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    Exam Review

    1. The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
      A
      Option A
      A)
      The nurse will call the client weekly to monitor the client's blood pressure and symptoms.
      B)
      The nurse will encourage the client to walk thirty minutes every day.
      C)
      The client will take up to 4 nitroglycerine tablets sublingually for chest pain.
      D)
      The client will record episodes of angina and self-management for one week.
    2. During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)
      (SATA)
      A)
      Measure the client's blood pressure in both arms.
      B)
      Screen for a family history of diabetes mellitus.
      C)
      Arrange for immediate transport to a medical facility.
      D)
      Advise the client to restrict fluids and keep feet elevated.
      E)
      Discuss the importance of a regular exercise program.
    3. Exhibits
      (Highlight — findings requiring follow-up are marked)
      Exhibits

      Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

      The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

      • Fatigue
      • Generalized weakness
      • Muscle cramps
      • Tingling sensation in her arms and legs
      • Lightheadedness

      She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

      Initial Vital Signs:

      • Blood Pressure: 146/82 mmHg
      • Heart Rate: 114 bpm
      • Respiratory Rate: 18 bpm
      • SpO₂: 98% on room air
      • Temperature: 98.2 °F (36.8 °C) orally
    4. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
      A)
      Postpone the client interview until the next day.
      B)
      Document the client's paranoid behavior.
      C)
      Attempt to ask the client simple questions.
      D)
      Ask another nurse to talk with the client.
    Page 1 of 10

    Exam Review

    1. A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
      A)
      The client should be aware of the signs and symptoms of his illness.
      B)
      The client should plan to participate in group or individual therapy while at college.
      C)
      Despite the illness, the client should be able to live away from home.
      D)
      The client's serum lithium levels should be routinely evaluated.
    2. A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
      A)
      Ecchymotic blood accumulations.
      B)
      Evidence of patches of lost hair.
      C)
      Episodic complaints of pruritus.
      D)
      Erythema of the localized lesions.
    3. A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
      A)
      Concentrate on and ventilate emotions when distressed.
      B)
      Shift attention from self to the needs and requests of others.
      C)
      Relax and reduce the amount of effort to solve the problem.
      D)
      Focus on small achievable tasks, not taxing problems.
    4. Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
      A)
      Any history of heart disease.
      B)
      Familial history of mental illness.
      C)
      Current weight.
      D)
      Medication history.
    Page 2 of 10

    Exam Review

    1. The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
      A)
      Bradycardia and bradypnea.
      B)
      Stimulation and dilated pupils.
      C)
      Hallucinations and delusions.
      D)
      Lethargy and depression.
    2. Patient Data Exhibits here The nurse is reviewing the history and physical. Choose the most likely options for the information missing from the statement below by selecting from the list of options provided. Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a ▾ hyperkalemia.
      Dropdown 1:
      Option 1: sinus tachycardia
      Option 2: hyperkalemia
      Option 3: hypermagnesemia
      Option 4: hypokalemia
    3. Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
      A)
      Basic metabolic panel
      B)
      Echocardiogram
      C)
      CT scan of abdomen
      D)
      Blood cultures times 2 sets
      E)
      Chest X-ray
      F)
      Place on a continuous cardiac monitor
      G)
      CBC
    4. Patient Data Exhibits The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client. Each row must have only one response option selected. Actions
      A)
      Monitor cardiac status
      B)
      Educate on compliance to hemodialysis
      C)
      Monitor client's vital signs
      D)
      Perform a head-to-toe assessment
      E)
      Monitor the client's heart rhythm
      F)
      Monitor Input and Output
      G)
      Monitor neuromuscular status
    Page 3 of 10

    Exam Review

    1. Patient Data Exhibits here On further assessment, the client reports that her doctor A had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room, and another set of vital signs is performed. Physician notified and orders received. ECG monitor shows a slight peaked T-wave. What treatments should the nurse anticipate for the client at this time? Select all that apply.
      A)
      Call and give a report immediately
      B)
      Administer loop diuretic
      C)
      Schedule for Hemodialysis immediately
      D)
      Check blood glucose level
      E)
      Draw a repeat potassium level
      F)
      Hold Lisinopril
      G)
      Administer insulin, dextrose 50%, and calcium gluconate. Then repeat 12 lead EKG
    2. Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.
      A)
      Denies cramps, weakness, or nausea
      B)
      BP 116/68 mm Hg, HR 75 bpm
      C)
      Potassium level 3.6 mEq/L (3.6 mmol/L)
      D)
      Verbalizes commitment to dialysis appointments
      E)
      Client states that she will need to resume her Lisinopril to control blood pressure
      F)
      The client is eager to add dark green vegetables and potatoes to her diet
    3. The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
      A)
      Applies prescribed lotions to the radiation site.
      B)
      Washes the radiation site with antibacterial soap and water.
      C)
      Wears clothing to cover the radiation site.
      D)
      Dries the area with patting motions after taking a shower.
    4. The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
      A)
      Sweet potatoes.
      B)
      Spinach salad.
      C)
      Bananas.
      D)
      Fish.
    Page 4 of 10

    Exam Review

    1. A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
      A)
      Use an incentive spirometer.
      B)
      Monitor the urinary stream for the decrease in output.
      C)
      Report when hematuria becomes pink-tinged.
      D)
      Restrict physical activities.
    2. Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
      A)
      Assist the client to the bathroom
      B)
      Assess mental status regularly
      C)
      Provide oral care at least twice a day
      D)
      Screen for orthostatic hypotension
      E)
      Monitor calcium levels
      F)
      Have an opioid agonist at the bedside
    3. Exhibits For each client statement, select the statement(s) below that require follow-up teaching by the nurse. "This diagnosis means that I am crazy." "I can learn to manage my thoughts better through therapy." "I can use holistic approaches like meditation to help my symptoms." "Many people have the same response to a stressful situation as I am having right” "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder” "I will probably need to be on medication for the rest of my life."
      A)
      "This diagnosis means that I am crazy."
      B)
      "I can learn to manage my thoughts better through therapy."
      C)
      "I can use holistic approaches like meditation to help my symptoms."
      D)
      "Many people have the same response to a stressful situation as I am having right”
      E)
      "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder”
      F)
      "I will probably need to be on medication for the rest of my life."
    4. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
      A)
      Cancer screening results, anger, gastritis, daily alcohol intake.
      B)
      Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
      C)
      Efforts to cut down, annoyance with questions, guilt, and drinking as an "Eye-opener."
      D)
      Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
    Page 5 of 10

    Exam Review

    1. An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?
      A)
      Vomiting, seizures, and loss of consciousness.
      B)
      Agitation, sweating, and abdominal cramps.
      C)
      Depression, fatigue, and dizziness.
      D)
      Hypotension, shallow respirations, and dilated pupils.
    2. A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
      A)
      Provide a supportive, structured environment for meals.
      B)
      Assess weight, vital signs, potassium, and other electrolytes.
      C)
      Discuss alternative strategies for binging and purging.
      D)
      Monitor the client after meals for possible vomiting.
    3. The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
      A)
      Explore changes in life that have occurred after the loss.
      B)
      Suggest the need for a psychiatric consultation.
      C)
      Offer a referral to pastoral counseling.
      D)
      Encourage attending a local support group.
    4. A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
      A)
      "I just feel like my life is filled with emptiness."
      B)
      "I have three firearms locked in a safe at home."
      C)
      "My daughter is the only reason I keep trying."
      D)
      "My panic attacks happen once every month."
    Page 6 of 10