A child diagnosed with poison ivy dermatitis has not been playing in or exposed to wooded areas. After asking the parent about possible contact, which of these situations should the nurse recognize as the highest risk for exposure to poison ivy?
Correct answer: B
A
Incorrect
Low risk. The dermatitis itself is not contagious once the oil has been washed off the skin.
B
Correct
Highest risk. Burning the plant releases urushiol in the smoke, which carries the oil onto skin and airways well away from any wooded area.
C
Incorrect
Low risk. The rash cannot be caught from another child; only the oil transmits it.
D
Incorrect
Low risk. A patio has no plant contact unless the oil has been carried there.
Full rationale from the source
Direct contact with the toxic oil, urushiol, is the most common cause of this dermatitis. However, smoke from burning leaves or stems of the poison ivy plant can produce a reaction. You cannot get poison ivy from another person unless you have direct contact with urushiol that is still on the person or their clothing. None of the other choices present this risk. A child diagnosed with poison ivy last week will no longer have urushiol on the body or clothes. Throwing a ball to a child with poison ivy is not direct contact. A patio is usually made of concrete or brick where there would be less chance of exposure to poison ivy.
2
The parent of a 4-month-old infant asks the nurse about how to protect the child from sunburn. Which of the following statements is most appropriate for the sun protection of infants?
Correct answer: B
A
Incorrect
Not recommended at this age. Sunscreen is generally avoided under six months, and shade and clothing are used instead.
B
Correct
Best advice. Lightweight covering clothing and a brimmed hat physically block ultraviolet light, which is the recommended protection for an infant under six months.
C
Incorrect
Overstated. Sunscreen is appropriate for older children; the restriction applies to young infants.
D
Incorrect
Inaccurate. Ultraviolet light penetrates cloud, so cloudy weather is not protective.
Full rationale from the source
Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands).
3
The nurse is discharging a 6-year-old child diagnosed with recurrent urinary tract infections (UTIs). Which of the following is the most appropriate instruction to give the caregiver?
Correct answer: A
A
Correct
Correct instruction. Plain water avoids irritating the urethra, and shampooing last means the child is not sitting in soapy water.
B
Incorrect
Harmful. Holding urine allows bacteria to multiply in the bladder and is a direct cause of recurrent infection.
C
Incorrect
Not the priority. Laundry rinsing has little bearing on urinary infection.
D
Incorrect
Harmful. Antibacterial and perfumed soaps irritate the perineum and disturb normal flora.
Full rationale from the source
Management of urinary tract infections includes hygiene practices. This includes using plain water for the bath, shampooing the hair last, and rinsing the genital area with plain water after shampoo is rinsed from the hair. The child should not delay voiding as this could promote UTIs. It is not necessary to rinse the laundry several times or use antibacterial soaps.
4
An 18-month-old child is awaiting a renal transplant. When reviewing the child's health history, the nurse notes that the child has not had the first measles, mumps, rubella (MMR) immunization. Which action should the nurse take?
Correct answer: D
A
Incorrect
Inaccurate as stated. Live vaccines are withheld after transplant, when the client is immunosuppressed, not because of chronic renal disease itself.
B
Incorrect
Inaccurate. There is no inactivated form of the measles, mumps and rubella vaccine.
C
Incorrect
Inaccurate. The risk of the diseases far outweighs the vaccine's side effects.
D
Correct
Correct. MMR is a live vaccine, so it is given before transplant while the child can still mount a response and before immunosuppression begins.
Full rationale from the source
The measles, mumps, and rubella (MMR) vaccine is a live virus vaccine and should be given at this time, pre-transplant. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the child's compromised immune system.
5
The nurse is caring for a client who asks the nurse to explain the basic ideas of homeopathic medicine. Which of the following responses by the nurse would best explain the approach of such remedies?
Correct answer: D
A
Incorrect
Describes other therapies. Energy work such as therapeutic touch aims to affect bodily energy.
B
Incorrect
Not the principle. Homeopathy is not concerned with fluid balance.
C
Incorrect
Describes conventional antimicrobials rather than homeopathy.
D
Correct
Correct. Homeopathy uses minute doses intended to provide a gentle stimulus that prompts the body's own defences.
Full rationale from the source
Homeopathic medicine treats clients with minute doses of plant, mineral, or animal substances that provide a gentle stimulus to the body's own defenses.
6
A community health nurse is speaking to a group of community members about alternative therapies. What is the focus of chiropractic treatment?
Correct answer: B
A
Incorrect
Describes physiotherapy or exercise therapy.
B
Correct
Correct. Chiropractic is based on manipulation of the spinal column to relieve interference with nerve transmission.
C
Incorrect
Describes energy-based therapies rather than chiropractic.
D
Incorrect
Describes mind-body practices such as meditation or yoga.
Full rationale from the source
The theory underlying chiropractic treatment is that interference with the transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).
7
The nurse is caring for a client who is frequently admitted for acute exacerbations of asthma. The client admits that she does not use her medications as prescribed because she often does not feel short of breath. Which explanation by the nurse best describes the long-term consequences of uncontrolled airway inflammation?
Correct answer: C
A
Incorrect
Not the consequence described. Asthma does not predispose specifically to recurrent pneumonia.
B
Incorrect
Describes emphysema. Alveolar destruction and ballooning belong to chronic obstructive pulmonary disease.
C
Correct
Correct. Repeated exacerbations cause airway remodelling, with thickening and fibrosis that produce permanent loss of lung function.
D
Incorrect
Inaccurate. Asthma affects the smaller terminal bronchioles, and the bronchoconstriction is episodic rather than continuous.
Full rationale from the source
Asthma is categorized as a chronic, hyper-responsive disorder affecting the terminal bronchioles. Exacerbation of asthma or an "asthma attack" is an acute event. However, the effects of an increased number of exacerbations and not using the medication is lung remodeling. This lung remodeling results in more narrow airways and increased mucous. By explaining the consequences of not using the medication, the nurse is reinforcing the need for daily management. Degeneration of alveoli causing increased expansion is a result of emphysema. Asthma does increase the risk of pneumonia, but this option does not address the permanent long-term issues associated with not taking the medication as prescribed. Chronic bronchoconstriction of the large airways is not associated with asthma.
8
The nurse is caring for a client who has active tuberculosis and a history of nonadherence. Which action by the nurse would represent the most appropriate care for this client?
Correct answer: B
A
Incorrect
Pointless. Once a skin test is positive it stays positive, so repeating it monitors nothing.
B
Correct
Best action. Twice-weekly visits allow directly observed therapy, which is the established approach for a client who has not adhered to treatment.
C
Incorrect
Disproportionate. Prolonged hospitalisation for months of therapy is neither feasible nor necessary once the client is no longer infectious.
D
Incorrect
Insufficient. A mask limits spread but does nothing to ensure the medication is actually taken.
Full rationale from the source
Recommended treatment for active tuberculosis (TB) requires multiple anti-TB (antimicrobial) drugs taken over many months, making adherence a very real problem. Dosing may be done daily or twice a week. Noncompliance with such a regimen can lead to persistent infection, re-infection, or antibiotic resistance. Direct-observed therapy (DOT), the practice of observing the client swallow their antituberculosis medications, is a recognized method for ensuring clients' compliance with the long drug regimens used for TB. A program such as regular clinic visits can be set up to directly observe the client taking the medication. The other interventions are not appropriate to ensure compliance.
9
A nurse is teaching a group of college students about breast self-examination when a student asks for the best time to perform the monthly self-exam. What is the best reply by the nurse?
Correct answer: B
A
Incorrect
Less specific. A fixed date ignores where the client is in her cycle, when tissue is least tender and least nodular.
B
Correct
Best timing. About a week after the period begins, breasts are least swollen and tender, so changes are easiest to feel.
C
Incorrect
Less specific. The first of the month has no relation to the hormonal cycle.
D
Incorrect
Poor timing. Mid-cycle breasts are more nodular and tender, which obscures findings.
Full rationale from the source
The best time for a breast self-exam (BSE) is one week or seven days after the first day of a menstrual cycle. This is when the breasts are no longer swollen or tender from hormonal elevation.
10
The school nurse is counseling a sexually active teenage girl about pregnancy prevention. The teenager reports a regular 32-day menstrual cycle. The nurse informs her she is most likely to get pregnant during which days in her menstrual cycle?
Correct answer: D
A
Incorrect
Too early for a 32-day cycle. These days would suit a 28-day cycle.
B
Incorrect
Far too early. Ovulation does not occur this early in a 32-day cycle.
C
Incorrect
Slightly early. This is the fertile window for a 28-day cycle.
D
Correct
Correct. Ovulation occurs about 14 days before menses, so in a 32-day cycle that falls near day 18, making days 17 to 19 the highest-risk window.
Full rationale from the source
Ovulation occurs 14 days before the onset of menses, thus the teenager with a 32-day cycle is most likely to get pregnant between days 17 and 19. The follicular phase occurs from menstruation to ovulation.
11
The nurse is informed by a client that her home pregnancy test was positive. The client asks what the pregnancy test is looking for. Which response by the nurse is appropriate?
Correct answer: D
A
Incorrect
Inaccurate. Estrogen rises in pregnancy but is not what the test detects.
B
Incorrect
Different test. Alpha-fetoprotein is measured later in pregnancy to screen for neural tube defects.
C
Incorrect
Reversed. Progesterone is maintained rather than absent in early pregnancy.
D
Correct
Correct. Home pregnancy tests detect human chorionic gonadotropin, which is produced by the developing placenta.
Full rationale from the source
Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy. Progesterone is the hormone that maintains pregnancy, and when its levels drop the woman will go into labor. Estrogen is at its highest level during pregnancy, however, it is not tested on a pregnancy test. Alpha-fetoprotein is part of a screening for birth defects.
12
The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. The client reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What should the nurse calculate as the estimated date of delivery (EDD)?
Correct answer: D
A
Incorrect
Incorrect. This does not follow the calculation.
B
Incorrect
Incorrect. This subtracts only one month.
C
Incorrect
Incorrect. This subtracts two months.
D
Correct
Correct. Naegele's rule: 16 March minus three months is 16 December, plus seven days gives 23 December.
Full rationale from the source
Naegele's rule states: add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery.
13
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about the client's obstetric history which includes 3-year-old twins and a miscarriage 10 years ago. How should the nurse accurately document this information?
Correct answer: C
A
Incorrect
Incorrect. This omits the miscarriage from the gravida count.
B
Incorrect
Incorrect. Twins count as one delivery, so para is 1 rather than 2.
C
Correct
Correct. Three pregnancies in total, the miscarriage, the twins and the current one, with one delivery beyond 20 weeks.
D
Incorrect
Incorrect. There have been three pregnancies, not four, and one delivery, not two.
Full rationale from the source
Para is the number of deliveries (of an infant more than 20 weeks gestation). Regardless of how many babies are delivered at one time (twins, triplets, etc.), the delivery is still counted as 1. Gravida is the number of pregnancies. This woman had a miscarriage (at 12 weeks), so that would be gravida 1, para 0. With the twins, the count would be gravida 2, para 1. With the current pregnancy, she is gravida 3, para 1 - 3rd pregnancy to date, but only one previous delivery (of the twins).
14
The nurse is beginning nutritional counseling with a pregnant client. Which step should the nurse take first?
Correct answer: C
A
Incorrect
Comes later. Assessing knowledge of a specific tool is part of teaching rather than the first step.
B
Incorrect
Comes later. Explaining changes is the teaching phase, which follows assessment.
C
Correct
Do this first. A diet history establishes what the client actually eats, which is what any teaching must be built on.
D
Incorrect
Comes later. Pica teaching is one topic among several and follows the assessment.
Full rationale from the source
Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information. The results of this information provide the basis of the planned educational needs.
15
The nurse is caring for a pregnant client who has orders for a routine alpha-fetoprotein (AFP) blood test. The client asks the nurse what is the purpose of this test. Which is the best response by the nurse?
Correct answer: A
A
Correct
Correct explanation. Alpha-fetoprotein screening identifies raised levels associated with neural tube defects such as spina bifida and anencephaly.
B
Incorrect
Inaccurate. Gestational age is established by dates and ultrasound.
C
Incorrect
Inaccurate. Placental function is assessed by other means.
D
Incorrect
Inaccurate. Growth is assessed by fundal height and ultrasound measurement.
Full rationale from the source
Alpha-fetoprotein (AFP) is a glycoprotein produced by the fetus's liver and small amounts are excreted in the urine and gastrointestinal secretions. The AFP level rises until 14 to 15 weeks of gestation and then will begin to decline. Elevated levels of AFP in maternal circulation are associated with an increased risk for neural tube defects, such as spina bifida and meningocele. If the test is elevated, further evaluative tests are indicated. The other responses are incorrect.
16
The nurse is reviewing the client's medical record and notes that the client has been taking an oral contraceptive for several years. For which potential complications should the nurse monitor the client? Select all that apply.Select all that apply
Correct answers: A, B, Frationale written to fill a gap in the source
A
Correct
Monitor for this. Mood changes, including depression, are a recognised adverse effect.
B
Correct
Monitor for this. Combined oral contraceptives increase clotting factors and raise the risk of venous thromboembolism, particularly with smoking or increasing age.
C
Incorrect
Not a risk. These agents are associated with a reduced incidence of colorectal cancer.
D
Incorrect
Not a risk. Lighter menstrual bleeding reduces rather than increases the risk of iron deficiency anemia.
E
Incorrect
Not a risk. Effects on bone density are neutral or slightly protective in most users.
F
Correct
Monitor for this. There is a small increase in breast cancer risk with current use, which declines after stopping.
Full rationale from the source
Combined oral contraceptives carry a recognised risk of venous thromboembolism through their effect on clotting factors, and that risk rises sharply with smoking and age. Mood changes including depression are a reported adverse effect, and there is a small increase in breast cancer risk with current use that declines after stopping. The other three options are the opposite of risks: these agents reduce the incidence of colorectal cancer, lighten menstrual bleeding and so protect against iron deficiency anemia, and have a neutral or slightly protective effect on bone density in most users.
17
The nurse is caring for a female client with a body mass index of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? Select all that apply.Select all that apply
Correct answers: A, B, C, E
A
Correct
Associated. Excess adipose tissue around the neck and chest predisposes to obstructive sleep apnea.
B
Correct
Associated. Adipose tissue produces estrogen, which raises postmenopausal breast cancer risk.
C
Correct
Associated. Obesity increases cholesterol saturation of bile and the likelihood of gallstones.
D
Incorrect
Not associated. Chronic obstructive pulmonary disease is caused by smoking and inhaled exposures.
E
Correct
Associated. Obesity contributes to dyslipidemia, hypertension and insulin resistance, all of which drive coronary artery disease.
F
Incorrect
Not associated. Hyperthyroidism causes weight loss rather than resulting from obesity.
Full rationale from the source
A client with a body mass index (BMI) of 40 or greater is considered extremely (i.e., morbidly, severely) obese. A number of health risks are associated with obesity, including obstructive sleep apnea (OSA), colorectal and breast cancer, gallstones, and cardiovascular diseases (e.g., hypertension, atherosclerosis, and coronary artery disease). Chronic obstructive pulmonary disease (COPD) is associated with smoking or exposure to smoke. Hyperthyroidism is not associated with being overweight or obese.
18
Which of these activities are examples of primary prevention activities? Select all that apply.Select all that apply
Correct answers: A, C, D
A
Correct
Primary prevention. Vaccination prevents disease before it occurs.
B
Incorrect
Tertiary prevention. Rehabilitation limits the effects of established disease.
C
Correct
Primary prevention. Correct car seat installation prevents injury from happening.
D
Correct
Primary prevention. Exercise reduces the likelihood of disease developing.
E
Incorrect
Secondary prevention. Self-examination screens for disease that may already be present.
F
Incorrect
Secondary prevention. Cholesterol screening detects an existing abnormality.
Full rationale from the source
Engaging in an exercise class, correctly installing a child safety or car seat, and getting vaccinations are considered primary prevention activities. Rehabilitation falls under tertiary prevention. Cholesterol screening and breast self-exam are secondary prevention interventions.
19
The nurse is interviewing a client who reports that she might be pregnant. What information from the client is considered a presumptive finding of pregnancy? Select all that apply.Select all that apply
Correct answers: A, B, C, D
A
Correct
Client reported. Fatigue is a subjective, presumptive sign the client notices herself.
B
Correct
Client reported. Breast tenderness is subjective and presumptive.
C
Correct
Client reported. A missed period is the classic presumptive sign.
D
Correct
Client reported. Nausea is subjective and presumptive.
E
Incorrect
Examiner observed. Uterine changes such as Hegar's sign are probable signs found on examination.
F
Incorrect
Examiner observed. Cervical changes such as Goodell's and Chadwick's signs are probable signs found on examination.
Full rationale from the source
A newly-pregnant client will typically report subjective (presumptive) changes such as breast sensitivity, missed periods, nausea, and fatigue. Uterine and/or cervical changes cannot be subjectively reported by the client but will be findings assessed during a physical exam by the health care provider.
20
The nurse is providing information to a pregnant client about the potential risks of an amniocentesis. Which risk factors shall the nurse include? Select all that apply.Select all that apply
Correct answers: A, C, D
A
Correct
A recognised risk. The needle passes through the membranes, so leakage of fluid can follow.
B
Incorrect
Not a risk. Preeclampsia is unrelated to the procedure.
C
Correct
A recognised risk. Pregnancy loss is the most serious complication, though uncommon.
D
Correct
A recognised risk. Uterine irritation from the procedure can precipitate contractions.
E
Incorrect
Not a risk. An ectopic pregnancy is established long before amniocentesis is performed.
F
Incorrect
Not a risk. The procedure does not affect blood glucose.
Full rationale from the source
During amniocentesis, amniotic fluid is removed from the uterus through the insertion of a hollow needle through the abdominal wall and into the uterus. Reasons include genetic testing, fetal lung testing, and removal of excess amniotic fluid (polyhydramnios). Amniocentesis carries various risks, including leaking amniotic fluid, rupture of amniotic membrane, miscarriage or spontaneous abortion, preterm labor, needle injury to the fetus, Rh sensitization, and infection.
21
The nurse is caring for a client who has just experienced a spontaneous abortion (miscarriage). Which action should the nurse implement first?
Correct answer: B
A
Incorrect
Important but not first. Rho(D) immune globulin is given to an Rh-negative client, but only once she is physically stable.
B
Correct
Priority action. Hemorrhage is the immediate physical threat after spontaneous abortion, so bleeding is monitored before anything else.
C
Incorrect
Comes later. Grief support matters greatly but follows attention to physical safety.
D
Incorrect
Comes much later, and only if the client raises it. Contraceptive information immediately after a pregnancy loss is insensitive.
Full rationale from the source
The nurse's priority is to address the client's physical needs (A-B-C) according to Maslow's hierarchy of needs. The nurse must first assess and monitor bleeding and be prepared to act if there is a complication such as a hemorrhage. The other actions are also part of the nurse's plan/implementation but are not the initial priority.
