CREEI
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EXAM PREPARATION |
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QUESTIONS |
ANSWER AND EXPLANATION |
MORE EXPLANATION |
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1 A client exposed to Mycobacterium tuberculosis Correct answer: 1 To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen, starts on chemoprophylaxis. The nurse provides what usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of instruction to the client? antitubercular agents is used for at least the first several weeks: isoniazid (INH), rifampin (Rifadin), and pyrazinamide (Tebrazid). The combination therapy lessens the risk of drug resistance (option 3). Except for streptomycin, which is for IM use, the antitubercular agents are administered orally (option 4). 1. ‐ “You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months.” 2. ‐ “You will be on at least two drugs effective against the tubercle bacillus for three months.” 3. ‐ “You will be on combination therapy in order to prevent development of drug resistance.” 4. ‐ “You will need to learn to give yourself subcutaneous injections.” |
The critical words in the stem of the question are exposed and chemoprophylaxis. Differentiate exposure from infection as the key concept being tested. Recall that if active infection requires multi‐drug therapy, exposure can be managed with a single agent alone. |
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2 The nurse delegates an unlicensed assistive person Correct answer: 2 The nurse ensures that the UAP understands the importance of reporting immediately any (UAP) to assist a client with a clean urinary difficulties during the procedure such as bleeding. This provides for safe and effective care. catheterization procedure. The client had formerly Option 1 is incorrect because the client cannot do the procedure because of arthritis. Option 3 been able to do the procedure but because of arthritis, is unnecessary if the UAP is qualified to do the procedure. Option 4 is a function of the nurse, he has been unable to perform the catheterization. not the UAP. Although the UAP has done this procedure before, which of the following must the nurse emphasize to the UAP? 1. ‐ Let the client do most of the procedure and report the expected output. 2. ‐ Report immediately any unusual observations, such as bleeding. 3. ‐ Complete in proper order the steps of the procedure. 4. ‐ Perform health teaching while performing the procedure. |
The core issue of the question is the appropriate procedure for the nurse to use when delegating care to a UAP. Eliminate option 4 first because it is the role of the nurse. Eliminate options 1 and 3 next, because they are not indicated or unnecessary, respectively. |
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3 The client is in the operating room for a surgical Correct answer: 4 Only option 4 relates to the client’s physiological integrity. Options 1 and 2 pertain to the procedure. The nurse in the operating room is psychological aspects of client care, while option 3 relates to the safety in the environment. monitoring the physiological integrity of the client. Which of the following activities is most appropriate?
1. ‐ Determine client satisfaction with care received. 2. ‐ Assess client’s emotional status. 3. ‐ Monitor asepsis in the environment. 4. ‐ Calculate fluid loss and its effects. |
The core issue of the question is knowledge of physiological assessment priorities in the perioperative client. Fluid loss directly relates to cardiovascular status, which is one of the ABCs (airway, breathing, and circulation). Use nursing knowledge and the process of elimination to make a selection. |
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4 The clinic nurse is conducting health screenings. Correct answer: 1, 2, 4 Obesity, hypertension, and smoking are modifiable risk factors for stroke. Which of the following client assessment findings Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but indicates that client teaching is needed about the risk this client’s level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol for stroke? Select all that apply. levels low and is not a risk factor for stroke. 1. ‐ Weight 205 lbs and height 5 feet 4 inches 2. ‐ Blood pressure 164/92 mmHg 3. ‐ Eats bran for breakfast daily 4. ‐ Smokes 1/2 pack cigarettes per day 5. ‐ Serum cholesterol level is 172 mg/dL |
The core issue of the question is knowledge of risk factors for stroke. Recall that these are similar to the risk factors for cardiac disease to help make your selections. |
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5 Which of the following actions would the nurse take Correct answer: 1, 2, 5 Options 1, 2, and 5 are core principles of medical asepsis. Option 3 violates principles of to maintain medical asepsis when caring for a client medical asepsis. Option 4 uses principles of surgical asepsis. Option 6 is unrelated to the needs with diabetes mellitus on the medical nursing unit who of this client. requires irrigation of a leg ulcer and insulin injections? Select all that apply. 1. ‐ Wash hands before and after client care. 2. ‐ Wear personal protective equipment during the dressing change. 3. ‐ Recap a needle after administering insulin. |
Use knowledge of medical versus surgical asepsis as essential core concepts. Eliminate options that utilize surgical asepsis or are unrelated to the needs of the client. |
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‐ Change the dressing for a diabetic ulcer using sterile gloves. ‐ Wipe the rubber stopper on the insulin vial before withdrawing dose. |
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6 Laboratory test results indicate a client is in the nadir Correct answer: 2 Red blood cells, white blood cells, and platelet counts may be decreased during the nadir period that follows administration of a chemotherapy period following administration of chemotherapy that has hematological toxicity. Medications drug. Which drug should the nurse avoid administering that inhibit platelet aggregation should be avoided during the nadir period following to this client at this time? antineoplastic therapy. Aspirin, ibuprofen, and indomethacin are examples of some of these agents. Tylenol is the drug of choice for mild pain and fever. Benadryl is often used for sinus drainage or as an antihistamine and Robitussin is used to manage cough.
1. ‐ Acetaminophen (Tylenol) 2. ‐ Ibuprofen (Motrin) 3. ‐ Diphenhydramine (Benadryl) 4. ‐ Guanefesin (Robitussin) |
The core issue of the question is the ability to determine which drugs could increase the risk of bleeding when a client’s blood counts may be low. Use the process of elimination and knowledge of drug actions and adverse effects to make a selection. |
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7 The newborn nursery has recently formed a unit Correct answer: 4 A situational leader recognizes that leadership style depends on the readiness and willingness policy and procedure committee. The nurse, while of the group or the individuals to perform the assigned tasks. The democratic or participative attending and participating in the meetings, leader offers suggestions, asks questions, and guides the group toward achieving the group determines that which nurse exemplifies a situational goals. The laissez‐faire leader recognizes the group’s need for autonomy and abdicates leader? responsibility. A bureaucratic leader relies on the organization’s rules, policies, and procedures to direct the group’s work. 1. ‐ The nurse who offers suggestions, asks questions, and guides the group toward achieving group goals. 2. ‐ The nurse who recognizes the group’s need for autonomy and abdicates responsibility. 3. ‐ The nurse who relies on the organization’s rules, policies, and procedures to direct the group’s work. 4. ‐ The nurse who recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks. |
The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection. |
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8 The nurse places highest priority on taking which of Correct answer: 1 Hand hygiene is a core principle of standard precautions. Using gloves is appropriate when the following actions to reduce the spread of there is a risk of exposure to blood, body fluids, secretions, and excretions. However, microorganisms when caring for a client at risk for handwashing should be done after removal of gloves. Not all clients require transmission‐ infection? based precautions (option 3) or a private room (option 4). 1. ‐ Wash hands before and after client care. 2. ‐ Use clean gloves when implementing client care. 3. ‐ Institute transmission‐based precautions. 4. ‐ Place the client in a private room. |
Use the process of elimination based on nursing knowledge of standard precautions. Elements of transmission‐based precautions are not initiated with all clients. |
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9 The nurse would report to the physician which of the Correct answer: 1, 4 The white blood cell count is elevated (normal 5,000–10,000/mm<sup>3</sup>), following abnormal laboratory values for a 58‐year‐old as is the BUN (0.8–22 mg/dL). These changes would be expected with infection (noted by client newly admitted to the nursing unit with fever fever) and possibly accompanying dehydration from diarrhea. The sodium (135–145 mEq/L), and diarrhea? Select all that apply. potassium (3.5–5.1 mEq/L), and serum creatinine (0.8–1.6 mg/dL) are all within normal limits.
1. ‐ White blood cell count 12,260/mm3 2. ‐ Sodium 142 mEq/L 3. ‐ Potassium 3.9 mEq/L 4. ‐ Blood urea nitrogen 38 mg/dL 5. ‐ Serum creatinine 0.9 mg/dL |
The core issue of the question is the ability to discriminate between normal and abnormal laboratory values. Note the critical symptoms fever and diarrhea, which could lead you to select elevated white count for infection and elevated BUN with fluid loss from diarrhea. |
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10 The mental health nurse working with children Correct answer: 3 According to Erikson’s stages of development, a 10‐year‐old child is experiencing industry vs. anticipates that unrealistic expectations or a sense of inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other failure to meet standards would cause a 10‐year‐old developmental levels. child to develop a sense of which of the following?
1.‐ Shame |
The core issue of the question is the ability to anticipate levels of growth and development in a 10‐year‐old child. Use knowledge of Erikson’s theory to make a selection. |
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‐ Guilt ‐ Inferiority ‐ Role confusion |
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11 A postoperative client who has an order for 5,000 Correct answer: 4 Low‐dose heparin therapy is indicated in many postoperative clients to prevent the units of heparin SubQ for three doses wants to know development of thromboembolic episodes. It is not used in every postoperative situation why this drug is being ordered. What information (option 1), but it is usually used for clients who have orthopedic surgery or are anticipated to would the nurse provide to the client to best answer be immobilized for a time following surgery. Short‐term therapy is not given to maintain the question? adequate blood clotting levels (option 2) but merely to intervene as a preventative measure. While the statement that heparin is given SC into the abdomen and is not usually painful is factual, it is not the reason for the medication being given to the client (option 3).
1. ‐ “Heparin is used as a common medication in many clients who have surgery.” 2. ‐ “Heparin is essential during the postoperative period to maintain adequate blood clotting levels.” 3. ‐ “The injections will be given in the abdomen and are not usually associated with discomfort.” 4. ‐ “Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility.” |
The critical words in the stem of the question are best answer the question. This tells you that the correct answer is one that responds to the client’s concern, rather than just reciting a fact about the medication. Use nursing knowledge and the process of elimination to answer the question. |
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12 The Emergency Department has recently experienced Correct answer: 1 Shared leadership recognizes that there are many leaders within a group so the leader a significant increase in client visits. The year‐to‐date encourages the formation of self‐directed work teams. In transformational leadership, the census reveals a 20% increase in admission from the leader encourages risk taking such as trying out nursing approaches that are evidence‐based or same period last year. In an effort to reduce staff research‐based. A transactional leader uses incentives to promote productivity such as giving stress and burnout by empowering the staff, the nurse rewards for excellent performance. A democratic leader provides constructive criticism and manager uses which of the following approaches to facilitates the group to meet their goals. demonstrate shared leadership?
1. ‐ Encourages the formation of self‐directed work teams. 2. ‐ Encourages the group to try out nursing approaches that are evidence‐based. 3. ‐ Suggests that staff who have demonstrated charting excellence be given opportunities for professional development activities. 4. ‐ Provides constructive criticism and facilitates the group to meet their goals. |
The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection. |
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13 A 56‐year‐old client reports to the nurse that his sleep Correct answer: 2 Middle‐aged adults have a decrease in deep sleep, stage IV NREM. Option 1 is an expected patterns are different than when he was younger. The pattern in older adults; option 3 is expected in young adults, and option 4 is expected in nurse anticipates that this client is likely to be neonates. experiencing which normal developmental pattern?
1. ‐ 6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked decrease in Stage IV non‐REM (NREM) sleep. 2. ‐ 6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep. 3. ‐ Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV NREM sleep. 4. ‐ Light sleep with equal amounts of REM sleep and NREM sleep. |
The core issue of the question is knowledge of age‐related changes in sleep pattern. Use this knowledge and the process of elimination to make a selection. |
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14 The nurse concludes that teaching has been effective Correct answer: 3 Crowning is the point in time when the perineum is thin and stretching around the fetal head when the laboring client’s partner shouts, “She’s both between and during contractions. Delivery is imminent when crowning occurs. Crowning crowning!” as: occurs later than the first sight of the infant’s head. A head that recedes upward between contractions is not crowning. The mouth and nose cannot be suctioned during crowning because they are not accessible, nor is it timely.
1. ‐ The nurse first starts to see a little of the baby’s head. 2. ‐ The baby’s head recedes upward between pushing contractions. 3. ‐ The perineum is thin and stretching around the occiput. 4. ‐ The mouth and nose are being suctioned. |
The critical word in the stem of the question is crowning. Use knowledge of what occurs during crowning and the process of elimination to make a selection. Visualize the word crown and select the answer that matches the part of the head that a crown would sit on. |
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15 A client questions the surgical nurse about the Correct answer: 4 Option 4 gives the client an opportunity to explain to the nurse the reason for asking the personnel in the operating room. Which of the question. This helps the nurse understand the client’s frame of reference and allows the nurse following initial responses by a nurse to the client’s to best address the client’s concern. Options 1 and 3 offer false reassurance and can give the concern is most therapeutic? impression that the nurse did not listen to or address the client’s concerns. Option 2 is a close‐ ended question and may not help the nurse explore the client’s concerns.
1. ‐ “The nurses are well‐qualified for the job they do.” 2. ‐ “Have you had a bad experience in the OR?” 3. ‐ “You’re concerned about the personnel, but you have no need to worry.” 4. ‐ “Can you tell me about why you are interested in the personnel?” |
The core issue of the question is knowledge of communication techniques that are effective when working with a client who will undergo surgery. Use knowledge of communication theory and the process of elimination to make a selection. |
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16 After three defibrillation attempts, the client Correct answer: 3 Lidocaine is the primary medication used to treat ventricular dysrhythmias. Lidocaine continues to be in a pulseless ventricular tachycardia. suppresses automaticity in the HIS‐Purkinje system by elevating electrical stimulation A lidocaine bolus of 100 mg IV is administered. The threshold of the ventricle during diastole, thus decreasing ventricular irritability. Ventricular nurse would expect to see which of the following as a fibrillation (option 1) is a worsening dysrhythmia. Slowing the heart rate (option 2) without therapeutic response to lidocaine? converting the rhythm to an atrial or sinus rhythm is not therapeutic. An increase in level of consciousness (option 4) would only occur once the ventricular rhythm is terminated.
1. ‐ Conversion from a ventricular tachycardia to a ventricular fibrillation 2. ‐ Slowing of heart rate to 80 beats per minute 3. ‐ A reduction in ventricular irritability 4. ‐ An increase in the level of consciousness |
The core issue of the question is knowledge that Lidocaine is an antidysrhythmic that should reduce the irritability of the ventricle, thus making it more amenable to shock therapy. The reduction in ventricular irritability could manifest as a conversion to a supraventricular rhythm. |
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17 The nurse is assigned to a client diagnosed with head Correct answer: 4 The UAP is qualified to complete simple procedures, such as bathing a client and changing and neck cancer who is receiving enteral feedings via bed linens. While the UAP could possibly administer mouth care to this client, the nurse must gastrostomy tube. When the nurse is called away to assess the oral cavity (option 2) and should be the one to assess tube feeding residual (option care for another client, which task for this client could 1). UAPs are not trained in therapeutic communication skills and techniques (option 3). most appropriately be delegated to the unlicensed assistive person (UAP)?
1. ‐ Determining the amount of residual for the tube feeding 2. ‐ Giving mouth care and assessing the oral cavity 3. ‐ Exploring how the client is currently coping with the diagnosis 4. ‐ Administering a bath and changing bed linens |
The core issue of the question is an appropriate activity to delegate to an unlicensed assistant. Keep in mind that any activity that involves assessment is retained by the RN, so eliminate options 1 and 2. Choose option 4 over 3 because it is procedural in nature. |
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18 A client with metabolic acidosis is admitted. Which of Correct answer: 3 A client in metabolic acidosis may also be hyperkalemic. As the hydrogen ions shift from the the following laboratory values would the nurse expect ECF to the ICF, potassium enters the ECF, leading to an increased serum potassium. pH values to find in this client? of &lt; 7.35 are associated with acidosis (option 2). Options 3 and 4 have K<sup>+</sup> levels above 5.5 mEq/ L that are associated with acidosis, but option 3 contains the higher value. Option 1 has a normal pH and serum potassium level.
1. ‐ pH 7.40; serum potassium 3.8 mEq/L 2. ‐ pH 7.36; serum potassium 3.1 mEq/ L 3. ‐ pH 7.2; serum potassium 6.2 mEq/ L 4. ‐ pH 7.0; serum potassium 5.5 mEq/ L |
Note the critical word acidosis in the question. Use this to eliminate options 1 and 2 because the pH is not low in either option. Focus on the critical word metabolic to pick the option that contains a cation with the highest value since hydrogen ions can enter the cell, which in this case is option 3. |
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19 A client has a BUN of 68 mg/dL and a creatinine level Correct answer: 4 Potassium (KCL) is contraindicated in clients with renal dysfunctions. It can not be filtered out of 6.0 mg/dL. The IV fluid is 5% dextrose in 0.9% if there is decreased renal filtration. With increased damage in tissues additional potassium is sodium chloride with 40 mEq KCL @ 100 mL/hour. released, causing an even greater level of potassium that can be life‐threatening. Encouraging Which action would be most appropriate for the nurse protein, ambulation, and taking vital signs do not safeguard the client from the danger of this to take? potential electrolyte imbalance.
1. ‐ Encourage more protein in the diet. 2. ‐ Ambulate the client more to increase circulation. 3. ‐ Take vital signs every hour. 4. ‐ Question the use of potassium in the IV fluids. |
Protein creates more potassium in the body and the lab shows that the kidneys are not filtering as they should. Additional potassium from protein metabolism may cause death. Activities, such as ambulation, will not change the BUN or creatinine since they reflect filtration of the renal system and not the rate of circulation of the blood. Taking the vital signs every hour only tells you information about the circulatory status and does not explain or improve the renal functions. Action needs to be taken immediately to discontinue the IV with the potassium to minimize the buildup of potassium to toxic levels that could be life‐threatening. |
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20 The nurse concludes that a child is in Piaget’s Correct answer: 1 In Piaget’s theory on development the conservation is a hallmark sign in the concrete concrete operations stage after observing which of the operational stage. Options 2, 3, and 4 are not characteristic of this stage. following traits in the child? 1. ‐ Conservation. 2. ‐ Egocentrism. 3. ‐ Animism. 4. ‐ Preconventional thought. |
The core issue of the question is knowledge of characteristics of various cognitive developmental levels according to Piaget. Use this knowledge and the process of elimination to make a selection. |
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21 A 60‐year‐old client has been prescribed rabeprazole Correct answer: 3 Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and (Aciphex) for symptoms of gastroesophageal reflux esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of disease (GERD). He has trouble swallowing pills. What juice. alternate medication should the nurse plan to request for this client?
1. ‐ Omeprazole (Prilosec) 2. ‐ Pantoprazole (Protonix) 3. ‐ Lansoprazole (Prevacid) 4. ‐ There is no substitute for Aciphex |
The core issue of the question is knowledge of which medications used for GERD can be opened because they come in capsule form. Use knowledge of pharmacology to answer this question, which tests specific nursing knowledge of drug forms. |
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22 At the start of the shift there were only three Correct answer: 4 It is an RN’s responsibility to do assessments, analyze the data, plan and implement care and newborns in the nursery, so staffing consisted of one teaching, and evaluate the outcomes. A second RN needs to be assigned to the nursery to RN and one LPN. Within two hours, three more safely manage the care of the Level I newborns. newborns were admitted to the nursery, one requiring Level II care, and the parents of two newborns needed discharge teaching so they could go home. The RN was needed full time in the Level II nursery as the newborn was stabilized. What staffing is needed to provide appropriate care in this situation?
1. ‐ The LPN can complete the admission assessments and discharge teaching for the five Level 1 newborns. 2. ‐ An UAP from the postpartum unit can be reassigned to the nursery to do the discharge teaching. 3. ‐ The RN can complete the admission assessments while continuing to stabilize the Level II newborn. 4. ‐ Another RN needs to be assigned to the nursery to implement the admission assessments and discharge teaching. |
Recognize that assessment and client education are part of the professional scope of practice. The correct answer would be the option that safely retains these functions for the RN given the change in unit census. |
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23 The nurse is working with a client suffering from Correct answer: 3 Anxiety or anger increases peristalsis leading to subsequent diarrhea. Excessive intake of chronic diarrhea. In teaching ways to reduce diarrhea, cheese or eggs, ignoring the urge to defecate, and lack of exercise can lead to the development the nurse would encourage the client to avoid which of of constipation. the following that contribute to the development of diarrhea? |
The core issue of the question is knowledge of ordinary factors that can contribute to diarrhea. Evaluate each of the options in turn and determine whether it is likely to aggravate diarrhea. Note that anxiety and anger stimulate the sympathetic nervous system, which then increases peristalsis; this will help you to choose correctly. |
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‐ Excessive intake of cheese and eggs ‐ Habitually ignoring the urge to defecate ‐ Anxiety or anger ‐ Lack of exercise |
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24 The fetal head is determined to be presenting in a Correct answer: 2 The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, position of complete extension. After learning of this, particularly the position of the head, present larger diameters to the maternal pelvis, which the nurse anticipates which of the following? contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery.
1. ‐ Precipitous labor and delivery 2. ‐ Prolonged labor and possible cesarean delivery 3. ‐ Normal labor and spontaneous vaginal delivery 4. ‐ Forceps‐assisted vaginal delivery |
The core issue of the question is the significance of moderate flexion of the fetal head. Recognize that changes in the position of the fetal head affect delivery to choose the correct option. |
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25 The nurse notices that an elderly nursing home Correct answer: 3 Mental status changes and concentrated urine are common signs of dehydration in the resident has not been eating or drinking as much as elderly. Tenting and dry, flaky skin are consistent changes seen with normal aging. Hand veins usual. Which assessment finding would best indicate that fill within 3 to 5 seconds and clear lungs sounds with unlabored breathing are normal the presence of fluid volume deficit? findings.
1. ‐ Clear lung fields with unlabored respirations 2. ‐ Tenting and dry, flaky skin 3. ‐ Increased drowsiness, mild confusion, and concentrated urine 4. ‐ Hand veins that fill within 3 to 5 seconds of being lowered below the heart |
Note the critical words in the question are not eating or drinking and deficit. With this in mind, look for a physical assessment finding that is consistent with dehydration. Eliminate options 1 and 2 first because of the words clear and dry respectively. Choose option 3 over 4 recalling that neurological symptoms are often present with altered fluid balance because sodium imbalance may occur simultaneously. |
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26 Following a liver transplant the client is taking Correct answer: 4 Liver function includes the regulation of blood clotting and corticosteroids can impair wound prednisone among other medications to prevent organ healing and irritate the GI tract. Thus, the client should be instructed to report signs and rejection. The nurse should instruct the client to make symptoms of bleeding. Option 1 is a side effect of corticosteroids but is not the priority from a it a priority to report which of the following signs and physiological basis. Options 2 and 3 do not reflect the associated risk of bleeding with symptoms to the health care provider? corticosteroid medications.
1. ‐ Moon face 2. ‐ Diminished pigmentation 3. ‐ Dysphagia 4. ‐ Bleeding |
The core issue of the question is knowledge that the liver is a vascular organ and that some medications used to suppress the immune system to prevent rejection, such as corticosteroids, can lead to bleeding. |
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27 The nurse would place highest priority on which of Correct answer: 1 Frequent coughing and deep breathing is an easy maneuver that has great benefit to optimize the following nursing interventions when planning to ventilation in the postoperative client. Good pain management facilitates effective coughing prevent atelectasis in the newly admitted and deep breathing. Getting the client out of bed and administering oxygen and postoperative client? bronchodilators are all appropriate interventions for preventing or treating atelectasis, but clearly the best option is to prevent its occurrence by simple maneuvers such as coughing and deep breathing. 1. ‐ Hourly coughing and deep breathing 2. ‐ Assisting the client out of bed 3. ‐ Administration of bronchodilators 4. ‐ Supplemental oxygen |
Note the client in the question has newly arrived to the nursing unit following surgery. The critical words “nursing interventions” help you to eliminate options 3 and 4, which require a medical order. Choose option 1 over 2 because of the word “hourly” and because there is not enough information in the stem to determine whether the client can safely get out of bed at this time. |
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28 A 14‐year‐old client has been diagnosed with bipolar Correct answer: 4 Children with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD. disorder. The nurse would expect to see which of the Intense mood swings (option 1), inflated self‐esteem (option 2), and spending sprees (option 3) following problems? occur more often in adults. 1. ‐ Intense mood swings lasting only 1 to 2 hours 2. ‐ Inflated self‐esteem |
The core issue of the question is knowledge of how bipolar disorders may present in a child that is in early adolescence. Use nursing knowledge and the process of elimination to make a selection. |
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‐ Spending sprees ‐ Fire‐setting and gang behavior |
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29 A client’s hemoglobin level is 14 grams/dL. Which Correct answer: 2 The laboratory value given is within normal limits (12–16.5 grams/dL). All the other interpretation of the laboratory value by the nurse is statements are inaccurate. The client is not malnourished (option 1), at nutritional risk (option most accurate? 3), and does not have polycythemia (high level) as indicated by option 4.
1. ‐ Client has a low value and is malnourished. 2. ‐ Client has a normal laboratory value and has no nutritional risk. 3. ‐ Client has a low to normal value indicative of a nutritional risk. 4. ‐ Client has an elevated value indicative of polycythemia. |
The core issue of the question is knowledge of normal and abnormal hematological laboratory values. Use specific nursing knowledge and the process of elimination to make a selection. Note that options 1 and 3 are somewhat similar so you may eliminate both of those initially. |
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30 Which of the following care measures should the Correct answer: 1 Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the nurse include in the discussion when teaching home child’s vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and care measures to the parents of a child who has they need to be disposable to reduce the risk of transmitting the infection to others in the bilateral bacterial conjunctivitis? home. Oral antihistamines, ophthalmic corticosteroids, and topical anesthetics are not indicated in the management of bacterial conjunctivitis. 1. ‐ Use of warm, moist, disposable compresses to remove crusting 2. ‐ Use of oral antihistamine medication to relieve eye itching 3. ‐ Use of ophthalmic corticosteroids to decrease inflammatory response 4. ‐ Use of topical anesthetics applied to relieve discomfort |
Note the critical word conjunctivitis in the stem of the question. Recall that this infection is highly contagious. Then determine the correct option by associating the word disposable in the correct option with the concept of infection in the stem of the question. |
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31 After a client has experienced a seizure, what is the Correct answer: 2 After the seizure, the client will be postictal, which is a deep sleeping state. She/he could most appropriate position in which the nurse should aspirate secretions unless side‐lying to promote drainage from the upper airway. Positioning place the client? the client on the back (option 1) increases risk of aspiration. Positioning the client on the abdomen (option 3) or upright in chair (option 4) is unrealistic given the client’s postictal state.
1. ‐ On back with head raised 15 degrees 2. ‐ On the side 3. ‐ On abdomen 4. ‐ Upright in chair |
The core issue of the question is knowledge of a position that will reduce the risk of aspiration following seizure activity. Use nursing knowledge and the process of elimination to make a selection. Recall that the side‐lying position is commonly used in any situation in which aspiration is a risk. |
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32 After correctly positioning a client for a wound Correct answer: 1 A client fall is a potential medical emergency; however, the nurse’s responsibility is ensuring dressing change, the nurse sets up a sterile field, the safety of the client being attended to. Option 2 ignores the safety of the potentially injured placing the wound supplies in the field. The nurse client. Option 3 wastes supplies. Option 4 could lead to a contaminated sterile field. hears a page to respond to another client who has fallen in the hallway. Which of the following is the most appropriate nursing action for the nurse to take?
1. ‐ Ensure the client’s safety, cover the field with a sterile towel, and respond to the other client. 2. ‐ Continue quickly with the procedure, and then assist the other client, checking back with the first client as soon as possible. 3. ‐ Ensure the client’s safety, discard the sterile equipment, and respond to the other client. 4. ‐ Explain the situation to the client needing wound dressing change, leave the sterile supplies in place, and attend to the other client. |
Options 1 and 4 are incorrect, sterile equipment is considered contaminated if left unattended and therefore must be thrown away. Option 2 is incorrect; the nurse needs to prioritize care appropriately. Thus the nurse needs to respond to the client who fell rather than continue with the wound dressing change. |
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33 A client recently diagnosed with type 1 diabetes Correct answer: 4 The American Diabetes Association Exchange Lists divide food into groups with similar mellitus is learning to use the American Diabetes content (milk, vegetables, fruit, starch/bread, meat, and fat). All foods within a list are similar Association exchange lists. The nurse determines that in calories, protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be the teaching has been effective if the client chooses exchanged within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, which of the following as an appropriate exchange for and orange is fruit. white rice? 1. ‐ Egg 2. ‐ Tomato |
First recall the basic food groups that are part of the American Diabetes Association Exchange Lists. Then compare each food choice identified with the list. Eliminate options 2 and 3 first as vegetables and fruits, then pick option 4 over 1 because it is a starch/bread. |
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‐ Orange ‐ Bread |
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34 The nurse is teaching a group of adults about health Correct answer: 1, 3 Genetic screening can identify markers for several types of cancer. One method to remind screenings for cancer. The nurse would include in the men to perform self‐checks for cancer is to mark a calendar to monthly check for changes. Self discussion which of the following points? Select all that exams as well as regular medical tests and exams uncover tumors. After a total mastectomy, apply. women do not need mammograms. Skin cancer risk increases with age.
1. ‐ Genetic screening is helpful in identification of cancer risks. 2. ‐ Annual medical exams uncover most tumors. 3. ‐ Men need to perform breast and testicle exams monthly. 4. ‐ Annual mammograms are recommended after a total mastectomy. 5. ‐ Inspection of the skin for cancer becomes less important as one ages. |
Elimination of number 4 and looking suspiciously at the phrase most tumors will help to discriminate between the options. When in doubt, identify alternatives with most or all in the answer as false. |
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35 During a coffee break, the nurse notices two Correct answer: 2 The nurse should speak privately to the coworkers about their behavior and the impact on coworkers arguing about how to handle a difficult the nurse overhearing them. It does not help the climate of the unit to let it pass (option 1). client. Their voices are raised and body postures are The nurse is not in a position to confront and reprimand coworkers (option 3). Option 4 is tense and defensive. Which would be the most somewhat plausible but option 2 personalizes the discussion between the nurse and the appropriate approach for the nurse to use to address coworkers, and thus is best to diffuse the situation. this conflict between staff members?
1. ‐ Let it pass because the coworkers probably did not intend to be critical. 2. ‐ Speak privately to the coworkers, telling them about personal reactions to this public encounter. 3. ‐ Confront and reprimand the coworkers publicly. 4. ‐ Inform each coworker privately that it would be most helpful not to display this behavior again. |
Options 1, 3, and 4 are incorrect. To effectively manage conflict between staff members, address the conflict within an appropriate timeframe; do not let it pass unattended. Do not openly and publicly reprimand staff in front of other staff members or clients. Finally, address staff members privately but keep in mind what behavior is acceptable on the unit. |
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36 The school nurse is assessing a muscular 17‐year‐old Correct answer: 2 The student’s age, along with symptoms of hair loss and edema indicate that this is not a female who is coming to the high school health service stage of puberty. The symptoms are not indicated in abuse of barbiturates or marijuana use. for complaints of edema, voice changes, and hair loss. By the process of elimination, the correct answer is option 2. The nurse’s primary analysis based on the subjective and objective data is that the student:
1. ‐ Is going through a stage of puberty. 2. ‐ May be using steroids. 3. ‐ May be abusing barbiturates. 4. ‐ Is using marijuana regularly. |
The core issue of the question is knowledge of adverse effects of steroid use. Use this information and the process of elimination to make a selection. |
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37 A 4‐year‐old child has been exposed to chickenpox. Correct answer: 1 The prodomal period refers to the period of time between the initial symptoms and the After the nurse has provided information about presence of the full‐blown disease. The rash would not be apparent during this time. All the chickenpox, the nurse asks the mother to repeat the other statements are correct. information. Which statement by the mother indicates a need for additional information?
1. ‐ “During the prodomal period, my child will have pox all over his body.” 2. ‐ “Chickenpox is a viral infection that can be spread to other children.” 3. ‐ “I should monitor my child for Reye syndrome, which is a complication of chickenpox.” 4. ‐ “My child should not visit my pregnant sister at this time.” |
The critical words in the stem of the question are need for additional information. This tells you that the correct option is an incorrect statement. Use knowledge of this communicable viral infection and the process of elimination to make a selection. |
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38 The school health nurse is interested in promoting Correct answer: 2 Adolescents tend to feel that they are invulnerable and that if anything bad will happen, it will safety in the high school population. In planning safety affect others but not themselves. They also tend to feel immortal, as it is difficult for them to education for this age group and their parents, the comprehend their own death. Option 1 is a factor related to the adult, option 3 is related to nurse would recognize that which of the following is a school‐age children, and option 4 is related to the elderly. developmental risk factor for adolescents?
1. ‐ Substance abuse as a lifestyle means of dealing with stress 2. ‐ Feelings of immortality related to perception of being invulnerable to risks that affect others 3. ‐ Sports‐related injuries that are usually related to not obeying rules and/or intense competition 4. ‐ Polypharmacy, which results in mixing of multiple medications |
Focus on the developmental level of the client. To answer this question correctly, it is necessary to understand growth and development and apply this knowledge to the needs of the adolescent for safety. |
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39 When giving directions to a 24‐year‐old female with Correct answer: 3 A full bladder is necessary to bounce the sound waves off to compare other tissues or possible appendicitis who is about to undergo a pelvic structures are being assessed. If done during pregnancy, the fetus must be over 26 weeks to sonogram, which statement should the nurse make to not have the restriction for the full bladder, since the amniotic fluid would be used at that the client? point. It would not be helpful to be NPO, because this would deprive the client of fluids. Enemas and refraining from medications are unnecessary. 1. ‐ “Drink nothing for several hours prior to the exam.” 2. ‐ “You will be given an enema to cleanse the bowel.” 3. ‐ “Drink plenty of liquids so you will have a full bladder.” 4. ‐ Do not take any medications prior to the exam.” |
Fluids are needed to fill the bladder and are not withheld prior to testing. Bowel structures do not interfere with the assessment of structures and an enema is not required. Medications do not impact on sound waves and holding medications is not necessary for any reason. |
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40 The nurse is conducting an initial interview with a 10‐ Correct answer: 2 Children at 10 years of age are egocentric and concerned with themselves. Asking about year‐old boy who has been brought to the mental interests and hobbies is likely to foster establishment of rapport. Focusing on behavioral health clinic by his parents. The nurse can establish symptoms (option 1) could lead to an adversarial relationship. Children often are rapport and credibility with the child by asking the uncomfortable talking about friends and family (option 3) until they get to know a person child about his: better. Most children are unconcerned about past medical problems (option 4); they are focused on the here‐and‐now. 1. ‐ Behavioral symptoms. 2. ‐ Interests and hobbies. 3. ‐ Relationships with friends and family members. 4. ‐ Medical problems in the past. |
The core issue of the question is knowledge of communication strategies that are likely to be effective in developing a therapeutic relationship. Focus on the age of the child and cognitive developmental level to make a selection. |
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41 The nurse is providing medication instructions to a Correct answer: 3 Spironolactone is a potassium‐sparing diuretic used to treat hypertension. Gynecomastia is client. The nurse informs the client that persistent one of its adverse reactions. Adverse reactions usually disappear after the drug is gynecomastia can result from taking which of the discontinued; however, gynecomastia may persist after discontinuing spironolactone. following newly prescribed diuretics?
1. ‐ Hydrochlorothiazide (HCTZ) 2. ‐ Furosemide (Lasix) 3. ‐ Spironolactone (Aldactone) 4. ‐ Indapamide (Lozol) |
The core issue of the question is knowledge of adverse drug effects of spironolactone. Use specific drug knowledge and the process of elimination to make a selection. |
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42 As the nursing unit representative member serving on Correct answer: 3 Client and family satisfaction surveys are a formal set of activities that can be used to remedy the hospital quality management committee, the deficiencies identified in the quality of direct patient care, administrative, and support services. nurse has been asked to evaluate the quality of nursing Incident reports (option 1) serve as an indicator of risk. Documentation of time and activities services on the unit. What would be an appropriate related to direct care may be done as part of time and motion studies. Acuity relates to the quality improvement activity for the nurse to ask team need for nursing staff on the unit. members to participate in?
1. ‐ Tracking the number of accidents or incidents on the unit 2. ‐ Documenting nursing time and activities spent on direct client care 3. ‐ Administering a client and family satisfaction survey 4. ‐ Assessing clients and report acuity to shift managers daily |
Note the critical word services in the stem of the question. With this in mind, the correct option is one that gathers data from the recipients of services. Options 1, 2, and 4 are not quality service measures. |
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43 When a female client preparing for surgery suddenly Correct answer: 3 Option 3 is best because it represents a communication with the client and is open‐ended. bursts into tears, the preoperative holding unit nurse Options 1 and 2 are not the most appropriate initial approaches since the client is not should take which of the following actions? encouraged to share her concerns, although later on in the interaction these may be appropriate. Option 4 ignores the client and does not address the client’s concerns.
1. ‐ Pull the curtain closed and leave the area to provide privacy. 2. ‐ Be silent as a sign of compassion. 3. ‐ Ask the client to share what she is feeling. 4. ‐ Continue with the physical preparation of the client. |
The core issue of the question is the ability of the nurse to care for the emotional needs of a perioperative client. Since this is potentially an anxiety‐producing time for clients, choose the option in which the nurse provides a therapeutic response to the client. |
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44 After reviewing the client’s health history, the nurse Correct answer: 3 Cigarette smoking is the leading cause of lung cancer. Smokeless tobacco is more often concludes that which of the following is the most associated with oral cancer. Air pollution may also be a contributing factor to development of significant factor related to the development of lung cancer. History of asthma is not associated with greater risk of lung cancer. bronchogenic carcinoma for this client?
1. ‐ Asthma 2. ‐ Smokeless tobacco 3. ‐ Cigarette smoking 4. ‐ Air pollution |
Eliminate option 1 first because it is a health problem, not a risk factor. From there, choose cigarette smoking over the other options because it is highly associated with lung cancer. |
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45 The nurse is setting up the breakfast tray for a client Correct answer: 3 Foods that reduce lower esophageal sphincter (LES) pressure will increase reflux symptoms. with gastroesophageal reflux disease (GERD) and These include coffee, fatty foods, alcohol, and chocolate. All the other items can be given to notices one food that the client should not eat. Which the client. food should the nurse remove from the meal tray?
1. ‐ Poached egg 2. ‐ Dry toast 3. ‐ Coffee with cream 4. ‐ Skim milk |
The core issue of the question is knowing that certain types of foods lower LES pressure, and then being able to take it a step further and identify what types of foods those are. Eliminate each option systematically by reasoning that any foods high in fat (such as the cream in the coffee) can have this effect. |
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46 The nurse is assessing a 30‐year‐old client with a prior Correct answer: 2 Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. history of smoking who takes theophylline (Theo‐Dur) Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 for chronic obstructive pulmonary disease. Additional is incorrect because the client is young and therefore the age is insignificant. The smoking diagnoses include liver disease and congestive heart history (option 1) is not an issue; in fact, smokers metabolize theophylline more quickly and failure. The client is experiencing tremors, dizziness, may need increased doses. There is no data about the client’s weight (option 4) in the stem. tachycardia, and nausea. The nurse explains to the client that these symptoms may be the result of:
1. ‐ A history of smoking cigarettes. 2. ‐ Liver disease. 3. ‐ The client’s age. 4. ‐ The client’s weight. |
The core issue of the question is knowledge that adverse effects of xanthine medication such as theophylline are increased in liver disease. Use specific knowledge of drug adverse effects and the process of elimination to make a selection. |
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47 The nurse has admitted to the surgical unit a client Correct answer: 1, 2, 4, The LPN/LVN is trained to collect data that is then reported to the registered nurse (RN). who just underwent open reduction and internal 5 However, assessment remains the responsibility of the RN. For these reasons, the LPN/LVN can fixation of a severely fractured right radius and ulna. be expected to take vital signs, report drainage, administer medication, and elevate the casted Which nursing care activities would be appropriate for limb. The RN should retain the responsibility for assessing neurovascular status to the casted the nurse to delegate to the Licensed extremity in the immediate postoperative period. Practical/Vocational Nurse (LPN/LVN)? Select all that apply. 1.‐ Measure vital signs every 30 minutes. |
Recall that procedures and simple data collection can be delegated to the LPN/LVN. With this in mind, eliminate each of the incorrect options systematically. |
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‐ Report drainage on the cast if it appears. ‐ Assess neurovascular status of the fingers of the casted arm hourly. ‐ Elevate the casted arm above heart level. ‐ Administer the prescribed intramuscular analgesic as ordered. |
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48 Which of the following actions would the nurse Correct answer: 1 Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 institute that is specific to the care of the assigned microns in size. client who has tuberculosis?
1. ‐ Wearing a particulate respirator mask when taking vital signs. 2. ‐ Instructing the client to cover the mouth with the sheet from the stretcher when transported to other hospital departments. 3. ‐ Wearing sterile gloves when collecting a sputum specimen. 4. ‐ Keeping the client’s door open to promote ventilation. |
Specific knowledge of the mode of transmission of Mycobacterium tuberculosis and the types of transmission‐based precautions is needed to select the correct answer. Eliminate 2 and 3 as tuberculosis is transmitted via air currents. Choose option 1 over option 4 because tuberculosis is transmitted via airborne droplet nuclei less than 5 microns in size. |
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49 A client has a potassium level of 6.8 mEq/L. Which Correct answer: 1 The potassium level is abnormally high (normal 3.5–5.1 mEq/L). Since potassium is an sign or symptom would the nurse expect to find when intracellular ion, higher levels will alter the electrical pattern of the EKG. “Peaking of a T wave” assessing this client? is an indication that potassium is too high. With hyperkalemia (higher than normal potassium levels), muscle weakness, flaccidity of muscles, diarrhea, abdominal cramping, cerebral irritability/restlessness are present. Therefore, bowel sounds would be hyperactive and not silent, such as with an ileus. Muscles are weak and flaccid, not in a cramping state. Cerebral functions are stimulated and somnolence (sleeping, sluggishness) is not present.
1. ‐ Peaking of T wave on the telemetry monitor 2. ‐ The absence of bowel sounds, such as in an ileus 3. ‐ Muscle cramping of the lower extremities 4. ‐ Somnolence with early changes |
The core issue of the question is accurate interpretation of the potassium level and its significance. From there, associate the symptoms of hyperkalemia to make a selection. |
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50 The nurse is preparing to take a client to the Correct answer: 3 The client should be NPO before the procedure in order to be given anesthesia for the electroconvulsive therapy (ECT) treatment suite. The procedure (options 3 and 4). The client, not the husband, should sign the consent form (option nurse must ensure that which of the following 1). The client should be wearing loose‐fitting clothing (option 2). pretreatment processes has been completed?
1. ‐ The client’s husband has signed the consent form. 2. ‐ The client is wearing snug‐fitting clothing. 3. ‐ The client is NPO. 4. ‐ The client has been given ample liquids before the procedure. |
The core issue of the question is knowledge that ECT requires anesthesia, which leads to loss of airway protective reflexes. Use this knowledge to reason that the client must be NPO to prevent the risk of aspiration during the procedure. |
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51 To minimize the pain related to intramuscular Correct answer: 4 Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be injection of 2 mL of penicillin G benzathine (Bicillin LA) painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be in an adult client, the nurse would take which of the administered over 12 to 15 seconds to separate the muscle fibers more gradually. Cold following actions? compresses to the injection site would delay absorption of the drug (option 1). Aspiration for blood return with all IM injections is necessary for safety since muscles contain larger blood vessels (option 3). Injection into the deltoid may also result in prolonged discomfort resulting in limited motion of the upper extremities (option 2). Rotating sites, light massage, and warm compress to site may also be employed to limit discomfort.
1. ‐ Apply cold compress to site after injection. 2. ‐ Divide the dose and inject half into each deltoid. 3. ‐ Limit prolonging the time taken to administer the drug by not aspirating. 4. ‐ Administer the drug deep IM slowly into a large muscle such as the gluteus. |
The core issue of the question is knowledge of proper administration technique for thick liquid parenteral medications. Use knowledge of intramuscular injection techniques and knowledge of drug absorption principles to make a selection. |
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52 The nurse is assigned to the care of an obese client Correct answer: 4 Teaching and assessment are within the domain of the registered nurse (RN) and cannot be who has gastroesophageal reflux disease (GERD). delegated to a UAP. The UAP is also not trained in therapeutic communication or counseling Which of the following activities could the nurse techniques. These ancillary caregivers can complete tasks under the supervision and direction appropriately delegate to the unlicensed assistant of the nurse, and report simple data when asked to do so. With this in mind, the only activity person (UAP)? that can be delegated is the simple direction to the client to remain upright after eating.
1. ‐ Teach the client about the need for weight loss. 2. ‐ Explore any concerns about the prescribed regimen for managing GERD. 3. ‐ Explain why it is important to eat several small meals per day. 4. ‐ Instruct the client to remain upright for at least 2 hours after eating. |
The core issue of the question is knowledge of the appropriate tasks to delegate to a UAP. Recalling that teaching, counseling, and assessment remain the RN’s responsibility assists in eliminating each of the incorrect options. |
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53 The nurse is admitting a client with thermal burns to Correct answer: 1 Clients should remain NPO upon admission to the clinical setting with a major burn. Initial both arms and anterior trunk. The client asks for a fluid replacement is started via the parenteral route. NPO status is maintained because the drink of water. What is the most appropriate response client may be in shock with blood flow directed away from the digestive organs to more vital for the nurse to make? tissues. In addition it is possible that the client suffered burn injuries that could cause internal damage to body structures, and aspiration is also a risk initially. Options 2, 3, and 4 are incorrect—fluids and food via the mouth would be restricted at this time.
1. ‐ “I’m sorry, you cannot drink anything right now; let me moisten your mouth instead.” 2. ‐ “I can only give you juice to drink, not water.” 3. ‐ “I’ll get you a drink as soon as I’m finished.” 4. ‐ “Would you also like me to order you a meal tray?” |
The core issue of the question is knowledge that the client who has experienced burn injury is under severe physiological stress, and as such, blood flow is directed away from the digestive tract. Focus on the need to stabilize the client physiologically and provide fluids by the IV route to help you choose correctly. |
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54 A mother brings a 3‐year‐old child to the clinic for a Correct answer: 4 Every time a child enters the healthcare system, the immunization status should be checked. well‐child checkup. The child has not been to the clinic Some children have uncertain history of immunization because of parental noncompliance or since 6 months of age. The nurse determines that special circumstances such as being refugees. Once immunization status has been determined, which of the following is the priority of care for this the nurse can go on to assess growth and development and hearing, and to teach the parents child? about dental care as necessary.
1. ‐ Assess growth and development. 2. ‐ Begin dental care. 3. ‐ Complete hearing screening. 4. ‐ Update vaccinations. |
The critical word in the stem of the question is priority. This tells you that more than one option is likely to be a correct nursing action, but that one is more important than the others. Note the age of the child to help you choose immunizations as the priority, especially noting that the child has not received healthcare for 2.5 years, during a time when vaccinations should be kept up to date. |
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55 A client who has pancreatitis is experiencing pain. Correct answer: 4 The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved After administering an analgesic, the nurse should by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. place the client in which of the following positions to This position reduces pressure caused by contact of the inflamed pancreas with the posterior promote comfort? abdominal wall. 1. ‐ Supine 2. ‐ Prone 3. ‐ Left lateral decubitus 4. ‐ Sitting up and leaning forward |
The core issue of the question is knowledge of proper positioning techniques to reduce the pain of inflammation that can be aggravated by movement. Use the process of elimination to select the position in which the pancreas is not as likely to be compressed against other body structures. |
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56 The nurse would be most careful to assess for Correct answer: 1 Although many chemotherapy agents can cause stomatitis, the antimetabolites are stomatitis in a client receiving which of the following commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. chemotherapeutic agents? Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid. 1. ‐ Fluorouracil (5‐FU) 2. ‐ Cisplatin (Platinol) 3. ‐ Bleomycin (Blenoxane) 4. ‐ Vincristine (Oncovin) |
The core issue of the question is knowledge of which antineoplastic agents cause stomatitis as an adverse effect. Use nursing knowledge and the process of elimination to answer the question. |
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57 The nurse will be working with an unlicensed assistive Correct answer: 1 Safe and effective delegation is based on knowledge of the laws governing nursing practice person (UAP) for the work shift. Prior to delegating and knowledge about job duties and responsibilities. Nurses must understand the care to the UAP, the nurse places high priority on competencies and training of unlicensed assistive personnel. which of the following?
1. ‐ Determining that the UAP is competent to perform the required task 2. ‐ Providing written directions to the UAP 3. ‐ Making sure all the necessary supplies are available at the client’s bedside 4. ‐ Informing clients that an unlicensed staff member will be assigned to them |
Option 2 is incorrect; it is not necessary to provide written directions when delegating tasks to UAPs as long as verbal directions are clear and expectations are understood. Option 3 is incorrect; your responsibility is not preparing the supplies for a delegated task but rather to ensure the delegated task is completed safely and correctly. Option 4 is incorrect; it is not necessary to inform the client about the tasks or assignments delegated to non‐staff members. It is however, the responsibility of the staff member to inform the client prior to the assigned task what will be accomplished. |
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58 The nurse believes a client has slight one‐sided Correct answer: 1 This assessment may be done to detect small changes in muscle strength that might not weakness and further tests the client’s muscle otherwise be noted. Pronator drift occurs when a client cannot maintain the hands in a strength. The nurse asks the client to hold the arms up supinated position with the arms extended and eyes closed. Nystagmus is the presence of fine, with hands supinated, as if holding a tray, and then involuntary eye movements. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance asks the client to close the eyes. The client’s right hand in gait. moves downward slightly and turns. The nurse documents and reports that the client has which of the following findings on assessment?
1. ‐ Pronator drift 2. ‐ Nystagmus 3. ‐ Hyperreflexia 4. ‐ Ataxia |
Specific knowledge of physical assessment techniques is needed to answer the question. Note the association between the terms supinated in the question and pronator in the correct answer, in response to the client’s change in hand position. |
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59 When a client has arterial blood gases drawn from Correct answer: 3 Packing the sample in ice will minimize the changes in gas levels during the transportation of the radial artery, the nurse should plan to do which of the specimen to the lab. The arterial site should be held for 5 minutes or longer if the client is the following? receiving anticoagulant therapy. The blood is drawn originally in a heparinized syringe and does not need to be transferred to one. A second specimen is not necessary.
1. ‐ Hold the site for up to 1 minute. 2. ‐ Transfer the blood sample to a heparinized test tube. 3. ‐ Pack the sample in ice for transporting to the laboratory. 4. ‐ Obtain a second specimen after 10 minutes for comparison. |
The wording of the question tells you that the correct answer is also a true statement of fact. Eliminate option 1 first as being factually incorrect. Next, eliminate option 2 because the syringe is heparinized and the blood is not transferred to a test tube. Finally, eliminate option 4 because it is unnecessary. |
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60 The nurse knows that a client in the long‐term care Correct answer: 2 For clients with dysthymia, a major concern is social isolation. Option 1 is contraindicated, as unit suffers from dysthymia. The most important is option 3. If the client has a poor appetite, assigning 2 liters of liquid intake (option 4) is not nursing intervention to include in the nursing care plan therapeutic, nor is planning three regular meals per day (option 3). is: 1. ‐ Provide at least 2 hours of quiet time every morning for the client. 2. ‐ Encourage the client to eat in the main dining room with other clients. 3. ‐ Include at least three regular meals per day and no snacks. 4. ‐ Include at least 2 liters of clear liquids per day in the diet regime. |
The core issue of the question is knowledge of strategies to reduce the risk of isolation in a client with dysthymia. Use nursing knowledge and the process of elimination to make a selection. |
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61 A client who is receiving intravenous heparin by Correct answer: 3 The effectiveness of a heparin protocol is monitored by trending APTT results to achieve a protocol orders has an activated partial therapeutic level. An APTT of 140 is above the therapeutic level of anticoagulation and thromboplastin time (APTT) level of 140 seconds therefore the infusion should be stopped per protocol, and resumed at a decreased dose in (control time is 36 seconds). What is the priority action one hour’s time with a repeat APTT ordered in 2–3 hours per protocol. The dose should not be that the nurse should institute? increased, as this would cause serious consequence to the client. Stopping the medication for a total 6 hours would undermine the anticoagulation control that the physician is trying to achieve. Ordering another APTT and continuing to run the infusion could also cause serious consequences to the client.
1. ‐ Increase the heparin dose as the APTT level is not therapeutic. Obtain a repeat APTT in 6 hours. 2. ‐ Stop the heparin therapy for 6 hours, then restart the therapy at the same unit dose and obtain a repeat APTT in 6 hours. 3. ‐ Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat APTT in 2 to 3 hours from the restart of the infusion. 4. ‐ Obtain an additional APTT in 1 hour and continue to monitor the client. |
The core issue of the question is recognition that this is a critically high value for the APTT and that the action that will maintain client safety is to turn off the heparin for a period of time. Use the process of elimination and knowledge of the effects of heparin on APTT times to answer the question. |
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62 The nurse has admitted to the intermediate care unit Correct answer: 1, 3 The UAP can perform tasks or nursing care activities under the direct supervision of the a client who sustained a spinal cord injury at T1 in a registered nurse (RN). The nurse retains responsibility for assessment (options 2 and 5) and motor vehicle accident. Which of the following nursing teaching (option 4). care activities can the nurse delegate to the unlicensed assistive person (UAP) when working with this client? Select all that apply.
1. ‐ Measure oxygen saturation level every hour. 2. ‐ Listen to breath sounds. 3. ‐ Provide mouth care. 4. ‐ Teach use of incentive spirometer. 5. ‐ Assess for Homan’s sign while bathing client. |
The core issue of the question is the ability to discriminate between what the RN may delegate and what he or she may not. Evaluate each option and either choose it because it is a simple procedure or task, or choose not to select it because it involves assessment or teaching. |
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63 The nurse has been instructed to have a surgical Correct answer: 4 The client’s right to withdraw consent is necessary to be part of the consent and it means that consent form signed by a client who will be undergoing coercion was not utilized in obtaining the signature. It is the physician’s responsibility, not the a surgical procedure. What is the most essential nurse’s, to explain the diagnosis (option 1) and the need for the surgical procedure (option 2). information to include in the discussion prior to the Cost (option 2) is not an important aspect for informed consent. The technical aspects of the client signing the permission? procedure are not needed by the client, although an overview of the procedure should be included (option 3), but again this is the role of the physician. All preparation for the procedure should include information about what the client will see, feel, and hear.
1. ‐ The client’s diagnosis 2. ‐ Treatment proposed and the cost 3. ‐ The technical aspects of the procedure 4. ‐ Right to withdraw consent |
The core issue of the question is knowledge of the nurse’s role in obtaining informed consent. Keep in mind that the nurse reinforces explanations already given by the physician and use the process of elimination to make a selection. |
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64 The pregnant client is 7 centimeters, 100% effaced, Correct answer: 1 Presentation refers to the part of the fetus that is coming through the cervix and birth canal and at a +1 station. The fetus is in a face presentation. first. Thus a face presentation occurs when the face is coming through first. The nurse concludes that teaching has been effective when the client’s husband states:
1. ‐ “Our baby will come out face first.” 2. ‐ “Our baby will come out facing one hip.” 3. ‐ “Our baby will come out buttocks first.” 4. ‐ “Our baby will come out with the back of the head first.” |
Associate the word face in the question with the word face in the correct response. The word presentation helps you to choose option 1 over option 2, which also contains the word face, but in an inappropriate context to this question. |
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65 A client is scheduled to have a transverse colostomy Correct answer: The correct area is the proximal stoma, not the distal one that is nearer to the distal colon performed. While doing client teaching, the nurse and rectum. Coming from the small bowel in the center of the diagram, the stomas represent, points to which stoma on the diagram to show the in anatomical order, an ileostomy, cecostomy, ascending colostomy, transverse colostomy, client the location of the stoma? Select the correct descending colostomy, and sigmoidoscopy. stoma. |
To answer this question correctly, recall the names of the anatomic portions of bowel. It will also help you to choose correctly if you recall that the prefix trans means across. This might help you select the stoma that is halfway across the abdomen. |
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66 A child diagnosed with deficiency of growth hormone Correct answer: 2 Children with growth hormone deficiency are smaller than their peers and frequently who needs replacement drug therapy comes to the experience problems with self‐esteem and body image. Option 1 would be the opposite clinic for treatment. Which one of the following problem of what the client is experiencing. The nursing diagnoses in options 3 and 4 are nursing diagnoses would be most appropriate for this unrelated to the client in this question. client? 1. ‐ Imbalanced nutrition: More than body requirements 2. ‐ Disturbed body image 3. ‐ Diversional activity deficit 4. ‐ Decreased cardiac output |
The core issue of the question is knowledge that deficiency of growth hormone leads to short stature and often disturbed body image in the child. Use nursing knowledge and the process of elimination to make a selection. |
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67 The nursing unit is understaffed and a nurse from the Correct answer: 3, 4 The intermediate care surgical nurse should be most comfortable assuming the care of surgical intermediate care unit has been floated to the surgical clients. Heart failure, diabetes, and thyrotoxicosis are medical problems, and the client unit for the day shift. Which of the following two with diabetes will also require extensive teaching. The client with nephrolithiasis may also clients should the nurse assign to this RN float nurse? require teaching about the procedure, but since the client will undergo moderate sedation, the Select all that apply. nurse would be completing typical preoperative care.
1. ‐ A client newly admitted with exacerbation of heart failure 2. ‐ A client newly diagnosed with type 2 diabetes mellitus 3. ‐ A client who underwent emergency appendectomy during the night 4. ‐ A client with nephrolithiasis scheduled for lithotripsy later in the morning 5. ‐ A client admitted with thyrotoxicosis |
Note the critical word surgical in the description of the work setting of the float nurse. With this in mind, choose the two clients that have procedures that are surgical in nature. |
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68 The nurse would conclude that hypomagnesemia has Correct answer: 2 Effects of hypomagnesemia are mainly due to increased neuromuscular responses. Paralysis, not resolved if which of the following neuromuscular flaccidity, and decreased reflexes may be present with hypermagnesemia. signs is still present after treatment?
1. ‐ Paralysis 2. ‐ Tetany 3. ‐ Flaccidity 4. ‐ Decreased reflexes |
Recall that options that have similarities are not likely to be correct. Examine the options from the viewpoint of neurological stimulation. Eliminate each of the incorrect responses because they reflect abnormally low activity of the nervous system. |
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69 A client presents to the Emergency Department with Correct answer: 2 Troponin is a sensitive test that indicates damage to the myocardial cells. A CK‐MM a complaint of chest pain. Which serum laboratory test isoenzyme elevation would indicate skeletal muscle damage. The LDH<sup>4</sup> does the nurse check off on the laboratory slip as part isoenzyme is utilized to determine hepatic function and amylase is a digestive enzyme. of a protocol order to rule out an acute myocardial infarction? 1. ‐ LDH4 2. ‐ Troponin 3. ‐ Amylase 4. ‐ CK‐MM |
Specific knowledge is needed to answer this question. Recall that troponin is a newer enzyme that can be measured very early during myocardial damage and is an indicator of myocardial damage and thus myocardial infarction. |
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70 The nurse is planning for a multidisciplinary team Correct answer: 2 The client’s level of risk for self‐harm is a major concern. The client may need a private room meeting concerning a client with bipolar disorder. In (option 1) and restricted visitors (option 3) if in a manic state. The client should not be discussing the client’s safety needs, the nurse would be overstimulated (option 4). sure to include: 1.‐ Placement of the client in a four‐bed room. |
Critical words in the stem of the question are safety and bipolar disorder. Use nursing knowledge to associate depression as part of bipolar disorder with the threat to safety with suicide as a form of self‐harm. This will lead you to the correct answer. |
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‐ The client’s risk level for self‐harm. ‐ Unrestricted visitors. ‐ The need of the client to participate daily in many concentrated activities. |
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71 A nurse is teaching a female client newly diagnosed Correct answer: 4 Ciprofloxacin is not recommended for Helicobacter pylori infection during pregnancy. The with Helicobacter pylori infection. The nurse other medications can be used after consulting with the physician. anticipates that which of the following medications will not be used after learning the client is pregnant?
1. ‐ Metronizadole 2. ‐ Amoxicillin 3. ‐ Clarithromycin 4. ‐ Ciprofloxacin |
The core issue of the question is knowledge of the pregnancy categories of the specific drugs listed. Use the process of elimination to make a selection, realizing that specific drug knowledge is needed to answer the question. |
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72 The nurse admitting a client with a history of Correct answer: 2 Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere trigeminal neuralgia (tic Douloureux) would question from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric the client about which of the following manifestations? shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth.
1. ‐ Facial droop accompanied by numbness and tingling 2. ‐ Stabbing pain that occurs with twitching of part of the face 3. ‐ Aching pain and ptosis of the eyelid 4. ‐ Burning pain and intermittent facial paralysis |
Note the critical word neuralgia in the question, which tells you the pain is of nervous system origin. Recalling that this type of pain is usually sharp, stabbing, and possibly burning may help you to eliminate some incorrect options. Distinguish between spasm associated with this disorder and paralysis (an opposite finding) to discriminate between options 2 and 4. |
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73 Which of the following would be an appropriate Correct answer: 1 Abuse of laxatives and diuretics is a frequent purging behavior for bulimic clients. Options 2 intervention for the nurse to include in a plan of care and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a for a client with clinical diagnosis of bulimia? reward.
1. ‐ Assess for laxative and diuretic possession. 2. ‐ Supervise mealtimes to ensure eating. 3. ‐ Observe for ritualistic eating patterns. 4. ‐ Reward nonpurging behavior with a favorite snack. |
The critical word in the question is bulimia. Recall that this disorder has the classic features of binging and purging to guide you to the correct answer, which in this question is one that signifies agents that help one to purge. |
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74 A client has a strong family tendency toward Correct answer: 3 Lifestyle modifications and recognition of risk factors are important parts of prevention of hypertension. He denies that he will get hypertension long‐term complications. Family history is a very strong risk factor but encouraging the client because he watches what he eats, gets plenty of to maintain his current lifestyle and following up with health screening would be the best plan exercise, and keeps his weight within normal range. of action. False reassurance that he will never be hypertensive and prophylactic When implementing the plan of care, the nurse would antihypertensive medications are inappropriate. do which of the following?
1. ‐ Praise the client and reassure him that these actions will prevent him from becoming hypertensive. 2. ‐ Emphasize that no matter what he does, the client will eventually develop hypertension because of his family history. 3. ‐ Recognize the client’s efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications. 4. ‐ Recommend that the client request antihypertensive medications prophylactically because of his family history. |
The core issue of the question is lifestyle management to reduce the risk of developing hypertension. Select the option that focuses on prevention while addressing the continued risk that the client faces. |
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75 A parent asks the nurse what to do with rough edges Correct answer: 4 When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be of her child’s cast, which are beginning to cause covered to prevent skin irritation. This can be done by petaling the cast edges with strips of excoriation on the child’s skin. Which of the following adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the responses by the nurse describes the appropriate outside of the cast. action to take? 1. ‐ “Perform good skin care to the skin around the cast edges, with a protective barrier like Vaseline.” 2. ‐ “Call the physician to have the rough edges of the cast cut away.” |
The wording of the question indicates that the correct response is a true statement. Eliminate options 1 and 3 first as least plausible after visualizing these options, then discard option 2 as unrealistic, since the procedure would be completed at the time of application. |
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‐ “Tape a soft towel to the edge of the cast to provide some protection from the rough edges.” ‐ “Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast.” |
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76 A 3‐month‐old infant is diagnosed with leukemia. Correct answer: 3 Immunizations should be withheld during leukemia exacerbations because the immune Which of the following does the nurse anticipate will system is compromised and the client cannot manage an appropriate response to the be part of the plan of care for this infant? immunization. There is no need to place the client in isolation without added evidence of immunosuppression (option 1). Options 2 and 4 are irrelevant to the issue of the question.
1. ‐ The baby will be placed in isolation. 2. ‐ Leukemia is familial and other children should be assessed. 3. ‐ All immunizations will be withheld during exacerbations. 4. ‐ The baby will be NPO during chemotherapy. |
The core issue of the question is knowledge that leukemia adversely affects the immune system. With this in mind, the nurse needs to be mindful that immunizations will need to be withheld during an exacerbation. Use nursing knowledge and the process of elimination to make a selection. |
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77 The registered nurse (RN) is assigned to the Correct answer: 1 The RN is responsible for delegating tasks appropriately and is responsible for the actions of postpartum unit. Which task could the RN safely unlicensed personnel. Ambulating a postoperative client is the only task from those listed that delegate to a beginning student nurse? the RN could delegate to a novice student. The other tasks require higher level assessment and critical thinking skills and should be performed by the RN.
1. ‐ Ambulate a client who delivered by cesarean 2 days ago. 2. ‐ Complete the admission assessment on a newly delivered client. 3. ‐ Call the physician to report a low hemoglobin level. 4. ‐ Verify a unit of blood prior to transfusion. |
Note the critical word beginning to describe the student nurse. With this in mind, select the delegation assignment that is simple and procedural in nature, and does not require assessment, teaching, or advanced knowledge in nursing. |
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78 A client presents to the Emergency Department with Correct answer: 2 The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of a stab wound to the right upper abdominal quadrant. the early shock symptoms, which are presented, it would be expected that this organ has The client’s vital signs are BP 85/60, pulse 125, and possibly been lacerated, causing extensive uncontrolled internal bleeding. The other organ respiratory rate of 28 breaths/minute. The nurse systems would not be located in this area. should immediately suspect damage to what organ?
1. ‐ Stomach 2. ‐ Liver 3. ‐ Large intestine 4. ‐ Kidney |
First analyze the client’s vital signs to determine that the client’s status is consistent with a shock state. Then determine which organs are located in the right upper quadrant. Associate the liver, which is a vascular organ, and the location to determine the correct option. |
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79 The client is scheduled for a barium enema and is Correct answer: 2 The client will, in most cases, return to the unit with barium still present in the bowel. The expressing concern that the barium will not be physician will order laxatives or enemas if the client is potentially not able to expel the barium evacuated and a bowel obstruction will occur. What on his or her own. The nurse should encourage the client to increase fluid intake if possible as would be the best response for the nurse to make to well. This is a common concern for many clients undergoing this procedure, and their feelings the client? should not be ignored or belittled. 1. ‐ “Don’t worry. The physicians will make sure that all of the barium is out of your bowel before you return to the unit.” 2. ‐ “You will be given extra fluids, laxatives, and an enema if you have not expelled the barium within 24 hours.” 3. ‐ “The barium they are using will not cause an obstruction.” 4. ‐ “Should I have the test rescheduled for when you are less concerned about it?” |
Note the critical words best response in the stem of the question. This tells you that the correct response is a true statement of fact. Recall that this test can cause constipation from residual barium to aid in selecting the correct option. |
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80 The nurse is conducting an educational group on an Correct answer: 1 The only respectful therapeutic response here is option 1. The others are contraindicated for inpatient unit. One of the clients has not spoken during any group process. Everyone does not need to participate in every session (option 2). It is the group. An effective therapeutic response by the inappropriate to focus the group’s attention on one individual because of level of participation nurse would include: (option 3). The client should be allowed to remain part of the group until the client is ready to participate (option 4). 1. ‐ Allowing the client to remain present but nonparticipative. 2. ‐ Explaining to the client that everyone in the group needs to participate. 3. ‐ Asking the rest of the group members how they feel about this member not sharing. |
The core issue of the question is knowledge of group process and conduct of a group meeting. Use knowledge of this treatment modality and the process of elimination to make a selection. |
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4.‐ Stopping the group and asking the client to leave. |
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81 A client is experiencing seizure activity. The nurse Correct answer: 3 Phenytoin is a first‐line anticonvulsant medication that is used to control seizure activity. should prepare to administer which of the following Selegilene (option 1) is used to treat Parkinson’s disease. Diclofenac (option 2) is an NSAID, medications according to protocol? while sumatriptan (option 4) is used to treat headaches. 1. ‐ Selegilene (Eldepryl) 2. ‐ Diclofenac sodium (Voltaren) 3. ‐ Phenytoin (Dilantin) 4. ‐ Sumatriptan (Imitrex) |
The core issue of the question is knowledge of medications that are effective against seizure activity. Use specific drug knowledge and the process of elimination to make a selection. |
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82 As part of the ongoing assessment of a client who has Correct answer: 1 After burn injuries, an elevated potassium level (normal 3.5–5.1 mEq) is expected because of an electrical burn, a complete blood count (CBC), cellular tissue damage with release of intracellular potassium into the bloodstream. The electrolyte panel, and renal panel were ordered. The hematocrit will be elevated (not decreased as in option 4) due to hemoconcentration, and the nurse would expect to find which of the following white blood cell count will be elevated as part of the inflammatory response to injury. results? 1. ‐ Potassium level of 5.9 mEq/L 2. ‐ Potassium level of 2.8 mEq/L 3. ‐ Hematocrit of 28 mg/dL 4. ‐ White blood cell count of 4,000/mm3 |
First visualize what happens when cells are destroyed—intracellular contents are released into the circulation. Secondly, with burn injury fluid is lost through the burn surface and can lead to hemoconcentration. With this in mind, eliminate each option except potassium, which increases for both of the reasons just stated. |
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83 A client with congestive heart failure (CHF) has been Correct answer: 2 In a 2‐gram sodium diet, foods high in sodium content should be eliminated. It is not enough advised to follow a low‐sodium diet. Which statement to stop adding salt or to go only by taste; clients should also be taught to read food labels for by the client indicates to the nurse that diet teaching hidden sodium content. Added salt while cooking is allowed in a 4‐gram sodium diet, not a 2‐ has been effective? gram sodium diet. 1. ‐ “If I stop adding table salt, I shouldn’t have any problems.” 2. ‐ “I need to avoid eating processed foods and canned meats and vegetables.” 3. ‐ “I can still use a small amount of table salt in cooking.” 4. ‐ “I only have to worry about salty‐tasting foods like potato chips.” |
The critical words in the question are low‐sodium. With this in mind, eliminate options 3 and 4 first because they are the least restrictive. Then eliminate option 1 because it is less comprehensive than option 2 and because option 2 addresses other sources of hidden sodium. |
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84 After delivery, a Chinese client states she needs to Correct answer: 2 Chinese clients may perceive an imbalance in the hot and cold forces in the body after restore the balance between hot and cold forces in her delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if body and refuses to bathe. The most appropriate warmed) to regain a sense of balance between these extremes. A client’s culture plays a very nursing intervention is to: important part in who they are, and nurses should respect the client’s wishes as long as it will not result in harm to the client or others. 1. ‐ Show her a videotape on postpartum self‐care. 2. ‐ Recognize her cultural beliefs and respect her wishes. 3. ‐ Discuss postpartum complications related to poor personal hygiene. 4. ‐ Request a psychiatric consult for this client. |
Use principles of culturally competent care to answer this question. If using a multicultural perspective rather than one centered in a Western health care approach, you will be able to eliminate each incorrect response easily. |
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85 While talking with a client the nurse notes that the Correct answer: 3 When a client’s level of anxiety markedly increases the nurse can relieve the anxiety by client rapidly becomes more uncomfortable and altering the focus of the discussion. Asking the client more details or abruptly stopping the anxious. What action should the nurse take? interview will probably increase the client’s anxiety level. Asking the client to relax may or may not be effective in reducing the client’s anxiety.
1. ‐ Ask specific, focused questions to elicit detailed information about the source of the client’s stress. 2. ‐ Encourage the client to try to relax by using guided imagery or other means preferred by the client. 3. ‐ Refocus the conversation on a less threatening topic. 4. ‐ Stop the interview at this time. |
The core issue of the question is the ability to recognize escalating anxiety in a client and determining the best means to effectively reduce it. Use knowledge of therapeutic measures for anxious clients and the process of elimination to make a selection. |
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