Nursing Diagnostic Examination Quiz

1. The visiting nurse makes a postpartum visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The initial nursing intervention would be to

Call the police to report indications of domestic violence

Confront the husband about abusing his wife

Leave the home because of the unsafe environment

Interview the client alone to determine the origin of the injuries

It would be wrong to assume domestic violence without further assessment. Separate the suspected victim from the partner until battering has been ruled out.

Explanation

It would be wrong to assume domestic violence without further assessment. Separate the suspected victim from the partner until battering has been ruled out.

2. The nurse is assessing a client's home in preparation for discharge. Which of the following should be given priority consideration?

Family understanding of client needs

Financial status

Location of bathrooms

Proximity to emergency services

Functional communication patterns between family members are fundamental to meeting the needs of the client and family.

Explanation

Functional communication patterns between family members are fundamental to meeting the needs of the client and family.

3. The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be to

Medicate the client for pain

Call the provider

Cover the wound with sterile saline dressing

Place the bed in a flat position

When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be affected.

Explanation

When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be affected.

4. After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states "I am so confused. I lost my money. I just can't remember telephone numbers." The most therapeutic response for the nurse to make is

"You were seriously ill and needed the treatments."

"Don't get upset. The confusion will clear up in a day or two."

"It is to be expected since most clients have the same results."

"I can hear your concern and that your confusion is upsetting to you."

Communicating caring and empathy with the acknowledgment of feelings is the initial response. Afterward, teaching about the expected short-term effects would be discussed.

Explanation

Communicating caring and empathy with the acknowledgment of feelings is the initial response. Afterward, teaching about the expected short-term effects would be discussed.

5. What must be the priority consideration for nurses when communicating with children?

Present environment

Physical condition

Nonverbal cues

Developmental level

While each of the factors affect communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child’s developmental level must be considered when selecting communication approaches.

Explanation

While each of the factors affect communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child’s developmental level must be considered when selecting communication approaches.

6. A client has been started on long-term corticosteroid therapy. Which of the following comments by the client indicate the need for further teaching?

"I will stop taking the medication for 1 week every month."

"I will eat foods high in potassium."

"I will keep a weekly weight record."

"I will take medication with food."

Emphatically warn against discontinuing steroid dosage abruptly because that may produce a fatal adrenal crisis.

Explanation

Emphatically warn against discontinuing steroid dosage abruptly because that may produce a fatal adrenal crisis.

7. The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?

Link the caregiver with a support group

Ask friends to visit regularly

Schedule a home visit each week

Request anti-anxiety prescriptions

Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer''s chapters.

Explanation

Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer''s chapters.

8. A client telephoned the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant.

Estrogen

HCG

Alpha-fetoprotein

Progesterone

Human chorionic gonadotropin (HCG) is the biological marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.

Explanation

Human chorionic gonadotropin (HCG) is the biological marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.

9. The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?

"The first of every month, because it is easiest to remember"

"Right after the period, when your breasts are less tender"

"Do the exam at the same time every month"

"Ovulation, or mid-cycle is the best time to detect changes"

The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.

Explanation

The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.

10. A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?

"When I take in a deep breath, it stabs like a knife."

"The pain came on after dinner. That soup seemed very spicy."

"When I turn in bed to reach the remote for the TV, my chest hurts."

"I feel pressure in the middle of my chest, like an elephant is sitting on my chest."

This is a classic description of chest pain in men caused by myocardial ischemia. Women experience vague feelings of fatigue and back and jaw pain.

Explanation

This is a classic description of chest pain in men caused by myocardial ischemia. Women experience vague feelings of fatigue and back and jaw pain.

11. A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?

, beer, cheese, liver and chocolate

Wine, citrus fruits, yogurt and broccoli

Beer, cheese, beef and carrots

Wine, apples, sour cream and beef steak

These foods are tyramine rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.

Explanation

These foods are tyramine rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.

12. A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?

Fresh juice, carrots, vanilla pudding

Apple juice, ham salad, fresh pineapple

Hamburger, fries, strawberry shake

Red wine, fava beans, aged cheese

Red wine and cheese contain tyramine (as do chicken liver and ripe bananas) and so are contraindicated when taking MAOIs. Fava beans contain other vasopressors that can interact with MAOIs also causing malignant hypertension.

Explanation

Red wine and cheese contain tyramine (as do chicken liver and ripe bananas) and so are contraindicated when taking MAOIs. Fava beans contain other vasopressors that can interact with MAOIs also causing malignant hypertension.

13. The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?

Central venous pressure reading of 11

Respiratory rate of 22

Pulse rate of 48 BPM

Blood pressure of 144/92

One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).

Explanation

One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).

14. The nurse is caring for a 2-month-old infant with a congenital heart defect. Which of the following is a priority nursing action?

Provide small feedings every 3 hours

Maintain intravenous fluids

Add strained cereal to the diet

Change to reduced calorie formula

Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.

Explanation

Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.

15. When teaching a client with a new prescription for lithium (Lithane) for the treatment of bipolar disorder, which of these should the nurse emphasize?

Maintaining a salt restricted diet

Reporting vomiting or diarrhea

Taking other medication as usual

Substituting generic form if desired

If dehydration results from vomiting, diarrhea or excessive perspiration, tolerance to the drug may be altered and symptoms may return.

Explanation

If dehydration results from vomiting, diarrhea or excessive perspiration, tolerance to the drug may be altered and symptoms may return.

16. The nurse is assessing a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What should be the initial nursing action?

Call the health care provider

Encourage deep breathing

Elevate the foot of the bed

Turn her to her left side

The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the side reduces this pressure and relieves postural hypotension.

Explanation

The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the side reduces this pressure and relieves postural hypotension.

17. The nurse is assessing a client with chronic obstructive pulmonary disease receiving oxygen for low PaO2 levels. Which assessment is a nursing priority?

Evaluating SaO2 levels frequently

Observing skin color changes

Assessing for clubbing fingers

Identifying tactile fremitus

The best method to evaluate a client''s oxygenation is to evaluate the SaO2. This is just as effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive.

Explanation

The best method to evaluate a client''s oxygenation is to evaluate the SaO2. This is just as effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive.

18. The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?

Heart rate

Neurologic status

Urine output

Blood pressure

The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.

Explanation

The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.

19. A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest

During the night shift when staffing is limited

When the client’s mood improves with an increase in energy level

At the time of the client's greatest despair

After a visit from the client's estranged partner

Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

Explanation

Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

20. When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on

Recognizing findings of toxicity

Taking the medication at specified times

Increasing the dosage based on blood glucose

Distinguishing hypoglycemia from hyperglycemia

A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Langerhans to produce insulin.

Explanation

A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Langerhans to produce insulin.

21. Which medication is more helpful in treating bulimia than anorexia?

Amphetamines

Sedatives

Anticholinergics

Narcotics

In contrast to anorexics, individuals with bulimia are troubled by their behavioral characteristics and become depressed. The person feels compelled to binge, purge and fast. Feeling helpless to stop the behavior, feelings of self-disgust occur.

Explanation

In contrast to anorexics, individuals with bulimia are troubled by their behavioral characteristics and become depressed. The person feels compelled to binge, purge and fast. Feeling helpless to stop the behavior, feelings of self-disgust occur.

22. The nurse is working in a high-risk antepartum clinic. A 40-year-old woman in the first trimester gives a thorough health history. Which information should receive priority attention from the nurse?

Her father and brother are insulin dependent diabetics

She has taken 800 mcg of folic acid daily for the past year

Her husband was treated for tuberculosis as a child

She reports recent use of over-the counter sinus remedies

Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.

Explanation

Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.

23. . A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

Bowel sounds

Heart rate

Peripheral pulses

Lung sounds

Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

Explanation

Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

24. A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?

Ataxia and coarse hand tremors

Vomiting, diarrhea and lethargy

Pruritus, rash and photosensitivity

Electrolyte imbalance and cardiac arrhythmias

These are early signs of lithium toxicity.

Explanation

These are early signs of lithium toxicity.

25. As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?

What and how much the client drinks, according to family and friends

The blood alcohol level of the client

The blood pressure level of the client

The blood glucose level of the client

Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.

Explanation

Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.

26. A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to

Begin intravenous therapy

Initiate continuous blood pressure monitoring

Administer oxygen therapy

Institute cardiac monitoring

Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.

Explanation

Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.

27. Initial postoperative nursing care for an infant who has had a pyloromyotomy would initially include

Bland diet appropriate for age

Intravenous fluids for 3-4 days

NPO then glucose and electrolyte

Formula or breast milk as tolerated

Post-operatively, the initial feedings are clear liquids in small quantities to provide calories and electrolytes.

Explanation

Post-operatively, the initial feedings are clear liquids in small quantities to provide calories and electrolytes.

28. The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75-year-old client's

Poor nutritional status

Decreased gastrointestinal motility

Increased splanchnic blood flow

Altered peripheral resistance

Together with shrinkage of the gastric mucosa, and changes in the levels of hydrochloric acid, this will decrease absorption of medications and interfere with their actions.

Explanation

Together with shrinkage of the gastric mucosa, and changes in the levels of hydrochloric acid, this will decrease absorption of medications and interfere with their actions.

29. A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?

Give him written material from the American Heart Association about sexual activity with heart disease

Answer his questions accurately in a private environment

Schedule a private, uninterrupted teaching session with both the client and his wife

Assess the client's knowledge about his health problems

The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.

Explanation

The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.

30. A client is treated in the emergency room for diabetic ketoacidosis and a glucose level of 650mg.D/L. In assessing the client, the nurse's review of which of the following tests suggests an understanding of this health problem?

Serum calcium

Serum magnesium

Serum creatinine

Serum potassium

Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Review of this lab finding suggests the nurse has knowledge of this problem.

Explanation

Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Review of this lab finding suggests the nurse has knowledge of this problem.

31. The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regard to tardive dyskinesia?

TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30

It can occur in clients taking antipsychotic drugs longer than 2 years

Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible

TD can easily be treated with anticholinergic drugs

Tardive dyskinesia is an extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early symptoms of tardive dyskinesia are fasciculations of the tongue or constant smacking of the lips.

Explanation

Tardive dyskinesia is an extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early symptoms of tardive dyskinesia are fasciculations of the tongue or constant smacking of the lips.

32. A nurse is caring for a client who has just been admitted with an overdose of aspirin. The following lab data is available: PaO2 95, PaCO2 30, pH 7.5, K 3.2 mEq/l. Which should be the nurse's first action?

Monitor respiratory rate

Monitor intake and output every hour

Assist the client to breathe into a paper bag

Prepare to administer oxygen by mask

Side effects of aspirin toxicity include hyperventilation, which can result in respiratory alkalosis in the initial stages. Breathing into a paper bag will prevent further reduction in PaCO2.

Explanation

Side effects of aspirin toxicity include hyperventilation, which can result in respiratory alkalosis in the initial stages. Breathing into a paper bag will prevent further reduction in PaCO2.

33. The client asks the nurse how the health care provider could tell she was pregnant "just by looking inside." What is the best explanation by the nurse?

Bluish coloration of the cervix and vaginal walls

Pronounced softening of the cervix

Clot of very thick mucous that obstructs the cervical canal

Slight rotation of the uterus to the right

Chadwick''s sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.

Explanation

Chadwick''s sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.

34. The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?

Repeatedly remind the client of the time and location

Explain the risks of walking with no purpose

Use protective devices to keep the client in the bed or chair in the room

Attach a wander-guard sensor band to the client's wrist

This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.

Explanation

This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.

35. In response to a call for assistance by a client in labor, the nurse notes that a loop on the umbilical cord protrudes from the vagina. What is the priority nursing action?

Call the health care provider

Check fetal heartbeat

Put the client in knee-chest position

Turn the client to the side

Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The Trendelenburg position accomplishes this. The exposed cord is covered with saline soaked gauze, not reinserted. The fetal heart rate also should be checked, and the provider called. A prolapsed umbilical cord is a medical emergency.

Explanation

Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The Trendelenburg position accomplishes this. The exposed cord is covered with saline soaked gauze, not reinserted. The fetal heart rate also should be checked, and the provider called. A prolapsed umbilical cord is a medical emergency.

36. Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?

Potassium

Sodium

Chloride

Calcium

Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.

Explanation

Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.

37. A client is discharged on warfarin sulfate (Coumadin). Which statement by the client indicated a need for further teaching?

"I know I must avoid crowds."

"I will keep all laboratory appointments."

"I plan to use an electric razor for shaving."

"I will report any bruises for bleeding."

There are no specific reasons for the client on Coumadin to avoid crowds. General instructions for any cardiac surgical client include limiting exposure to infection.

Explanation

There are no specific reasons for the client on Coumadin to avoid crowds. General instructions for any cardiac surgical client include limiting exposure to infection.

38. Which clinical finding would the nurse expect to assess first in a newborn with spastic cerebral palsy?

Cognitive impairment

Hypotonic muscular activity

Seizures

Criss-crossing leg movement

Cerebral palsy is a neuromuscular impairment resulting in muscular and reflexive hypertonicity and the criss-crossing, or scissoring leg movements.

Explanation

Cerebral palsy is a neuromuscular impairment resulting in muscular and reflexive hypertonicity and the criss-crossing, or scissoring leg movements.

39. After assessing a 70-year-old male client's laboratory results during a routine clinic visit, which one of the following findings would indicate an area in which teaching is needed:

Serum albumin 2.5 g/dl

LDL Cholesterol 140 mg/dl

Serum glucose 90 mg/dl

RBC 5.0 million/mm3

Serum albumin level is low (normal 3.0 – 5.0 g/dl in elders), indicating nutritional counseling to increase dietary protein is needed. Socioeconomic factors may need to be addressed to help the client comply with the recommendation.

Explanation

Serum albumin level is low (normal 3.0 – 5.0 g/dl in elders), indicating nutritional counseling to increase dietary protein is needed. Socioeconomic factors may need to be addressed to help the client comply with the recommendation.

40. A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse knows that fetal monitoring must now assess for what complication?

Early decelerations

Late accelerations

Variable decelerations

Periodic accelerations

When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.

Explanation

When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.