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    Exam Review

    1. A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yester noon the sun noon went over the rover to see the lawnmower." Which of the following manifestations is the client exhibiting?
      A)
      Delusional disorder
      B)
      Associative looseness
      C)
      Hallucination
      D)
      Anhedonia
    2. A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
      A)
      Ask the client to describe the situation
      B)
      Inform the client photographs of injuries are required for a police report
      C)
      Give the client a bed bath prior to physical examination
      D)
      Discuss self-defense techniques with the client
    3. A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
      A)
      An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication.
      B)
      A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min.
      C)
      A toddler who has otitis media, a temperature of 39.2 °C (102 °F), and purulent ear discharge.
      D)
      A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough.
    4. A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
      (SATA)
      A)
      The nurse has a disagreement with the nursing supervisor about inadequate staffing.
      B)
      A staff member does not show up to work her assigned shift.
      C)
      A client discovers that his dentures are missing.
      D)
      The nurse identifies a broken piece of equipment.
    Page 1 of 6

    Exam Review

    1. A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate?
      A)
      Tell me about the bugs that you see in your room.
      B)
      I do not see anything. This is part of the withdrawal process.
      C)
      I don’t see any bugs, but you seem very frightened.
      D)
      I’m sure that the bugs you see will not harm you.
    2. A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three doses, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
      A)
      Autonomy
      B)
      Nonmaleficence
      C)
      Justice
      D)
      Fidelity
    3. A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate?
      A)
      You should support this policy change because it was based on evidence-based practice.
      B)
      Why didn’t you voice your concerns before the new policy was implemented?
      C)
      Let’s talk about your concerns about the new policy.
      D)
      Being open to change is an expectation of the nurses who work on this unit.
    4. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
      A)
      Why do you think you are so anxious?
      B)
      It sounds like you’re a difficult person.
      C)
      How long has this been going on?
      D)
      Have you talked to your parents about this yet?
    Page 2 of 6

    Exam Review

    1. A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to informed consent is which of the following?
      A)
      Discussing alternate treatment options
      B)
      Determining the client’s level of understanding about the procedure
      C)
      Explaining the risks involved with the procedure
      D)
      Ensuring the charge nurse is available to witness the signature on the consent form
    2. A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
      A)
      A client who has a massive head injury and is experiencing no signs of responsiveness.
      B)
      A client who has severe respiratory stridor and a deviated trachea.
      C)
      A client who has a splinted open fracture of the left medial malleolus.
      D)
      A client who has a small circular partial-thickness burn of the left calf.
    3. A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having some improvement but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?
      A)
      Speak to the provider about adding an MAOI to the current medication regimen.
      B)
      Tell the client that the provider needs to change citalopram to a different medication.
      C)
      Explain that antidepressants often take several weeks to be fully effective.
      D)
      Recommend a sleep study be done on the client.
    4. A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
      A)
      Were you trying to harm yourself by taking an overdose?
      B)
      Do you know how many were in the bottle?
      C)
      I’m glad you called, and I want to send an ambulance to help you.
      D)
      You must have been feeling pretty depressed to do that.
    Page 3 of 6

    Exam Review

    1. A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.36 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)
      A)
      Bradycardia
      B)
      Altered body image
      C)
      Verbalized desire to gain weight
      D)
      Amenorrhea
      E)
      Hyperactivity
    2. A nurse is assessing the client for manifestations of anorexia nervosa. Which of the following findings should the nurse expect? Select all that apply.
      A)
      Client reports preoccupation with thoughts about food.
      B)
      Client comments that they are too thin and need to gain weight.
      C)
      Client reports consuming around 600 calories each day.
      D)
      Client’s hair appears brittle and thin.
      E)
      Client voices being “too tired” and lacks interest in daily activities.
      F)
      Client has soft, unpigmented hair on arms.
    3. A nurse is assessing the client for manifestations of anorexia nervosa. Which of the following findings should the nurse expect? Select all that apply.
      A)
      Client reports preoccupation with thoughts about food.
      B)
      Client comments that they are too thin and need to gain weight.
      C)
      Client reports consuming around 600 calories each day.
      D)
      Client’s hair appears brittle and thin.
      E)
      Client voices being “too tired” and lacks interest in daily activities.
      F)
      Client has soft, unpigmented hair on arms.
    4. A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
      A)
      I cannot promise that. I must share this information with other members of the team who are responsible for planning your care.
      B)
      I can see that you trust me, but you should share those feelings with your psychiatrist, not me.
      C)
      Because you are a minor, I have to share any information that I feel is important with your parents.
      D)
      I will not violate our nurse-client relationship. The information we discuss remains confidential between us.
    Page 4 of 6

    Exam Review

    1. A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
      A)
      Dilated pupils
      B)
      Depression
      C)
      Nystagmus
      D)
      Hypersomnia
    2. A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client’s wishes is a violation of which of the following ethical principles?
      A)
      Justice
      B)
      Autonomy
      C)
      Veracity
      D)
      Fidelity
    3. A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate?
      A)
      You should support this policy change because it was based on evidence-based practice.
      B)
      Why didn’t you voice your concerns before the new policy was implemented?
      C)
      Let’s talk about your concerns about the new policy.
      D)
      Being open to change is an expectation of the nurses who work on this unit.
    4. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
      A)
      Why do you think you are so anxious?
      B)
      It sounds like you’re a difficult person.
      C)
      How long has this been going on?
      D)
      Have you talked to your parents about this yet?
    Page 5 of 6

    Exam Review

    1. A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to informed consent is which of the following?
      A)
      Discussing alternate treatment options
      B)
      Determining the client’s level of understanding about the procedure
      C)
      Explaining the risks involved with the procedure
      D)
      Ensuring the charge nurse is available to witness the signature on the consent form
    Page 6 of 6