Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the

knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.
Question 1 Explanation:
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.
Question 2

CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by

nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal

movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2

CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4

CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.

When caring for a client with a central venous line, which of the following
nursing actions should be implemented in the plan of care for chemotherapy
administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.

The condition was caused by the student's competitive

C swimming schedule.
D The student will most likely require surgical intervention.
Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound

Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6

WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.

Assess for bladder distention and bowel impaction

Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia

Question 1
CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:

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.
Question 2

CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT

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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5

CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction

Administer antihypertensive medication

Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:

The probable signs of pregnancy include: -Uterine Enlargement

-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4

CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5

CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be long-

term venous access devices. Thus, difficulty drawing or aspirating

blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.
Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7
WRONG

Claudication is a well-known effect of peripheral vascular disease.

Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.

Home Practice Exams NCLEX Exam NCLEX- RN Practice Exam 4

NCLEX- RN Practice Exam 4

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Practice Mode Questions and choices are randomly arranged, the
answer is revealed instantly after each question, and there is no
time limit for the exam.
Question 1
CORRECT
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?

B
C

The student experiences pain in the inferior aspect of the

knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4

CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6

WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,

pounding headache. Which of the following nursing interventions

would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7
WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT

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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5

CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction

Administer antihypertensive medication

Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9
WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10

CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2

CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish

coloration of the mucous membranes of the cervix, vagina and

vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4

CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis

Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to

verify placement if the status is questionable and may require a

declotting regimen.
Question 6

WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.

It is characterized by pain that often occurs duing rest.

It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8
WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9
WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.

The child has a poor chance of recovery without joint

C deformity.

Most children progress to adult rheumatoid arthritis.

Question 9 Explanation:
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
Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11

CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia

D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12
CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.

No treatment is necessary; the fluid is reabsorbing

normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.

The student is trying to avoid participation in physical

B education.
The condition was caused by the student's competitive
C swimming schedule.
D The student will most likely require surgical intervention.
Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal

movement palpable by the examiners -Outline of the fetus via

radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6

WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,

pounding headache. Which of the following nursing interventions

would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7
WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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
Question 10

CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:

Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12
CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.

No treatment is necessary; the fluid is reabsorbing

normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13

WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.

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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.

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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.

Question 1

CORRECT

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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and

vulva. Occurs at week 6. -Ballottement or rebounding of the fetus

against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis

Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6

WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.

Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

C

Nonsteroidal anti-inflammatory drugs are the first choice

in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.

Question 9 Explanation:
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
Question 10

CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12

CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13
WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:

Raynaud's disease is most common in young women and is

frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14
WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.
Question 15
WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.

Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.
Question 16 Explanation:
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.
Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2

CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.

D Leg length disparity.

Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return

at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack

of control over the autonomic nervous system. The nurse should

immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7
WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8
WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.

Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.

C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12
CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing

normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13

WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14
WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.
Question 15

WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.
Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.
Question 16 Explanation:
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.
Question 17

CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18
CORRECT
The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:
Appropriate nursing diagnoses for clients with chronic renal failure
include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to

fatigue. The nursing diagnoses of impaired gas exchange and pain

are not commonly related to chronic renal failure.
Question 19

CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.
Question 19 Explanation:
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.
Thrombolytic therapy is frequently used in the treatment of suspected stroke.
Which of the following is a significant complication associated with
thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.

Question 1
CORRECT

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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and

vulva. Occurs at week 6. -Ballottement or rebounding of the fetus

against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis

Question 4 Explanation:
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.
Question 5
CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6

WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.

Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

C

Nonsteroidal anti-inflammatory drugs are the first choice

in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.

Question 9 Explanation:
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
Question 10

CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12

CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13
WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:

Raynaud's disease is most common in young women and is

frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14
WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.
Question 15
WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.

Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.
Question 16 Explanation:
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.
Question 17

CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18
CORRECT

The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:
Appropriate nursing diagnoses for clients with chronic renal failure
include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain
are not commonly related to chronic renal failure.
Question 19
CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.
Question 19 Explanation:
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.
Question 20

CORRECT
Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.

C Apply continuous passive motion machine during day.
Elevate head of bed 30 degrees before meals.
Question 20 Explanation:
It is specific in what to do and when.
Question 21
WRONG
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?
Each child has a 1 in 4 (25%) chance of developing the
disorder.
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.
Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
Sons only have a 1 in 4 (25%) chance of developing the
disorder.
Question 21 Explanation:
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.

Question 22
CORRECT
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which
information would the nurse expect to be included in the clients
history? Select all that apply.
Self-destructive behavior

B Ritualistic behavior
C psychomotor retardation
Impulsiveness
Lability of mood
Question 23

WRONG
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant complication
associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.
Question 24

CORRECT
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.
Parent support groups are helpful for sharing strategies
and managing health care issues.
Regular developmental screening is important to avoid
secondary developmental delays.
Developmental milestones may be slightly delayed but
usually will require no additional intervention
Cerebral palsy is caused by injury to the upper motor
neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
Question 24 Explanation:

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.
Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement

Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4

CORRECT

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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5

CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society

and hospital guidelines require frequent evaluation of blood return

when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.
Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.

A fan shouldnt be used because cold drafts may trigger autonomic

dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.

Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.

Question 11

CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12

CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13

WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14
WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.
Question 15
WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.
Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.
Question 16 Explanation:
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.
Question 17

CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18
CORRECT
The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:
Appropriate nursing diagnoses for clients with chronic renal failure
include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain
are not commonly related to chronic renal failure.
Question 19

CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.

Question 19 Explanation:
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.
Question 20

CORRECT
Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.
C Apply continuous passive motion machine during day.
Elevate head of bed 30 degrees before meals.
Question 20 Explanation:
It is specific in what to do and when.
Question 21

WRONG
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?
Each child has a 1 in 4 (25%) chance of developing the
disorder.
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.
Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
Sons only have a 1 in 4 (25%) chance of developing the
disorder.
Question 21 Explanation:
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.
Question 22
CORRECT
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which
information would the nurse expect to be included in the clients
history? Select all that apply.
Self-destructive behavior

B Ritualistic behavior
C psychomotor retardation
Impulsiveness
Lability of mood
Question 23
WRONG
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant complication
associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.
Question 24
CORRECT

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.
Parent support groups are helpful for sharing strategies
and managing health care issues.
Regular developmental screening is important to avoid
secondary developmental delays.
Developmental milestones may be slightly delayed but
usually will require no additional intervention
Cerebral palsy is caused by injury to the upper motor
neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
Question 24 Explanation:
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.

Question 25
CORRECT
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?
The tumor has spread into the abdominal cavity and
cannot be resected.
The tumor extended beyond the kidney but was
completely resected.
The tumor is less than 3 cm. in size and requires no
chemotherapy.
The tumor did not extend beyond the kidney and was
completely resected.
Question 25 Explanation:
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.

C
D

Question 26

CORRECT
A nurse is providing discharge information to a patient with peripheral vascular
disease. Which of the following information should be included in instructions?
Use antibacterial ointment to treat skin lesions at risk of
infection.
Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.
Question 26 Explanation:
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.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2

CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3
CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5
CORRECT

When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing

Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7
WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8
WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks

Place the client in good body alignment

Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12
CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13
WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14

WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem

C Unemployment
Single status
Question 14 Explanation:
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.
Question 15

WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.
Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.

Question 16 Explanation:
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.
Question 17
CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18

CORRECT
The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:

Appropriate nursing diagnoses for clients with chronic renal failure

include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain
are not commonly related to chronic renal failure.
Question 19

CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.
Question 19 Explanation:
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.
Question 20
CORRECT
Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.
C Apply continuous passive motion machine during day.
Elevate head of bed 30 degrees before meals.
Question 20 Explanation:
It is specific in what to do and when.
Question 21
WRONG
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?
Each child has a 1 in 4 (25%) chance of developing the
disorder.
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.
Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
Sons only have a 1 in 4 (25%) chance of developing the
disorder.
Question 21 Explanation:
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.

Question 22

CORRECT
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which
information would the nurse expect to be included in the clients
history? Select all that apply.
Self-destructive behavior

B Ritualistic behavior
C psychomotor retardation
Impulsiveness
Lability of mood
Question 23

WRONG
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant complication
associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.
Question 24
CORRECT
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.
Parent support groups are helpful for sharing strategies
and managing health care issues.
Regular developmental screening is important to avoid
secondary developmental delays.
Developmental milestones may be slightly delayed but
usually will require no additional intervention
Cerebral palsy is caused by injury to the upper motor
neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
Question 24 Explanation:
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.

Question 25

CORRECT
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?

The tumor has spread into the abdominal cavity and

A cannot be resected.

The tumor extended beyond the kidney but was

completely resected.
The tumor is less than 3 cm. in size and requires no
chemotherapy.
The tumor did not extend beyond the kidney and was
completely resected.
Question 25 Explanation:
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.

C
D

Question 26

CORRECT
A nurse is providing discharge information to a patient with
peripheral vascular disease. Which of the following information
should be included in instructions?
Use antibacterial ointment to treat skin lesions at risk of
infection.
Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.
Question 26 Explanation:
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.
Question 27
WRONG

The nurse is evaluating the discharge teaching for a client who has
an ileal conduit. Which of the following statements indicates that the
client has correctly understood the teaching? Select all that apply.
I can usually keep my ostomy pouch on for 3 to 7 days
before changing it.
I should empty my ostomy pouch of urine when it is full.
I can place an aspirin tablet in my pouch to decrease
odor.
If I limit my fluid intake I will not have to empty my
ostomy pouch as often.
I must use a skin barrier to protect my skin from urine.
Question 27 Explanation:
The client with an ileal conduit must learn self-care activities related
to care of the stoma and ostomy appliances. The client should be
taught to increase fluid intake to about 3,000 ml per day and should
not limit intake. Adequate fluid intake helps to flush mucus from the
ileal conduit. The ostomy appliance should be changed
approximately every 3 to 7 days and whenever a leak develops.

C
D

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions
Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT
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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5
CORRECT

When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society
and hospital guidelines require frequent evaluation of blood return
when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.

Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing

Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.
A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
Question 7
WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8
WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks

Place the client in good body alignment

Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.
Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.
Question 11
CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12
CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13
WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14

WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem

C Unemployment
Single status
Question 14 Explanation:
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.
Question 15

WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.
Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.

Question 16 Explanation:
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.
Question 17
CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18

CORRECT
The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:

Appropriate nursing diagnoses for clients with chronic renal failure

include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain
are not commonly related to chronic renal failure.
Question 19

CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.
Question 19 Explanation:
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.
Question 20
CORRECT
Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.
C Apply continuous passive motion machine during day.
Elevate head of bed 30 degrees before meals.
Question 20 Explanation:
It is specific in what to do and when.
Question 21
WRONG
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?
Each child has a 1 in 4 (25%) chance of developing the
disorder.
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.
Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
Sons only have a 1 in 4 (25%) chance of developing the
disorder.
Question 21 Explanation:
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.

Question 22

CORRECT
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which
information would the nurse expect to be included in the clients
history? Select all that apply.
Self-destructive behavior

B Ritualistic behavior
C psychomotor retardation
Impulsiveness
Lability of mood
Question 23

WRONG
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant complication
associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.
Question 24
CORRECT
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.
Parent support groups are helpful for sharing strategies
and managing health care issues.
Regular developmental screening is important to avoid
secondary developmental delays.
Developmental milestones may be slightly delayed but
usually will require no additional intervention
Cerebral palsy is caused by injury to the upper motor
neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
Question 24 Explanation:
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.

Question 25

CORRECT
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?

The tumor has spread into the abdominal cavity and

A cannot be resected.

The tumor extended beyond the kidney but was

completely resected.
The tumor is less than 3 cm. in size and requires no
chemotherapy.
The tumor did not extend beyond the kidney and was
completely resected.
Question 25 Explanation:
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.

C
D

Question 26

CORRECT
A nurse is providing discharge information to a patient with
peripheral vascular disease. Which of the following information
should be included in instructions?
Use antibacterial ointment to treat skin lesions at risk of
infection.
Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.
Question 26 Explanation:
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.
Question 27
WRONG

The nurse is evaluating the discharge teaching for a client who has
an ileal conduit. Which of the following statements indicates that the
client has correctly understood the teaching? Select all that apply.
I can usually keep my ostomy pouch on for 3 to 7 days
before changing it.
I should empty my ostomy pouch of urine when it is full.
I can place an aspirin tablet in my pouch to decrease
odor.
If I limit my fluid intake I will not have to empty my
ostomy pouch as often.
I must use a skin barrier to protect my skin from urine.
Question 27 Explanation:
The client with an ileal conduit must learn self-care activities related
to care of the stoma and ostomy appliances. The client should be
taught to increase fluid intake to about 3,000 ml per day and should
not limit intake. Adequate fluid intake helps to flush mucus from the
ileal conduit. The ostomy appliance should be changed
approximately every 3 to 7 days and whenever a leak develops. A
skin barrier is essential to protecting the skin from the irritation of
the urine. An aspirin should not be used as a method of odor control
because it can be an irritant to the stoma and lead to ulceration. The
ostomy pouch should be emptied when it is one-third to one-half full
to prevent the weight from pulling the appliance away from the skin.

C
D

Question 28
WRONG
When assessing a client diagnosed with impulse control disorder,
the nurse observes violent, aggressive, and assaultive behavior.
Which of the following assessment data is the nurse also likely to
find? Select all that apply.
The client has no remorse about the inability to control his
anger.
The client has a history of parental alcoholism and chaotic,
abusive family life.
The degree of aggressiveness is out of proportion to the
stressor.

D The violent behavior is most often justified by the stressor.

The client functions well in other areas of his life.
Question 28 Explanation:

A client with an impulse control disorder who displays violent,

aggressive, and assaultive behavior generally functions well in other
areas of his life. The degree of aggressiveness is typically out of
proportion with the stressor. Such a client commonly has a history of
parental alcoholism and a chaotic family life, and often verbalizes
sincere remorse and guilt for the aggressive behavior.

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions

Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT

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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5

CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society

and hospital guidelines require frequent evaluation of blood return

when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.
Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.

A fan shouldnt be used because cold drafts may trigger autonomic

dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.

Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.

Question 11

CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12

CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13

WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14
WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.
Question 15
WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.
Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.
Question 16 Explanation:
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.
Question 17

CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18
CORRECT
The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:
Appropriate nursing diagnoses for clients with chronic renal failure
include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain
are not commonly related to chronic renal failure.
Question 19

CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.

Question 19 Explanation:
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.
Question 20

CORRECT
Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.
C Apply continuous passive motion machine during day.
Elevate head of bed 30 degrees before meals.
Question 20 Explanation:
It is specific in what to do and when.
Question 21

WRONG
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?
Each child has a 1 in 4 (25%) chance of developing the
disorder.
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.
Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
Sons only have a 1 in 4 (25%) chance of developing the
disorder.
Question 21 Explanation:
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.
Question 22
CORRECT
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which
information would the nurse expect to be included in the clients
history? Select all that apply.
Self-destructive behavior

B Ritualistic behavior
C psychomotor retardation
Impulsiveness
Lability of mood
Question 23
WRONG
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant complication
associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.
Question 24
CORRECT

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.
Parent support groups are helpful for sharing strategies
and managing health care issues.
Regular developmental screening is important to avoid
secondary developmental delays.
Developmental milestones may be slightly delayed but
usually will require no additional intervention
Cerebral palsy is caused by injury to the upper motor
neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
Question 24 Explanation:
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.

Question 25
CORRECT
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?
The tumor has spread into the abdominal cavity and
cannot be resected.
The tumor extended beyond the kidney but was
completely resected.
The tumor is less than 3 cm. in size and requires no
chemotherapy.
The tumor did not extend beyond the kidney and was
completely resected.
Question 25 Explanation:
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.

C
D

Question 26

CORRECT
A nurse is providing discharge information to a patient with
peripheral vascular disease. Which of the following information
should be included in instructions?
Use antibacterial ointment to treat skin lesions at risk of
infection.
Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.
Question 26 Explanation:
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.
Question 27
WRONG
The nurse is evaluating the discharge teaching for a client who has
an ileal conduit. Which of the following statements indicates that the
client has correctly understood the teaching? Select all that apply.
I can usually keep my ostomy pouch on for 3 to 7 days
before changing it.
I should empty my ostomy pouch of urine when it is full.
I can place an aspirin tablet in my pouch to decrease
odor.
If I limit my fluid intake I will not have to empty my
ostomy pouch as often.
I must use a skin barrier to protect my skin from urine.
Question 27 Explanation:
The client with an ileal conduit must learn self-care activities related
to care of the stoma and ostomy appliances. The client should be
taught to increase fluid intake to about 3,000 ml per day and should
not limit intake. Adequate fluid intake helps to flush mucus from the
ileal conduit. The ostomy appliance should be changed
approximately every 3 to 7 days and whenever a leak develops. A
skin barrier is essential to protecting the skin from the irritation of

C
D

the urine. An aspirin should not be used as a method of odor control

because it can be an irritant to the stoma and lead to ulceration. The
ostomy pouch should be emptied when it is one-third to one-half full
to prevent the weight from pulling the appliance away from the skin.
Question 28

WRONG
When assessing a client diagnosed with impulse control disorder,
the nurse observes violent, aggressive, and assaultive behavior.
Which of the following assessment data is the nurse also likely to
find? Select all that apply.
The client has no remorse about the inability to control his
anger.
The client has a history of parental alcoholism and chaotic,
abusive family life.
The degree of aggressiveness is out of proportion to the
stressor.

D The violent behavior is most often justified by the stressor.

The client functions well in other areas of his life.
Question 28 Explanation:
A client with an impulse control disorder who displays violent,
aggressive, and assaultive behavior generally functions well in other
areas of his life. The degree of aggressiveness is typically out of
proportion with the stressor. Such a client commonly has a history of
parental alcoholism and a chaotic family life, and often verbalizes
sincere remorse and guilt for the aggressive behavior.
Question 29

CORRECT
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 radius.

Possible fracture of the tibia.

C Bruising of the gastrocnemius muscle.

No anatomic injury, the child wants his mother to carry
D him.

Question 29 Explanation:
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

Question 1

CORRECT
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?
The student experiences pain in the inferior aspect of the
knee.
The student is trying to avoid participation in physical
education.
The condition was caused by the student's competitive
swimming schedule.

B
C
D The student will most likely require surgical intervention.

Question 1 Explanation:
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.
Question 2
CORRECT
A nurse is assisting in performing an assessment on a client who
suspects that she is pregnant and is checking the client for probable
signs of pregnancy. Select all probable signs of pregnancy.
Chadwicks sign

B Fetal heart rate detected by nonelectric device

Braxton Hicks contractions

Uterine enlargement
Ballottement

Outline of the fetus via radiography or ultrasound

Question 2 Explanation:
The probable signs of pregnancy include: -Uterine Enlargement
-Hegars sign or softening and thinning of the uterine segment that
occurs at week 6. -Goodells sign or softening of the cervix that
occurs at the beginning of the 2nd month -Chadwicks sign or bluish
coloration of the mucous membranes of the cervix, vagina and
vulva. Occurs at week 6. -Ballottement or rebounding of the fetus
against the examiners fingers of palpation -Braxton-Hicks
contractions -Positive pregnancy test measuring for hCG. Positive
signs of pregnancy include: -Fetal Heart Rate detected by electronic
device (doppler) at 10-12 weeks -Fetal Heart rate detected by
nonelectronic device (fetoscope) at 20 weeks AOG -Active fetal
movement palpable by the examiners -Outline of the fetus via
radiography or ultrasound
Question 3

CORRECT
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 Hypostatic blood pressure.

Scoliosis

C Spinal flexibility.
D Leg length disparity.
Question 3 Explanation:
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. Other choices are not part of the routine
adolescent exam.
Question 4
CORRECT

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 Congestive heart failure due to fluid overload.

Pulmonary embolism due to deep vein thrombosis (DVT)

C Anxiety attack due to worries about her baby's health

D Myocardial infarction due to a history of atherosclerosis
Question 4 Explanation:
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.
Question 5

CORRECT
When caring for a client with a central venous line, which of the
following nursing actions should be implemented in the plan of care
for chemotherapy administration?Select all that apply.
Verify patency of the line by the presence of a blood return
at regular intervals.
Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or
drainage.
If unable to aspirate blood, reposition the client and
encourage the client to cough.
Contact the health care provider about verifying
placement if the status is questionable.
Question 5 Explanation:
A major concern with intravenous administration of cytotoxic agents
is vessel irritation or extravasation. The Oncology Nursing Society

and hospital guidelines require frequent evaluation of blood return

when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and
central venous lines. In addition, central venous lines may be longterm venous access devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the vessel wall or may indicate
the line has occlusion. Having the client cough or move position may
change the status of the line if it is temporarily against a vessel wall.
Occlusion warrants more thorough evaluation via x-ray study to
verify placement if the status is questionable and may require a
declotting regimen.
Question 6
WRONG
The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above
the T5, and a blood pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
Assess for bladder distention and bowel impaction
Administer antihypertensive medication
Place the client in a supine position with legs elevated
Elevate the HOB to 90 degrees
Use a fan to reduce diaphoresis
Loosen constrictive clothing
Question 6 Explanation:
The client has signs and symptoms of autonomic dysreflexia. The
potentially life-threatening condition is caused by an uninhibited
response from the sympathetic nervous system resulting from a lack
of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities
dependently to decrease venous return to the heart and increase
venous return from the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive clothing should be loosened.
The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke,
MI, or seizures. If removing the triggering event doesnt reduce the
clients blood pressure, IV antihypertensives should be administered.

A fan shouldnt be used because cold drafts may trigger autonomic

dysreflexia.
Question 7

WRONG
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? (Choose 3
answers)
It is a result of tissue hypoxia.
It is characterized by cramping and weakness.
It is characterized by pain that often occurs duing rest.
It results when oxygen demand is greater than oxygen
supply.
Question 7 Explanation:
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.
Question 8

WRONG
The nurse is monitoring a client receiving peritoneal dialysis and
nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take. (Select all that apply.)
Check the peritoneal dialysis system for kinks
Place the client in good body alignment
Contact the physician
Check the level of the drainage bag
Reposition the client to his or her side.
Question 8 Explanation:
If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the clients position. Turning the client to the
other side or making sure that the client is in good body alignment
may assist with outflow drainage. The drainage bag needs to be
lower than the clients abdomen to enhance gravity drainage. The
connecting tubing and the peritoneal dialysis system is also checked
for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the
physician.

Question 9

WRONG
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 Physical activity should be minimized.

Nonsteroidal anti-inflammatory drugs are the first choice
in treatment.
The child has a poor chance of recovery without joint
deformity.
Most children progress to adult rheumatoid arthritis.
Question 9 Explanation:
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

Question 10
CORRECT
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 Fluid overload leading to compression of nerve tissue.

B Inflammation of the skin on the hands and feet.
C Sensation distortion due to psychiatric disturbance.
Inadequate tissue perfusion leading to nerve damage.
Question 10 Explanation:
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.

Question 11

CORRECT
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate?Select all that apply.
Head tilt
Vomiting

C Polydipsia
D Increased pulse
Lethargy

Increased appetite

Question 11 Explanation:
Head tilt, vomiting, and lethargy are classic signs assessed in a child
with a brain tumor. Clinical manifestations are the result of location
and size of the tumor.
Question 12

CORRECT
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 Referral to a surgeon for repair.

Keeping the infant in a flat, supine position until the fluid is
B gone.
No treatment is necessary; the fluid is reabsorbing
normally.
Massaging the groin area twice a day until the fluid is
gone.
Question 12 Explanation:
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.

Question 13

WRONG
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?
An elderly woman.
A young woman.

C An adolescent male.
D An elderly man.
Question 13 Explanation:
Raynaud's disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis.
Question 14
WRONG
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?
Self-blame for the injury to the child.

B Low self-esteem
C Unemployment
Single status
Question 14 Explanation:
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.
Question 15
WRONG
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 complete blood count with differential is drawn.

B The parents arrive.

C The admission orders are written.
A blood culture is drawn.
Question 15 Explanation:
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.
Question 16

WRONG
Which of the following conditions most commonly causes acute
glomerulonephritis?
Viral infection of the glomeruli.

B A congenital condition leading to renal dysfunction.

Prior infection with group A Streptococcus within the past
10-14 days.

D Nephrotic syndrome.
Question 16 Explanation:
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.
Question 17

CORRECT
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 Smoking
B Age
Family history of heart disease.

D Overweight
Question 17 Explanation:
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
Question 18
CORRECT
The nurse is caring for a hospitalized client who has chronic renal
failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

A Pain.
B Impaired Gas Exchange
Activity Intolerance
Imbalanced Nutrition; Less than Body Requirements
Excess Fluid Volume
Question 18 Explanation:
Appropriate nursing diagnoses for clients with chronic renal failure
include excess fluid volume related to fluid and sodium retention;
imbalanced nutrition, less than body requirements related to
anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain
are not commonly related to chronic renal failure.
Question 19

CORRECT
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. (Choose 3 answer)
Urine specific gravity of 1.040

B Generalized edema
Brown ("tea-colored") urine
Urine output of 350 ml in 24 hours.

Question 19 Explanation:
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.
Question 20

CORRECT
Which of the following nursing interventions are written correctly?

A Change dressing once a shift.

B Perform neurovascular checks.
C Apply continuous passive motion machine during day.
Elevate head of bed 30 degrees before meals.
Question 20 Explanation:
It is specific in what to do and when.
Question 21

WRONG
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?
Each child has a 1 in 4 (25%) chance of developing the
disorder.
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.
Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
Sons only have a 1 in 4 (25%) chance of developing the
disorder.
Question 21 Explanation:
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.
Question 22
CORRECT
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which
information would the nurse expect to be included in the clients
history? Select all that apply.
Self-destructive behavior

B Ritualistic behavior
C psychomotor retardation
Impulsiveness
Lability of mood
Question 23
WRONG
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant complication
associated with thrombolytic therapy?

A Expansion of the clot

B Air embolus.
Cerebral hemorrhage
Resolution of the clot
Question 23 Explanation:
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.
Question 24
CORRECT

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.
Parent support groups are helpful for sharing strategies
and managing health care issues.
Regular developmental screening is important to avoid
secondary developmental delays.
Developmental milestones may be slightly delayed but
usually will require no additional intervention
Cerebral palsy is caused by injury to the upper motor
neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
Question 24 Explanation:
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.

Question 25
CORRECT
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?
The tumor has spread into the abdominal cavity and
cannot be resected.
The tumor extended beyond the kidney but was
completely resected.
The tumor is less than 3 cm. in size and requires no
chemotherapy.
The tumor did not extend beyond the kidney and was
completely resected.
Question 25 Explanation:
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.

C
D

Question 26

CORRECT
A nurse is providing discharge information to a patient with
peripheral vascular disease. Which of the following information
should be included in instructions?
Use antibacterial ointment to treat skin lesions at risk of
infection.
Avoid crossing the legs

C Walk barefoot whenever possible.

D Use a heating pad to keep feet warm.
Question 26 Explanation:
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.
Question 27
WRONG
The nurse is evaluating the discharge teaching for a client who has
an ileal conduit. Which of the following statements indicates that the
client has correctly understood the teaching? Select all that apply.
I can usually keep my ostomy pouch on for 3 to 7 days
before changing it.
I should empty my ostomy pouch of urine when it is full.
I can place an aspirin tablet in my pouch to decrease
odor.
If I limit my fluid intake I will not have to empty my
ostomy pouch as often.
I must use a skin barrier to protect my skin from urine.
Question 27 Explanation:
The client with an ileal conduit must learn self-care activities related
to care of the stoma and ostomy appliances. The client should be
taught to increase fluid intake to about 3,000 ml per day and should
not limit intake. Adequate fluid intake helps to flush mucus from the
ileal conduit. The ostomy appliance should be changed
approximately every 3 to 7 days and whenever a leak develops. A
skin barrier is essential to protecting the skin from the irritation of

C
D

the urine. An aspirin should not be used as a method of odor control

because it can be an irritant to the stoma and lead to ulceration. The
ostomy pouch should be emptied when it is one-third to one-half full
to prevent the weight from pulling the appliance away from the skin.
Question 28

WRONG
When assessing a client diagnosed with impulse control disorder,
the nurse observes violent, aggressive, and assaultive behavior.
Which of the following assessment data is the nurse also likely to
find? Select all that apply.
The client has no remorse about the inability to control his
anger.
The client has a history of parental alcoholism and chaotic,
abusive family life.
The degree of aggressiveness is out of proportion to the
stressor.

D The violent behavior is most often justified by the stressor.

The client functions well in other areas of his life.
Question 28 Explanation:
A client with an impulse control disorder who displays violent,
aggressive, and assaultive behavior generally functions well in other
areas of his life. The degree of aggressiveness is typically out of
proportion with the stressor. Such a client commonly has a history of
parental alcoholism and a chaotic family life, and often verbalizes
sincere remorse and guilt for the aggressive behavior.
Question 29

CORRECT
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 radius.

Possible fracture of the tibia.

C Bruising of the gastrocnemius muscle.

No anatomic injury, the child wants his mother to carry
D him.

Question 29 Explanation:
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.
Question 30

CORRECT
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 Hydrocephalus, with increased head size

B Plagiocephaly, with flattening of one side of the head.
Craniosynostosis, with premature closure of the cranial
C sutures.

Torticollis, with shortening of the sternocleidomastoid

muscle.
Question 30 Explanation:
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.