1.) The mother of a child in well-baby clinic asks the nurse which immunizations contain live virus. The nurse’s best response is
1.MMR and OPV
2.Hib and MMR
3.DTaP and OPV
4.DTaP and Hib
Answer no. 1
Rationale:
The measles, mumps, and rubella vaccine (MMR) and oral Sabin polio vaccine (OPV) contain live virus.
2.) Mr. T. has been informed that he needs surgery for rectal cancer. His response is, “There’s nothing wrong with me. I just have hemorrhoids.” The nurse knows this response to be which defense mechanism?
1.Projection
2.Repression
3.Denial
4.Displacement
Answer no. 3
Rationale:
Denial is the blocking out of thoughts or feelings perceived as painful. Mr. T. is blocking the news that he has rectal cancer and needs surgery.
3.) The nurse is assessing an elderly client. Which finding is most apt to be seen in the elderly client with dementia?
1.Good hygiene and grooming
2.Rapid mood swings
3.Agnosia
4.Phobias and unwanted thoughts and behaviors
Answer no. 3
Rationale:
Agnosia, the inability to identify familiar objects, is a key finding in dementia. For example, the client may not be able to recognize a pencil or a watch and may not know what they do.
4.) Ms. C. has had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?
1.Holding the cane in her left hand, Ms. C. moves the cane forward first, then her right leg, and finally her left leg.
2.Holding the cane in her right hand, Ms. C. moves the cane forward first, then her left leg, and finally her right leg.
3.Holding the cane in her right hand, Ms. C. moves the cane and her right leg forward, then moves her left leg forward.
4.Holding the cane in her left hand, Ms. C. moves the cane and her left leg forward, then moves her right leg forward.
Answer no. 1
Rationale:
When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Ms. C. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg.
5.) A two-year-old child with congestive heart failure has been receiving digoxin for one week. The nurse needs to recognize that an early sign of digitalis toxicity is
1.Bradypnea
2.Failure to thrive
3.Tachycardia
4.Vomiting
Answer no. 4
Rationale:
The earliest sign of digitalis toxicity is vomiting, although one episode does not warrant discontinuing medication.
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