❍ A. Pull against the palms
❍ B. Grimace the facial muscles
❍ C. Cross the legs at the ankles
❍ D. Perform Valsalva maneuver
Answer A is correct. If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test.
2. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching?
❍ A. “When drawing up my insulin, I should draw up the regular insulin first.”
❍ B. “When drawing up my insulin, I should draw up the NPH insulin first.”
❍ C. “It doesn’t matter which insulin I draw up first.”
❍ D. “I cannot mix the insulin, so I will need two shots.”
Answer A is correct. Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it does matter which is drawn first: Contamination of NPH into regular insulin will
result in a hypoglycemic reaction at unexpected times.
3. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
❍ A. Decreased appetite
❍ B. A low-grade fever
❍ C. Chest congestion
❍ D. Constant swallowing
Answer D is correct. A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the tonsillectomy.
4. The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
❍ A. Peanuts, dates, raisins
❍ B. Figs, chocolate, eggplant
❍ C. Pickles, salad with vinaigrette dressing, beef
❍ D. Milk, cottage cheese, ice cream
Answer C is correct. The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers A, B, and D are allowed.
5. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
❍ A. Anger
❍ B. Mania
❍ C. Depression
❍ D. Psychosis
Answer B is correct. The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.
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