Question # 1. A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is:
❍ A. Superior intelligence
❍ B. Underlying hostility
❍ C. Dependence on others
❍ D. Ability to share feelings
Answer B is correct. The client with passive-aggressive personality disorder often has underlying hostility that is exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals might have a high IQ, it cannot be said that they have superior intelligence. They also do not necessarily have dependence on others or an inability to share feelings.
Question # 2. The nurse Greeshma is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to:
❍ A. Maintain a patent airway
❍ B. Perform meticulous oral care every 2 hours
❍ C. Ensure that the incisional area is kept as dry as possible
❍ D. Assess the client frequently for pain using the visual
Answer A is correct. Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain medications should beadministered PRN.
Question #3. The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should:
❍ A. Call the Board of Nursing
❍ B. File a formal reprimand
❍ C. Terminate the nurse
❍ D. Charge the nurse with a tort
Answer B is correct. The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect.
Question # 4. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
❍ A. Document the finding
❍ B. Send a specimen to the lab
❍ C. Strain the urine
❍ D. Obtain a complete blood count
Answer B is correct. If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, as not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.
Question # 5. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
❍ A. A history of radiation treatment in the neck region
❍ B. A history of recent orthopedic surgery
❍ C. A history of minimal physical activity
❍ D. A history of the client’s food intake
Answer A is correct. Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.
❍ A. Superior intelligence
❍ B. Underlying hostility
❍ C. Dependence on others
❍ D. Ability to share feelings
Answer B is correct. The client with passive-aggressive personality disorder often has underlying hostility that is exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals might have a high IQ, it cannot be said that they have superior intelligence. They also do not necessarily have dependence on others or an inability to share feelings.Question # 2. The nurse Greeshma is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to:
❍ A. Maintain a patent airway
❍ B. Perform meticulous oral care every 2 hours
❍ C. Ensure that the incisional area is kept as dry as possible
❍ D. Assess the client frequently for pain using the visual
Answer A is correct. Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain medications should beadministered PRN.
Question #3. The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should:
❍ A. Call the Board of Nursing
❍ B. File a formal reprimand
❍ C. Terminate the nurse
❍ D. Charge the nurse with a tort
Answer B is correct. The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect.
Question # 4. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
❍ A. Document the finding
❍ B. Send a specimen to the lab
❍ C. Strain the urine
❍ D. Obtain a complete blood count
Answer B is correct. If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, as not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.
Question # 5. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
❍ A. A history of radiation treatment in the neck region
❍ B. A history of recent orthopedic surgery
❍ C. A history of minimal physical activity
❍ D. A history of the client’s food intake
Answer A is correct. Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.
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