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    Exam Review

    1. A nurse is collecting data from a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
      (SATA)
      A)
      (Select All that Apply.)
      B)
      Thrives in new environments
      C)
      short attention span
      D)
      Delayed language development
      E)
      Ritualistic behavior
      F)
      Enjoys sensory play
    2. A nurse is caring for a teenage client who has autism spectrum disorder and repeatedly pulls on his NG tube. Which of the following interventions should the nurse consider before requesting a prescription for restraints? (Select all that apply.)
      (SATA)
      A)
      Provide diversionary activities
      B)
      Assist with cares at frequent intervals
      C)
      Involve the family in the client's care
      D)
      Dim the lights and play calming piano music
      E)
      Explain that restraints will be the next step
    3. A nurse is preparing to administer potassium chloride 30 mEq PO daily. The amount available is potassium chloride 20 mEq/15mL. How many m should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:22.5 mL
    4. A nurse is caring for an 80-year-old client who expresses feelings of grief for opportunities he missed in his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
      A)
      Listen attentively when the client talks about the past.
      B)
      Let the client know that this is a common problem of the aging population.
      C)
      Provide the client with activities to perform so he won't have time to dwell on the past.
      D)
      Tell the client about some of the younger clients in the hospital who have experienced loss.
    Page 1 of 11

    Exam Review

    1. A nurse is caring for a couple who experienced the loss of a young child. Which of the following responses by the nurse is therapeutic?
      A)
      "You will start to feel better in 3-6 months. Right now, you just need to put one foot in front of the other."
      B)
      "This is why I am such an advocate for early and timely vaccination against deadly diseases,"
      C)
      "This must be incredibly difficult. When you are ready, I can offer recommendations for group therapy sessions."
      D)
      "At least you have two other children to keep you busy and distracted during the grieving process."
    2. A nurse is providing education to the family of a client recently diagnosed with dementia. Which statement, made by the family, requires clarification?
      A)
      "Dementia develops gradually over time, rather than suddenly within hours or days."
      B)
      "Dementia is typically caused by a sudden change in environment."
      C)
      "My family member will experience a decline in cognition."
      D)
      The manifestations of dementia are progressive and irreversible."
    3. During a grief support group session, a nurse observes several participants expressing apprehension and helplessness about taking on the roles and responsibilities previously managed by their spouse. What type of stress manifestation is most likely to result from these feelings?
      A)
      Depression
      B)
      Anger
      C)
      Contentment
      D)
      Anxiety
    4. A nurse is assisting with the admission of a client who has autism spectrum disorder. Which of the following resources should be included as part of the data collection?
      A)
      Mini Mental State Examination (MMSE)
      B)
      Hamilton Anxiety Scale
      C)
      Autism Mental Status Exam (AMSE)
      D)
      Abnormal Involuntary Movements Exam (AIMS)
    Page 2 of 11

    Exam Review

    1. A nurse is collecting data from a client and their full-time caregiver, who is the client's adult child. The caregiver appears disheveled and irritable. Which of the following caregiver concerns should the nurse prioritize to address?
      A)
      Isolation experienced by the caregiver
      B)
      Emotional well-being and stress levels of the caregiver
      C)
      Financial burdens associated with caregiving
      D)
      Scheduling challenges faced by the caregiver
    2. A nurse is caring for a child who is allergic to penicillin. Which of the following medications should the nurse identify as contraindicated for the child?
      A)
      Gentamicin sulfate
      B)
      Erythromycin
      C)
      Zosyn (Piperacillin + Tazobactam)
      D)
      Tylenol (Acetaminophen)
    3. A nurse is caring for a client who begins showing signs of alcohol withdrawal delirium. Which of the following medications should the nurse administer?
      A)
      Lorazepam
      B)
      Disulfiram
      C)
      Methadone
      D)
      Acamprosate
    4. A nurse is caring for a client who is has alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?
      A)
      Develop goals for treatment.
      B)
      Prevent the client from harming herself or others.
      C)
      Identify the use of defense mechanisms.
      D)
      Support the client's coping skills
    Page 3 of 11

    Exam Review

    1. A nurse is assisting with the development of a community education course about the physical complications related to substance use disorder. Which of the following substances should the nurse identify as a primary cause of cirrhosis (late-stage liver disease)?
      A)
      Cocaine
      B)
      Caffeine
      C)
      Inhalants
      D)
      Alcohol
    2. A nurse is caring for an 18-month-old toddler exhibiting early signs of autism spectrum disorder. Which of the following behaviors suggest the need for speech therapy?
      A)
      Points to a picture of an animal and imitates the corresponding animal sound
      B)
      Ignores parents
      C)
      Has difficulty following directions
      D)
      Refuses to speak
      E)
      Responds to his/her name
    3. A nurse is assessing a husband who has recently learned that his unborn child has a congenital defect and may not survive after birth. He is displaying symptoms of acute stress. Which physiological response might the nurse expect in this client?
      A)
      Polyuria
      B)
      Cold and clammy skin
      C)
      Tachycardia
      D)
      Bradypnea
    4. A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. T nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)
    Page 4 of 11

    Exam Review

    1. A nurse is conducting the Mini Mental State Examination (MMSE) for a client with dementia. Which tasks should the nurse include as part of this assessment? (Select all that apply)
      A)
      Ability to concentrate
      B)
      Ability to perform basic self-care tasks
      C)
      Assessment of orientation
      D)
      Assessment of cranial nerve functioning
      E)
      Assessment of verbal skills
    2. A nurse is assisting in developing a care plan for a client with dementia. Which of the following interventions should be modified?
      A)
      Create an environment that promotes some cognitive stimulation
      B)
      Limit the number of choices available for the client's daily activities
      C)
      Alternate staff assignments to reduce caregiver role strain
      D)
      Avoid confrontation when addressing negative behavior
    3. When educating a client on warfarin therapy, which considerations should the nurse prioritize? Select all that apply:
      A)
      Educating the client about the need for regular INR monitoring
      B)
      Encouraging the client to take herbal supplements to enhance the effects of warfarin
      C)
      Encouraging the use of over-the-counter NSAIDS for mild pain relief
      D)
      Instructing the client to maintain a consistency in their intake of Vitamin K rich foods
      E)
      Monitoring for signs of bleeding such as unusual bruising:
      F)
      Educating the client to avoid contact sports or activities with a high risk of injury
    4. A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and an eating disorder. Which of the following actions should the nurse take first?
      A)
      Initiate Cognitive-behavioral therapy (CBT)
      B)
      Review the client's toxicology laboratory report.
      C)
      Begin continuous one-on-one supervision.
      D)
      Make a contract with the client for weight gain.
    Page 5 of 11

    Exam Review

    1. A nurse is assisting with the admission of a confused older adult. Which statement by the client's partner suggests the client may be experiencing delirium?
      A)
      "She became very withdrawn and extremely sad."
      B)
      "Her behavior changed so quickly, I wasn't sure what was happening."
      C)
      "Her speech was slow and repetitious."
      D)
      "She's been making up stories the past few weeks."
    2. A nurse manager at a health clinic is educating a newly licensed nurse about complications related to sexually transmitted infections (STIs). Which of the following statements should be included in the discussion?
      A)
      "Herpes simplex virus is rarely spread to neonates."
      B)
      "Gonorrhea is a viral infection that results in painful urination."
      C)
      "Human papillomavirus can lead to cancer of the cervix."
      D)
      Chlamydia is not curable but it can be managed with medication.
    3. A nurse in an acute care facility is caring for a terminally ill preschool-age child receiving palliative care. The child's life expectancy is less than 6 months. The parents inform the nurse of their decision to transition their child to hospice care at home. Which response should the nurse provide?
      A)
      "We need to check if your state's guidelines qualify you for a hospital bed at home."
      B)
      "We all agree that you are making the right decision."
      C)
      "If you go home, your child might not be able to continue receiving oxygen therapy."
      D)
      "Would you like to talk about what to expect in hospice care?"
    4. A nurse is facilitating the court-ordered admission of a client into a substance abuse program. The client states, "I drink because of idiots like you who think you know everything." This response is an example of which defense mechanism?
      A)
      Regression
      B)
      Undoing
      C)
      Projection
      D)
      Compensation
    Page 6 of 11