testicular cancer.

9) C
- the client should be turned to the right side after liver biopsy, not on the left side. Turning the client on the right side will apply pressure on the site and will prevent bleeding.

10) D
- high fat, high protein and high carbohydrate diet increase the risk of cancer in the colon.



11. Which of the following should the nurse assess prior to administration of cisplatin?

a) hydration
b) hemoglobin
c) weight
d) ECG

12. The client is receiving internal radiation therapy. What is the appropriate nursing action to minimize radiation contamination?

a) put the soiled linens in double bag
b) keep clients things close to her bedside
c) always wear gloves when entering the client's room
d) minimize contact with the client

13. A client is suspected of having pheochromocytoma. Which of the following signs and symptoms would help support this diagnosis?

a) abdominal pain
b) anuria
c) hypertension
d) weight gain

14. Before uterine radioactive implant is inserted, which of the following physician's orders does the nurse expect?

a) administer analgesic
b) administer sedative
c) administer enema
d) administer antibiotic

15. The nurse is admitting a patient with jaundice, due to pancreatic cancer. Which of the following would the nurse give highest priority?

a) body image
b) nutrition
c) skin integrity
d) anticipatory grieving




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

11) A
- cisplatin, a neoplastic agent is nephrotoxic. The client should be adequately hydrated before administration of the drug.

12) D
- Each contact with the client undergoing internal radiation therapy should last for 5 minutes only, a total of 30 minutes in an 8-hour shift, to minimize radiation contamination. The nurse should wear dosimeter badge to measure radiation exposure.

13) C
- pheochromocytoma is a tumor in the adrenal medulla that stimulates increased secretion of catecholamines (epinephrine/norepinephrine). This causes hypertension.

14) C
- during uterine radioactive implant, the client should be on bedrest. Defecation should be avoided during treatment to prevent dislodgement of the implant. Therefore, enema is usually ordered by the physician before the treatment.

15) C
- give priority to physiologic before psychosocial needs. Jaundice causes severe pruritus. Therefore, maintaining skin integrity is a priority.



16. After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/cu.mm. What term should the nurse use to describe this low platelet count?

17. Which of the following should the nurse include when providing health teachings for patients at risk of developing prostatic cancer?

a) participate in smoking cessation program
b) perform monthly self-testicular examination
c) maintain daily walking exercise
d) undergo monthly digital rectal examination

18. Which of the following questions should the nurse ask in a client who is at risk for breast cancer?

a) does your family have a history of multiple gestation?
b) does your family have a history of ovarian cancer?
c) does your family have a history of early menopause?
d) does your family have a history of late menarche?

19. Which of the following client history increases risk for anorectal cancer?

a) chronic constipation
b) high fiber diet
c) alcohol abuse
d) chronic inflammatory bowel disease

20. A client will be for uterine radium implant. Which of the following statement when made by the client indicates the need for further teaching?

a) my sister is coming to stay with me today after implant insertion
b) I will be in bed for the duration of the treatment
c) I will have a foley catheter in place
d) I will have enema before the procedure



ANSWERS AND RATIONALE

16) thrombocytopenia
- the normal thrombocyte count is 150,000 to 450,000/ cu.mm.

17) A
- smoking increases risk for prostatic cancer. Choice B is done to detect cancer of the testes. Choice D, digital rectal examination is recommended annually, not monthly.

18) B
- history of cancer of the reproductive system (cancer of the uterus, cervix, and ovaries) increase risk for breast cancer.

19) D
- chronic inflammatory bowel disease are primarily associated with anorectal cancer.

20) A
- the client on internal radiation therapy should be on isolation to prevent radiation contamination of other people.



21. Which of the following nursing actions is most appropriate when caring for a client with radium implant?

a) wear gloves when entering the client's room
b) wear masks and gloves when performing procedures to the client
c) avoid staying with the client for more than 30 minutes in a shift
d) place client's soiled gowns and linens in a plastic bag

22. A woman had been diagnosed to have breast cancer. Which of the following factors is most significant to her prognosis?

a) she had her menarche at age 12 years
b) her sister died of breast cancer 5 years ago
c) she delivered her first born at age 25 years
d) she had her menopause at age 50 years

23. Which of the following are characteristics of a client most susceptible to develop malignant melanoma?

a) dark skin, black hair
b) coarse skin, black hair
c) fair skin, blond hair
d) oily skin, brown hair

24. Which of the following statements when made by the client with implant radiation therapy needs intervention by the nurse?

a) I will have to go to the toilet to void
b) my visitors are allowed to visit me for 30 minutes only in a day
c) the nurse needs to wear a badge when caring for me
d) I need to remain in bed during the entire duration of the treatment

25. Which of the following statements when made by the client with leukemia indicates that the client understands the health teachings given by the nurse? Select all that apply

a) I am allowed to eat raw foods
b) I have to avoid raw fruits and vegetables
c) fresh flowers should not be allowed in my room
d) if I developed joint pains, I should apply cold compress to the area
e) if I developed high fever, I should take aspirin
f) I am allowed to watch baseball games
g) I should use soft-bristled toothbrush






NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

21) C
- the nurse must limit her exposure to the client having internal radiation therapy to prevent contamination. The nurse must observe DTS (distance, time, and shielding). Time: 5 minutes/exposure; maximum of 30 minutes in an 8-hour shift.

22) B
- positive family history plays vital role in the predisposition to cancer.

23) C
- clients with fair skin, blond hair are prone to skin cancer. This is because they have lesser melanin in their skin, which serves as protection of the skin.

24) A
- the client receiving internal radiation therapy should be on complete bed rest to prevent dislodgement of the implant. The client has 2-way foley catheter during the treatment.
Choices B, C, and D indicate correct understanding of the patient on internal radiation therapy, and do not need intervention by the nurse.

25) B, C, D, G
- indicates that the client with leukemia understands health teachings. A client with leukemia has low resistance to infection and bleeding tendencies.



26. A 40-year old woman is admitted to the hospital for a radiation implant therapy to treat recently diagnosed cervical cancer. The most important consideration when planning care is her

a) level of anxiety
b) loss of income due to inability to work
c) support system
d) energy level to perform ADL's

27. When the nurse is discussing risk factors for cervical cancer, which of these women would be at greatest risk?

a) a 25-year old woman with family history of cancer and using birth control pills
b) a 50-year old woman who has several exposures to radiation and has chronic anemia
c) a 19-year old woman who initiated sexual intercourse early with multiple partners
d) a 60-year old woman who had smoked cigarettes for 5 years and used diaphragm for birth control

28. Which of the following nursing diagnoses would rank as the most important in the planning of care for a client in two weeks after the chemotherapy has begun?

a) potential for infection
b) activity intolerance
c) impaired skin integrity
d) self-esteem disturbance

29. During the administration of a chemotherapeutic drug, the nurse observes that there is a lack of blood return from the intravenous catheter. The priority action by the nurse would be to

a) stop the administration of the drug immediately
b) reposition the client's arm and continue with the administration of the drug
c) apply a tourniquet to the patient's affected arm and notify the doctor
d) continue to administer the drug and assess for edema at the IV site

30. A patient who is receiving chemotherapy develops stomatitis. Which of the following actions would be priority for the nurse to incorporate into the plan of care?

a) rinse the patient's mouth with full strength hydrogen peroxide every 4 hours
b) use a soft toothbrush after each meal
c) provide hot tea with honey to soothe the patient's painful oral mucosa
d) use dental floss only





NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

26) A
- anxiety is the usual response to a change in life situation like undergoing treatment for cancer.

27) C
- early sexual intercourse and having multiple sexual partners pose highest risk to cervical cancer.

28) A
- chemotherapy causes immunosuppression. Therefore, the patient is at risk to develop infection.

29) A
- chemotherapeutic agents are irritating to tissues. Lack of blood return from the IV catheter indicates that it is out of vein. Therefore, administration of the drug should be stopped immediately.

30) B
- use soft toothbrush in a client with stomatitis to prevent further trauma and pain to the oral mucosa. Half-strength hydrogen peroxide is recommended to relieve stomatitis not full strength. Hot beverages will further cause irritation. Honey may support proliferation of microorganisms in the oral mucosa. Flossing may also cause trauma to the mouth and gums of the patient with stomatitis.



31. Which of these findings in the breast of a patient who is suspected of having breast cancer would support the diagnosis?

a) complaints of dull, achy, pain
b) palpation of a mobile mass
c) presence of an inverted nipple
d) area of discoloration skin

32. A nurse is caring for a client with an internal radiation implant. Which of the following instructions is appropriate?

a) allow the client to go to the bathroom
b) avoid creams and lotions
c) visitors are allowed to stay in the room
d) the client should remain in bed during the entire duration of treatment

33. How often should a female who is above 40 years old, go for cancer detection examination?

a) daily
b) weekly
c) monthly
d) yearly


34. The client is receiving internal radiation therapy. The nurse should

a) remember to give the badge to the next-shift nurse
b) maintain a 30-minute close contact with the patient in a shift
c) wear gloves, mask and gown when entering the client's room
d) instruct relatives no to visit the client during the entire duration of the treatment

35. A nurse is assessing a client with metastatic breast cancer who reports nocturia, weakness, nausea and vomiting. The client's serum electrolytes include potassium 4.2 mEq/L, sodium 135 mEq/L, calcium 7.0 mEq/L, and magnesium 2.0 mEq/L. Based on the assessment findings, the priority action for the nurse is to:

a) start client on fluid restriction
b) administer calcium gluconate
c) increase the client's IV fluids
d) administer Allopurinol




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

31) C
- inversion of nipple is one of the manifestations of breast cancer. A cancerous lesion is non-mobile.

32) D
- the client with internal radiation implant should be on bed rest. This is to prevent dislodgment of the implant.

33) D
- cancer screening for females who are above 40 years of age should be yearly.

34) A
- dosimeter badge is used to measure amount of exposure to radiation. It should be endorsed to the next shift.

35) C
- nocturia, nausea and vomiting cause dehydration. Therefore, the correct nursing action is to increase the client's IV fluids.
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Karmela
Wanderer
[ * ]
NCLEX Tumor Review
From: http://www.nclexinfo.com


Primary Tumors:

Neuromas- 80-90% of brain tumors, named for what part of nerve cell affected.
Meningiomas- outside of arachnoidal tissue, usually benign and slow growing
Glioblastoma Multiform-50% of all primary tumors, linked to specific genetic mutations

Secondary Tumors

Metastatic carcinomas:

Scale –degree of anaplasia: differentiation of mature (good) vs. immature cells (bad)

Grade I: up to 25% anaplasia

Grade II: 26-50% anaplasia

Grade III: 51-75% anaplasia

Grade IV: 76-100% anaplasia

Primary Tumor Effect:

Headaches
Vomiting

Secondary Tumor Effect:

Direct compression/necrosis
Herniation of brain tissue
Increase ICP

Noteworthy Tumor Markers:

AFP
Alkaline phosphatase
b-hCG
CA-125
PSA
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Karmela
Wanderer
[ * ]
NCLEX Pharmacology Review Part 1



I found a lot of review questions here but no answers were included:
http://www.slideshare.net/thinkrn/kaplan-nclex-sample-exam-3?from=embed

Nursing Tip: How To Answer Nursing Exam Questions

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LittleBoPeep
Wanderer
[ * ]
There are more Kaplan review questions here:

http://www.slideshare.net/thinkrn/kaplan-nclex-sample-exam-2?from=embed

http://nursing.slcc.edu/nclexrn3500/numberSelect.do;jsessionid=B213E6B7B37A653A3C57BAA47FA05114

You can choose which practice test you want to take here:

http://nursing.slcc.edu/nclexrn3500/mainMenu.do


NCLEX Practice Questions 1
1. A nurse is reviewing a patient’s medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.

A: Coumadin
B: Finasteride
C: Celebrex
D: Catapress
E: Habitrol
F: Clofazimine
2. A nurse is reviewing a patient’s PMH. The history indicates photosensitive reactions to medications. Which of the following drugs has not been associated with photosensitive reactions? Note: More than one answer may be correct.

A: Cipro
B: Sulfonamide
C: Noroxin
D: Bactrim
E: Accutane
F: Nitrodur
3. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?

A: Sulfasalazine
B: Levodopa
C: Phenolphthalein
D: Aspirin
4. You are responsible for reviewing the nursing unit’s refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator’s contents?

A: Corgard
B: Humulin (injection)
C: Urokinase
D: Epogen (injection)
5. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?

A: IgA
B: IgD
C: IgE
D: IgG
6. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?

A: Immediately see a social worker
B: Start prophylactic AZT treatment
C: Start prophylactic Pentamide treatment
D: Seek counseling
7. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

A: Atherosclerosis
B: Diabetic nephropathy
C: Autonomic neuropathy
D: Somatic neuropathy
8. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?

A: Multiple sclerosis
B: Anorexia nervosa
C: Bulimia
D: Systemic sclerosis
9. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?

A: Diverticulosis
B: Hypercalcaemia
C: Hypocalcaemia
D: Irritable bowel syndrome
10. Rho gam is most often used to treat____ mothers that have a ____ infant.

A: RH positive, RH positive
B: RH positive, RH negative
C: RH negative, RH positive
D: RH negative, RH negative

11. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?

A: A Guthrie test can check the necessary lab values.
B: The urine has a high concentration of phenylpyruvic acid
C: Mental deficits are often present with PKU.
D: The effects of PKU are reversible.
12. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?

A: Onset of pulmonary edema
B: Metabolic alkalosis
C: Respiratory alkalosis
D: Parkinson’s disease type symptoms
13. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is?

A: Let others know about the patient’s deficits.
B: Communicate with your supervisor your patient safety concerns.
C: Continuously update the patient on the social environment.
D: Provide a secure environment for the patient.
14. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?

A: Deep breathing techniques to increase O2 levels.
B: Cough regularly and deeply to clear airway passages.
C: Cough following bronchodilator utilization
D: Decrease CO2 levels by increase oxygen take output during meals.
15. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?

A: Slow pulse rate
B: Weight gain
C: Decreased systolic pressure
D: Irregular WBC lab values
16. A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome?

A: Simian crease
B: Brachycephaly
C: Oily skin
D: Hypotonicity
17. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?

A: Streptokinase
B: Atropine
C: Acetaminophen
D: Coumadin
18. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”

A: Green vegetables and liver
B: Yellow vegetables and red meat
C: Carrots
D: Milk
19. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans?

A: S. pneumonia
B: H. influenza
C: N. meningitis
D: Cl. difficile
20. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is.

A: The life span of RBC is 45 days.
B: The life span of RBC is 60 days.
C: The life span of RBC is 90 days.
D: The life span of RBC is 120 days.

21. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?

A: Following surgery
B: Upon admit
C: Within 48 hours of discharge
D: Preoperative discussion
22. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in?

A: Trust vs. mistrust
B: Initiative vs. guilt
C: Autonomy vs. shame
D: Intimacy vs. isolation
23. A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in?

A: Trust vs. mistrust
B: Initiative vs. guilt
C: Autonomy vs. shame
D: Intimacy vs. isolation
24. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in?

A: Trust vs. mistrust
B: Initiative vs. guilt
C: Autonomy vs. shame
D: Intimacy vs. isolation
25. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?

A: 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg
B: 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
C: 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
D: 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg
26. When you are taking a patient’s history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?

A: Elavil
B: Calcitonin
C: Pergolide
D: Verapamil
27. Which of the following conditions would a nurse not administer erythromycin?

A: Campylobacterial infection
B: Legionnaire’s disease
C: Pneumonia
D: Multiple Sclerosis
28. A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?

A: Decreased HR
B: Paresthesias
C: Muscle weakness of the extremities
D: Migranes
29. A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?

A: Vomiting
B: Extreme Thirst
C: Weight gain
D: Acetone breath smell
30. A patient’s chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute?

A: Increased appetite
B: Vomiting
C: Fever
D: Poor tolerance of light
31. A nurse if reviewing a patient’s chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition?

A: Yersinia pestis
B: Helicobacter pyroli
C: Vibrio cholera
D: Hemophilus aegyptius
32. A nurse if reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?

A: Borrelia burgdorferi
B: Streptococcus pyrogens
C: Bacilus anthracis
D: Enterococcus faecalis
33. A fragile 87 year-old female has recently been admitted to the hospital with increased confusion and falls over last 2 weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?

A: FBC (full blood count)
B: ECG (electrocardiogram)
C: Thyroid function tests
D: CT scan
34. A 84 year-old male has been loosing mobility and gaining weight over the last 2 months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed?

A: FBC (full blood count)
B: ECG (electrocardiogram)
C: Thyroid function tests
D: CT scan
35. A 20 year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. 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
36. A 28 year old male has been found wandering around in a confused 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
37. 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 ability to understand instruction.
C: The overall mental and physical abilities of the child.
D: Frequent attempts with positive reinforcement.
38. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank 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 ipecac
39. 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
40. 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 on any identification. What should the nurse do?

A: Contact the provider
B: Ask the child to write their name on paper.
C: Ask a co-worker about the identification of the child.
D: Ask the father who is in the room the child’s name.


Answer and Rationale - NCLEX Practice Questions 1

1. (A) and (B) are both contraindicated with pregnancy.

2. (F) All of the others have can cause photosensitivity reactions.

3. (D) All of the others can cause urine discoloration.

4. (A) Corgard could be removed from the refigerator.

5. (D) IgG is the only immunoglobulin that can cross the placental barrier.

6. (B) AZT treatment is the most critical innervention.

7. (C) Autonomic neuropathy can cause inability to urinate.

8. (B) All of the clinical signs and systems point to a condition of anorexia nervosa.

9. (B) Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion.

10. (C) Rho gam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.

11. (D) The effects of PKU stay with the infant throughout their life.

12. (D) Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.

13. (D) This patient’s safety is your primary concern.

14. (C) The bronchodilator will allow a more productive cough.

15. (B) Weight gain is associated with CHF and congenital heart deficits.

16. (C) The skin would be dry and not oily.

17. (A) Streptokinase is a clot busting drug and the best choice in this situation.

18. (A) Green vegetables and liver are a great source of folic acid.

19. (D) Cl. difficile has not been linked to meningitis.

20. (D) RBC’s last for 120 days in the body.

21. (B) Discharge education begins upon admit.

22. (B) Initiative vs. guilt- 3-6 years old

23. (A) Trust vs. Mistrust- 12-18 months old

24. (D) Intimacy vs. isolation- 18-35 years old

25. (B) HR and Respirations are slightly increased. BP is down.

26. (A) Elavil is a tricyclic antidepressant.

27. (D) Erythromycin is used to treat conditions A-C.

28. (D) Answer choices A-C were symptoms of acute hyperkalemia.

29. (C) Weight loss would be expected.

30. (A) Loss of appetite would be expected.

31. (D) Choice A is linked to Plague, Choice B is linked to peptic ulcers, Choice C is linked to Cholera.

32. (A) Choice B is linked to Rheumatic fever, Choice C is linked to Anthrax, Choice D is linked to Endocarditis.

33. (D) A CT scan would be performed for further investigation of the hemiparesis.

34. (C) Weight gain and poor temperature tolerance indicate something may be wrong with the thyroid function.

35. (C) Blood cultures would be performed to investigate the fever and rash symptoms.

36. (A) With a history of diabetes, the first response should be to check blood sugar levels.

37. (C) Age is not the greatest factor in potty training. The overall mental and physical abilities of the child is the most important factor.

38. (C) The poison control center will have an exact plan of action for this child.

39. (C) Vastus lateralis is the most appropriate location.

40. (D) In this case you are able to determine the name of the child by the father’s statement. You should not withhold the medication from the child following identification.




NCLEX Practice Questions 2
1. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient's medication does not cause urine discoloration?

A. Sulfasalazine
B. Levodopa
C. Phenolphthalein
D. Aspirin

2. You are responsible for reviewing the nursing unit's refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator's contents?

A. Corgard
B. Humulin (injection)
C. Urokinase
D. Epogen (injection)

3. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?

A. IgA
B. IgD
C. IgE
D. IgG

4. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?

A. Immediately see a social worker
B. Start prophylactic AZT treatment
C. Start prophylactic Pentamide treatment
D. Seek counseling

5. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

A. Atherosclerosis
B. Diabetic nephropathy
C. Autonomic neuropathy
D. Somatic neuropathy

6. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?

A. Multiple sclerosis
B. Anorexia nervosa
C. Bulimia
D. Systemic sclerosis

7. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?

A. Diverticulosis
B. Hypercalcaemia
C. Hypocalcaemia
D. Irritable bowel syndrome

8. Rho gam is most often used to treat____ mothers that have a ____ infant.

A. RH positive, RH positive
B. RH positive, RH negative
C. RH negative, RH positive
D. RH negative, RH negative

9. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?

A. A Guthrie test can check the necessary lab values.
B. The urine has a high concentration of phenylpyruvic acid
C. Mental deficits are often present with PKU.
D. The effects of PKU are reversible.

10. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?

A. Onset of pulmonary edema
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Parkinson's disease type symptoms

11. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is?

A. Let others know about the patient's deficits
B. Communicate with your supervisor your concerns about the patient's deficits.
C. Continuously update the patient on the social environment.
D. Provide a secure environment for the patient.

12. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?

A. Deep breathing techniques to increase O2 levels.
B. Cough regularly and deeply to clear airway passages.
C. Cough following bronchodilator utilization
D. Decrease CO2 levels by increase oxygen take output during meals.

13. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?

A. Slow pulse rate
B. Weight gain
C. Decreased systolic pressure
D. Irregular WBC lab values

14. A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down's syndrome?

A. Simian crease
B. Brachycephaly
C. Oily skin
D. Hypotonicity

15. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?

A. Streptokinase
B. Atropine
C. Acetaminophen
D. Coumadin

16. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids?”

A. Green vegetables and liver
B. Yellow vegetables and red meat
C. Carrots
D. Milk

17. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans?

A. S. pneumonia
B. H. influenza
C. N. meningitis
D. Cl. difficile

18. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is.

A. The life span of RBC is 45 days.
B. The life span of RBC is 60 days.
C. The life span of RBC is 90 days.
D. The life span of RBC is 120 days.

19. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?

A. Following surgery
B. Upon admit
C. Within 48 hours of discharge
D. Preoperative discussion

20. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in?

A. Trust vs. mistrust
B. Initiative vs. guilt
C. Autonomy vs. shame
D. Intimacy vs. isolation

21. A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in?

A. Trust vs. mistrust
B. Initiative vs. guilt
C. Autonomy vs. shame
D. Intimacy vs. isolation

22. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in?

A. Trust vs. mistrust
B. Initiative vs. guilt
C. Autonomy vs. shame
D. Intimacy vs. isolation

23. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?

A. 11 year old male – 90 b.p.m, 22 resp/min., 100/70 mm Hg
B. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
C. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
D. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg

24. When you are taking a patient's history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?

A. Elavil
B. Calcitonin
C. Pergolide
D. Verapamil

25. Which of the following conditions would a nurse not administer erythromycin?

A. Campylobacterial infection
B. Legionnaire's disease
C. Pneumonia
D. Multiple Sclerosis


Answer Key - NCLEX Practice Questions 2

1. D
2. A
3. D
4. B
5. C
6. B
7. B
8. C
9. D
10. D
11. D
12. C
13. B
14. C
15. A
16. A
17. D
18. D
19. B
20. B
21. A
22. D
23. B
24. A
25. D


NCLEX Practice Questions 3
1. 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.


2. 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.


3. A patient with a history of diabetes mellitus is in the second post-operative 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 following is the most likely explanation for the patient's symptoms?

A. Anesthesia reaction.
B. Hyperglycemia.
C. Hypoglycemia.
D. Diabetic ketoacidosis.


4. 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 concern?

A. Bowel perforation.
B. Viral gastroenteritis.
C. Colon cancer.
D. Diverticulitis.


5. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation?

A. Partial thromboplastin time.
B. Prothrombin time.
C. Platelet count.
D. Hemoglobin


6. 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.


7. 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.


8. 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).


9. 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.


10. 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.


11. A nurse caring for several patients on 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 post-operative 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.


12. 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 anti-psychotic medication.


13. 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.


14. 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.


15. 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 platelet count should be included on the nursing care plan?

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.


16. 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.


17. 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 "tear drop on a rose petal" appearance.


18. 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.


19. 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/day. Which of the following best describes the prescribed drug dose?

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.


20. 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 with only one testis.
D. Normally, the testes descend by one year of age.


Answer and Rationale- NCLEX Practice Questions 3

1. Answer: A

The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones.

2. Answer: D

A patient with Addison's disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates, including grains.

3. Answer: C

A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia reaction would not occur on the second post-operative day. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.

4. Answer: A

Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate advancing peritonitis. Viral gastroenteritis and colon cancer do not cause these symptoms. Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis.

5. Answer: A, B, and C

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

6. Answer: B

Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Hepatitis B, C, and D are transmitted through infected bodily fluids.

7. Answer: A

Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis (gall bladder disease), diverticulosis, and history of Crohn's disease do not preclude blood donation.

8. Answer: A

Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Furosemide is a loop diuretic and is contraindicated in a patient with gastritis.

9. Answer: D

Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.

10. Answer: D

Patients with pulmonary edema experience air hunger, anxiety, and agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing caused by laryngeal swelling or spasm and is not associated with pulmonary edema.

11. Answer: C

An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. A patient recovering well from coronary bypass would not need the device. Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.

12. Answer: B

The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Psychiatric medication is not a contraindication to MRI scanning.

13. Answer: B

Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia.

14. Answer: C

A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist.

15. Answer: D

A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Transfusion of red cells is indicated for severe anemia.

16. Answer: B

Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. The anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is normal for a four year old. The average 4-year-old child cannot read yet, so this too is normal.

17. Answer: A

Koplik's spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. The body rash typically begins on the face and travels downward. High fever is often present. "Tear drop on a rose petal" refers to the lesions found in varicella (chicken pox).

18. Answer: C

Petechiae on the soft palate are characteristic of rubella infection. Choices A, B, and D are characteristic of scarlet fever, a result of group A Streptococcus infection.

19. Answer: B

This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should not be titrated based on symptoms without consulting a physician.

20. Answer: D

Normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. Exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. If not, a full assessment will determine the appropriate treatment.
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NCLEX Practice Test for Oncology 1
1. A male client has an abnormal result on a Papanicolaou test. After admitting, he read his chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?

a. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin
b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
c. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found
d. Alteration in the size, shape, and organization of differentiated cells


2. For a female client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?

a. “Client verbalizes feelings of anxiety.”
b. “Client doesn’t guess at prognosis.”
c. “Client uses any effective method to reduce tension.”
d. “Client stops seeking information.”


3. A male client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?

a. Related to visual field deficits
b. Related to difficulty swallowing
c. Related to impaired balance
d. Related to psychomotor seizures


4. A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:

a. hair loss.
b. stomatitis.
c. fatigue.
d. vomiting.


5. Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:

a. breast self-examination.
b. mammography.
c. fine needle aspiration.
d. chest X-ray.


6. A male client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

a. “Keep the stoma uncovered.”
b. “Keep the stoma dry.”
c. “Have a family member perform stoma care initially until you get used to the procedure.”
d. “Keep the stoma moist.”


7. A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?

a. Urine output of 400 ml in 8 hours
b. Serum potassium level of 3.6 mEq/L
c. Blood pressure of 120/64 to 130/72 mm Hg
d. Dry oral mucous membranes and cracked lips


8. Nurse April is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

a. cancerous lumps.
b. areas of thickness or fullness.
c. changes from previous self-examinations.
d. fibrocystic masses.


9. A client, age 41, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?

a. Onset of sporadic sexual activity at age 17
b. Spontaneous abortion at age 19
c. Pregnancy complicated with eclampsia at age 27
d. Human papillomavirus infection at age 32


10. A female client is receiving methotrexate (Mexate), 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

a. probenecid (Benemid)
b. cytarabine (ara-C, cytosine arabinoside [Cytosar-U])
c. thioguanine (6-thioguanine, 6-TG)
d. leucovorin (citrovorum factor or folinic acid [Wellcovorin])


11. The nurse is interviewing a male client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

a. Duodenal ulcers
b. Hemorrhoids
c. Weight gain
d. Polyps


12. Nurse Amy is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:

a. perform breast self-examination annually.
b. have a mammogram annually.
c. have a hormonal receptor assay annually.
d. have a physician conduct a clinical examination every 2 years.


13. A male client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?

a. Persistent nausea
b. Rash
c. Indigestion
d. Chronic ache or pain


14. For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?

a. Administering aspirin if the temperature exceeds 102° F (38.8° C)
b. Inspecting the skin for petechiae once every shift
c. Providing for frequent rest periods
d. Placing the client in strict isolation


15. Nurse Lucia is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms:

a. yearly after age 40.
b. after the birth of the first child and every 2 years thereafter.
c. after the first menstrual period and annually thereafter.
d. every 3 years between ages 20 and 40 and annually thereafter.


16. Which intervention is appropriate for the nurse caring for a male client in severe pain receiving a continuous I.V. infusion of morphine?

a. Assisting with a naloxone challenge test before therapy begins
b. Discontinuing the drug immediately if signs of dependence appear
c. Changing the administration route to P.O. if the client can tolerate fluids
d. Obtaining baseline vital signs before administering the first dose


17. A 35 years old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:

a. cell division or mitosis during the M phase of the cell cycle.
b. normal cellular processes during the S phase of the cell cycle.
c. the chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle–nonspecific).
d. one or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle–nonspecific).


18. The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

a. Actinic
b. Asymmetry
c. Arcus
d. Assessment


19. When caring for a male client diagnosed with a brain tumor of the parietal lobe, the nurse expects to assess:

a. short-term memory impairment.
b. tactile agnosia.
c. seizures.
d. contralateral homonymous hemianopia.


20. A female client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:

a. a decreased serum creatinine level.
b. hypocalcemia.
c. Bence Jones protein in the urine.
d. a low serum protein level.


21. A 35 years old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?

a. White, cottage cheese–like patches on the tongue
b. Yellow tooth discoloration
c. Red, open sores on the oral mucosa
d. Rust-colored sputum


22. During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

a. Recommending that the client discontinue chemotherapy
b. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
c. Monitoring the client’s platelet and leukocyte counts
d. Checking regularly for signs and symptoms of stomatitis


23. What should a male client over age 52 do to help ensure early identification of prostate cancer?

a. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
b. Have a transrectal ultrasound every 5 years.
c. Perform monthly testicular self-examinations, especially after age 50.
d. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly.


24. A male client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?

a. Anticipatory grieving
b. Impaired swallowing
c. Disturbed body image
d. Chronic low self-esteem


25. A male client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?

a. Stand as far away from the implant as possible and call for help.
b. Pick up the implant with long-handled forceps and place it in a lead-lined container.
c. Leave the room and notify the radiation therapy department immediately.
d. Put the implant back in place, using forceps and a shield for self-protection, and call for help.


26. Jeovina, with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?

a. Vision changes
b. Hearing loss
c. Headache
d. Anorexia


27. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)


28. A 34-year-old female client is requesting information about mammograms and breast cancer. She isn’t considered at high risk for breast cancer. What should the nurse tell this client?

a. She should have had a baseline mammogram before age 30.
b. She should eat a low-fat diet to further decrease her risk of breast cancer.
c. She should perform breast self-examination during the first 5 days of each menstrual cycle.
d. When she begins having yearly mammograms, breast self-examinations will no longer be necessary.


29. Nurse Brian is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

a. 24 hours
b. 2 to 4 days
c. 7 to 14 days
d. 21 to 28 days


30. The nurse is preparing for a female client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?

a. The client lies still.
b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band.



Answer and Rationale- NCLEX Practice Test for Oncology 1

1.Answer D. Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found is called metaplasia.

2.Answer A. Verbalizing feelings is the client’s first step in coping with the situational crisis. It also helps the health care team gain insight into the client’s feelings, helping guide psychosocial care. Option B is inappropriate because suppressing speculation may prevent the client from coming to terms with the crisis and planning accordingly. Option C is undesirable because some methods of reducing tension, such as illicit drug or alcohol use, may prevent the client from coming to terms with the threat of death as well as cause physiologic harm. Option D isn’t appropriate because seeking information can help a client with cancer gain a sense of control over the crisis.

3.Answer C. A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.

4.Answer C. Radiation therapy may cause fatigue, skin toxicities, and anorexia regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific, not generalized, adverse effects of radiation therapy.

5.Answer C. Fine needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the most reliable method for detecting breast lumps early. Mammography is used to detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib metastasis.

6.Answer D. The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.

7.Answer D. Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include dry oral mucous membranes, cracked lips, decreased urine output (less than 40 ml/hour), abnormally low blood pressure, and a serum potassium level below 3.5 mEq/L.

8.Answer C. Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

9.Answer D. Like other viral and bacterial venereal infections, human papillomavirus is a risk factor for cervical cancer. Other risk factors for this disease include frequent sexual intercourse before age 16, multiple sex partners, and multiple pregnancies. A spontaneous abortion and pregnancy complicated by eclampsia aren’t risk factors for cervical cancer.

10.Answer D. Leucovorin is administered with methotrexate to protect normal cells, which methotrexate could destroy if given alone. Probenecid should be avoided in clients receiving methotrexate because it reduces renal elimination of methotrexate, increasing the risk of methotrexate toxicity. Cytarabine and thioguanine aren’t used to treat osteogenic carcinoma.

11.Answer D. Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren’t preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

12.Answer B. The American Cancer Society guidelines state, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually [not every 2 years]; all women should perform breast self-examination monthly [not annually]." The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

13.Answer C. Indigestion, or difficulty swallowing, is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn’t one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer.

14.Answer B. Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

15.Answer A. The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are incorrect. It’s recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years.

16.Answer D. The nurse should obtain the client’s baseline blood pressure and pulse and respiratory rates before administering the initial dose and then continue to monitor vital signs throughout therapy. A naloxone challenge test may be administered before using a narcotic antagonist, not a narcotic agonist. The nurse shouldn’t discontinue a narcotic agonist abruptly because withdrawal symptoms may occur. Morphine commonly is used as a continuous infusion in clients with severe pain regardless of the ability to tolerate fluids.

17.Answer B. Antimetabolites act during the S phase of the cell cycle, contributing to cell destruction or preventing cell replication. They’re most effective against rapidly proliferating cancers. Miotic inhibitors interfere with cell division or mitosis during the M phase of the cell cycle. Alkylating agents affect all rapidly proliferating cells by interfering with DNA; they may kill dividing cells in all phases of the cell cycle and may also kill nondividing cells. Antineoplastic antibiotic agents interfere with one or more stages of the synthesis of RNA, DNA, or both, preventing normal cell growth and reproduction.

18.Answer B. When following the ABCD method for assessing skin lesions, the A stands for "asymmetry," the B for "border irregularity," the C for "color variation," and the D for "diameter."

19.Answer B. Tactile agnosia (inability to identify objects by touch) is a sign of a parietal lobe tumor. Short-term memory impairment occurs with a frontal lobe tumor. Seizures may result from a tumor of the frontal, temporal, or occipital lobe. Contralateral homonymous hemianopia suggests an occipital lobe tumor.

20.Answer C. Presence of Bence Jones protein in the urine almost always confirms the disease, but absence doesn’t rule it out. Serum calcium levels are elevated because calcium is lost from the bone and reabsorbed in the serum. Serum protein electrophoresis shows elevated globulin spike. The serum creatinine level may also be increased.

21.Answer C. The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese–like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia.

22.Answer B. To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen peroxide and water for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer viscous lidocaine or systemic analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn’t be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn’t decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn’t decrease the pain.

23.Answer A. The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won’t identify changes in the prostate gland due to its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastases

24.Answer A. Anticipatory grieving is an appropriate nursing diagnosis for this client because few clients with gallbladder cancer live more than 1 year after diagnosis. Impaired swallowing isn’t associated with gallbladder cancer. Although surgery typically is done to remove the gallbladder and, possibly, a section of the liver, it isn’t disfiguring and doesn’t cause Disturbed body image. Chronic low self-esteem isn’t an appropriate nursing diagnosis at this time because the diagnosis has just been made.

25.Answer B. If a radioactive implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in a lead-lined container, then notify the radiation therapy department immediately. The highest priority is to minimize radiation exposure for the client and the nurse; therefore, the nurse must not take any action that delays implant removal. Standing as far from the implant as possible, leaving the room with the implant still exposed, or attempting to put it back in place can greatly increase the risk of harm to the client and the nurse from excessive radiation exposure.

26.Answer A. The client must report changes in visual acuity immediately because this adverse effect may be irreversible. Tamoxifen isn’t associated with hearing loss. Although the drug may cause anorexia, headache, and hot flashes, the client need not report these adverse effects immediately because they don’t warrant a change in therapy.

27.Answer A. The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

28.Answer B. A low-fat diet (one that maintains weight within 20% of recommended body weight) has been found to decrease a woman’s risk of breast cancer. A baseline mammogram should be done between ages 30 and 40. Monthly breast self-examinations should be done between days 7 and 10 of the menstrual cycle. The client should continue to perform monthly breast self-examinations even when receiving yearly mammograms.

29.Answer C. Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.

30.Answer D. During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.



NCLEX Practice Test for Oncology 2
1. Nina, an oncology nurse educator is speaking to a women’s group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?

a. Mammography is the most reliable method for detecting breast cancer.
b. Breast cancer is the leading killer of women of childbearing age.
c. Breast cancer requires a mastectomy.
d. Men can develop breast cancer.


2. Nurse Meredith is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:

a. at the end of her menstrual cycle.
b. on the same day each month.
c. on the 1st day of the menstrual cycle.
d. immediately after her menstrual period.


3. Nurse Kent is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?

a. Testicular cancer is a highly curable type of cancer.
b. Testicular cancer is very difficult to diagnose.
c. Testicular cancer is the number one cause of cancer deaths in males.
d. Testicular cancer is more common in older men.


4. Rhea, has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10 mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chlorambucil might this reaction occur?

a. Immediately
b. 1 week
c. 2 to 3 weeks
d. 1 month


5. A male client is receiving the cell cycle–nonspecific alkylating agent thiotepa (Thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of a chemotherapeutic regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?

a. It interferes with deoxyribonucleic acid (DNA) replication only.
b. It interferes with ribonucleic acid (RNA) transcription only.
c. It interferes with DNA replication and RNA transcription.
d. It destroys the cell membrane, causing lysis.


6. The nurse is instructing the 35 year old client to perform a testicular self-examination. The nurse tells the client:

a. To examine the testicles while lying down
b. That the best time for the examination is after a shower
c. To gently feel the testicle with one finger to feel for a growth
d. That testicular self-examination should be done at least every 6 months


7. A female client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care?

a. Monitoring temperature
b. Ambulation three times daily
c. Monitoring the platelet count
d. Monitoring for pathological fractures


8. Gian, a community health nurse is instructing a group of female clients about breast self-examination. The nurse instructs the client to perform the examination:

a. At the onset of menstruation
b. Every month during ovulation
c. Weekly at the same time of day
d. 1 week after menstruation begins


9. Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client?

a. Elevating the knee gatch on the bed
b. Assisting with range-of-motion leg exercises
c. Removal of antiembolism stockings twice daily
d. Checking placement of pneumatic compression boots


10. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which preprocedure instruction to the client?

a. Eat a light breakfast only
b. Maintain an NPO status before the procedure
c. Wear comfortable clothing and shoes for the procedure
d. Drink six to eight glasses of water without voiding before the test


11. A male client is diagnosed as having a bowel tumor and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy?

a. Biopsy of the tumor
b. Abdominal ultrasound
c. Magnetic resonance imaging
d. Computerized tomography scan


12. A female client diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder?

a. Altered red blood cell production
b. Altered production of lymph nodes
c. Malignant exacerbation in the number of leukocytes
d. Malignant proliferation of plasma cells within the bone


13. Nurse Bea is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which of the following would the nurse expect to note specifically in this disorder?

a. Increased calcium
b. Increased white blood cells
c. Decreased blood urea nitrogen level
d. Decreased number of plasma cells in the bone marrow


14. Vanessa, a community health nurse conducts a health promotion program regarding testicular cancer to community members. The nurse determines that further information needs to be provided if a community member states that which of the following is a sign of testicular cancer?

a. Alopecia
b. Back pain
c. Painless testicular swelling
d. Heavy sensation in the scrotum


15. The male client is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is:

a. Dyspnea
b. Diarrhea
c. Sore throat
d. Constipation


16. Nurse Joy is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?

a. Limit the time with the client to 1 hour per shift
b. Do not allow pregnant women into the client’s room
c. Remove the dosimeter badge when entering the client’s room
d. Individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client


17. A cervical radiation implant is placed in the client for treatment of cervical cancer. The nurse initiates what most appropriate activity order for this client?

a. Bed rest
b. Out of bed ad lib
c. Out of bed in a chair only
d. Ambulation to the bathroom only


18. A female client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to:

a. Call the physician
b. Reinsert the implant into the vagina immediately
c. Pick up the implant with gloved hands and flush it down the toilet
d. Pick up the implant with long-handled forceps and place it in a lead container.


19. The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plans to:

a. Restrict all visitors
b. Restrict fluid intake
c. Teach the client and family about the need for hand hygiene
d. Insert an indwelling urinary catheter to prevent skin breakdown


20. The home health care nurse is caring for a male client with cancer and the client is complaining of acute pain. The appropriate nursing assessment of the client’s pain would include which of the following?

a. The client’s pain rating
b. Nonverbal cues from the client
c. The nurse’s impression of the client’s pain
d. Pain relief after appropriate nursing intervention


21. Nurse Mickey is caring for a client who is postoperative following a pelvic exenteration and the physician changes the client’s diet from NPO status to clear liquids. The nurse makes which priority assessment before administering the diet?

a. Bowel sounds
b. Ability to ambulate
c. Incision appearance
d. Urine specific gravity


22. A male client is admitted to the hospital with a suspected diagnosis of Hodgkin’s disease. Which assessment findings would the nurse expect to note specifically in the client?

a. Fatigue
b. Weakness
c. Weight gain
d. Enlarged lymph nodes


23. During the admission assessment of a 35 year old client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?

a. Diarrhea
b. Hypermenorrhea
c. Abdominal bleeding
d. Abdominal distention


24. Nurse Kate is reviewing the complications of colonization with a client who has microinvasive cervical cancer. Which complication, if identified by the client, indicates a need for further teaching?

a. Infection
b. Hemorrhage
c. Cervical stenosis
d. Ovarian perforation


25. Mr. Miller has been diagnosed with bone cancer. You know this type of cancer is classified as:

a. sarcoma.
b. lymphoma.
c. carcinoma.
d. melanoma.


26. Sarah, a hospice nurse visits a client dying of ovarian cancer. During the visit, the client expresses that “If I can just live long enough to attend my daughter’s graduation, I’ll be ready to die.” Which phrase of coping is this client experiencing?

a. Anger
b. Denial
c. Bargaining
d. Depression


27. Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?

a. Pain at the incisional site
b. Arm edema on the operative side
c. Sanguineous drainage in the Jackson-Pratt drain
d. Complaints of decreased sensation near the operative site


28. The nurse is admitting a male client with laryngeal cancer to the nursing unit. The nurse assesses for which most common risk factor for this type of cancer?

a. Alcohol abuse
b. Cigarette smoking
c. Use of chewing tobacco
d. Exposure to air pollutants


29. The female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing:

a. Rupture of the bladder
b. The development of a vesicovaginal fistula
c. Extreme stress caused by the diagnosis of cancer
d. Altered perineal sensation as a side effect of radiation therapy


30. The client with leukemia is receiving busulfan (Myleran) and allopurinol (Zyloprim). The nurse tells the client that the purpose if the allopurinol is to prevent:

a. Nausea
b. Alopecia
c. Vomiting
d. Hyperuricemia


Answer and Rationale- NCLEX Practice Test for Oncology 2

1. Answer D. Men can develop breast cancer, although they seldom do. The most reliable method for detecting breast cancer is monthly self-examination, not mammography. Lung cancer causes more deaths than breast cancer in women of all ages. A mastectomy may not be required if the tumor is small, confined, and in an early stage.

2. Answer D. Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts are least tender and least lumpy. On the 1st and last days of the cycle, the woman’s breasts are still very tender. Postmenopausal women because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast self-examination.

3. Answer A. Testicular cancer is highly curable, particularly when it’s treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men.

4. Answer C. Chlorambucil-induced alopecia occurs 2 to 3 weeks after therapy begins.

5. Answer C. Thiotepa interferes with DNA replication and RNA transcription. It doesn’t destroy the cell membrane.

6. Answer B. The testicular-self examination is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

7. Answer C. Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Option A elates to monitoring for infection, particularly if leukopenia is present. Options B and D, although important in the plan of care, are not related directly to thrombocytopenia.

8. Answer D. The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

9. Answer A. The client is at risk of deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Range-of-motion exercises, antiembolism stockings, and pneumatic compression boots are helpful. The nurse should avoid using the knee gatch in the bed, which inhibits venous return, thus placing the client more at risk for deep vein thrombosis or thrombophlebitis.

10. Answer D. A pelvic ultrasound requires the ingestion of large volumes of water just before the procedure. A full bladder is necessary so that it will be visualized as such and not mistaken for a possible pelvic growth. An abdominal ultrasound may require that the client abstain from food or fluid for several hours before the procedure. Option C is unrelated to this specific procedure.

11. Answer A. A biopsy is done to determine whether a tumor is malignant or benign. Magnetic resonance imaging, computed tomography scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy.

12. Answer D. Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Options A and B are not characteristics of multiple myeloma. Option C describes the leukemic process.

13. Answer A. Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

14. Answer A. Alopecia is not an assessment finding in testicular cancer. Alopecia may occur, however, as a result of radiation or chemotherapy. Options B, C, and D are assessment findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

15. Answer C. In general, only the area in the treatment field is affected by the radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the larynx is most likely to experience a sore throat. Options B and D may occur with radiation to the gastrointestinal tract. Dyspnea may occur with lung involvement.

16. Answer B. The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client’s room. Children younger than 16 years of age and pregnant women are not allowed in the client’s room.

17. Answer A. The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids turning the client on the side. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled.

18. Answer D. A lead container and long-handled forceps should be kept in the client’s room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. Options A, B, and C are inaccurate interventions.

19. Answer C. In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.

20. Answer A. The client’s self-report is a critical component of pain assessment. The nurse should ask the client about the description of the pain and listen carefully to the client’s words used to describe the pain. The nurse’s impression of the client’s pain is not appropriate in determining the client’s level of pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. Assessing pain relief is an important measure, but this option is not related to the subject of the question.

21. Answer A. The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options B, C, and D are unrelated to the subject of the question.

22. Answer D. Hodgkin’s disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

23. Answer D. Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

24. Answer D. Conization procedure involves removal of a cone-shaped area of the cervix. Complications of the procedure include hemorrhage, infection, and cervical stenosis. Ovarian perforation is not a complication.

25. Answer A. Tumors that originate from bone,muscle, and other connective tissue are called sarcomas.

26. Answer C. Denial, bargaining, anger, depression, and acceptance are recognized stages that a person facing a life-threatening illness experiences. Bargaining identifies a behavior in which the individual is willing to do anything to avoid loss or change prognosis or fate. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn. Anger also may be a first response to upsetting news and the predominant theme is “why me?” or the blaming of others.

27. Answer B. Arm edema on the operative side (lymphedema) is a complication following mastectomy and can occur immediately postoperatively or may occur months or even years after surgery. Options A, C, and D are expected occurrences following mastectomy and do not indicate a complication.

28. Answer B. The most common risk factor associated with laryngeal cancer is cigarette smoking. Heavy alcohol use and the combined use of tobacco increase the risk. Another risk factor is exposure to environmental pollutants.

29. Answer B. A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina. The client’s complaint is not associated with options A, C, and D.

30. Answer D. Allopurinol decreases uric acid production and reduces uric acid concentrations in serum and urine. In the client receiving chemotherapy, uric acid levels increase as a result of the massive cell destruction that occurs from the chemotherapy. This medication prevents or treats hyperuricemia caused by chemotherapy. Allopurinol is not used to prevent alopecia, nausea, or vomiting.
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Jena Ortiz
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Here are some questions I found when I was reviewing. Share some of yours:

FROM: http://gino-memoirofaschizo.blogspot.com/search/label/NCLEX%20Reviewer

Nursing Pharmacology (Pharmacological & Parenteral Therapies)

Question 1
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
A) Bleeding time
B) Hemoglobin and hematocrit
C) White blood cells
D) Platelets

Review Information: The correct answer is B: Hemoglobin and hematocrit
The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 2
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
A) diaphoresis with decreased urinary output
B) increased heart rate with increase respirations
C) improved respiratory status and increased urinary output
D) decreased chest pain and decreased blood pressure

Review Information: The correct answer is C: improved respiratory status and increased urinary output
Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, with the findings of this toxicity being bradycardia, dysrhythmia, visual and GI disturbances. Clients being treated with digoxin should have their apical pulse evaluated for 1 full minute prior to the administration of the drug.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.
White, L., and Duncan, G,. (2002) Medical-Surgical Nursing An Integrated Approach (2nd ed.). Australia. Delmar

Question 3
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
A) Stop the infusion
B) Slow the rate of infusion
C) Take vital signs and observe for further deterioration
D) Administer Benadryl and continue the infusion

Review Information: The correct answer is A: Stop the infusion
This is an indication of an allergy to the plasma protein. The first action of the nurse is to stop the transfusion.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 4
A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?
A) Bleeding time
B) Platelet count
C) Activated PTT
D) Clotting time

Review Information: The correct answer is C: Activated PTT
Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.
Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Question 5
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
A) Change in libido, breast enlargement
B) Sore throat, fever
C) Abdominal pain, nausea, diarrhea
D) Dsypnea, nasal congestion

Review Information: The correct answer is B: Sore throat, fever
A sore throat and fever may be symptoms of agranulocytosis, a side effect of chlorpromazine (Thorazine).
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 6
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?
A) "As you urinate more, you will need less medication to control fluid."
B) "You will have to take this medication for about a year."
C) "The medication must be continued so the fluid problem is controlled."
D) "Please talk to your health care provider about medications and treatments."

Review Information: The correct answer is C: "The medication must be continued so the fluid problem is controlled."
This is the most therapeutic response and gives the client accurate information.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

Question 7
Although nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
A) Urinary incontinence
B) Constipation
C) Nystagmus
D) Occult bleeding

Review Information: The correct answer is D: Occult bleeding
Nonsteroidal anti-inflammatory drugs taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal track.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 8
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
A) Cut the child's hair short to remove the nits
B) Apply warm soaks to the head twice daily
C) Wash the child's linen and clothing in a bleach solution
D) Application of pediculicides

Review Information: The correct answer is D: Application of pediculicides
Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 9
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
A) Orthostatic hypotension is a common side effect
B) Most antipsychotic drugs cause elevated blood pressure
C) This provides information on the amount of sodium allowed in the diet
D) It will indicate the need to institute antiparkinsonian drugs

Review Information: The correct answer is A: Orthostatic hypotension is a common side effect
Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 10
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to
A) enhance absorption of the medication
B) ensure that the entire dose of medication is given
C) provide more even distribution of the drug
D) prevent the drug from tissue irritation

Review Information: The correct answer is D: prevent the drug from tissue irritation
Deep injection or Z-track is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the drug.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 11
Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
A) Sedative hypnotics are effective analgesics
B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
C) Caffeine beverages can increase the effect of sedative hypnotics
D) Avoidance of excessive exercise and high temperature is recommended

Review Information: The correct answer is B: Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 12
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
A) Bruising at the operative site
B) Elevated heart rate
C) Decreased platelet count
D) No bowel movement for 3 days

Review Information: The correct answer is D: No bowel movement for 3 days
With opioid analgesics observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.
Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

Question 13
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
A) "I use a sliding scale to adjust regular insulin to my sugar level."
B) "Since my eyesight is so bad, I ask the nurse to fill several syringes."
C) "I keep my regular insulin bottle in the refrigerator."
D) "I always make sure to shake the NPH bottle hard to mix it well."

Review Information: The correct answer is D: "I always make sure to shake the NPH bottle hard to mix it well."
The bottle should by rolled gently, not shaken.
Deglin, J.D. and Vallerand, A.H. (2001). Davis' drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 14
The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?
A) Avoid chocolate and cheese
B) Take frequent naps
C) Take the medication with milk
D) Avoid walking without assistance

Review Information: The correct answer is A: Avoid chocolate and cheese
Foods high in tryptophan, tyramine and caffeine, such as chocolate and cheese may precipitate hypertensive crisis.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 15
A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?
A) Sodium
B) Potassium
C) Phosphate
D) Albumin

Review Information: The correct answer is B: Potassium
If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.
Deglin, J.D. and Vallerand, A.H. (2001). Davis' drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 16
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to
A) administer the medication in 2 separate injections
B) give the medication in the dorsal gluteal site
C) call to get a smaller volume ordered
D) check with pharmacy for a liquid form of the medication
Skip

Review Information: The correct answer is A: administer the medication in 2 separate injections
Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby

Question 17
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
A) Pulverize all medications to a powdery condition
B) Squeeze the tube before using it to break up stagnant liquids
C) Cleanse the skin around the tube daily with hydrogen peroxide
D) Flush adequately with water before and after using the tube
Skip

Review Information: The correct answer is D: Flush adequately with water before and after using the tube
Flushing the tube before and after use not only provides for good flow and keeps the tube patent, it also provides water to maintain hydration. While medications should be crushed to pass through the tube, it is flushing that moves them through. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 18
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
A) "We will call the health care provider if the child develops acne."
B) "Our child should brush and floss carefully after every meal."
C) "We will skip the next dose if vomiting or fever occur."
D) "When our child is seizure-free for 6 months, we can stop the medication."

Review Information: The correct answer is B: "Our child should brush and floss carefully after every meal."
Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri

Question 19
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
A) Protamine
B) Amicar
C) Imferon
D) Diltiazem

Review Information: The correct answer is A: Protamine
Protamine binds heparin making it ineffective.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 20
The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
A) Non-steroidal anti-inflammatory drugs
B) Cough medicines with guaifenesin
C) Histamine blockers
D) Laxatives containing magnesium salts

Review Information: The correct answer is A: Non-steroidal anti-inflammatory drugs
Medications with NSAIDS may increase the response to Coumadin (warfarin) and increase the risk of bleeding.
Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.


Psychiatric Nursing 4

76. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks.

Which of the following statements is most appropriate to make to this patient?
A. What is causing you to become agitated?
B. You need to stop that behavior now.
C. You will need to be restrained if you do not change your behavior.
D. You will need to be placed in seclusion.

Answer: (A) What is causing you to become agitated?
In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.

77. The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client’s anger is escalating. Which approach is least helpful for the client at this time?
A. Acknowledge the client’s behavior
B. Maintain a safe distance from the client
C. Assist the client to an area that is quiet
D. Initiate confinement measures

Answer: (D) Initiate confinement measures
The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression.

78. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following:
A. A timid nurse
B. A mature experienced nurse
C. an inexperienced nurse
D. a soft spoken nurse

Answer: (B) A mature experienced nurse
The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.

79. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints

Answer: (A) Taking a directive role in verbalizing feelings
Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful.

80. The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient’s rights?
A. There was a doctor’s order for restraints/seclusion
B. The patient’s rights were explained to him.
C. The staff observed confidentiality
D. The staff carried out less restrictive measures but were unsuccessful.

Answer: (D) The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.

81. Situation: Clients with personality disorders have difficulties in their social and occupational functions.
Clients with personality disorder will most likely:
A. recover with therapeutic intervention
B. respond to antianxiety medication
C. manifest enduring patterns of inflexible behaviors
D. Seek treatment willingly from some personally distressing symptoms

Answer: (C) manifest enduring patterns of inflexible behaviors
Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. B. Medications are generally not recommended for personality disorders.

82. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have?
A. Narcissistic
B. Paranoid
C. Histrionic
D. Antisocial

Answer: (D) Antisocial
These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors.

83. The client joins a support group and frequently preaches against abuse, is demonstrating the use of:
A. denial
B. reaction formation
C. rationalization
D. projection

Answer: (B) reaction formation
Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. A. Denial is refusal to accept a painful reality. C. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. D. Projection is attributing of one’s behaviors and feelings to another person.

84. A teenage girl is diagnosed to have borderline personality disorder. Which manifestations support the diagnosis?
A. Lack of self esteem, strong dependency needs and impulsive behavior
B. social withdrawal, inadequacy, sensitivity to rejection and criticism
C. Suspicious, hypervigilance and coldness
D. Preoccupation with perfectionism, orderliness and need for control

Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior
These are the characteristics of client with borderline personality. B. This describes the avoidant personality. C. These are the characteristics of a client with paranoid personality D. This describes the obsessive compulsive personality

85. The plan of care for clients with borderline personality should include:
A. Limit setting and flexibility in schedule
B. Giving medications to prevent acting out
C. Restricting her from other clients
D. Ensuring she adheres to certain restrictions

Answer: (D) Ensuring she adheres to certain restrictions
The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission. A. Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. B. There is no specific medication prescribed for this condition. C. This is not part of the care plan. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others.

86. Situation: A 42 year old male client, is admitted in the ward because of bizarre behaviors. He is given a diagnosis of schizophrenia paranoid type.

The client should have achieved the developmental task of:
A. Trust vs. mistrust
B. Industry vs. inferiority
C. Generativity vs. stagnation
D. Ego integrity vs. despair

Answer: (D) Ego integrity vs. despair
The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. (A) Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future.

87. Clients who are suspicious primarily use projection for which purpose:

A. deny reality
B. to deal with feelings and thoughts that are not acceptable
C. to show resentment towards others
D. manipulate others

Answer: (B) to deal with feelings and thoughts that are not acceptable
Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather than others

88. The client says "the NBI is out to get me." The nurse’s best response is:
A. "The NBI is not out to catch you."
B. "I don’t believe that."
C. "I don’t know anything about that. You are afraid of being harmed."
D. "What made you think of that."

Answer: (C) "I don’t know anything about that. You are afraid of being harmed."
This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary exploration of the false

89. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:
A. tardive dyskinesia
B. Pseudoparkinsonism
C. akinesia
D. dystonia

Answer: (B) Pseudoparkinsonism
Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like facies, pill rolling tremors, muscle rigidity A. Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue C. Akinesia is characterized by feeling of weakness and muscle fatigue D. Dystonia is manifested by torticollis and rolling back of the eyes

90. The client is very hostile toward one of the staff for no apparent reason. The client is manifesting:
A. Splitting
B. Transference
C. Countertransference
D. Resistance

Answer: (B) Transference
Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. Counterttransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the client’s refusal to submit himself to the care of the nurse

91. Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother.

Rape is an example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal

Answer: (B) Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life

92. During the initial care of rape victims the following are to be considered EXCEPT:
A. Assure privacy.
B. Touch the client to show acceptance and empathy
C. Accompany the client in the examination room.
D. Maintain a non-judgmental approach.

Answer: (B) Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.

93. The nurse acts as a patient advocate when she does one of the following:
A. She encourages the client to express her feeling regarding her experience.
B. She assesses the client for injuries.
C. She postpones the physical assessment until the client is calm
D. Explains to the client that her reactions are normal

Answer: (C) She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher

94. Crisis intervention carried out to the client has this primary goal:
A. Assist the client to express her feelings
B. Help her identify her resources
C. Support her adaptive coping skills
D. Help her return to her pre-rape level of function

Answer: (D) Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal

95. Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:
A. Adjustment disorder
B. Somatoform Disorder
C. Generalized Anxiety Disorder
D. Post traumatic disorder

Answer: (D) Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months

96. Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying.

The nurse assesses the level of anxiety as:
A. Mild
B. Moderate
C. Severe
D. Panic

Answer: (C) Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization

97. Anxiety is caused by:
A. an objective threat
B. a subjectively perceived threat
C. hostility turned to the self
D. masked depression

Answer: (B) a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression

98. It would be most helpful for the nurse to deal with a client with severe anxiety by:
A. Give specific instructions using speak in concise statements.
B. Ask the client to identify the cause of her anxiety.
C. Explain in detail the plan of care developed
D. Urge the client to focus on what the nurse is saying

Answer: (A) Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.

99. Which of the following medications will likely be ordered for the client?
A. Prozac
B. Valium
C. Risperdal
D. Lithium

Answer: (B) Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic

100. Which of the following is included in the health teachings among clients receiving Valium?:
A. Avoid foods rich in tyramine.
B. Take the medication after meals.
C. It is safe to stop it anytime after long term use.
D. Double up the dose if the client forgets her medication.

Answer: (B) Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.
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Psychiatric Nursing 3

51. Which is the best indicator of success in the long term management of the client?
A. His symptoms are replaced by indifference to his feelings
B. He participates in diversionary activities.
C. He learns to verbalize his feelings and concerns
D. He states that his behavior is irrational.

Answer: (C) He learns to verbalize his feelings and concerns
C. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. A. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. B. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. D. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational.

52. Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident.

The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is:

A. "I feel envious of mothers who have toddlers"
B. "I haven’t been able to open the door and go into my baby’s room"
C. "I watch other toddlers and think about their play activities and I cry."
D. "I often find myself thinking of how I could have prevented the death."

Answer: (B) "I haven’t been able to open the door and go into my baby’s room"
This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and negative aspects of the deceased love one signals successful mourning.

53. The client said "I can’t even take care of my baby. I’m good for nothing." Which is the appropriate nursing diagnosis?
A. Ineffective individual coping related to loss.
B. Impaired verbal communication related to inadequate social skills.
C. Low esteem related to failure in role performance
D. Impaired social interaction related to repressed anger.

Answer: (C) Low esteem related to failure in role performance
This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange

54. The following medications will likely be prescribed for the client EXCEPT:
A. Prozac
B. Tofranil
C. Parnate
D. Zyprexa

Answer: (D) Zyprexa
This is an antipsychotic. A. This is a SSRI antidepressant. B. This antidepressant belongs to the Tricyclic group. C. This is a MAOI antidepressant.

55. Which is the highest priority in the post ECT care?
A. Observe for confusion
B. Monitor respiratory status
C. Reorient to time, place and person
D. Document the client’s response to the treatment

Answer: (B) Monitor respiratory status
A side effect of ECT which is life threatening is respiratory arrest. A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.

56. Situation: A 27 year old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant talked fast and hyperactive.

Initially the nurse should plan this for a manic client:

A. set realistic limits to the client’s behavior
B. repeat verbal instructions as often as needed
C. allow the client to get out feelings to relieve tension
D. assign a staff to be with the client at all times to help maintain control

Answer: (A) set realistic limits to the client’s behavior
The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. B. Clear, concise directions are given because of the distractibility of the client but this is not the priority. C. The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed D. Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.

57. An activity appropriate for the client is:
A. table tennis
B. painting
C. chess
D. cleaning

Answer: (D) cleaning
The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension. A. Tennis is a competitive activity which can stimulate the client.

58. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following:
A. Agree on a consistent approach among the staff assigned to the client.
B. Suggest that the client take a leading role in the social activities
C. Provide the client with extra time for one on one sessions
D. Allow the client to negotiate the plan of care

Answer: (A) Agree on a consistent approach among the staff assigned to the client.
A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction time. D. Allowing the client to negotiate may reinforce manipulative behavior.

59. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints

Answer: (A) Taking a directive role in verbalizing feelings
The client has the right to be free from unnecessary restraints. Verbalization of feelings or "talking down" in a non-threatening environment is helpful to relieve the client’s anger. B. This is a threatening approach. C and D. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client's anger.

60. A client on Lithium has diarrhea and vomiting. What should the nurse do first:
A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects of lithium therapy
D. Hold the next dose and obtain an order for a stat serum lithium level

Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level
Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.

61. Situation: A widow age 28, whose husband died one year ago due to AIDS, has just been told that she has AIDS.
Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is one of:
A. Depression
B. Denial
C. anger
D. bargaining

Answer: (C) anger
Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others. A. Depression is a painful stage where the individual mourns for what was lost. B. Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. D. In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…”

62. The nurse’s therapeutic response is:
A. "I will refer you to a clergy who can help you understand what is happening to you."
B. "It isn’t fair that an innocent like you will suffer from AIDS."
C. "That is a negative attitude."
D. "It must really be frustrating for you. How can I best help you?"

Answer: (D) "It must really be frustrating for you. How can I best help you?"
This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. C. This statement passes judgment on the client.

63. One morning the nurse sees the client in a depressed mood. The nurse asks her "What are you thinking about?" This communication technique is:
A. focusing
B. validating
C. reflecting
D. giving broad opening

Answer: (D) giving broad opening
Broad opening technique allows the client to take the initiative in introducing the topic. A,B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement.

64. The client says to the nurse "Pray for me" and entrusts her wedding ring to the nurse. The nurse knows that this may signal which of the following:
A. anxiety
B. suicidal ideation
C. Major depression
D. Hopelessness

Answer: (B) suicidal ideation
The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate suicide.

65. Which of the following interventions should be prioritized in the care of the suicidal client?
A. Remove all potentially harmful items from the client’s room.
B. Allow the client to express feelings of hopelessness.
C. Note the client’s capabilities to increase self esteem.
D. Set a "no suicide" contract with the client.

Answer: (A) Remove all potentially harmful items from the client’s room.
Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide.

66. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning that his mother was leaving soon for U.K. to work as nurse.

The client has which of the following developmental focus:
A. Establishing relationship with the opposite sex and career planning.
B. Parental and societal responsibilities.
C. Establishing ones sense of competence in school.
D. Developing initial commitments and collaboration in work

Answer: (A) Establishing relationship with the opposite sex and career planning.
The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the family and decides what career to pursue, what set of friends to have and what value system to uphold. B. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. D. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex, establishment of a safe and congenial family environment and building of one’s lifework.

67. The personality type of Ryan is:
A. conforming
B. dependent
C. perfectionist
D. masochistic

Answer: (B) dependent
A client with dependent personality is predisposed to develop asthma. A. The conforming non-assertive client is predisposed to develop hypertension because of the tendency to repress rage. C. The perfectionist and compulsive tend to develop migraine. D. The masochistic, self sacrificing type are prone to develop rheumatoid arthritis.

68. The nurse ensures a therapeutic environment for the client. Which of the following best describes a therapeutic milieu?
A. A therapy that rewards adaptive behavior
B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment

Answer: (C) A living, learning or working environment.
A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms, limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu.

69. Included as priority of care for the client will be:
A. Encourage verbalization of concerns instead of demonstrating them through the body
B. Divert attention to ward activities
C. Place in semi-fowlers position and render O2 inhalation as ordered
D. Help her recognize that her physical condition has an emotional component

Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered
Since psychopysiologic disorder has organic basis, priority intervention is directed towards disease-specific management. Failure to address the medical condition of the client may be a life threat. A and B. The client has physical symptom that is adversely affected by psychological factors. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. However, these are not the priority. D. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready.

70. The client is concerned about his coming discharge, manifested by being unusually sad. Which is the most therapeutic approach by the nurse?
A. "You are much better than when you were admitted so there’s no reason to worry."
B. "What would you like to do now that you’re about to go home?"
C. "You seem to have concerns about going home."
D. "Aren’t you glad that you’re going home soon?"

Answer: (C) "You seem to have concerns about going home."
This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.. A. Giving false reassurance is not therapeutic. B. While this technique explores plans after discharge, it does not focus on expression of feelings. D. This close ended question does not encourage verbalization of feelings.

71. Situation: The nurse may encounter clients with concerns on sexuality.
The most basic factor in the intervention with clients in the area of sexuality is:
A. Knowledge about sexuality.
B. Experience in dealing with clients with sexual problems
C. Comfort with one’s sexuality
D. Ability to communicate effectively

Answer: (C) Comfort with one’s sexuality
The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority.

72. Which of the following statements is true for gender identity disorder?
A. It is the sexual pleasure derived from inanimate objects.
B. It is the pleasure derived from being humiliated and made to suffer
C. It is the pleasure of shocking the victim with exposure of the genitalia
D. It is the desire to live or involve in reactions of the opposite sex

Answer: (D) It is the desire to live or involve in reactions of the opposite sex
Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism.

73. The sexual response cycle in which the sexual interest continues to build:
A. Sexual Desire
B. Sexual arousal
C. Orgasm
D. Resolution

Answer: (B) Sexual arousal
Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state.

74. The inability to maintain the physiologic requirements in sexual intercourse is:
A. Sexual Desire Disorder
B. Sexual Arousal Disorder
C. Orgasm Disorder
D. Sexual Pain disorder

Answer: (B) Sexual Arousal Disorder
This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse.

75. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is:
A. "You’re attractive but I’m not interested."
B. "You wouldn’t be the first that I will see naked."
C. "I will report you to the guard if you don’t control yourself."
D. "I only need access to your arm. Putting up your sleeve is fine."

Answer: (D) "I only need access to your arm. Putting up your sleeve is fine."
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic.


Psychiatric Nursing 2

26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders.

A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
A. withdrawal
B. tolerance
C. intoxication
D. psychological dependence

Answer: (B) tolerance
tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.

27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
A. delirium tremens
B. Korsakoff’s syndrome
C. esophageal varices
D. Wernicke’s syndrome

Answer: (A) delirium tremens
Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.

28. The care for the client places priority to which of the following:
A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
C. Encouraging adequate fluids and nutritious foods
D. Administering Librium as ordered

Answer: (A) Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.

29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. cocaine
C. LSD
D. marijuana

Answer: (B) cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations.

30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)

Answer: (B) Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine

31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.

The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
A. apraxia
B. aphasia
C. agnosia
D. amnesia

Answer: (C) agnosia
This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.

32. She tearfully tells the nurse "I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
A. "Don’t take it personally. Your mother does not mean it."
B. "Have you tried discussing this with your mother?"
C. "This must be difficult for you and your mother."
D. "Next time ask your mother where her things were last seen."

Answer: (C) "This must be difficult for you and your mother."
This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.

33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
A. receives adequate nutrition and hydration
B. will reminisce to decrease isolation
C. remains in a safe and secure environment
D. independently performs self care

Answer: (C) remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently

34. She says to the nurse who offers her breakfast, "Oh no, I will wait for my husband. We will eat together." The therapeutic response by the nurse is:
A. "Your husband is dead. Let me serve you your breakfast."
B. "I’ve told you several times that he is dead. It’s time to eat."
C. "You’re going to have to wait a long time."
D. "What made you say that your husband is alive?"

Answer: (A) "Your husband is dead. Let me serve you your breakfast."
The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation.

35. Dementia unlike delirium is characterized by:
A. slurred speech
B. insidious onset
C. clouding of consciousness
D. sensory perceptual change

Answer: (B) insidious onset
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.

36. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation.

Which of the following nursing diagnoses will be given priority for the client?
A. altered self-image
B. fluid volume deficit
C. altered nutrition less than body requirements
D. altered family process

Answer: (B) fluid volume deficit
Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.

37. What is the best intervention to teach the client when she feels the need to starve?
A. Allow her to starve to relieve her anxiety
B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings
D. Call her mother on the phone and tell her how she feels

Answer: (C) Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.

38. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.
B. Weight gain
C. She attends ward activities.
D. She has a more realistic self concept.

Answer: (B) Weight gain
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.

39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight
C. have peculiar food handling patterns
D. have threatened self-esteem

Answer: (A) have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders

40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
A. Patient will learn problem solving skills
B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self care activities daily.
D. Patient will verbalize how to set limits on others.

Answer: (A) Patient will learn problem solving skills
if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.

41. In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust
B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa

Answer: (B) Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship
42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies

The client is suffering from:

A. agoraphobia
B. social phobia
C. Claustrophobia
D. xenophobia

Answer: (C) Claustrophobia
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.

43. Initial intervention for the client should be to:
A. Encourage to verbalize his fears as much as he wants.
B. Assist him to find meaning to his feelings in relation to his past.
C. Establish trust through a consistent approach.
D. Accept her fears without criticizing.

Answer: (D) Accept her fears without criticizing.
The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions.

44. The nurse develops a countertransference reaction. This is evidenced by:
A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-verbal behavior
D. The client feels angry towards the nurse who resembles his mother.

Answer: (A) Revealing personal information to the client
A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past.

45. Which is the desired outcome in conducting desensitization:
A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.

Answer: (D) The client will be able to overcome his disabling fear.
The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization.

46. Which of the following should be included in the health teachings among clients receiving Valium:
A. Avoid taking CNS depressant like alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
D. Any beverage like coffee may be taken

Answer: (A) Avoid taking CNS depressant like alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium.

47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint.

The nurse plans intervention based on which correct statement about conversion disorder?
A. The symptoms are conscious effort to control anxiety
B. The client will experience high level of anxiety in response to the paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.

Answer: (C) The conversion symptom has symbolic meaning to the client
the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety.

48. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
A. "I can refer you to a spiritual counselor if you like."
B. "You shouldn’t allow anyone to pressure you into sex."
C. "It sounds like this problem is related to your paralysis."
D. "How do you feel about being pressured into sex by your boyfriend?"

Answer: (D) "How do you feel about being pressured into sex by your boyfriend?"
Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.

49. Malingering is different from somatoform disorder because the former:
A. Has evidence of an organic basis.
B. It is a deliberate effort to handle upsetting events
C. Gratification from the environment are obtained.
D. Stress is expressed through physical symptoms.

Answer: (B) It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder.

50. Unlike psychophysiologic disorder Linda may be best managed with:
A. medical regimen
B. milieu therapy
C. stress management techniques
D. psychotherapy

Answer: (C) stress management techniques
Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best.
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Jena Ortiz
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Psychiatric Nursing

26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders.

A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
A. withdrawal
B. tolerance
C. intoxication
D. psychological dependence

Answer: (B) tolerance
tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.

27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
A. delirium tremens
B. Korsakoff’s syndrome
C. esophageal varices
D. Wernicke’s syndrome

Answer: (A) delirium tremens
Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.

28. The care for the client places priority to which of the following:
A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
C. Encouraging adequate fluids and nutritious foods
D. Administering Librium as ordered

Answer: (A) Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.

29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. cocaine
C. LSD
D. marijuana

Answer: (B) cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations.

30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)

Answer: (B) Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine

31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.

The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
A. apraxia
B. aphasia
C. agnosia
D. amnesia

Answer: (C) agnosia
This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.

32. She tearfully tells the nurse "I can’t take it when she accuses me of stealing her things." Which response by the nurse will be most therapeutic?
A. "Don’t take it personally. Your mother does not mean it."
B. "Have you tried discussing this with your mother?"
C. "This must be difficult for you and your mother."
D. "Next time ask your mother where her things were last seen."

Answer: (C) "This must be difficult for you and your mother."
This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.

33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
A. receives adequate nutrition and hydration
B. will reminisce to decrease isolation
C. remains in a safe and secure environment
D. independently performs self care

Answer: (C) remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently

34. She says to the nurse who offers her breakfast, "Oh no, I will wait for my husband. We will eat together." The therapeutic response by the nurse is:
A. "Your husband is dead. Let me serve you your breakfast."
B. "I’ve told you several times that he is dead. It’s time to eat."
C. "You’re going to have to wait a long time."
D. "What made you say that your husband is alive?"

Answer: (A) “Your husband is dead. Let me serve you your breakfast.”
The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation.

35. Dementia unlike delirium is characterized by:
A. slurred speech
B. insidious onset
C. clouding of consciousness
D. sensory perceptual change

Answer: (B) insidious onset
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.

36. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation.

Which of the following nursing diagnoses will be given priority for the client?
A. altered self-image
B. fluid volume deficit
C. altered nutrition less than body requirements
D. altered family process

Answer: (B) fluid volume deficit
Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.

37. What is the best intervention to teach the client when she feels the need to starve?
A. Allow her to starve to relieve her anxiety
B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings
D. Call her mother on the phone and tell her how she feels

Answer: (C) Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.

38. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.
B. Weight gain
C. She attends ward activities.
D. She has a more realistic self concept.

Answer: (B) Weight gain
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.

39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight
C. have peculiar food handling patterns
D. have threatened self-esteem

Answer: (A) have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders

40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
A. Patient will learn problem solving skills
B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self care activities daily.
D. Patient will verbalize how to set limits on others.

Answer: (A) Patient will learn problem solving skills
if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.

41. In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust
B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa

Answer: (B) Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship
42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies

The client is suffering from:

A. agoraphobia
B. social phobia
C. Claustrophobia
D. xenophobia

Answer: (C) Claustrophobia
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.

43. Initial intervention for the client should be to:
A. Encourage to verbalize his fears as much as he wants.
B. Assist him to find meaning to his feelings in relation to his past.
C. Establish trust through a consistent approach.
D. Accept her fears without criticizing.

Answer: (D) Accept her fears without criticizing.
The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions.

44. The nurse develops a countertransference reaction. This is evidenced by:
A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-verbal behavior
D. The client feels angry towards the nurse who resembles his mother.

Answer: (A) Revealing personal information to the client
A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past.

45. Which is the desired outcome in conducting desensitization:
A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.

Answer: (D) The client will be able to overcome his disabling fear.
The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization.

46. Which of the following should be included in the health teachings among clients receiving Valium:
A. Avoid taking CNS depressant like alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
D. Any beverage like coffee may be taken

Answer: (A) Avoid taking CNS depressant like alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium.

47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint.

The nurse plans intervention based on which correct statement about conversion disorder?
A. The symptoms are conscious effort to control anxiety
B. The client will experience high level of anxiety in response to the paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.

Answer: (C) The conversion symptom has symbolic meaning to the client
the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety.

48. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
A. "I can refer you to a spiritual counselor if you like."
B. "You shouldn’t allow anyone to pressure you into sex."
C. "It sounds like this problem is related to your paralysis."
D. "How do you feel about being pressured into sex by your boyfriend?"

Answer: (D) "How do you feel about being pressured into sex by your boyfriend?"
Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.

49. Malingering is different from somatoform disorder because the former:
A. Has evidence of an organic basis.
B. It is a deliberate effort to handle upsetting events
C. Gratification from the environment are obtained.
D. Stress is expressed through physical symptoms.

Answer: (B) It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder.

50. Unlike psychophysiologic disorder Linda may be best managed with:
A. medical regimen
B. milieu therapy
C. stress management techniques
D. psychotherapy

Answer: (C) stress management techniques
Stress management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best.


Psychiatric Nursing

1. Mental health is defined as:

A. The ability to distinguish what is real from what is not.
B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation
D. Absence of mental illness

Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness.

2. Which of the following describes the role of a technician?
A. Administers medications to a schizophrenic patient.
B. The nurse feeds and bathes a catatonic client
C. Coordinates diverse aspects of care rendered to the patient
D. Disseminates information about alcohol and its effects.

Answer: (A) Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher.

3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego

Answer: (A) Subconscious
Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.

4. The superego is that part of the psyche that:
A. Uses defensive function for protection.
B. Is impulsive and without morals.
C. Determines the circumstances before making decisions.
D. The censoring portion of the mind.

Answer: (D) The censoring portion of the mind.
The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego.

5. Primary level of prevention is exemplified by:
A. Helping the client resume self care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community

Answer: (C) Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness.

6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse.

Which of the following is the most appropriate for the nurse to ask?
A. "Are you being threatened or hurt by your partner?
B. "Are you frightened of you partner"
C. "Is something bothering you?"
D. "What happens when you and your partner argue?"

Answer: (A) "Are you being threatened or hurt by your partner?"
The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse.

7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is:
A. Sexual desire disorder
B. Sexual arousal Disorder
C. Orgasm Disorder
D. Sexual Pain Disorder

Answer: (A) Sexual desire disorder
Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse.

8. What would be the best approach for a wife who is still living with her abusive husband?
A. "Here’s the number of a crisis center that you can call for help ."
B. "Its best to leave your husband."
C. "Did you discuss this with your family?"
D. "Why do you allow yourself to be treated this way"

Answer: (A) "Here’s the number of a crisis center that you can call for help."
Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault.

9. Which comment about a 3 year old child if made by the parent may indicate child abuse?
A. "Once my child is toilet trained, I can still expect her to have some"
B. "When I tell my child to do something once, I don’t expect to have to tell"
C. "My child is expected to try to do things such as, dress and feed.”
D. "My 3 year old loves to say NO.”

Answer: (B) "When I tell my child to do something once, I don’t expect to have to tell"
Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old.

10. The primary nursing intervention for a victim of child abuse is:
A. Assess the scope of the problem
B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills

Answer: (C) Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later.

11. Situation: A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results.

The client has which somatoform disorder?
A. Somatization Disorder
B. Hypochondriaisis
C. Conversion Disorder
D. Somatoform Pain Disorder

Answer: (D) Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict.

12. Freud explains anxiety as:
A. Strives to gratify the needs for satisfaction and security
B. Conflict between id and superego
C. A hypothalamic-pituitary-adrenal reaction to stress
D. A conditioned response to stressors

Answer: (B) Conflict between id and superego
Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model.

13. The following are appropriate nursing diagnosis for the client EXCEPT:
A. Ineffective individual coping
B. Alteration in comfort, pain
C. Altered role performance
D. Impaired social interaction

Answer: (D) Impaired social interaction
The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain.

14. The following statements describe somatoform disorders:
A. Physical symptoms are explained by organic causes
B. It is a voluntary expression of psychological conflicts
C. Expression of conflicts through bodily symptoms
D. Management entails a specific medical treatment

Answer: (C) Expression of conflicts through bodily symptoms
Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis.

15. What would be the best response to the client’s repeated complaints of pain:
A. “I know the feeling is real tests revealed negative results.”
B. . “I think you’re exaggerating things a little bit.”
C. “Try to forget this feeling and have activities to take it off your mind”
D. “So tell me more about the pain”

Answer: (A) “I know the feeling is real tests revealed negative results.”
Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint.

16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital.

When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to:
A. provide as much structure as possible for the child
B. ignore the child’s overactivity.
C. encourage the child to engage in any play activity to dissipate energy
D. remove the child from the classroom when disruptive behavior occurs

Answer: (A) provide as much structure as possible for the child
Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non –confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure.

17. The child with conduct disorder will likely demonstrate:
A. Easy distractibility to external stimuli.
B. Ritualistic behaviors
C. Preference for inanimate objects.
D. Serious violations of age related norms.

Answer: (D) Serious violations of age related norms.
This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder.


18. Ritalin is the drug of choice for chidren with ADHD. The side effects of the following may be noted:
A. increased attention span and concentration
B. increase in appetite
C. sleepiness and lethargy
D. bradycardia and diarrhea

Answer: (A) increased attention span and concentration
The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.

19. School phobia is usually treated by:
A. Returning the child to the school immediately with family support.
B. Calmly explaining why attendance in school is necessary
C. Allowing the child to enter the school before the other children
D. Allowing the parent to accompany the child in the classroom

Answer: (A) Returning the child to the school immediately with family support.
Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear

20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe

Answer: (C) Moderate
The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35.

21. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except:
A. overprotection of the child
B. patience, routine and repetition
C. assisting the parents set realistic goals
D. giving reasonable compliments

Answer: (A) overprotection of the child
The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability.

22. The parents express apprehensions on their ability to care for their maladaptive child. The nurse identifies what nursing diagnosis:
A. hopelessness
B. altered parenting role
C. altered family process
D. ineffective coping

Answer: (B) altered parenting role
Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources

23. A 5 year old boy is diagnosed to have autistic disorder.
Which of the following manifestations may be noted in a client with autistic disorder?

A. argumentativeness, disobedience, angry outburst
B. intolerance to change, disturbed relatedness, stereotypes
C. distractibility, impulsiveness and overactivity
D. aggression, truancy, stealing, lying

Answer: (B) intolerance to change, disturbed relatedness, stereotypes
These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder

24. The therapeutic approach in the care of an autistic child include the following EXCEPT:
A. Engage in diversionary activities when acting -out
B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child

Answer: (D) Rearrange the environment to activate the child
The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.

25. According to Piaget a 5 year old is in what stage of development:
A. Sensory motor stage
B. Concrete operations
C. Pre-operational
D. Formal operation

Answer: (C) Pre-operational
Pre-operational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop.
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Karsie
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I highly recommend this free ebook for nursing students who are considering taking the NCLEX exam. You can download it from this site:
http://www.studyguidezone.com/nclexrntest.htm
The ebook is titled NCLEX RN Study Guide. Read it from cover to cover. It has test-taking strategies, review questions and extensive study notes.

Here are some of the review questions I found at the above link (answers are provided at the bottom):

1. A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority?

A. A complete history with emphasis on preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation.

2. A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information?

A. The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest.
B. The patient should resume a normal diet with emphasis on nutritious, healthy foods.
C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.
D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions.

3. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?

A. Restrict visiting hours and ask the family to limit visitors to two at a time.
B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed.
C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family.
D. Contact the physician to report the unusual rituals and activities.

4. The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?

A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge.
B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram.
C. A patient with unstable angina being closely monitored for pain and medication titration.
D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.

5. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?

A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection.
B. Glucagon treats hypoglycemia resulting from insulin overdose.
C. Glucagon treats lipoatrophy from insulin injections.
D. Glucagon prolongs the effect of insulin, allowing fewer injections.

6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct placement of the conductive gel pads?

A. The left clavicle and right lower sternum.
B. Right of midline below the bottom rib and the left shoulder.
C. The upper and lower halves of the sternum.
D. The right side of the sternum just below the clavicle and left of the precordium.

7. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct?

A. The frequency and intensity of bowel sounds varies depending on the phase of digestion.
B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched.
C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal.
D. All of the above.

8. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority?

A. Irrigate the eye repeatedly with normal saline solution.
B. Place fluorescein drops in the eye.
C. Patch the eye.
D. Test visual acuity.

9. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings?

A. Complaints of pain during repositioning.
B. Scant bloody discharge on the surgical dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C).

10. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be included?

A. Notify the physician.
B. Restrain the patient's limbs.
C. Position the patient on his/her side with the head flexed forward.
D. Administer rectal diazepam.

11. Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?

A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.

12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient?

A. Numbness in hands and feet.
B. Muscle cramping.
C. Hypoactive bowel sounds.
D. Positive Chvostek's sign.

13. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient?

A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg.

14. A patient is admitted to the hospital for routine elective surgery. Included in the list of current medications is Coumadin (warfarin) at a high dose. Concerned about the possible effects of the drug, particularly in a patient scheduled for surgery, the nurse anticipates which of the following actions?

A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level.
B. Administer vitamin K.
C. Draw a blood sample for type and crossmatch and request blood from the blood bank.
D. Cancel the surgery after the patient reports stopping the Coumadin one week previously.

15. The follow lab results are received for a patient. Which of the following results are abnormal? Note: More than one answer may be correct.

A. Hemoglobin 10.4 g/dL.
B. Total cholesterol 340 mg/dL.
C. Total serum protein 7.0 g/dL.
D. Glycosylated hemoglobin A1C 5.4%.

16. A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and medications through the line. Which of the following would indicate the need for discontinuation of the IV line as the next nursing action?

A. The patient complains of pain on movement.
B. The area proximal to the insertion site is reddened, warm, and painful.
C. The IV solution is infusing too slowly, particularly when the limb is elevated.
D. A hematoma is visible in the area of the IV insertion site.

17. A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles are heard in the bases of both lungs, probably indicating that the patient is experiencing a complication of transfusion. Which of the following complications is most likely the cause of the patient's symptoms?

A. Febrile non-hemolytic reaction.
B. Allergic transfusion reaction.
C. Acute hemolytic reaction.
D. Fluid overload.

18. A patient in labor and delivery has just received an amniotomy. Which of the following is correct? Note: More than one answer may be correct.

A. Frequent checks for cervical dilation will be needed after the procedure.
B. Contractions may rapidly become stronger and closer together after the procedure.
C. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord compression.
D. The procedure is usually painless and is followed by a gush of amniotic fluid.

19. A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following instructions by the nurse is NOT correct?

A. Continue to breastfeed frequently, at least every 2-4 hours.
B. Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and exam.
C. Watch for signs of dehydration, including decreased urinary output and changes in skin turgor.
D. Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.

20. A nurse is giving discharge instructions to the parents of a healthy newborn. Which of the following instructions should the nurse provide regarding car safety and the trip home from the hospital?

A. The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position.
B. The infant should be restrained in an infant car seat, properly secured in the front passenger seat.
C. The infant should be restrained in an infant car seat facing forward or rearward in the back seat.
D. For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.

Answer Key

1. Answer: C

The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

2. Answer: C

It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.

3. Answer: C

When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.

4. Answer: A

The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also requires close monitoring and cardiac experience.

5. Answer: B

Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.

6. Answer: D

One gel pad should be placed to the right of the sternum, just below the clavicle and the other just left of the precordium, as indicated by the anatomic location of the heart. To defibrillate, the paddles are placed over the pads. Options A, B, and C are not consistent with the position of the heart and are therefore incorrect responses.

7. Answer: D

All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds, which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism, for example, and should always be considered abnormal.

8. Answer: A

Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash, nor is patching the eye. Following irrigation, visual acuity will be assessed.

9. Answer: D

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.

10. Answer: B

During a witnessed seizure, nursing actions should focus on securing the patient's safely and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back, blocking the airway. Rectal diazepam may be a treatment ordered by the physician, who should be notified of the seizure.

11. Answer: C

Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-urgent.

12. Answer: C

Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek's sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia.

13. Answer: A

A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2.

14. Answer: A

The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient's anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. Preparation for transfusion, as described in option C, is only indicated in the case of significant blood loss. If lab results indicate an anticoagulation level that would place the patient at risk of excessive bleeding, the surgeon may choose to delay surgery and discontinue the medication.

15. Answer: A and B

Normal hemoglobin in adults is 12 - 16 g/dL. Total cholesterol levels of 200 mg/dL or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are both normal levels.

16. Answer: B

An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. An IV line that is running slowly may simply need flushing or repositioning. A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line.

17. Answer: D

Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Febrile non-hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death.

18. Answer: B, C, and D

Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid. Following amniotomy, cervical checks are minimized because of the risk of infection

19. Answer: D

An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to metabolize the bilirubin. A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is falling and the infant is thriving and is well hydrated. Signs of dehydration, including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen the hyperbilirubinemia.

20. Answer: A

All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured properly in the back seat. Infant car seats should never be placed in the front passenger seat. Infants should always be placed in an approved car seat during travel, even on that first ride home from the hospital.
Edited by Karsie, Nov 8 2011, 10:20 AM.
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Karsie
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From: http://www.studyguidezone.com/nclexrn_practice2.htm

1. A mother complains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is particularly concerned that, although he reliably uses the potty seat for bowel movements, he isn't able to hold his urine for long periods. Which of the following statements by the nurse is correct?

A. The child should have been trained by age 2 and may have a psychological problem that is responsible for his "accidents."
B. Bladder control is usually achieved before bowel control, and the child should be required to sit on the potty seat until he passes urine.
C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training varies widely from 24 to 36 months.
D. The child should be told "no" each time he wets so that he learns the behavior is unacceptable.

2. The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a bottle of milk in the crib and often wakes during the night asking for another. Which of the following instructions by the nurse is correct?

A. Allow the child to have the bottle at bedtime, but withhold the one later in the night.
B. Put juice in the bottle instead of milk.
C. Give only a bottle of water at bedtime.
D. Do not allow bottles in the crib.

3. Which of the following actions is NOT appropriate in the care of a 2-month-old infant?

A. Place the infant on her back for naps and bedtime.
B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep.
C. Talk to the infant frequently and make eye contact to encourage language development.
D. Wait until at least 4 months to add infant cereals and strained fruits to the diet.

4. An older patient asks a nurse to recommend strategies to prevent constipation. Which of the following suggestions would be helpful? Note: More than one answer may be correct.

A. Get moderate exercise for at least 30 minutes each day.
B. Drink 6-8 glasses of water each day.
C. Eat a diet high in fiber.
D. Take a mild laxative if you don't have a bowel movement every day.

5. A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is NOT confirming of the diagnosis?

A. A reddened rash visible over the trunk and extremities.
B. A history of sore throat that was self-limited in the past month.
C. A negative antistreptolysin O titer.
D. An unexplained fever.

6. An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased?

A. Sudden weight gain.
B. Decreased blood pressure.
C. Slow, shallow breathing.
D. Bradycardia.

7. A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level?

A. 15 mcg/mL.
B. 4 mcg/mL.
C. 10 mcg/dL.
D. 5 mcg/dL.

8. A patient arrives at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity?

A. Tinnitus.
B. Diarrhea.
C. Hypertension.
D. Hepatic damage.

9. A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate for pain. Which of the following nursing actions is most important in the care of this patient?

A. Monitor urine output.
B. Monitor respiratory rate.
C. Monitor heart rate.
D. Monitor temperature.

10. A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment?

A. Apply heat to the painful area.
B. Apply an elastic bandage to the leg.
C. X-ray the leg.
D. Give pain medication.

11. A nurse is evaluating a post-operative patient and notes a moderate amount of serous drainage on the dressing 24 hours after surgery. Which of the following is the appropriate nursing action?

A. Notify the surgeon about evidence of infection immediately.
B. Leave the dressing intact to avoid disturbing the wound site.
C. Remove the dressing and leave the wound site open to air.
D. Change the dressing and document the clean appearance of the wound site.

12. A patient returns to the emergency department less than 24 hours after having a fiberglass cast applied for a fractured right radius. Which of the following patient complaints would cause the nurse to be concerned about impaired perfusion to the limb?

A. Severe itching under the cast.
B. Severe pain in the right shoulder.
C. Severe pain in the right lower arm.
D. Increased warmth in the fingers.

13. An older patient with osteoarthritis is preparing for discharge. Which of the following information is correct.

A. Increased physical activity and daily exercise will help decrease discomfort associated with the condition.
B. Joint pain will diminish after a full night of rest.
C. Nonsteroidal anti-inflammatory medications should be taken on an empty stomach.
D. Acetaminophen (Tylenol) is a more effective anti-inflammatory than ibuprofen (Motrin).

14. Which patient should NOT be prescribed alendronate (Fosamax) for osteoporosis?

A. A female patient being treated for high blood pressure with an ACE inhibitor.
B. A patient who is allergic to iodine/shellfish.
C. A patient on a calorie restricted diet.
D. A patient on bed rest who must maintain a supine position.

15. Which of the following strategies is NOT effective for prevention of Lyme disease?

A. Insect repellant on the skin and clothes when in a Lyme endemic area.
B. Long sleeved shirts and long pants.
C. Prophylactic antibiotic therapy prior to anticipated exposure to ticks.
D. Careful examination of skin and hair for ticks following anticipated exposure.

16. A nurse is counseling patients at a health clinic on the importance of immunizations. Which of the following information is the most accurate regarding immunizations?

A. All infectious diseases can be prevented with proper immunization.
B. Immunizations provide natural immunity from disease.
C. Immunizations are risk-free and should be universally administered.
D. Immunization provides acquired immunity from some specific diseases.

17. A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, and the patient appears to have some oral swelling. Which of the following is the most urgent nursing action?

A. Consult a physician.
B. Maintain a patent airway.
C. Administer epinephrine subcutaneously.
D. Administer diphenhydramine (Benadryl) orally.

18. A mother calls the clinic to report that her son has recently started medication to treat attention deficit/hyperactivity disorder (ADHD). The mother fears her son is experiencing side effects of the medicine. Which of the following side effects are typically related to medications used for ADHD? Note: More than one answer may be correct:

A. Poor appetite.
B. Insomnia.
C. Sleepiness.
D. Agitation.

19. A patient at a mental health clinic is taking Haldol (haloperidol) for treatment of schizophrenia. She calls the clinic to report abnormal movements of her face and tongue. The nurse concludes that the patient is experiencing which of the following symptoms:

A. Co-morbid depression.
B. Psychotic hallucinations.
C. Negative symptoms of schizophrenia.
D. Tardive dyskinesia.

20. A patient with newly diagnosed diabetes mellitus is learning to recognize the symptoms of hypoglycemia. Which of the following symptoms is indicative of hypoglycemia?

A. Polydipsia.
B. Confusion.
C. Blurred vision.
D. Polyphagia.

Answer Key

1. Answer: C

Toddlers typically learn bowel control before bladder control, with boys often taking longer to complete toilet training than girls. Many children are not trained until 36 months and this should not cause concern. Later training is rarely caused by psychological factors and is much more commonly related to individual developmental maturity. Reprimanding the child will not speed the process and may be confusing.

2. Answer: C

Babies and toddlers should not fall asleep with bottles containing liquid other than plain water due to the risk of dental decay. Sugars in milk or juice remain in the mouth during sleep and cause caries, even in teeth that have not yet erupted. When water is substituted for milk or juice, babies will often lose interest in the bottle at night.

3. Answer: B

Infants under 6 months may not be able to sleep for long periods because their stomachs are too small to hold adequate nourishment to take them through the night. After 6 months, it may be helpful to let babies put themselves back to sleep after waking during the night, but not prior to 6 months. Infants should always be placed on their backs to sleep. Research has shown a dramatic decrease in sudden infant death syndrome (SIDS) with back sleeping. Eye contact and verbal engagement with infants are important to language development. The best diet for infants under 4 months of age is breast milk or infant formula.

4. Answer: A, B, and C

A daily bowel movement is not necessary if the patient is comfortable and the bowels move regularly. Moderate exercise, such as walking, encourages bowel health, as does generous water intake. A diet high in fiber is also helpful. ). Laxatives should be used as a last resort and should not be taken regularly. Over time, laxatives can desensitize the bowel and worsen constipation.

5. Answer: C

Rheumatic fever is caused by an untreated group A B hemolytic Streptococcus infection in the previous 2-6 weeks, confirmed by a positive antistreptolysin O titer. Rheumatic fever is characterized by a red rash over the trunk and extremities as well as fever and other symptoms.

6. Answer: A

Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. When diuretic therapy is inadequate, one would expect an increase in blood pressure, tachypnea, and tachycardia to result.

7. Answer: B

The therapeutic serum level for Dilantin is 10 - 20 mcg/mL. A level of 4 mcg/mL is sub-therapeutic and may be caused by patient non-compliance or increased metabolism of the drug. A leve of 15 mcg/mL is therapeutic. Choices C and D are expressed in mcg/dL, which is the incorrect unit of measurement.

8. Answer: D

Acetaminophen in even modestly large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N-acetylcysteine administration as an antidote. Tinnitus is associated with aspirin overdose, not acetaminophen. Diarrhea and hypertension are not associated with acetaminophen.

9. Answer: B

Morphine sulfate can suppress respiration and respiratory reflexes, such as cough. Patients should be monitored regularly for these effects to avoid respiratory compromise. Morphine sulfate does not significantly affect urine output, heart rate, or body temperature.

10. Answer: C

Following triage, an x-ray should be performed to rule out fracture. Ice, not heat, should be applied to a recent sports injury. An elastic bandage may be applied and pain medication given once fracture has been excluded.

11. Answer: D

A moderate amount of serous drainage from a recent surgical site is a sign of normal healing. Purulent drainage would indicate the presence of infection. A soiled dressing should be changed to avoid bacterial growth and to examine the appearance of the wound. The surgical site is typically covered by gauze dressings for a minimum of 48-72 hours to ensure that initial healing has begun.

12. Answer: C

Impaired perfusion to the right lower arm as a result of a closed cast may cause neurovascular compromise and severe pain, requiring immediate cast removal. Itching under the cast is common and fairly benign. Neurovascular compromise in the arm would not cause pain in the shoulder, as perfusion there would not be affected. Impaired perfusion would cause the fingers to be cool and pale. Increased warmth would indicate increased blood flow or infection.

13. Answer: A

Physical activity and daily exercise can help to improve movement and decrease pain in osteoarthritis. Joint pain and stiffness are often at their worst during the early morning after several hours of decreased movement. Acetaminophen is a pain reliever, but does not have anti-inflammatory activity. Ibuprofen is a strong anti-inflammatory, but should always be taken with food to avoid GI distress.

14. Answer: D

Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position. It should be taken upon rising in the morning with 8 ounces of water on an empty stomach to increase absorption. The patient should not eat or drink for 30 minutes after administration and should not lie down. ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship.

15. Answer: C

Prophylactic use of antibiotics is not indicated to prevent Lyme disease. Antibiotics are used only when symptoms develop following a tick bite. Insect repellant should be used on skin and clothing when exposure is anticipated. Clothing should be designed to cover as much exposed area as possible to provide an effective barrier. Close examination of skin and hair can reveal the presence of a tick before a bite occurs.

16. Answer: D

Immunization is available for the prevention of some, but not all, specific diseases. This type of immunity is "acquired" by causing antibodies to form in response to a specific pathogen. Natural immunity is present at birth because the infant acquires maternal antibodies Immunization, like all medication, cannot be risk-free and should be considered based on the risk of the disease in question.

17. Answer: B

The patient may be experiencing an anaphylactic reaction. The most urgent action is to maintain an airway, particularly with visible oral swelling, followed by the administration of epinephrine by subcutaneous injection. The physician will see the patient as soon as possible with the above actions underway. Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis.

18. Answer: A, B, and D

ADHD in children is frequently treated with CNS stimulant medications, which increase focus and improve concentration. Children often experience insomnia, agitation, and decreased appetite. Sleepiness is not a side effect of stimulants.

19. Answer: D

Abnormal facial movements and tongue protrusion in a patient taking haloperidol is most likely due to tardive dyskinesia, an adverse reaction to the antipsychotic. Depression may occur along with schizophrenia and would be characterized by such symptoms as loss of affect, appetite and/or sleep changes, and anhedonia. These depressive changes and lack of volition are part of the negative symptoms of schizophrenia. Psychotic hallucinations may be visual or auditory but do not include abnormal movements.

20. Answer: B

Hypoglycemia in diabetes mellitus causes confusion, indicating the need for carbohydrates. Polydipsia, blurred vision, and polyphagia are symptoms of hyperglycemia.


From: http://www.studyguidezone.com/nclexrn_practice3.htm

1. 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.

2. 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.

3. A patient with a history of diabetes mellitus is in the second post-operative 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 following is the most likely explanation for the patient's symptoms?

A. Anesthesia reaction.
B. Hyperglycemia.
C. Hypoglycemia.
D. Diabetic ketoacidosis.

4. 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 concern?

A. Bowel perforation.
B. Viral gastroenteritis.
C. Colon cancer.
D. Diverticulitis.

5. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation?

A. Partial thromboplastin time.
B. Prothrombin time.
C. Platelet count.
D. Hemoglobin

6. 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.

7. 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.

8. 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).

9. 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.

10. 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.

11. A nurse caring for several patients on 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 post-operative 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.

12. 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 anti-psychotic medication.

13. 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.

14. 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.

15. 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 platelet count should be included on the nursing care plan?

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.

16. 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.

17. 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 "tear drop on a rose petal" appearance.

18. 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.

19. 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/day. Which of the following best describes the prescribed drug dose?

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.

20. 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 with only one testis.
D. Normally, the testes descend by one year of age.

Answer Key

1. Answer: A

The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones.

2. Answer: D

A patient with Addison's disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates, including grains.

3. Answer: C

A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia reaction would not occur on the second post-operative day. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.

4. Answer: A

Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate advancing peritonitis. Viral gastroenteritis and colon cancer do not cause these symptoms. Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis.

5. Answer: A, B, and C

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

6. Answer: B

Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Hepatitis B, C, and D are transmitted through infected bodily fluids.

7. Answer: A

Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis (gall bladder disease), diverticulosis, and history of Crohn's disease do not preclude blood donation.

8. Answer: A

Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Furosemide is a loop diuretic and is contraindicated in a patient with gastritis.

9. Answer: D

Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.

10. Answer: D

Patients with pulmonary edema experience air hunger, anxiety, and agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing caused by laryngeal swelling or spasm and is not associated with pulmonary edema.

11. Answer: C

An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. A patient recovering well from coronary bypass would not need the device. Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.

12. Answer: B

The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Psychiatric medication is not a contraindication to MRI scanning.

13. Answer: B

Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia.

14. Answer: C

A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist.

15. Answer: D

A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Transfusion of red cells is indicated for severe anemia.

16. Answer: B

Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. The anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is normal for a four year old. The average 4-year-old child cannot read yet, so this too is normal.

17. Answer: A

Koplik's spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. The body rash typically begins on the face and travels downward. High fever is often present. "Tear drop on a rose petal" refers to the lesions found in varicella (chicken pox).

18. Answer: C

Petechiae on the soft palate are characteristic of rubella infection. Choices A, B, and D are characteristic of scarlet fever, a result of group A Streptococcus infection.

19. Answer: B

This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should not be titrated based on symptoms without consulting a physician.

20. Answer: D

Normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. Exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. If not, a full assessment will determine the appropriate treatment.
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From: http://www.studyguidezone.com/nclexrn_practice4.htm

1. A child is admitted to the hospital with a diagnosis of Wilm's 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 abdominal cavity and cannot be resected.

2. 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? Note: More than one answer may be correct.

A. Urine specific gravity of 1.040.
B. Urine output of 350 ml in 24 hours.
C. Brown ("tea-colored") urine.
D. Generalized edema.

3. 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.

4. 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.

5. 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.

6. 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.

7. Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct?

A. It results when oxygen demand is greater than oxygen supply.
B. It is characterized by pain that often occurs duing rest.
C. It is a result of tissue hypoxia.
D. It is characterized by cramping and weakness.

8. 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.

9. 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.

10. 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 attack due to worries about her baby's health.
D. Congestive heart failure due to fluid overload.

11. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

A. Air embolus.
B. Cerebral hemorrhage.
C. Expansion of the clot.
D. Resolution of the clot.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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. Which of the following actions is done immediately before the antibiotic is started?

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.

18. 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.

19. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

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.

20. A child has recently been diagnosed with Duchenne's muscular dystrophy. 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 developing the disease.
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.

Answer Key

1. Answer: C

The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.

2. Answer: A, B, and C

Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.

3. Answer: B

Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

4. Answer: C

A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.

5. Answer: A

Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.

6. Answer: A

Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor.

7. Answer: A, C, and D

Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

8. Answer: C

Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

9. Answer: C

Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.

10. Answer: B

In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

11. Answer: B

Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.

12. Answer: A

In torticollis, the sternocleidomastoid muscle is contracted, limiting range of motion of the neck and causing the chin to point to the opposing side. In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape. Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time. Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size.

13. Answer: C

Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.

14. Answer: D

A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Choices A, B, and C are not part of the routine adolescent exam.

15. Answer: C

The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.

16. Answer: 3

Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy.

17. Answer: B

Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.

18. Answer: A

The child's refusal to walk, combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign injury to be carried, and swelling indicates a physical injury.

19. Answer: A, B, D

Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.

20. Answer: A

The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.


From: http://www.studyguidezone.com/nclexrn_practice5.htm

1. A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is NOT expected?

A. Increased urinary output.
B. Decreased edema.
C. Decreased pain.
D. Decreased blood pressure.

2. There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?

A. Obesity.
B. Heredity.
C. Gender.
D. Age.

3. Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?

A. Worsening chest pain that began earlier in the evening.
B. History of cerebral hemorrhage.
C. History of prior myocardial infarction.
D. Hypertension.

4. Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?

A. Increases fitness and prevents future heart attacks.
B. Prevents bedsores.
C. Prevents DVT (deep vein thrombosis).
D. Prevent constipations.

5. A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?

A. Hypertension.
B. Bradycardia.
C. Bounding pulse.
D. Confusion.

6. A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?

A. Ask the patient to lie down on the exam table.
B. Draw blood for chemistry panel and arterial blood gas (ABG).
C. Send the patient for a chest x-ray.
D. Check blood pressure.

7. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?

A. "Stop taking the nitroglycerin and see if the headaches improve."
B. "Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain."
C. "Headaches are a frequent side effect of nitroglycerine because it causes vasodilation."
D. "The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation."

8. A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms?

A. The symptoms may be the result of anemia caused by chemotherapy.
B. The patient may be immunosuppressed.
C. The patient may be depressed.
D. The patient may be dehydrated.

9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the follow nutritional advice is appropriate?

A. The diet is providing adequate sources of iron and requires no changes.
B. The patient should add meat to her diet; a vegetarian diet is not advised.
C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron.
D. A cup of coffee or tea should be added to every meal.

10. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?

A. Transfusion reaction is most likely immediately after the infusion is completed.
B. PRBCs are best infused slowly through a 20g. IV catheter.
C. PRBCs should be flushed with a 5% dextrose solution.
D. A nurse should remain in the room during the first 15 minutes of infusion.

11. A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?

A. An increase in neutrophil count.
B. An increase in hematocrit.
C. An increase in platelet count.
D. An increase in serum iron.

12. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis?

A. Weight loss.
B. Increased clotting time.
C. Hypertension.
D. Headaches.

13. A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?

A. Observe for evidence of spontaneous bleeding.
B. Limit visitors to family only.
C. Give aspirin in case of headaches.
D. Impose immune precautions.

14. A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More than one answer may be correct.

A. Hypertension.
B. Cushingoid features.
C. Hyponatremia.
D. Low serum albumin.

15. A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?

A. Change the disposable mask immediately after use.
B. Change gloves immediately after use.
C. Minimize patient contact.
D. Minimize conversation with the patient.

16. A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?

A. We will bring in books and magazines for entertainment.
B. We will bring in personal care items for comfort.
C. We will bring in fresh flowers to brighten the room.
D. We will bring in family pictures and get well cards.

17. A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?

A. 3-10 years.
B. 25-35 years.
C. 45-55 years.
D. over 60 years.

18. A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin's disease. Which of the following symptoms is typical of Hodgkin's disease?

A. Painful cervical lymph nodes.
B. Night sweats and fatigue.
C. Nausea and vomiting.
D. Weight gain.

19. The Hodgkin's disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin's disease were correct, which of the following cells would the pathologist expect to find?

A. Reed-Sternberg cells.
B. Lymphoblastic cells.
C. Gaucher's cells.
D. Rieder's cells

20. A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response?

A. Warn the patient to stay very still because the smallest movement will increase her pain.
B. Encourage the family to stay in the room for the procedure.
C. Stay with the patient and focus on slow, deep breathing for relaxation.
D. Delay the procedure to allow the patient to deal with her feelings.

Answer Key

1. Answer: C

Furosemide, a loop diuretic, does not alter pain. Furosemide acts on the kidneys to increase urinary output. Fluid may move from the periphery, decreasing edema. Fluid load is reduced, lowering blood pressure.

2. Answer: A

Obesity is an important risk factor for coronary artery disease that can be modified by improved diet and weight loss. Family history of coronary artery disease, male gender, and advancing age increase risk but cannot be modified.

3. Answer: B

A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. Prior MI is not a contraindication to tPA. Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension.

4. Answer: C

Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. This exercise is not sufficiently vigorous to increase physical fitness, nor is it intended to prevent bedsores or constipation.

5. Answer: D

Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate.

6. Answer: D

A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient's blood pressure should be the first action. Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment.

7. Answer: C

Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache, dizziness, and hypotension. Patients should be counseled, and the dose titrated, to minimize these effects. In spite of the side effects, nitroglycerine is effective at reducing myocardial oxygen consumption and increasing blood flow. The patient should not stop the medication. Nitroglycerine does not cause bleeding in the brain.

8. Answer: A

Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects, which often includes anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or dehydration is a cause of her symptoms.

9. Answer: 3

Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. In addition, dark green leafy vegetables, such as spinach and kale, and legumes are high in iron. Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.

10. Answer: D

Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this period. PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.

11. Answer: B

Epoetin is a form of erythropoietin, which stimulates the production of red blood cells, causing an increase in hematocrit. Epoetin is given to patients who are anemic, often as a result of chemotherapy treatment. Epoetin has no effect on neutrophils, platelets, or serum iron.

12. Answer: B, C, and D

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.

13. Answer: A

Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When the count falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of thrombocytopenia. Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long as any physical trauma is prevented.

14. Answer: A, B, and D

Side effects of corticosteroids include weight gain, fluid retention with hypertension, Cushingoid features, a low serum albumin, and suppressed inflammatory response. Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low in sodium. Corticosteroids cause hypernatremia, not hyponatremia.

15. Answer: B

The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up on hospital surfaces. This contamination can have serious consequences for an immunocompromised patient. Changing the respiratory mask is desirable, but not nearly as urgent as changing gloves. Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the patient's symptoms or condition.

16. Answer: C

During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. Books, pictures, and other personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination.

17. Answer: A

The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years.

18. Answer: B

Symptoms of Hodgkin's disease include night sweats, fatigue, weakness, and tachycardia. The disease is characterized by painless, enlarged cervical lymph nodes. Weight loss occurs early in the disease. Nausea and vomiting are not typically symptoms of Hodgkin's disease.

19. Answer: A

A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found on pathologic examination of the excised lymph node. Lymphoblasts are immature cells found in the bone marrow of patients with acute lymphoblastic leukemia. Gaucher's cells are large storage cells found in patients with Gaucher's disease. Rieder's cells are myeloblasts found in patients with acute myelogenous leukemia.

20. Answer: C

Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the level of carbon dioxide in the brain to increase calm and relaxation. Warning the patient to remain still will likely increase her anxiety. Encouraging family members to stay with the patient may make her worry about their anxiety as well as her own. Delaying the procedure is unlikely to allay her fears.
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