FULL-TEXT: Select All That Apply NCLEX Practice Quiz (100 Questions)


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Select All That Apply NCLEX Practice #1


A patient is admitted to the same-day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. 

  • A. Partial thromboplastin time.
  • B. Prothrombin time.
  • C. Platelet count.
  • D. Hemoglobin
  • E. Complete Blood Count
  • F. White Blood Cell Count

Correct Answer: A, B, and C.

Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

  • Option A: Partial thromboplastin time (PTT) is the time it takes for a patient’s blood to form a clot as measured in seconds. It is used to measure the activity of the intrinsic pathway of the clotting cascade. PTT tests the function of all clotting factors except factor VII (tissue factor) and factor XIII (fibrin stabilizing factor).
  • Option B: Prothrombin time (PT) is one of several blood tests routinely used in clinical practice to evaluate the coagulation status of patients. More specifically, PT is used to evaluate the extrinsic and common pathways of coagulation, which would detect deficiencies of factors II, V, VII, and X, and low fibrinogen concentrations.
  • Option C: Platelet count is being assessed to determine the number of platelets in a sample of the blood as part of a health exam; to screen for, diagnose, or monitor conditions that affect the number of platelets, such as a bleeding disorder, a bone marrow disease, or other underlying conditions.
  • Option D: Hemoglobin is used to evaluate the hemoglobin content of your blood as part of a general health checkup; to screen for and help diagnose conditions that affect red blood cells (RBCs); if there is anemia (low hemoglobin) or polycythemia (high hemoglobin), and to assess the severity of these conditions and to monitor response to treatment.
  • Option E: The complete blood count (CBC) is a group of tests that evaluate the cells that circulate in blood, including red blood cells (RBCs), white blood cells (WBCs), and platelets (PLTs). The CBC can evaluate your overall health and detect a variety of diseases and conditions, such as infections, anemia and leukemia.
  • Option F: WBC count is used to screen for or diagnose a variety of conditions that can affect the number of white blood cells (WBCs), such as an infection, inflammation or a disease that affects WBCs; to monitor treatment of a disorder or to monitor therapy that is known to affect WBCs.


A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. 

  • A. Weight loss.
  • B. Prolonged clotting time.
  • C. Hypertension.
  • D. Headaches.
  • E. Polyphagia.
  • F. Pruritus.

Correct Answer: B, C, D, and F.

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Bleeding is also a complication, possibly because the platelets are often very large and somewhat dysfunctional. The bleeding can be significant and can occur in the form of nosebleeds, ulcers, frank GI bleeding, hematuria, and intracranial hemorrhage.

  • Option A: Weight loss is not a manifestation of polycythemia vera. Weight loss may result from early satiety or from the increased myeloproliferative activity of the abnormal clone.
  • Option B: Patients with polycythemia vera are at increased risk for thrombosis that may result in CVAs (strokes, brain attacks) or myocardial infarctions (MIs); thrombotic complications are the most common cause of death.
  • Option C: Cardiovascular effects include increased blood pressure and delayed clotting time. Thrombotic complications (1%) include venous thrombosis or thromboembolism and an increased prevalence of stroke and other arterial thrombosis.
  • Option D: Physical complaints can include fatigue, headache, dizziness, tinnitus, vision changes, insomnia, claudication, pruritus, gastritis, and early satiety. Subsequent sludging of blood flow and thrombosis lead to poor oxygen delivery, with symptoms that include headache.
  • Option E: Early satiety can occur in patients with splenomegaly, because of gastric filling being impaired by the enlarged spleen or, rarely, as a symptom of splenic infarction.
  • Option F: Generalized pruritus is caused by histamine release due to an increased number of basophils. Aquagenic pruritus, which occurs during or after a hot shower, is a complaint in 40% of patients. The mechanism is likely from mast cell and basophil degranulation, causing a histamine surge.


The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.

  • A. The inhaler is held upright.
  • B. Head is tilted down while inhaling the medication.
  • C. Client waits 5 minutes between puffs.
  • D. Mouth is rinsed with water following administration.
  • E. Client lies supine for 15 minutes following administration.

Correct Answer: A & D.

In using a corticosteroid MDI, remove the cap and hold the inhaler upright, stand or sit up straight, shake the inhaler, tilt your head back slightly, put the inhaler in the mouth, press down on the inhaler quickly, breathe in slowly for 3 to 5 seconds, hold the breath for 10 seconds, breathe out slowly, repeat puffs as prescribed, rinse the mouth, and gargle using water or mouthwash after each use.

  • Option A: Keep the chin up and the inhaler upright (not aimed at the roof of the mouth or the tongue). Use a spacer/valve-holding chamber (the best way, useful for all patients) by putting the inhaler into the end with the hole and the mouthpiece end in the mouth. If there is no spacer, hold the inhaler 1 to 2 inches (or two-finger widths) in front of an open mouth.
  • Option B: Head is tilted up during inhalation of the medication. Start breathing in slowly through the mouth and press down on the inhaler one time. If using a spacer or valved-holding chamber, press down on the inhaler before starting to breathe in. Breathe in slowly.
  • Option C: For inhaled quick-relief medicine (like albuterol), wait about 1 minute between puffs. There is no need to wait between puffs for other medicines.
  • Option D: If the client is using this inhaler for a corticosteroid preventer medication, with or without a spacer, rinse the mouth with water and spit after inhaling the last dose to reduce the risk of side effects.
  • Option E: There is no need to lie supine after administration of the medication. If more than one dose is needed, repeat all the steps.


The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply.

  • A. Hearing loss
  • B. Visual disturbance
  • C. Headache
  • D. Orthopnea
  • E. Gout
  • F. Weight loss

Correct Answer: B, C, D, & E.

Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension

  • Option A: Hearing loss is not a manifestation associated with polycythemia vera. Polycythemia vera-related complications and mortality are related to thrombosis, hemorrhage, peptic ulcer disease, myelofibrosis, acute leukemia, or myelodysplastic syndrome (MDS).
  • Option B: Since red blood cells are overproduced in the marrow, this leads to abnormally high numbers of circulating red blood cells (red blood mass) within the blood. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head.
  • Option C: Thick blood can lead to strokes or tissue and organ damage. Symptoms include lack of energy (fatigue) or weakness, headaches, dizziness, shortness of breath, visual disturbances, nose bleeds, bleeding gums, heavy menstrual periods, and bruising.
  • Option D: The blood thickens and increases in volume, a condition called hyperviscosity. Thickened blood may not flow through smaller blood vessels properly. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time.
  • Option E: There are also symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Gout and kidney stones associated with polycythemia vera occur due to the high turnover of red blood cells, which results in higher-than-normal uric acid production.
  • Option F: Weight loss is not a manifestation associated with polycythemia vera. Weight loss may result from early satiety or from the increased myeloproliferative activity of the abnormal clone.


Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.

  • A. Auscultation of breath sounds
  • B. Auscultation of bowel sounds
  • C. Presence of chest pain.
  • D. Presence of peripheral edema
  • E. Color of nail beds

Correct Answer: A, C, & E.

Physical findings also vary from patient to patient and mainly depend on the severity of lung consolidation, the type of organism, the extent of the infection, host factors, and the existence or nonexistence of pleural effusion.

  • Option A: A respiratory assessment, which includes auscultation of breath sounds is a priority for clients with pneumonia. Low-pitched wheezing (rhonchi) may indicate pneumonia.
  • Option B: Auscultating bowel sounds may be an appropriate assessment, but this is not a priority assessment for the patient with pneumonia. Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileus. Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.
  • Option C: Assessing the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Grimaces or other expressions of discomfort occurring at the same point in each ventilatory cycle should influence the examiner to identify the origin of that discomfort more precisely.
  • Option D: Assessing for peripheral edema may be an appropriate assessment, but this is not a priority assessment for the patient with pneumonia.
  • Option E: Cyanosis is an indication of decreased perfusion and oxygenation. Alterations and bilateral inconsistencies in color may indicate underlying conditions or injury. With hypoxemia, cyanosis of the extremities or around the mouth may be noted.


The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse’s instructions? Select all that apply.

  • A. “I will need to dispose of my old clothing when I return home.”
  • B. “I should always cover my mouth and nose when sneezing.”
  • C. “It is important that I isolate myself from family when possible.”
  • D. “I should use paper tissues to cough in and dispose of them properly.”
  • E. “I can use a regular plate and utensils whenever I eat.”

Correct Answer: B, C, D, & E.

To avoid the spread of the disease, the client diagnosed with tuberculosis should take all the medicines as they’re prescribed and comply with all the doctor’s appointments. Self-isolation should always be strictly followed and also stop yourself from using public transportation.

  • Option A: TB is not spread by sharing glasses, plates, utensils, clothing, sheets, furniture or toilets. These items do not need any special cleaning. TB is not spread by direct physical contact, such as shaking hands, kissing or sex. TB is spread through the air when a person with active TB disease in their lungs coughs, sneezes, sings or talks.
  • Option B: Covering the mouth and nose with a tissue when sneezing is also very important. Hand washing should always be observed right after sneezing or coughing. Inhaling the aerosolized droplets from an infected person is the principal mechanism through which tuberculosis spreads.
  • Option C: Home isolation is when a person must stay at home because they have a contagious disease such as TB. The amount of time needed for home isolation is different for each person. Do not have visitors, especially children and people with weak immune systems. Do not use buses, trains, taxis or airplanes.
  • Option D: Used paper tissues should be disposed of properly. The organism is spread primarily as an airborne aerosol from an individual in the infectious stage of the disease, although transdermal and gastrointestinal (GI) transmission is also possible.
  • Option E: One can only get infected by breathing in TB germs that a person coughs into the air. You cannot get TB from someone’s clothes, drinking glass, eating utensils, handshake, toilet, or other surfaces where a TB patient has been.

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The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply.

  • A. Thirst
  • B. Palpitations
  • C. Diaphoresis
  • D. Slurred speech
  • E. Hyperventilation

Correct Answer: Answer: B, C, & D.

Hypoglycemia is often defined by a plasma glucose concentration below 70 mg/dL; however, signs and symptoms may not occur until plasma glucose concentrations drop below 55 mg/dL. In patients who do not have diabetes, hypoglycemia is uncommon, but when it occurs, there are a few major causes of hypoglycemia: pharmacologic, alcohol, critical illness, counter-regulatory hormone deficiencies, and non-islet cell tumors.

  • Option A: Neurogenic signs and symptoms can either be adrenergic (tremor, palpitations, anxiety) or cholinergic (hunger, diaphoresis, paresthesias). Neurogenic symptoms and signs arise from sympathoadrenal involvement (either norepinephrine or acetylcholine release) in response to perceived hypoglycemia. 
  • Option B: Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response.
  • Option C: Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Low blood sugars can affect activity in the autonomic nervous system (ANS), which is responsible for reactions that people cannot control, such as sweating and digestion.
  • Option D: Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed. These are often called the “warning signs” of hypoglycemia. Lack of glucose to the brain can cause trouble concentrating, changes in vision, slurred speech, lack of coordination, headaches, dizziness and drowsiness.
  • Option E: Ketones are cleared out of the body by the kidneys and expelled through urine. In DKA, ketones build up faster than the kidneys can remove them from the body. This results in a buildup of ketones, which is toxic. The body may try to use the lungs to expel the excess ketones, which causes shortness of breath.


Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply:

  • A. Sweating
  • B. Low PCO2
  • C. Retinopathy
  • D. Acetone breath
  • E. Elevated serum bicarbonate

Correct Answer: B and D.

Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.

  • Option A: Sweating is usually a symptom of hypoglycemia. In diabetic ketoacidosis, insulin deficiency and increased counter-regulatory hormones can lead to increased gluconeogenesis, accelerated glycogenolysis, and impaired glucose utilization. This will ultimately cause worsening hyperglycemia.
  • Option B: The decreased pCO2 that results from this increased respiration returns the pH towards normal but may not be sufficient to achieve a normal pH.
  • Option C: Diabetic retinopathy (DR) is a microvascular disorder occurring due to long term effects of diabetes, leading to vision-threatening damage to the retina, eventually leading to blindness. Uncontrolled diabetes can lead to many ocular disorders like cataract, glaucoma, ocular surface disorders, recurrent stye, non-arteritic anterior ischemic optic neuropathy, diabetic papillopathy, and diabetic retinopathy, out of which diabetic retinopathy is the most common and severe ocular complication.
  • Option D: Patients are often ill-appearing. Kussmaul breathing, which is labored, deep, and tachypneic, may occur. Some providers may appreciate a fruity scent to the patient’s breath, indicative of the presence of acetone.
  • Option E: Acidosis in DKA is due to the overproduction of β-hydroxybutyric acid and acetoacetic acid. At physiological pH, these 2 keto acids dissociate completely, and the excess hydrogen ions bind the bicarbonate, resulting in decreased serum bicarbonate levels.


When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply.

  • A. Assessing the client’s bowel sounds
  • B. Providing skin care following bowel movements
  • C. Evaluating the client’s response to antidiarrheal medications
  • D. Maintaining intake and output records
  • E. Obtaining the client’s weight

Correct Answer: Answer: B, D, and E.

Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment and professional knowledge.

  • Option A: Don’t delegate tasks that require specialized knowledge or complex observations, such as monitoring a patient with chest pain. Even experienced UAP aren’t educationally prepared or licensed to perform such complex tasks.
  • Option B: Examples of tasks which may be assigned include, but are not limited to: clean catheterization technique; simple dressing changes (i.e., clean technique where wound assessment is performed by a licensed nurse and where no wound debridement or packing is involved); suction of chronic tracheostomies (i.e., using clean technique); gastrostomy feedings in established, wound-healed gastrostomies.
  • Option C: As a general rule, don’t delegate the assessment, planning, and evaluation steps of the nursing process. Most nurse practice acts specifically prohibit nurses from delegating initial patient assessments, discharge planning, health education, care planning, triage, and interpretation of assessment data.
  • Option D: A delegatable task is one that doesn’t require nursing judgment. Typically, it’s repetitive—for instance, measuring urine output and vital signs. UAP, licensed practical nurses (LPNs), and licensed vocational nurses (LVNs) can collect patient data, but only the registered nurse can interpret data.
  • Option E: RNs may continue to assign to unlicensed assistive personnel those activities which unlicensed assistive personnel have traditionally performed in the delivery of patient care. Examples include but are not limited to: bathing, feeding, ambulating, vital signs, weight, assistance with elimination, maintaining a safe environment.


Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

Correct Answer: A and C.

HF is a result of structural and functional abnormalities of the heart tissue muscle. Heart failure results from changes in the systolic or diastolic function of the left ventricle. 

  • Option A: The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. 
  • Option B: Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. 
  • Option C: The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness, and paleness.
  • Option D: Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.


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.

  • A. Verify patency of the line by the presence of a blood return at regular intervals.
  • B. Inspect the insertion site for swelling, erythema, or drainage.
  • C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
  • D. If unable to aspirate blood, reposition the client, and encourage the client to cough.
  • E. Contact the health care provider about verifying placement if the status is questionable.

Correct Answer: A, B, D, and E.

A major concern with the intravenous administration of cytotoxic agents is vessel irritation or extravasation. In order to avoid additional chemotherapy adverse effects, every effort should be made to minimize the complications of chemotherapy administration. All the oncology team members share responsibility to ensure the safe administration of chemotherapy.

  • Option A: 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. 
  • Option B: Chemotherapy extravasation is manifested by a wide range of symptoms that can be mild and can present as an acute burning pain, swelling, at the infusion site. Symptoms vary according to the amount and concentration of extravasated drugs. Pain and erythema, induration and skin discoloration progresses over a few days and weeks, and may progress to blister formation. Unlike flare reaction and vessel irritation, extravasation is usually manifested with no or minimal blood return at the infusion site.
  • Option C: In case of chemotherapy extravasation and as soon as the patient complains of pain or swelling, the first step should be immediate cessation of the infusion while keeping the cannula or port needle in place. This is followed by attempts at aspiration of the chemotherapeutic agent and removing the cannula or port needle.
  • Option D: 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. 
  • Option E: Occlusion warrants a more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen. Any local incidence of extravasation should be reported. While documentation may differ among institutions, certain items remain essential and should be documented for every incident.


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 client’s history? Select all that apply.

  • A. Impulsiveness
  • B. Lability of mood
  • C. Ritualistic behavior
  • D. Psychomotor retardation
  • E. Self-destructive behavior

Correct Answer: A, B, and E.

Bipolar affective disorder is a chronic and complex disorder of mood that is characterized by a combination of manic (bipolar mania), hypomanic and depressive (bipolar depression) episodes, with substantial subsyndromal symptoms that commonly present between major mood episodes.

  • Option A: With BPD, the client may engage in harmful, sensation-seeking behaviors, especially when upset. The client may impulsively spend money he or she can’t afford, binge eat, drive recklessly, shoplift, engage in risky sex, or overdo it with drugs or alcohol. 
  • Option B: Unstable emotions and moods are also common with BPD. Affect is often heightened, intense, and extremely labile. Implicit with the affective lability of mania are hyperactivity and severe mobility. When presenting in a depressive state, the patient will report a sad or elegiac mood, while expressing a congruent affect (often tearful).
  • Option C: Ritualistic behavior is common in clients with Obsessive-Compulsive Disorder (OCD). To reduce the anxiety and distress associated with these thoughts, the patient may employ compulsions or rituals. These rituals may be personal and private, or they may involve others to participate; the rituals are to compensate for the ego-dystonic feelings of the obsessional thoughts and can cause a significant decline in function.
  • Option D: Psychomotor retardation occurs commonly during depressive episodes of bipolar disorder as well as major depressive disorder. Major depressive disorder is diagnosed when an individual has a persistently low or depressed mood, anhedonia or decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts.
  • Option E: Extremely depressed patients demonstrate avolition and abulia–lack of willpower. It has been postulated that suicidal ideation originates during the depressive phases and is made manifest upon the transition to baseline or a subsequent manic state. Manic patients are threatening and assaultive.


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.

  • A. The client functions well in other areas of his life.
  • B. The degree of aggressiveness is out of proportion to the stressor.
  • C. The violent behavior is most often justified by the stressor.
  • D. The client has a history of parental alcoholism and chaotic, abusive family life.
  • E. The client has no remorse about the inability to control his anger.

Correct Answer: A, B, and D.

Impulse control disorders are pervasive and often life long manifestations of disabling behavioral patterns. Unchecked, these disorders can result in deleterious outcomes for those afflicted. Disinhibited psychopathology has precipitated the nosologic identification of ‘impulse control disorders’ (ICD), in DSM 5. Those falling under the taxon of ICD experience “failure to resist an impulse, temptation, or drive to perform an act that is harmful to the other person or others.”

  • Option A: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. Between explosive episodes, these patients will demonstrate appropriate behavior; however, upon exposure to minimal adversity, these patients will respond with violent, disproportionate tantrums, which may seem “out of character.” Incidentally, the rapidity of the escalation is mirrored, temporally, by the de-escalation.
  • Option B: The degree of aggressiveness is typically out of proportion with the stressor. The patient may feel like a hapless bystander, victim to his impulses. Most importantly, these behavior patterns are extreme and inappropriate when contrasted with those of similar biological and developmental age, resulting in severe psychosocial and functional impairments. 
  • Option C: The disorders encompassed within impulse control disorder (ICD) are identified as externalizing disorders, as these individuals express hostility and resentment externally, made manifest by conflicts with others; whereas, those with internalizing disorders direct their distress inwardly onto themselves, ego-dystonically.
  • Option D: 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. Social factors implicated in the development of ICD include low socioeconomic status, community violence, lack of structure, neglect, abusive environment, and deviant peer relations.
  • Option E: Antisocial personality disorder causes people to act without thinking how they’re affecting others. Someone with ASPD may break rules or laws. They often show no remorse and take no responsibility. Psychotherapy and certain medications may help people with ASPD.


A nurse is caring for a middle-aged client who has undergone hemicolectomy for colon cancer. The client has two children. Which concepts about families should the nurse consider when providing care for this client? Select all that apply.

  • A. Illness in one family member can affect all members.
  • B. Family roles do not change because of illness.
  • C. A family member may perform more than one role at a time.
  • D. Children typically are not affected by adult illness.
  • E. The effects of an illness on a family depend on the stage of the family’s life cycle.
  • F. Changes in sleeping and eating patterns may be signs of stress in a family.

Correct Answer: A, C, E, and F.

Quality of life (QoL) of individuals is closely related to the QoL of those around them, including partners or parents. Therefore, any chronic illness carries the potential to impact on the life of the family.

  • Option A: Illness in one family member can affect all family members, even children. Family members suffer greatly from the emotional effects of living with, and caring for, a relative with a disease, with the impact of some diseases being felt by every member of the family.
  • Option B: Family members of patients experience a negative effect on their family relationships, both between the relative and the patient, and between other members of the family as a result of the patient’s illness.
  • Option C: Each member of a family may have several roles to perform. A middle-aged client, for example, may have the roles of father/mother, husband/wife, wage earner, child care provider, and housekeeper. When one family member cannot fulfill a role because of illness, the roles of the other family members are affected. 
  • Option D: Most chronic diseases have similar effects on family members including psychological and emotional functioning, disruption of leisure activities, effect on interpersonal relationships, and financial resources.
  • Option E: Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family depends on the stage of the life cycle as family members take on different roles and the family structure changes. 
  • Option F: Illness produces stress in families; changes in eating and sleeping patterns are signs of stress. The psychological distress felt by family members often results from their feelings of helplessness and lack of control. Many different emotions are mentioned by family members; guilt, anger, worry, upset, frustration, embarrassment, despair, loss, relief.

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The nurse is monitoring a client receiving peritoneal dialysis and the nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. Select all that apply. 

  • A. Place the client in good body alignment
  • B. Check the level of the drainage bag
  • C. Contact the physician
  • D. Check the peritoneal dialysis system for kinks
  • E. Reposition the client to his or her side

Correct Answer: A, B, D, and E.

Outflow (one-way) is the most common type of obstruction. This obstruction is caused by the closeness of the distal portion of the catheter to the omentum or intestine, which allows infusion of the solution, but little-to-no outflow.

  • Options A and E: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. 
  • Option B: The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. Using a titanium weight at the end of the catheter, front-loading , or laparoscopic salvage of the catheter with reposition and securing the internal tip of the catheter in the true pelvis with a stitch can prevent or correct this complication.
  • Option C: There is no reason to contact the physician. Omental wrapping can occur at any time after catheter insertion. Conservative therapy with enemas, change in position and ambulation often remedy this problem.
  • Option D: 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. Persistent obstruction may require catheter manipulation with reposition or replacement in extreme cases.


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.

Correct Answer: A, B, C, and E.

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. 

  • Option A: Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces.
  • Option B: Due restricted foods and prescribed dietary regimen, an individual experiencing renal problem cannot maintain ideal body weight and sufficient nutrition. At the same time patients may experience anemia due to decreased erythropoietic factors that cause decrease in production of RBC causing anemia and fatigue.
  • Option C: Assess the extent of weakness, fatigue,ability to participate in active and passive activities. This provides information about the impact of activities on fatigue and energy reserves.
  • Option D: Gas exchange is not impaired in CRF. Instead, there is a dysfunction in renal tissue perfusion. For optimal cell functioning the kidney excrete potentially harmful nitrogenous product- urea, creatinine, and uric acid, but because of the loss of kidney excretory functions there is impaired excretion of nitrogenous waste product causing an increase in laboratory results of BUN, creatinine, and uric acid level.
  • Option E: Pain is a discomfort that is caused by the stimulation of the nerve endings. Any trauma that the kidney experiences (by any causes or factors) perceived by the body as a threat, the body releases cytokine and prostaglandin causing pain which is felt by the patient at his flank area.


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.

  • A. Head tilt
  • B. Vomiting
  • C. Polydipsia
  • D. Lethargy
  • E. Increased appetite
  • F. Increased pulse

Correct Answer: A, B, and D.

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. Pediatric brain tumors are the most common type of solid childhood cancer and only second to leukemia as a cause of pediatric malignancies.

  • Option A: A brain tumour at the back of the head can cause the child to have a stiff neck. They may develop a head tilt. This is where the child holds their head or neck in an unusual way, such as at an awkward angle or in a twisted position. The child may develop what is called a ‘wry neck’.
  • Option B: As a brain tumor grows larger, it takes up more and more space within the skull, thereby increasing intracranial pressure. This increased pressure can lead to feelings of nausea. Nausea and vomiting also can occur when a tumor develops in a particular area of the brain. The cerebellum, for instance, is the part of the brain that controls balance, so if a brain tumor presses against the cerebellum, the person could end up feeling dizzy and nauseated.
  • Option C: Primary polydipsia can be categorized into two types. They are psychogenic polydipsia and dipsogenic polydipsia. Psychogenic polydipsia is a condition seen usually in patients with psychiatric diseases. Dipsogenic polydipsia is seen in patients with hypothalamic conditions and in otherwise healthy individuals who are drinking excessive amounts of fluids in today’s context of a healthier lifestyle.
  • Option D: In neonates and older children, the clinical presentation depends on the site of tumor involvement. Supratentorial tumors may present with limb weakness, convulsions, and altered level of consciousness.
  • Option E: The location of the tumor can make it difficult for the patient to eat, or cause symptoms that disturb the appetite. For instance, tumors located in the base of the skull can lead to swallowing difficulties. And depression and anxiety, common in people with spinal cord and brain tumors, can affect the diet, too.
  • Option F: Sinus bradycardia (sinus rhythm of less than 60 bpm), which can be a normal phenomenon, has been only sporadically documented in the literature as the first signs of a brain tumor.


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 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.

  • A. Elevate the HOB to 90 degrees
  • B. Loosen constrictive clothing
  • C. Use a fan to reduce diaphoresis
  • D. Assess for bladder distention and bowel impaction
  • E. Administer antihypertensive medication
  • F. Place the client in a supine position with legs elevated

Correct Answer: A, B, D, & E.

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. 

  • Option A: 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. 
  • Option B: Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. Removal of constrictive clothing and vascular support also promotes venous pooling to help lower BP.
  • Option C: A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia. Identify and monitor precipitating risk factors like temperature extremes or drafts.
  • Option D: The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Removing noxious stimuli usually terminates episodes and may prevent more serious autonomic dysreflexia.
  • Option E: 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 doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered.
  • Option F: Elevate head of bed to 45-degree angle or place patient in sitting position. This lowers BP to prevent intracranial hemorrhage, seizures, or even death. Placing tetraplegic in sitting position automatically lowers BP.


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.

  • A. “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”
  • B. “I can place an aspirin tablet in my pouch to decrease odor.”
  • C. “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”
  • D. “I must use a skin barrier to protect my skin from urine.”
  • E. “I should empty my ostomy pouch of urine when it is full.”

Correct Answer: C & D.

The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The ileal conduit is not continent because of its small size. Urine is not collected and held in the pouch but continuously flows out of the stoma. An ileal conduit requires the client to wear an external urostomy bag that adheres to the skin around the stoma and collects urine. 

  • Option A: 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. 
  • Option B: Aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. Devrom is a chewable odor eliminator that contains bismuth subgallate, which works to neutralize odors from stool and flatulence. Always make sure to talk to a doctor before using any medications and understand any side effects that may occur.
  • Option C: The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. If there is itching and burning around the stoma, it is a sign to change the pouching system and clean the surrounding skin.
  • Option D: A skin barrier is essential to protecting the skin from the irritation of the urine. Cleaning the stoma and skin with water is enough. If the client wishes to use soap, rinse well as soap might affect the adhesiveness of the skin barrier. Pat the skin dry before putting on the skin barrier and pouch. 
  • Option E: 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. The nighttime drainage bag and leg bag should be replaced every 30 days, with a limited number covered by insurance. The drainage bags should be cleansed, especially when switching from a leg bag to a night bag. Both should be rinsed with warm water after each use.


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.

  • A. Uterine enlargement
  • B. Fetal heart rate detected by a nonelectric device
  • C. Outline of the fetus via radiography or ultrasound
  • D. Goodell’s sign
  • E. Braxton Hicks contractions
  • F Ballottement

Correct Answer: A, D, E, & F.

Probable signs of pregnancy are those signs commonly noted by the physician upon examination of the patient. These signs include uterine changes, abdominal changes, cervical changes, basal body temperature, positive pregnancy test by physician, and fetal palpation.

  • Option A: The uterine increases in width and length approximately five times its normal size. Its weight increases from 50 grams to 1,000 grams. By the twelfth week, the uterus rises above the symphysis pubis and it should reach the xiphoid process by the 36th week of pregnancy.
  • Option B: Fetal heart sounds are positive signs of pregnancy. The fetal heart begins beating by the 24th day following conception. It is audible with a doppler by 10 weeks of pregnancy and with a fetoscope after the 16th week (see figure 3-5). It is not to be confused with uterine souffle or swishlike tone from pulsating uterine arteries. The normal fetal heart rate is 120 to 160 beats.
  • Option C: Confirmation of fetal outline through ultrasound is a positive sign of pregnancy. The gestation sac can be seen and photographed. An embryo as early as the 4th week after conception can be identified. The fetal parts begin to appear by the 10th week of gestation.
  • Option D: The cervix is normally firm like the cartilage at the end of the nose. The Goodell’s sign is when there is marked softening of the cervix. This is present at 6 weeks of pregnancy.
  • Option E: These contractions will, generally, cease with walking or other forms of exercise. The Braxton-Hicks contractions are distinct from contractions of true labor by the fact that they do not cause the cervix to dilate and can usually be stopped by walking.
  • Option F: This is demonstrated during the bimanual exam at the 16th to 20th week. Ballottement is when the lower uterine segment or the cervix is tapped by the examiner’s finger and left there, the fetus floats upward, then sinks back and a gentle tap is felt on the finger. This is not considered diagnostic because it can be elicited in the presence of ascites or ovarian cysts.

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A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia? Select all that apply.

  • A. Elevated blood pressure
  • B. Negative urinary protein
  • C. Facial edema
  • D. Increased respirations

Correct Answer: A & C.

The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia. Preeclampsia is a hypertensive disorder in pregnancy-related to 2% to 8% of pregnancy-related complications worldwide. It results in 9% to 26% of maternal deaths in low-income countries and 16% in high-income countries. Preeclampsia is defined as new-onset hypertension.

  • Option A: The parameters for initial identification of preeclampsia are specifically defined as a systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more on two occasions at least 4 hours apart; or shorter interval timing of systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more, all of which must be identified after 20 weeks of gestation.
  • Option B: Although elevated blood pressure with accompanying proteinuria is typically thought to be required for the diagnosis of preeclampsia, it may not be present in several cases. In such cases, where the absence of proteinuria and new-onset hypertension is discovered, other new-onset symptoms such as thrombocytopenia, renal insufficiency, pulmonary edema, impaired liver function, or new-onset headache with or without visual disturbance may be used for diagnosis.
  • Option C: Overall evaluation for edema should also be completed, specifically evaluating areas of dependent (gravity-related) edema like the lower extremities or independent edema, such as in the face or hands.
  • Option D: Shortness of breath and a perceived increase in swelling, both worsening from baseline pregnancy-related symptoms, may also be reported. Suppose patients present with shortness of breath, auscultation, and percussion of lungs should be undertaken to examine for pulmonary disturbances.


A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.

  • A. Monitor maternal vital signs every 2 hours
  • B. Notify the physician if respirations are less than 18 per minute.
  • C. Monitor renal function and cardiac function closely
  • D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
  • E. Monitor deep tendon reflexes hourly
  • F. Monitor I and O’s hourly
  • G. Notify the physician if urinary output is less than 30 ml per hour.

Correct Answer: C, D, E, F, & G.

Preeclampsia is a hypertensive disease that occurs during pregnancy. This disease encompasses 2% to 8% of pregnancy-related complications, greater than 50,000 maternal deaths, and over 500,000 fetal deaths worldwide.

  • Option A: Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete.
  • Option B: When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. 
  • Option C: Cardiac and renal function is monitored closely. The patient with PIH does not display the normal cardiovascular response to pregnancy (left ventricular hypertrophy, increase in plasma volume, vascular relaxation with decreased peripheral resistance).
  • Option D: Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. 
  • Option E: Deep tendon reflexes are assessed hourly. A therapeutic level of MgSO4is achieved with serum levels of 4.0–7.5 mEq/L or 6–8 mg/dL. Adverse/toxic reactions develop above 10–12 mg/dL, with loss of DTRs occurring first, respiratory paralysis between 15–17 mg/dL, or heart block occurring at 30–35 mg/dL.
  • Option F: Monitor intake and output. Note urine color, and measure specific gravity as indicated. Urine output is a sensitive indicator of circulatory blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. Administration of magnesium sulfate (MgSO4)may cause transient increase in output.
  • Option G: The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys. Urine output should be at least 30 mL/hour while administering magnesium sulfate. If less, notify the provider of decreased urine output.


When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.

  • A. Reflects electrical impulse beginning at the SA node
  • B. Indicated electrical impulse beginning at the AV node
  • C. Reflects atrial muscle depolarization
  • D. Identifies ventricular muscle depolarization
  • E. Has duration of normally 0.11 seconds or less

Correct Answer: A, C, & E.

The P wave and PR segment is an integral part of an electrocardiogram (ECG). It represents the electrical depolarization of the atria of the heart. It is typically a small positive deflection from the isoelectric baseline that occurs just before the QRS complex.

  • Options A and B: In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. The P wave represents the electrical depolarization of the atria.  In a healthy person, this originates at the sinoatrial node (SA node) and disperses into both left and right atria. 
  • Options C and D: In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. Depolarization of the right atrium is responsible for the early part of the P wave, and depolarization of the left atrium is responsible for the middle and terminal portions of the P wave. 
  • Option E: The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height. In a normal EKG, the P-wave precedes the QRS complex. It looks like a small bump upwards from the baseline. The amplitude is normally 0.05 to 0.25mV (0.5 to 2.5 small boxes). Normal duration is 0.06-0.11 seconds (1.5 to 2.75 small boxes).


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.

  • A. Verify patency of the line by the presence of a blood return at regular intervals.
  • B. Inspect the insertion site for swelling, erythema, or drainage.
  • C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
  • D. If unable to aspirate blood, reposition the client, and encourage the client to cough.
  • E. Contact the health care provider about verifying placement if the status is questionable.

Correct Answer: A, B, D, & E.

A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. In order to avoid additional chemotherapy adverse effects, every effort should be made to minimize the complications of chemotherapy administration. All the oncology team members share responsibility to ensure the safe administration of chemotherapy.

  • Option A: 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.
  • Option B: Chemotherapy extravasation is manifested by a wide range of symptoms that can be mild and can present as an acute burning pain, swelling, at the infusion site. Symptoms vary according to the amount and concentration of extravasated drugs. Pain and erythema, induration and skin discoloration progresses over a few days and weeks, and may progress to blister formation. Unlike flare reaction and vessel irritation, extravasation is usually manifested with no or minimal blood return at the infusion site.
  • Option C: In case of chemotherapy extravasation and as soon as the patient complains of pain or swelling, the first step should be immediate cessation of the infusion while keeping the cannula or port needle in place. This is followed by attempts at aspiration of the chemotherapeutic agent and removing the cannula or port needle.
  • Option D: 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. 
  • Option E: Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen. Any local incidence of extravasation should be reported. While documentation may differ among institutions, certain items remain essential and should be documented for every incident.


A nurse is assessing a newly admitted client. In the family assessment, who should be considered as part of the client’s family? Select all that apply.

  • A. People related by blood or marriage
  • B. People whom the client views as family
  • C. People who live in the same house
  • D. People whom the nurse thinks are important to the client
  • E. People of the same racial background who live in the same house as the client
  • F. People who provide for the physical and emotional needs of the client

Correct Answer: B & F.

The term “family” is difficult to define. The mid 20th century concept of family, with heterosexual parents and offspring living under the same roof is now seldom used, and many authors now consciously use a wider definition of family. The dynamics between family members are constantly evolving and there is evidence of many diverse family types in modern western European society.

  • Option A: Poston et al. define family as “people who think of themselves as part of the family, whether by blood or marriage or not, and who support and care for each other on a regular basis”, and this definition is thought to acknowledge the diverse social arrangements that may constitute a family. 
  • Option B: When providing care to a client, the nurse should consider family members to be all the people whom the client views as family. Rather than simply defining family by a dictionary definition, each individual should look to define a family by their own standards. 
  • Option C: The traditional definition of a family has changed and may include people who may not live in the same house as the client. Many people consider friends to be as close or even closer than extended (or immediate) family. People who have lost close family members or have become removed from them may create a family unit of friends with similar interests and goals to become replacements or enhancements to a lacking family structure.
  • Option D: Family members are defined by the client, not by the nurse. Who comprises a family is up to the people in the family themselves. People may opt to keep blood relatives in their lives, or let them go if they are toxic to their well-being. Many folks add caring and supportive people to their extended clan when they choose, deciding who belongs in their specific definition of family.
  • Option E: In addition to a universal family definition, plenty of people consider a group of friends to be family, and many consider pets as defining members of the family unit.
  • Option F: Family members may also include those people who provide for the physical and emotional needs of the client. The traditional definition of a family has changed and may include people not related by blood or marriage, those of a different racial background, and those who may not live in the same house as the client. 


The nurse recognizes that a client is experiencing insomnia when the client reports which of the following? Select all that apply.

  • A. Extended time to fall asleep
  • B. Falling asleep at inappropriate times
  • C. Difficulty staying asleep
  • D. Feeling tired after a night’s sleep

Correct Answer: A, C, & D.

These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia. According to the third edition of the International Classification of Sleep Disorders (ICSD-3), insomnia is characterized by difficulty in either initiating sleep, maintaining sleep continuity, or poor sleep quality.

  • Option A: Sleep-onset insomnia refers to difficulty falling asleep. This type of insomnia may occur with people who have a hard time relaxing in bed, as well as people whose circadian rhythm is not in sync due to factors like jet lag or irregular work schedules.
  • Option B: Hypersomnia is generally seen in adolescents or young adults. The patients with hypersomnia complain of disabling excessive daytime sleepiness. They find it difficult to maintain alertness during the major waking hours of the day with sleep occurring unintentionally or at inappropriate times that interfere with the daily routine.
  • Option C: Sleep maintenance insomnia refers to difficulty staying asleep after initially nodding off. This type of insomnia is common in elderly sleepers, as well as people who consume alcohol, caffeine, or tobacco before bed. Certain disorders like sleep apnea and periodic limb movement disorder can also cause sleep maintenance insomnia.
  • Option D: Chronic insomnia can adversely affect the health, quality of life, academic performance, increase the risk of motor vehicle accidents, decrease the productivity at work, irritability and increase daytime sleepiness.


The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is? Select all that apply.

  • A. Prone
  • B. Side-lying
  • C. Supine
  • D. Fowler’s

Correct Answer: B & C.

Research demonstrates that the occurrence of SIDS is reduced with these two positions. Sudden infant death syndrome (SIDS) is the abrupt and unexplained death of an infant less than 1-year old. Despite a thorough investigation (a careful review of clinical history, death scene investigation, and a complete autopsy), a cause for the patient’s demise is not identified.

  • Option A: Studies suggest that the prone positioning predisposes to suffocation, resulting from decreased arousal, the type of bedding material, and overheating. Studies have demonstrated that prone sleeping is associated with longer sleep duration, longer obstructive events, and decreased arousal.
  • Option B: Side sleeping can also be safe as the baby grows and gets stronger. The baby gets more and more active during sleep as they approach their first birthday — which, thankfully, is also when a lot of these sleep-position worries go away.
  • Option C: The incidence of SIDS declined by more than 50 percent in the United States after physicians began to promote “On the back to sleep.” After the American Academy of Pediatrics (AAP) issued a recommendation for supine sleeping in 1992, the incidence of SIDS decreased.
  • Option D: Back sleeping with an alternating head position is best. It’s true that babies are born with softer skulls. They also have weak neck muscles in the early months of life. Give the baby plenty of supervised tummy time during the day. This helps to prevent a flat head and encourages the baby to develop their neck, arm, and upper-body muscles.


A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply.

  • A. Chronic stress
  • B. Severe anxiety
  • C. Generalized pain
  • D. Excessive caffeine
  • E. Chronic depression
  • F. Environmental noise

Correct Answer: A, D, & F.

Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. 

  • Option A: This type of insomnia is usually idiopathic, although it can be impacted by mild to moderate stress. Idiopathic insomnia is truly without any identifiable contributory factor, while stress-related insomnia can be characterized by mild stress, such as rumination or other thoughts throughout the night.
  • Option B: Primary idiopathic insomnia occurs without any identifiable cause and in the absence of anxiety. Developmental issues during childhood, for example, separation anxiety, may predispose a child to develop sleep problems. People with certain personality traits like perfectionism, ambitiousness, neuroticism, low extraversion, and susceptibility to depression and worry are more likely to develop insomnia over time.
  • Option C: Comorbid medical issues like restless legs syndrome, chronic pain, gastroesophageal reflux disease (GERD), respiratory issues, and immobility are associated with risk of chronic insomnia.
  • Option D: Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Coffee, tea, cola and other caffeinated drinks are stimulants. Drinking them in the late afternoon or evening can keep the client from falling asleep at night.
  • Option E: The sleep problems of primary insomnia are not associated with lifestyle habits or a medical or psychiatric cause. Individuals who have difficulty coping with a stressful situation or those who report being habitual light sleepers have an elevated propensity to develop chronic insomnia. There is a high rate of association between insomnia and psychiatric disorders like depression, anxiety, and post-traumatic stress disorder.
  • Option F: Environmental noise causes physical and/or emotional effects and therefore is related to primary insomnia. Poor sleep habits include an irregular bedtime schedule, naps, stimulating activities before bed, an uncomfortable sleep environment, and using the bed for work, eating or watching TV.


The use of barbiturates in treating insomnia include which of the following? Select all that apply.

  • A. Barbiturates deprive people of NREM sleep
  • B. Barbiturates deprive people of REM sleep
  • C. When the barbiturates are discontinued, the NREM sleep increases.
  • D. When the barbiturates are discontinued, the REM sleep increases.
  • E. Nightmares are often an adverse effect when discontinuing barbiturates.

Correct Answer: B, D, & E.

Barbiturates are a group of sedative-hypnotic medications used for the treatment of seizure disorder, neonatal withdrawal, insomnia, preoperative anxiety, induction of coma for increased intracranial pressure

  • Option A: The demonstration of a relationship between the profusion of eye movements and the “activity” or vividness of the accompanying dream and the finding that barbiturates not only decrease the overall amount of REM sleep but also reduce the profusion of eye movements per minute of REM sleep led to the prediction that barbiturate administration would result in dream experiences of a more tranquil nature
  • Option B: Barbiturates deprive people of REM sleep. To determine the effect of barbiturates on sleep, two subjects, after a control period, received 200 mg. of sodium amylobarbitone for 26 nights. All night sleep records taken during this period showed that the barbiturate shortened the delay to sleep, increased the total sleep period, lengthened the delay to rapid eye movement (R.E.M.) sleep, and depressed R.E.M. sleep.
  • Option C: After five nights R.E.M. sleep returned to baseline values —that is, showed tolerance. On stopping the drug withdrawal phenomena were seen, even to this small dose of the drug. In a second experiment a subject dependent on 600 mg. of Tuinal was found to have low normal R.E.M. sleep while on drugs. On withdrawal, delay to sleep increased and total sleep time fell. R.E.M. sleep was doubled and the delay to R.E.M. became abnormally short.
  • Option D: When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the person’s dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.


Which of the following is appropriate when there is a benzodiazepine overdose? Select all that apply.

  • A. Administration of syrup of ipecac
  • B. Gastric lavage
  • C. Activated charcoal and a saline cathartic
  • D. Hemodialysis
  • E. Administration of Flumazenil

Correct Answer: B, C, & E.

Benzodiazepines are currently used to treat anxiety, seizures, withdrawal states, insomnia, agitation, and are commonly used for procedural sedation. Due to their many uses and addictive properties, benzodiazepines have been widely prescribed and abused since their development several decades ago.

  • Option A: The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Ipecac, or syrup of ipecac (SOI), is a medication once used to induce vomiting. Its medical use has virtually vanished, and it is no longer recommended for routine use in toxic ingestion. The abuse of SOI as a purgative in eating disorders, however, is increasing.
  • Option B: If ingestion is recent, the decontamination of the GI system is indicated. Gastric lavage is generally the best and most effective means of gastric decontamination. Occasionally, gastric lavage and administration of activated charcoal is indicated, but only if the patient is awake and potentially sensitive to benzodiazepines and if a large dose has been ingested within the last 1 to 2 hours.
  • Option C: Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Early administration of activated charcoal in patients able to protect their airway is only needed if there are coingestants.
  • Option D: Hemodialysis is not useful in the treatment of benzodiazepine overdose. Forced diuresis and dialysis techniques are not indicated since they will not significantly accelerate the elimination of these agents.
  • Option E: Flumazenil is a nonspecific competitive antagonist at the benzodiazepine receptor that can reverse benzodiazepine-induced sedation. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation. 


A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.

  • A. Restrict all visitors.
  • B. Place the child on a low-bacteria diet.
  • C. Change dressings using sterile technique.
  • D. Encourage the consumption of fresh fruits and vegetables.
  • E. Perform meticulous hand washing before caring for the child.
  • F. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.

Correct Answer: B, C, & E.

Leukemias are a group of hematologic disorders characterized by the dysfunctional proliferation and development of leukocytes. Many genetic and environmental risk factors have been identified, though the exact cause of most leukemia subtypes is unknown.

  • Option A: Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child’s room. Bone marrow suppression, neutropenia, and chemotherapy places the patient at high risk for infection.
  • Option B: The child is placed on a low-bacteria diet. Provide a nutritious diet, high in protein and calories, avoiding raw fruits, vegetables, or uncooked meats. Proper nutrition enhances the immune system. Minimizes potential sources of bacterial contamination.
  • Option C: Dressings are always changed with sterile technique. Provide thorough skin care by keeping the patient’s skin and perianal area clean, apply mild lotion or creams to keep the skin from drying or cracking. Thoroughly clean skin before all invasive skin procedures.
  • Option D: Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. Restrict fresh fruits and make sure they are properly washed or peeled.
  • Option E: Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy). This prevents cross-contamination and reduces risk of infection.
  • Option F: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible.


A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department, no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply.

  • A. Diazepam (Valium)
  • B. Alprazolam (Xanax)
  • C. Gabapentin (Neurontin)
  • D. Ethosuximide (Zarontin)
  • E. Carbamazepine (Tegretol)
  • F. Methylphenidate (Ritalin)

Correct Answer: C, D, & E.

Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. The decision to start chronic, prophylactic antiseizure medications is individualized based on numerous factors, including the chance of event being a seizure, confirmation of seizure based on history and physical examination, patient stability, and risk of recurrent seizures.

  • Option A: Diazepam is a medication that is prescribed to halt tonic-clonic episodes. Diazepam is a benzodiazepine medication that is FDA approved for the management of anxiety disorders, short-term relief of anxiety symptoms, spasticity associated with upper motor neuron disorders, adjunct therapy for muscle spasms, preoperative anxiety relief, management of certain refractory epilepsy patients, and adjunct in severe recurrent convulsive seizures, and an adjunct in status epilepticus.
  • Option B: Alprazolam is a medication used to treat anxiety. Alprazolam is frequently prescribed to manage panic and anxiety disorders. Alprazolam has also been misused for recreational purposes because of its disinhibition, euphoria, and anxiolytic effects. 
  • Option C: Gabapentin is an anticonvulsive medication that originally saw use as a muscle relaxer and anti-spasmodic medication, but later it was discovered it had the potential of the medication as anticonvulsant medication and as an adjunct to more potent anticonvulsants.
  • Option D: Ethosuximide is FDA approved for the management of absence seizures in patients over 3 years of age. Currently, there are no off-label uses for ethosuximide; however, there is some evidence it may have some analgesic effects.
  • Option E: Carbamazepine is used to manage and treat epilepsy, trigeminal neuralgia, and acute manic and mixed episodes in bipolar I disorder. Indications for epilepsy are specifically for partial seizures with complex symptomatology (psychomotor, temporal lobe), generalized tonic seizures (grand mal), and mixed seizure patterns.
  • Option F:  Methylphenidate is a medication used to treat attention deficit hyperactivity disorder. These medications are not suitable for long-term control of a seizure condition. Children diagnosed with ADHD should be at least six years of age or older before being started on this medication.


A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate? Select all that apply.

  • A. Enteric precautions
  • B. Neutropenic precautions
  • C. No precautions are required as long as antibiotics have been started
  • D. Isolation precautions for at least 24 hours after the initiation of antibiotics
  • E. Droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy
  • F. Negative pressure ventilation is not required.

Correct Answer: D, E, & F.

Meningococcal meningitis is the term used to describe a bacterial form of meningitis caused by Neisseria meningitidis. This form of meningitis is associated with high morbidity and mortality. Meningococcal meningitis is a medical emergency for which symptoms can range from transient fever to fulminant bacteremia and septic shock.

  • Option A: Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material. They’re indicated for patients with known or suspected infectious diarrhea or gastroenteritis. Clostridium difficile is the most common cause of hospital-acquired infectious diarrhea.
  • Option B: Neutropenic precautions are steps to take to prevent infections if there is moderate to severe neutropenia. Neutropenia is a condition that causes low neutrophils in the blood.
  • Option C: Patients with pneumococcal or viral meningitis do not require isolation. Viruses can penetrate the central nervous system (CNS) via retrograde transmission along neuronal pathways or by hematogenous seeding.
  • Option D: Isolation is begun and maintained for at least 24 hours after antibiotics are given. On initial encounter when the patient presents with an undifferentiated acute bacterial meningitis, administration of broad-spectrum antibiotics is appropriate pending bacterial isolation. Seven days course of antibiotic therapy is usually sufficient to treat suspected cases of meningococcal meningitis.
  • Option E: Meningococcal meningitis is transmitted primarily by droplet infection. The patient with suspected or confirmed N. meningitidis should follow droplet precaution. This should be continued until after 24 hours of effective antibiotics administration.
  • Option F: Negative pressure ventilation is not required. Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions as described. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission.


A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.

  • A. Monitor intake and output.
  • B. Monitor vital signs.
  • C. Maintain a sodium-reduced diet.
  • D. Monitor electrolyte levels.
  • E. Increase water intake orally.
  • F. Administer sodium replacements.

Correct Answer: A, B, C, D, and E.

Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. 

  • Option A: Monitor intake and output and specific gravity. Assess the presence and location of edema. Weigh the client daily. These parameters are variable, depending on the fluid status, and are indicators of therapy needs and effectiveness.
  • Option B: Depending on the fluid status, hypertension or hypotension may be present. The presence of postural hypotension may affect activity tolerance. Metabolic acidosis secondary to hyperchloremia may result in deep, labored breathing with air hunger, which can lead to a cardiopulmonary arrest if left untreated.
  • Option C: Teach the client to avoid foods high in sodium such as regular canned vegetables and vegetable juices, processed foods, snack foods, and condiments. Decreases the risk of sodium associated complications such as stroke, heart disease, and heart failure.
  • Option D: Monitor serum electrolytes, osmolality, and arterial blood gasses, as indicated. This will evaluate the therapy needs and effectiveness.
  • Option E: Encourage increased oral and IV fluid intake. Replacement of total body water deficit will gradually restore sodium and water balance.
  • Option F: Sodium replacement therapy would not be prescribed for a client with hypernatremia. Sodium intake restriction while promoting renal clearance decreases serum sodium levels in the presence of extracellular fluid excess.


A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse’s appropriate action is to? Select all that apply.

  • A. Show acceptance of feelings.
  • B. Provide information needed for decision making.
  • C. Suggest a referral to a mental health professional.
  • D. Remain with the family member without discussing funeral arrangements.
  • E. Let the family slowly acknowledge its impact.

Correct Answer: D & E.

Grief is a process that can begin long before the loss of a loved one. Similar to the stages of dying, individuals go through a process to help them eventually cope and be able to live with that loss. People never get over their loss, but find ways to live with the loss and without their deceased loved one (ELNEC, 2010).

  • Option A: This is an appropriate intervention for the acceptance or reorganization and restitution stage. In this final stage of grief, the person accepts the reality of the loss. It can’t be reversed. Although he or she still feels sad, he or she is ready to start moving on in life.
  • Option B: This may be an appropriate intervention for the bargaining stage. During this stage, he or she dwells on what could’ve done to counteract the loss. General thoughts are “If only…” and “What if…”.
  • Option C: This may be an appropriate intervention for depression. Sadness sets in as the person begins to understand the loss and its effect in life. Indications of depression include crying, sleep issues, and a decreased appetite.
  • Option D: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. One of the biggest facilitators of this process which nurses can engage in is active listening. By actively listening to the bereaved, it helps them express their feelings and feel as though they are being heard.
  • Option E: As the family moves through the experience and slowly acknowledges its impact, the initial denial and disbelief fade. Bereavement includes grief and mourning and has been considered to be the “time period in which the survivor adjusts to their life without their loved one” (ELNEC, 2010). This period can include the time right after the loss or death occurs, during the funeral proceedings, and during the grieving process afterward.


A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply.

  • A. Jewelry will need to be removed.
  • B. An informed consent will need to be signed.
  • C. A trained x-ray technician performs the procedure.
  • D. The procedure will take approximately 45 minutes.
  • E. A liquid diet can be consumed on the day of the procedure.
  • F. Solid food intake needs to be restricted only on the day of the procedure.

Correct Answer: A, B, & D.

A myelogram is an X-ray exam in which a contrast agent (X-ray dye) is injected into the spinal canal to visualize the bones, discs, muscles and nerves. A myelogram is used to detect abnormalities of the spine such as disc problems, tumors and bone spurs, narrowing of the spinal canal or malformations of the spine.

  • Option A: The client will need to remove jewelry and metal objects from the chest area. Try to wear non-restrictive, comfortable clothing and slip on shoes if possible. Remove all piercings and leave all jewelry and valuables at home.
  • Option B: An informed consent is required because the procedure is invasive. A myelogram may be done to assess the spinal cord, subarachnoid space, or other structures for changes or abnormalities.
  • Option C: The procedure is performed by the healthcare provider. The technologist will verify identification and exam requests. The technologist and radiologist will be available to answer any questions.
  • Option D: The client is told that the procedure takes about 45 minutes. The patient will lie on the stomach on the X-ray table. If the patient cannot tolerate lying on the stomach for at least 30 minutes, notify the doctor.
  • Option E: If not on a fluid restriction, drink at least 6-8 glasses of fluid the day before the procedure. Do not eat or drink anything for 4 hours before the exam.
  • Option F: Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is also told that pretest medications may be prescribed for relaxation.


A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply.

  • A. Ataxia
  • B. Sedation
  • C. Constipation
  • D. Bleeding gums
  • E. Hyperglycemia
  • F. Decreased platelet count

Correct Answer: C, D, E, & F.

Phenytoin toxicity can occur from an increase in the daily dose of phenytoin, changes in the formulations or brands as well as changes in the frequency of administration. It can also occur when patients are started on new medications that interact with the metabolism or binding capacity of phenytoin to plasma proteins.

  • Option A: Ataxia is a side effect of benzodiazepines. In most patients, symptoms occur within days or weeks after the introduction of a new drug or an increase in dose. In general, ataxia tends to disappear after discontinuation of the drug, but chronic ataxia has been described for some drugs.
  • Option B: Sedation is a side effect of barbiturates, not phenytoin. Unlike benzodiazepines and other anticonvulsants, phenytoin does not cause sedation in therapeutic doses. Phenytoin can be given orally and intravenously. Therapeutic levels are 10 to 20 mg/L. Adverse effects associated with phenytoin use can be subdivided based on acute use versus chronic use.
  • Option C: It contributes to constipation as well. In therapeutic doses, phenytoin is absorbed entirely and reaches peak plasma concentration at 1.5 to 3 hours. However, in settings of acute ingestions, absorption tends to last longer than two weeks; this is potentially attributable to its effects on reducing the gastrointestinal motility and poor water solubility.
  • Option D: Gingival hyperplasia can occur, causing gums to bleed easily. The etiology of phenytoin-induced gingival enlargement (PIGE) is likely due to the direct effects of the drug and its metabolites on the gingival fibroblasts.
  • Option E: Blood glucose levels can elevate when taking phenytoin. Phenytoin-induced hyperglycemia may be a serious problem in nondiabetic as well as diabetic patients. Non- ketotic hyperosmolar coma and death have also been associated with use of the drug. Phenytoin should be ad- ministered with caution, particularly to patients with an existing error in glucose metabolism.
  • Option F: Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts. Phenytoin has been reported to induce various hematologic reactions, including thrombocytopenia. An intermediate epoxide metabolite of phenytoin is suspected as the cause of platelet destruction, which may occur via a complement-antibody reaction.


A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.

  • A. Radiation
  • B. Chemotherapy
  • C. Increased fluid intake
  • D. Serum sodium blood levels
  • E. Decreased oral sodium intake
  • F. Medication that is antagonistic to antidiuretic hormone (ADH)

Correct Answer: A, B, D, & F.

Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. 

  • Option A: Syndrome of inappropriate antidiuretic hormone (SIADH) has been commonly associated with small cell carcinoma and is often seen in these patients. However, SIADH associated with squamous cell carcinoma has rarely been reported on, and the mechanism for this rare association is still unknown.
  • Option B: The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal.
  • Option C: Hyponatremia treatment needs to be personalized based on severity and duration of sodium serum reduction, extracellular fluid volume and etiology. However, literature data highlight the importance of early correction of the serum concentration levels. To achieve this the main options are fluid restriction, hypertonic saline, loop diuretics, isotonic saline, tolvaptan and urea. 
  • Option D: Sodium levels are monitored closely because hypernatremia can suddenly develop as a result of treatment. Firstly, it is recommended to detect the cause of reduced sodium concentration, although the increase in sodium concentration levels is likely to be the main issue in life-threatening hyponatremia.
  • Option E: SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. 
  • Option F: For patients affected by SIADH, vaptans represent a new class of drug antagonizing the V2 receptor on renal tubular cells. To date, two molecules are approved: conivaptan and tolvaptan. The prescription of conivaptan (intravenous use) has been authorized for euvolemic hyponatremia due to SIADH by the United States (US) Food and Drug Administration (FDA) but not by the European Medicines Agency (EMA).


The nurse is preparing to teach a client about the prescribed spironolactone (Aldactone) to monitor for adverse effects of the drug. The nurse should instruct the client about which adverse effects? Select all that apply.

  • A. Confusion.
  • B. Fatigue.
  • C. Hypertension.
  • D. Leg cramps.
  • E. Weakness.
  • F. Urinary retention.

Correct Answer: A, B, & E.

Spironolactone (Aldactone) is used to treat hypertension and edema by removing excess fluid. Aldactone is known as a potassium-sparing diuretic. Confusion, fatigue, and weakness are signs of hyperkalemia, an adverse effect of spironolactone. 

  • Option A: One study mentions the following additional adverse effects in order from more to less common: dehydration, hyponatremia, gastrointestinal problems (nausea, vomiting, diarrhea or anorexia), neurological abnormalities (headache, drowsiness, asterixis, confusion, or coma), and skin rashes.
  • Option B: Spironolactone blocks the hormone aldosterone, which can lead to fatigue. In addition, it can lower the blood pressure, and if this drop is sudden, the client may feel tired.
  • Option C: Spironolactone is used to treat hypertension, so it would not produce this effect. Spironolactone is recommended in patients with resistant hypertension which is defined as uncontrolled blood pressure despite three antihypertensive drug combinations including a diuretic. Spironolactone is a mineralocorticoid receptor antagonist and causes anti-androgenic side effects.
  • Option D: Leg cramps are an adverse effect of hypokalemia. Hyperkalemia is an adverse effect of spironolactone. This drug is contraindicated in patients with hyperkalemia and in those at increased risk of developing hyperkalemia.
  • Option E: Symptoms of hypokalemia may include attacks of severe muscle weakness, eventually leading to paralysis and possibly respiratory failure. Muscular malfunction may result in paralysis of the bowel, low blood pressure, muscle twitches and mineral deficiencies (tetany).
  • Option F: Urinary retention is a side effect of anticholinergics. Medications with anticholinergic properties, such as tricyclic antidepressants, cause urinary retention by decreasing bladder detrusor muscle contraction.


The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply.

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  • A. Auscultating lung sounds
  • B. Obtaining the client’s temperature
  • C. Checking the strength of peripheral pulses
  • D. Obtaining information about the client’s respirations
  • E. Performing a musculoskeletal and neurological examination
  • F. Asking the client about a family history of any illness or disease

Correct Answer: A, B, & D.

A focused data collection process focuses on a limited or short-term problem, such as the client’s complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion the nurse would focus on the respiratory system and the presence of an infection. 

  • Option A: Auscultation of the lungs should be systematic and follow a stepwise approach in which the examiner surveys all the lung zones. For practical purposes, the lung can be divided into apical, middle and basilar regions during auscultation.
  • Option B: An increase in temperature may be a sign of underlying infection. The diagnosis of a cough is an obvious clinical observation. A cough is a symptom rather than a diagnosis of disease. As such, many patients present for evaluation of the secondary or underlying effects of cough rather than a cough itself.
  • Option C: Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client’s complaints. Otherwise, a systemic approach should be used to identify any coexisting illness, which may be the origin or compounding factor of a cough.
  • Option D: During the inspection, the examiner should pay attention to the pattern of breathing: thoracic breathing, thoracoabdominal breathing, costal markings, and use of accessory breathing muscles. The use of accessory breathing muscles (i.e., scalenes, sternocleidomastoid muscle, intercostal muscles) could point to excessive breathing effort caused by pathologies.
  • Option E: A musculoskeletal and neurological examination also is not related to this client’s complaints. However, the strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection.
  • Option F: A complete data collection includes a complete health history and physical examination and forms a baseline database. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.


A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.

  • A. Skin
  • B. Kissing
  • C. Inhalation
  • D. Gastrointestinal
  • E. Direct contact with an infected individual
  • F. Sexual contact with an infected individual

Correct Answer: A, C, & D.

Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person.

  • Option A: Skin contact results in cutaneous anthrax. Cutaneous anthrax results from inoculation of B. anthracis spores through the abraded skin into subcutaneous tissues. The bacteria subsequently germinate and multiply locally and begin toxin production.  This leads to the characteristic edema and cutaneous ulceration. 
  • Option B: Viruses responsible for diseases such as hepatitis viruses, herpesvirus infections (e.g., with Herpes simplex types 1 and 2, Epstein-Barr virus, Cytomegalovirus, and Kaposi syndrome herpesvirus), and papillomaviruses can be conveyed by kissing—as can potentially other viruses present in saliva such as Ebola and Zika viruses.
  • Option C: Inhalation or ingestion of the spores leads to inhalational or gastrointestinal (GI) anthrax. Inhalational anthrax leads to accumulation of B. anthracis spores within the lung alveoli. The spores are engulfed by immune cells (macrophages, neutrophils, dendritic cells) and transported to regional lymph nodes where the bacteria germinate, multiply, and begin toxin production.
  • Option D: Human transmission occurs via contact with infected animals through butchering and working with hides or ingestion of raw or undercooked meat. GI anthrax occurs due to ingestion of contaminated meat, with spores introduced into the gastrointestinal tract, causing bacterial replication, mucosal ulcerations, and bleeding. 
  • Option E: Anthrax is acquired from animals; there are no reports of direct human to human transmission.
  • Option F: More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections which are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV).


The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following? Select all that apply.

  • A. “We will be sure to not leave hot liquids unattended.”
  • B. “I guess my child needs to understand what the word ‘hot’ means.”
  • C. “We will be sure that our child stays in his room when we work in the kitchen.”
  • D. “We will install a safety gate as soon as we get home so that our child can’t get into the kitchen.”
  • E. “We will not put adhesive bandages over the affected area.”

Correct Answer: A & E.

Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Pot handles should be turned inward and toward the middle of the stove. Options 2, 3, and 4 do not reflect an adequate understanding of the principles of safety.

  • Option A: Hot liquids should never be left unattended, and the toddler should always be supervised. Don’t cook, drink, or carry hot beverages or foods while holding a child. Keep hot foods and liquids away from table and counter edges. Don’t use tablecloths or place mats, which young children can pull down.
  • Option B: Store items designed to get hot, such as clothes irons or curling irons, unplugged and out of reach. Be careful with food or liquids warmed in a microwave, which might heat foods unevenly.
  • Option C: Don’t leave the stove unattended when cooking. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove.
  • Option D: Block access to the stove, fireplace, space heaters and radiators. Don’t leave a child unattended in a room when these items are in use.
  • Option E: Parents should not put adhesive bandages on very young kids, though, as these can be a choking hazard if they get loose. 


A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? Select all that apply.

  • A. A task approach method is used to provide care to clients.
  • B. Managed care concepts and tools are used when providing client care.
  • C. Nursing staff are led by a nurse when providing care to a group of clients.
  • D. A single registered nurse is responsible for providing nursing care to a group of clients.
  • E. This model utilizes the diversity of skills, education, and qualification level of the entire staff.

Correct Answer: C & E.

The team nursing approach allows our nurses to move from caring about “my” patients to teams caring for a group of “our patients.”  Team Nursing reduces the stress of one RN trying to care for a group of assigned patients by themselves, with the goal of each member of the team sharing the workload.

  • Option A: This identifies functional nursing. Functional nursing revolves around team ethic, and it produces a catalog of processes, which are undertaken by different individuals to ensure efficient patient care delivery.
  • Option B: This identifies a component of case management. Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs.
  • Option C: The team nursing model of care involves pairing nurses who work as a team to deliver patient care. In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. 
  • Option D: This identifies primary nursing. This model favors a more holistic approach to patient care, as it involves a single senior nurse taking responsibility for the patient throughout their hospital stay.
  • Option E: This model utilizes the diversity of skills, education, and qualification level of the entire staff. Team members work collaboratively and share responsibility. In the team nursing model, an experienced nurse for the unit or floor oversees the work of a team of clinicians and support staff for a group of patients.


A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? Select all that apply.

  • A. A client who requires wound irrigation
  • B. A client who requires frequent ambulation
  • C. A client who is receiving continuous tube feedings
  • D. A client who requires frequent vital signs after a cardiac catheterization
  • E. A client who needs to be turned or repositioned in bed

Correct Answer: B and E.

The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client.

  • Option A: Wound irrigations and tube feedings are not performed by unlicensed personnel. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
  • Option B: In general, simple, routine tasks such as making unoccupied beds, supervising patient ambulation, assisting with hygiene, and feeding meals can be delegated. But if the patient is morbidly obese, recovering from surgery, or frail, work closely with the UAP or perform the care yourself.
  • Option C: Care of the client receiving continuous tube feedings should be delegated to another registered nurse because it requires monitoring. Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.
  • Option D: The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.
  • Option E: In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires client repositioning. The nursing assistant is skilled in these tasks.


A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply.

  • A. Failure to replace body fluids
  • B. Increased risk of hypotension
  • C. Failure to teach the client adequately
  • D. Increased need to protect the client
  • E. Excessive bumetanide administration
  • F. Lack of follow-up nursing actions

Correct Answer: B, C, D, & F.

To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as result harm was caused to person or property. 

  • Option A: Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. Diuretics play a crucial role in treating edema and hypertension by causing the induction of a negative balance of solute and water. Loop diuretics are physiologically the most potent family of diuretics. 
  • Option B: The client has an increased risk of hypotension because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. 
  • Option C: The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions after administering the bumetanide. 
  • Option D: After the first 15-minute check, the nurse should continue monitoring the client to ensure compliance with safety measures. Blood pressure, uric acid, jugular venous pressure, blood glucose, electrolytes, blood urea nitrogen/serum creatinine, and urine output must all need monitoring in patients taking bumetanide.
  • Option E: No data indicate that the dose of bumetanide, a loop diuretic, was excessive. To control edema, a staggering dosing schedule or a 3 to 4 times daily dosing schedule with half-day rest intervals in between is recommended to increase tolerability and efficacy. It is the safest and most effective method for the continued control of edema.
  • Option F: However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.


A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

  • A. Monitor the client’s ability to void.
  • B. Maintain the client in a flat position.
  • C. Restrict fluid intake for a period of 2 hours.
  • D. Monitor the client’s ability to move the extremities.
  • E. Inspect the puncture site for swelling, redness, and drainage.
  • F. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

Correct Answer: A, B, D, & E.

Lumbar puncture, also known as a spinal tap, is an invasive procedure where a hollow needle is inserted into the space surrounding the subarachnoid space in the lower back to obtain samples of cerebrospinal fluid (CSF) for qualitative analysis.

  • Option A: The nurse should monitor the client’s ability to void. Take vital signs, measure intake and output, and assess neurologic status at least every 4 hours for 24 hours to allow further evaluation of the patient’s condition.
  • Option B: Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider’s prescriptions. He or she may turn from side to side as long as the head is not elevated.
  • Option C: A liberal fluid intake is encouraged to replace cerebrospinal fluid removed during the procedure unless contraindicated by the client’s condition. An increased amount of fluid intake (up to 3,000 ml in 24 hours) will replace CSF removed during the lumbar puncture.
  • Option D: The nurse should monitor the client’s ability to move the extremities. A feeling of tingling sensation and numbness in the lower back and legs is felt temporarily.
  • Option E: The nurse checks the puncture site for redness and drainage. Signs of CSF leakage include positional headaches, nausea and vomiting, neck stiffness, photophobia (sensitivity to light), sense of imbalance, tinnitus (ringing in the ear), and phonophobia (sensitivity to sound). 

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A nurse is assisting a gastroenterologist in caring for a client with complaints of epigastric pain. The nurse is explaining the role of the gastric glands in the fundus and body of the stomach which secrete intrinsic factor and hydrochloric acid. The nurse is correct when stating which of these substances as those needed in the GI tract. Select all that apply.

  • A. Vitamin B 12 absorption.
  • B. Emulsifying fats.
  • C. Dissolving food fibers.
  • D. Killing microorganisms.
  • E. Activating the enzyme pepsin.
  • F. Vitamin B 6 absorption.

Correct Answer: A, C, D, & E.

Hydrochloric acid (HCl), the main constituent of gastric acid, is secreted by parietal cells. The hydrogen (H) and chloride (Cl) components of HCl are secreted separately by hydrogen/potassium ATPase pumps and chloride channels in the stomach. Pepsinogen, a proenzyme for pepsin, is secreted by chief cells.

  • Option A: Intrinsic factor is needed for vitamin B12 absorption. Approximately 1.2% of vitamin B12 is absorbed passively without the help of intrinsic factors. If a patient receives the oral formulation at high doses, this passive absorption is sufficient to replenish vitamin B12 deficiency.
  • Option B: Bile is the substance secreted from the gallbladder to emulsify fats as they are consumed. Once the food is present in the duodenum (especially fatty food), the I cells are stimulated to secrete CCK which in turn causes gallbladder wall contraction as well as relaxation of the sphincter of Oddi. The bile then flows into the second part of the duodenum and causes emulsification of large fat droplets into small ones.
  • Option C: Hydrochloric acid is needed for dissolving food fibers. When pepsinogen and hydrochloric acid exist together in the gastric juice, pepsin takes its active form. Through the actions of pepsin and the squeezing properties of the stomach, the food bolus enters the intestines as a liquid mixture of partially digested food particles, called chyme.
  • Option D: Hydrochloric acid is needed for killing microorganisms. The acidic environment of the stomach is not only useful for protein denaturing but also for protection against potentially infectious agents. All material consumed by the body must pass through the stomach, making it an important defense against microbes. Many bacteria are killed or inhibited by the stomach’s acidity.
  • Option E: Hydrochloric acid is needed for activating the enzyme pepsin. Collectively, gastric acid creates an acidic environment that denatures proteins and activates the conversion of pepsinogen to pepsin. Pepsin breaks down proteins into smaller peptides, which may be further processed and later absorbed in the small intestine.
  • Option F: Vitamin B6, an essential nutrient, must be replaced daily because it is water-soluble and eliminated in urine. As a coenzyme, vitamin B6 is involved as a cofactor in over 100 enzymatic reactions including amino acid metabolism, carbohydrate metabolism, and lipid metabolism. It contributes to cognitive development via neurotransmitter synthesis, immune function via interleukin-2 production, and hemoglobin formation.


A nurse is developing a care plan for a client with an injury to the frontal lobe of the brain. Which nursing interventions should be included as part of the care plan? Select all that apply.

  • A. Keep instructions simple and brief because the client will have difficulty concentrating.
  • B. Speak clearly and slowly because the client will have difficulty hearing.
  • C. Assist with bathing because the client will have vision disturbances.
  • D. Orient the client to person, place, and time as needed because of memory problems.
  • E. Assess vital signs frequently because vital bodily functions are affected.

Correct Answer: A & D.

Damage to the frontal lobe affects personality, memory, reasoning, concentration, and motor control of speech. The cortex of the frontal lobe is the largest of the four, and in many ways the lobe which participates most in making us human.

  • Option A: The prefrontal cortex is known to be the higher-order association center of the brain as it is responsible for decision making, reasoning, personality expression, maintaining social appropriateness, and other complex cognitive behaviors. 
  • Option B: Damage to the temporal lobe, not the frontal lobe, causes hearing and speech problems. Another study divides the temporal area into 4 major subregions: a) dorsal, mostly language and auditory/somatosensory networks b) ventromedial, mostly visual network c) medial, connected to paralimbic structures and d) anterolateral, associated with a default-semantic network. These areas have many important functions such as processing of language, social cues, and emotions, facial recognition (auditory and visual aspects), emotional processing of different stimuli (auditory, olfactory and visual) and theory of mind.
  • Option C: Damage to the occipital lobe causes vision disturbances. The occipital lobe is the visual processing area of the brain. It is associated with visuospatial processing, distance and depth perception, color determination, object and face recognition, and memory formation.
  • Option D: Research has proven that the dominant (left) superior frontal gyrus is a key component in the neural network of working memory as well as spatial processing.Research has proven that the dominant (left) superior frontal gyrus is a key component in the neural network of working memory as well as spatial processing.
  • Option E: Damage to the brain stem affects vital functions. The brainstem is the structure that connects the cerebrum of the brain to the spinal cord and cerebellum. It is composed of four sections in descending order: the diencephalon, midbrain, pons, and medulla oblongata. It is responsible for many vital functions of life, such as breathing, consciousness, blood pressure, heart rate, and sleep.


A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.

  • A. “I enjoy exercising but I need to be careful.”
  • B. “I need to pace my activities throughout the day.”
  • C. “I need to limit playing football to only the weekends.”
  • D. “I should gauge my activity level by my energy level.”
  • E. “I should exercise in the evening to encourage a good sleep pattern.”

Correct Answer: C & E.

Primary hyperparathyroidism (PHPT) is a disorder of one or more of the parathyroid glands . The parathyroid gland(s) becomes overactive and secretes excess amounts of parathyroid hormone (PTH). As a result, the blood calcium rises to a level that is higher than normal (called hypercalcemia). An elevated calcium level can cause many short-term and long-term complications.

  • Option A: The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. Every person is different in terms of their fitness level and the severity of their disease. That’s why it is important to start slowly and gradually increase the intensity of the exercise routine over time.
  • Option B: The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest.
  • Option C: The client should be instructed to avoid high-impact activity or contact sports such as football. Research has shown that PTH levels tend to increase following either high-intensity exercise over a long period (greater than 50 minutes) or low-intensity exercise over a very long period (around five hours).
  • Option D: The client should be instructed to use energy levels as a guide to activity. Data suggested that short-duration exercise at high levels of exertion, or low-intensity exercise over a moderate time period (50 minutes), did not appear to affect PTH levels.
  • Option E: Exercising late in the evening may interfere with restful sleep. However, it can aid with sleeping and increasing the energy levels, as long as it isn’t overdone and if done at the right time.


A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

  • A. Administering oxygen
  • B. Inserting a Foley catheter
  • C. Administering furosemide (Lasix)
  • D. Administering morphine sulfate intravenously
  • E. Transporting the client to the coronary care unit
  • F. Placing the client in a low Fowler’s side-lying position

Correct Answer: A, B, C, & D.

A pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. 

  • Option A: Oxygen is always prescribed. Supplemental oxygen increases oxygen availability to the myocardium and can help relieve symptoms of hypoxemia, ischemia, and subsequent activity intolerance (Giordano, 2005; Haque et al., 1996). The need is based on the degree of pulmonary congestion and resulting hypoxia.
  • Option B: A Foley catheter is inserted to accurately measure output. Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night and/or during bed rest.
  • Option C: Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. Evaluate urine output in response to diuretic therapy. The focus is on monitoring the response to the diuretics rather than the actual amount voided.
  • Option D: Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. The use of morphine should be reserved for patients with myocardial ischemia who are refractory to drugs that favorably alter myocardial oxygen supply and demand.
  • Option E: Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful.
  • Option F: The client is placed in a high Fowler’s position to ease the work of breathing. Allows for better chest expansion, thereby improving pulmonary capacity. In this position, the venous return to the heart is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized.