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The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She
reports episodes of nausea and vomiting. Pregancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)?
Naegele''s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the
estimated date of delivery.
Question Number 2 of 20
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which
statement is true concerning long bone fractures in children?
The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern
The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in
either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious
because it can interrupt and alter growth
Question Number 3 of 20
A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are
important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20
minutes to go to the bathroom." Which of these is the best nursing diagnosis?
Question Number 4 of 20
The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?
The correct answer is B: Encourage the child to feed himself finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage
increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.
sease process
Question Number 5 of 20
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and
becomes disoriented when away from home. Which statement would provide the bestreality orientation for this client?
The correct answer is D: "Good morning. You’re in the hospital. I am your nurse Elaine Jones."
As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes
time, location and the caregivers name.
Question Number 6 of 20
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of
evaluation would best measure learning?
If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has
occurred. Additionally, physical assessments and lab data may confirm risk reduction.
Question Number 7 of 20
When teaching a 10 year-old child about their impending heart surgery, which form of explaination meets the
developmental needs of this age child?
The correct answer is D: Explain the surgery using a model of the heart
According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something
concrete, like a model will help the child understand the explanation of the heart surgery.
Question Number 8 of 20
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not
been following the prescribed diet. What would be the most appropriate nursing action?
The correct answer is C: Discuss diet with client to learn the reasons for not following the diet
When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting
findings to the health care provider, it is best to have a complete understanding of the client''s behavior and feelings as a
basis for future teaching and intervention.
Question Number 9 of 20
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant
until about 12 months of age?
Formula or breast milk are the perfect food and source of nutrients and liquids up until 1 year.
Question Number 10 of 20
The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child
to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?
Parents often blame themselves for their child''s illness. Feeling helpless and angry is normal and these feelings must be
accepted
Question Number 11 of 20
An appropriate goal for a client with anxiety would be to
Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn
self-help techniques will assist in learning to cope with anxiety
Question Number 12 of 20
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should
the nurse recommend?
Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-
operatively.
Question Number 13 of 20
When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?
Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the
preadolescent growth spurt. It is more common in females than in males
Question Number 14 of 20
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving
the unit for the operating room. What would be the most appropriate intervention by the nurse?
The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving
area
Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and
fosters the client''s sense of self-esteem and self-concept.
Question Number 15 of 20
When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the
children participating in?
Question Number 16 of 20
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following
assessments is appropriate for the nurse to perform?
Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the
basis of information given to the health care provider. The mass should not be palpated because of the risk of rupture.
Question Number 17 of 20
While the nurse is administering medications to a client, the client states "I do not want to take that medicine today."
Which of the following responses by the nurse would be best?
The correct answer is C: "Is there a reason why don''t you want to take your medicine?"
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to
ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should
try to discover the reason for the refusal which may be that the client has developed untoward side effects
Question Number 18 of 20
A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most
therapeutic?
The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that."
Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.
Question Number 19 of 20
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution
and crowding in southern California. The nurse explains that
The correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events
Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratifying unconscious wishes.
Question Number 20 of 20
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.