1.

What equipment would be necessary to complete an evaluation of cranial nerves 9

and 10 during a physical assessment?

A. A cotton ball
B. A penlight
C. An ophthalmoscope
D. A tongue depressor and flashlight

2. Which technique would be best in caring for a client following receiving a

diagnosis of a state IV tumor in the brain?

A. Offering the client pamphlets on support groups for brain cancer

B. Asking the client if there is anything he or his family needs
C. Reminding the client that advances in technology are occurring everyday
D. Providing accurate information about the disease and treatment options

3. An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing

intervention would be implemented when the neonate becomes jittery and lethargic?

A. Administer insulin
B. Administer oxygen
C. Feed the infant glucose water (10%)
D. Place infant in a warmer

4. What question would be most important to ask a male client who is in for a digital
rectal examination?

A. “Have you noticed a change in the force of the urinary system?”

B. “Have you noticed a change in tolerance of certain foods in your diet?”
C. “Do you notice polyuria in the AM?”
D. “Do you notice any burning with urination or any odor to the urine?”
5. The nurse assesses a prolonged late deceleration of the fetal heart ratewhile the
client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing
intervention would be to:

A. Turn off the infusion

B. Turn the client to the left
C. Change the fluid to Ringer’s Lactate
D. Increase mainline IV rate

6. Which nursing approach would be most appropriate to use while administering

an oral medication to a 4 month old?

A. Place medication in 45cc of formula

B. Place medication in an empty nipple
C. Place medication in a full bottle of formula
D. Place in supine position. Administer medication using a plastic syringe

7. Which nursing intervention would be a priority during the care of a 2-month-old

after surgery?

A. Minimize stimuli for the infant

B. Restrain all extremities
C. Encourage stroking of the infant
D. Demonstrate to the mother how she can assist with her infant’s care.

8. While performing a physical examination on a newborn, which assessment should

be reported to the physician?

A. Head circumference of 40 cm
B. Chest circumference of 32 cm
C. Acrocyanosis and edema of the scalp
D. Heart rate of 160 and respirations of 40
9. Which action by the mother of a preschooler would indicate a disturbed family
interaction?

A. Tells her child that if he does not sit down and shut up she will leave him there.
B. Explains that the injection will burn like a bee sting.
C. Tells her child that the injection can be given while he’s in her lap
D. Reassures child that it is acceptable to cry.

10. During the history, which information from a 21-year-old client would indicate a
risk for development of testicular cancer?

A. Genital Herpes
B. Hydrocele
C. Measles
D. Undescended testicle

11. While caring for a client, the nurse notes a pulsating mass in the client’s
periumbilical area. Which of the following assessments is appropriate for the nurse
to perform?

A. Measure the length of the mass

B. Auscultate the mass
C. Percuss the mass
D. Palpate the mass

12. When observing 4-year-old children playing in the hospital playroom, what
activity would the nurse expect to see the children participating in?

A. Competitive board games with older children

B. Playing with their own toys along side with other children
C. Playing alone with hand held computer games
D. Playing cooperatively with other preschoolers
13. The nurse is teaching the parents of a 3 month-old infant about nutrition. What
is the main source of fluids for an infant until about 12 months of age?

A. Formula or breastmilk
B. Dilute nonfat dry milk
C. Warmed fruit juice
D. Fluoridated tap water

14. While the nurse is administering medications to a client, the client states “I do
not want to take that medicine today.” Which of the following responses by the
nurse would be best?

A. “That’s OK, its alright to skip your medication now and then.”
B. “I will have to call your doctor and report this.”
C. “Is there a reason why you don’t want to take your medicine?”
D. “Do you understand the consequences of refusing your prescribed treatment?”

15. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?

A. Hold a rattle
B. Bang two blocks
C. Drink from a cup
D. Wave “bye-bye”

16. The nurse should recognize that all of the following physical changes of the head
and face are associated with the aging client except:

A. pronounced wrinkles on the face.

B. decreased size of the nose and ears.
C. increased growth of facial hair.
D. neck wrinkles.
17. All of the following characteristics would indicate to the nurse that an elder
client might experience undesirable effects of medicines except:

A. increased oxidative enzyme levels.

B. alcohol taken with medication.
C. medications containing magnesium.
D. decreased serum albumin.

18. When assessing a newborn whose mother consumed alcohol during

the pregnancy, the nurse would assess for which of these clinical manifestations?

A. wide-spaced eyes, smooth philtrum, flattened nose

B. strong tongue thrust, short palpebral fissures, simian crease
C. negative Babinski sign, hyperreflexia, deafness
D. shortened limbs, increased jitteriness, constant sucking

19. Which of these statements, when made by the nurse, is most effective when
communicating with a 4-year-old?

A. “Tell me where you hurt.”

B. “Other children like having their blood pressure taken.”
C. “This will be like having a little stick in your arm.”
D. “Anything you tell me is confidential.”

20. A 64-year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the nurse?

A. Explain to the client that the dentures must come out as they may get lost or broken in
the operating room
B. Ask the client if there are second thoughts about having the procedure
C. Notify the anesthesia department and the surgeon of the client’s refusal
D. Ask the client if the preference would be to remove the dentures in the operating room
receiving area

21. The nurse is assessing a client who states her last menstrual period was March
17, and she has missed one period. She reports episodes of nauseaand vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)?

A. November 8
B. May 15
C. February 21
D. December 24

22. The family of a 6-year-old with a fractured femur asks the nurse if the child’s
height will be affected by the injury. Which statement is true concerning long bone
fractures in children?

A. Growth problems will occur if the fracture involves the periosteum

B. Epiphyseal fractures often interrupt a child’s normal growth pattern
C. Children usually heal very quickly, so growth problems are rare
D. Adequate blood supply to the bone prevents growth delay after fractures

23. A client is admitted to the hospital with a history of confusion. The client has
difficulty remembering recent events and becomes disoriented when away from
home. Which statement would provide the best reality orientation for this client?

A. “Good morning. Do you remember where you are?”

B. “Hello. My name is Elaine Jones and I am your nurse for today.”
C. “How are you today? Remember, you’re in the hospital.”
D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
24. When a client wishes to improve the appearance of their eyes by removing excess
skin from the face and neck, the nurse should provide teaching regarding which of
the following procedures?

A. Dermabrasion
B. Rhinoplasty
C. Blepharoplasty
D. Rhytidectomy

25. A woman who is six months pregnant is seen in antepartal clinic. She states she
is having trouble with constipation. To minimize this condition, the nurse should
instruct her to

A. increase her fluid intake to three liters/day.

B. request a prescription for a laxative from her physician.
C. stop taking iron supplements.
D. take two tablespoons of mineral oil daily.

Answers and Rationale

1. Answer: D. A tongue depressor and flashlight

Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflexwould
be evaluated.

2. Answer: D. Providing accurate information about the disease and treatment

options

Providing information for the client is the best technique for a new diagnosis.

3. Answer: C. Feed the infant glucose water (10%)

After birth, the infant of a diabetic mother is often hypoglycemic.

4. Answer: A. “Have you noticed a change in the force of the urinary system?”

This change would be most indicative of a potential complication with (BPH) benign
prostate hypertrophy.

5. Answer: A. Turn off the infusion

Stopping the infusion will decrease contractions and possibly remove uterine pressure on
the fetus, which is a possible cause of the deceleration.

6. Answer: B. Place medication in an empty nipple

This is a convenient method for administering medications to an infant. Option D is

partially correct however, the infant is never placed in a reclining position during a
procedure due to a potential aspiration.

7. Answer: C. Encourage stroking of the infant

Tactile stimulation is imperative for an infant’s normal emotional development. After the
trauma of surgery, sensory deprivation can cause failure to thrive.

8. Answer: A. Head circumference of 40 cm

Average circumference of the head for a neonate ranges between 32 to 36 cm. An

increase in size may indicate hydrocephalus or increased intracranial pressure.

9. Answer: A. Tells her child that if he does not sit down and shut up she will leave
him there.

Threatening a child with abandonment will destroy the child’s trust in his family.
10. Answer: D. Undescended testicle

Undescended testicles make the client high risk for testicular cancer. Mumps,
inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are
other predisposing factors.

11. Answer: B. Auscultate the mass

Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the
presence of an abdominal aneurysm and will form the basis of information given to the
provider. The mass should not be palpated because of the risk of rupture.

12. Answer: D. Playing cooperatively with other preschoolers

Playing cooperatively with other preschoolers. Cooperative play is typical of the late
preschool period.

13. Answer: A. Formula or breastmilk

Formula or breast milk are the perfect food and source of nutrients and liquids up to 1
year of age.

14. Answer: C. “Is there a reason why you don’t want to take your medicine?”

When a new problem is identified, it is important for the nurse to collect accurate
assessment data. This is crucial to ensure that client needs are adequately identified in
order to select the best nursing care approaches. The nurse should try to discover the
reason for the refusal which may be that the client has developed untoward side effects.

15. Answer: A. Hold a rattle

The age at which a baby will develop the skill of grasping a toy with help is 4 to 6
months.

16. Answer: B. decreased size of the nose and ears.

The nose and ears of the aging client actually become longer and broader. The chin line is
also altered. Wrinkles on the face become more pronounced and tend to take on the
general mood of the client over the years. For example laugh or frown wrinkles about the
eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-
estrogen ratio causes an increase in growth of facial hair in most older adults. The aging
process shortens the platysma muscle, which contributes to neck wrinkles.

17. Answer: A. increased oxidative enzyme levels.

Oxidative enzyme levels decrease in the elderly, which affects the disposition of
medication and can alter the therapeutic effects of medication. Alcohol has a smaller
water distribution level in the elderly, resulting in higher blood alcohol levels. Alcohol
also interacts with various drugs to either potentiate or interfere with their effects.
Magnesium is contained in a lot of medications elder clients routinely obtain over the
counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding
protein. Decreased levels of serum albumin mean that higher levels of the drug remain
free and that there are less therapeutic effects and increased drug interactions.

18. Answer: A. wide-spaced eyes, smooth philtrum, flattened nose

The nurse should anticipate that the infant may have fetal alcohol syndrome and should
assess for signs and symptoms of it. These include the characteristics listed in choice A.

19. Answer: A. “Tell me where you hurt.”

Four-year-olds are egocentric and interested in having the focus on themselves. They will
not be interested in what it feels like to other children. Preschoolers are concrete thinkers
and would literally interpret any analogies so they are not helpful in explaining
procedures. Assurance of confidential communication is most appropriate for the
adolescent. In addition, confidentiality is not maintained if the child plans to harm
themselves, harm someone else, or discloses abuse.

20. Answer: D. Ask the client if the preference would be to remove the dentures in
the operating room receiving area

Clients anticipating surgery may experience a variety of fears. This choice allows the
client control over the situation and fosters the client’s sense of self-esteem and self-
concept.

21. Answer: D. December 24

Naegele’s rule: add 7 days and subtract 3 months from the first day of the last regular
menstrual period to calculate the estimated date of delivery.

22. Answer: B. Epiphyseal fractures often interrupt a child’s normal growth pattern

Epiphyseal fractures often interrupt a child’s normal growth pattern

23. Answer is D. “Good morning. You’re in the hospital. I am your nurse Elaine
Jones.”

As cognitive ability declines, the nurse provides a calm, predictable environment for the
client. This response establishes time, location and the caregiver’s name.

24. Answer: D. Rhytidectomy

Rhytidectomy is the procedure for removing excess skin from the face and neck. It is
commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause
light freezing of the skin, which is then abraded with sandpaper or a revolving wire
brush. It is used to remove facial scars, severe acne, and pigment from tattoos.
Rhinoplasty is done to improve the appearance of the nose and involves reshaping the
nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and
protruding fat from the upper and lower eyelids.

25. Answer: A. increase her fluid intake to three liters/day.

In pregnancy, constipation results from decreased gastric motility and increased water
reabsorption in the colon caused by increased levels of progesterone. Increasing fluid
intake to three liters a day will help prevent constipation. The client should increase fluid
intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not
recommended because of the possible development of laxative dependence or abdominal
cramping. Iron supplements are necessary during pregnancy, as ordered, and should not
be discontinued. The client should increase fluid intake, increase roughage in the diet,
and increase exercise as tolerated. Laxatives are not recommended because of the
possible development of laxative dependence or abdominal cramping. Mineral oil is
especially bad to use as a laxative because it decreases the absorption of fat-soluble
vitamins (A, D, E, K) if taken near mealtimes.