Nursing Process

Nursing Process:ASSESSMENT 1. The nurse is assessing a client on 2nd post partum day. Under normal circumstances, the tone and location of the client fundus is: a. soft and one fingerbreath below the umbilicus b. firm and two fingerbreath below the umbilicus c. firm and to the left or right of midline d. soft and at the level of the umbilicus 2. The nurse expects to observe an infant transferring an object from one hand to another at which age? a. 4 montha b. 6 months c. 9 months d. 12 months 3. The best way for the nurse to assess pain in an 18-month-old child is to: a. check the child’s pupils b. observe for behavioral changes c. ask the child, “are you feeling any pain”? d. tell the parents to call if the child has pain 4. A 4-year-old child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect: a. subdural hematoma b. epidural hematoma c. subarachnoid hemmorhage d. concussion 5. When a client’s ventilation is impaired, the body retains which substance? a. sodium bicarbonate b. carbon dioxide c. nitrous oxide d. oxygen 6. Which laboratory test is the most accurate indicator of client’s renal function? a. blood urea nitrogen b. createnine clearance c. serum createnine d. urinalysis 7. Which of the following describes how the nurse interprets the newborn’s apgar score of 8 at 5 minutes? a. an infant who’s in good condition b. an infant who’s mildly depressed c. an infant who’s moderately depressed d. an infant who needs additional oxygen to improve the apgar score 8. The nurse is examining with suspected peritonitis. How does the nurse elicit rebound tenderness? a. pressing the affected are firmly with one hand, releasing pressure quickly, and noting any tenderness on release b. using light palpation, noting any tenderness over the area c. using deep ballottment, noting any tenderness over an area

d. pressing firmly with one hand’ releasing pressure while maintaining fingertip contact with the skin, and noting tenderness on release 9. To evaluate a client’s cerebellar function, the nurse should ask: a. “do you have any problem with balance?” b. “do you have any difficulty speaking?” c. “do tou have any trouble swallowing food or fluid?” d. “have you noticed any changes in muscle strength?” 10. A client comes to the physician’s office for a a complete physical examination required for employment. The physician assesses the clients arms and legs for evidence of peripheral vascular disease. What is the most commonly used overall indicator of arm and leg circulation? a. exercise testing b. ankle-brachial index c. limb blood pressure d. allen’s test 11. A child is diagnosed with wilm’s tumor. During assessment, the nurse expects to detect: a. gross hematuria b. dysuria c. nausea and vomiting d. an abdominal mass 12. What does a positive chvostek’s sign indicate? a. hypocalcemia b. hyponatremia c. hypokalemia d. hypomagnesemia 13. A client enters the crisis unit complaining of increased stress from her studies as a medical student. She states the she has been increasingly anxious for the past month. Her physician prescribes alprazolam (xanax), 25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client’s medical history. Which drug can produce additive effects when given concomitantly with alprazolam? a. levadopa (dopar) b. famotidine (pepcid) c. diphenhydramine (benadryl) d. norgestrell (ovrette) 14. When caring for a client who has recently deliverd, the nurse assesses the client for urinary retention with overflow. Which of the following provide the most accurate picture of retention with overflow? a. frequent trips to the bathroom with an average output of 200 to 300 ml per period. b. intense urge to urinate with an average output of 250 ml c. a varying urge to urinate with an average output of 100 ml d. uterus displaced to the right with increased vaginal bleeding 15. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. what does this score indicate?

a. the fetus should be delivered within 24 hours b. the client should repeat the test within 24 hours c. the fetus isn’t distress at this time d. the client should repeat the test in 1 week 16. The nurse is reviewing a client’s prenatal history. Which finding indicates a genetic risk factor? a. the client is 25 years old b. the client has a child with cystic fibrosis c. the client was exposed to rubella at 36 weeks gestation d. the client has a history of preterm labor at 32 weeks gestation 17. The nurse is assessing a client’s pulse. Which pulse feature should the nurse document? a. timing in the cycle b. amplitude c. pitch d. intensity 18. A client takes prednisone (deltasone), as prescribed, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as: a. tetany and tremors b. anorexia and weight loss c. fliud retention and weight gain d. abdominal cramps and diarrhea 19. Which of the following is not a contributing factor to unstable blood sugars in the newborn? a. prematurity b. respiratory distress c. postdated infant d. cesarian section delivery 20. When caring a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? a. jaundice b. pruritus of the arm and legs c. fatigue during ambulation d. irritability and drowsiness 21. An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician prescribes a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the clients well-beibg because his rece, sex, and age increase his risk for coronary artery disease (CAD). To determine if the client has other major risk factors for CAD, the nurse should assess for: a. a history of diabetes mellitus b. elevated high density lipoprotein (HDL) level c. a history of ischemic heart disease d. alcoholism 22. A client is recovering from an acute myocardial infarction (MI). during the first week of recovery, the nurse should stay alert for which abdominal heart sound:

a. opening snap b. graham steel’s murmur c. ejection click d. pericardial friction rub 23. During a non stress test (NST), the nurse notes three fetal heart rate (FHR) increases of 20 beats per minute, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest? a. the client should undergo an oxytocin challenge test b. the test is inconclusive and must be repeated c. the fetus is nonreactive and hypoxic d. the fetus isn’t in distress at this time 24. A client with chronis sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client’s paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the: a. frontal sinuses only b. sphenoidal sinuses only c. frontal and maxillary sinuses d. sphenoidal and ethmoidal sinuses 25. A client with cushing syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings is consistent with witch problem? a. depression b. neuropathy c. hypoglycemia d. hyperthyroidism 26. When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect: a. a blood pressure of 130/70 mm hg b. a blood glucose level of 130 mg/dl c. bradycardia d. a blood pressure of 176/88 mg hg 27. An appropriate for gestational age newborn should weigh: a. between the 10th and 99th percentiles for age b. at least 2,500 g (5 lbs, 8 oz) c. between 2,000 and 4,000 g (4 lbs, 6 oz and 8 lbs, 12 oz) d. in the 5th percentile 28. A 3 ½ -year-old viatnamese child with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, weltlike lesions on the child’s upper back and chest. The nurse would interpret these lesions to be caused by which of the following: a. shingles b. child abuse c. allergic reaction d. cultural practice

29. The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level: a. below 70 mg/dl b. between 70 and 120 mg/dl c. between 120 and 180 mg/dl d. over 180 mg/dl 30. When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening? a. have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed b. listen for a clicking sound as the child abduct the hips c. have the child run the heel of one foot down the shin of the other leg while standing d. have the child shrug the shoulders as the nurse applies mild pressure to the shoulders