Psych
A nurse is caring for a client with major depressive disorder. Which symptom should the nurse expect?
A. Flight of ideas
B. Anhedonia
C. Grandiosity
D. Increased energy
B. Anhedonia
A nurse is caring for a client with heart failure. Which finding indicates fluid overload?
A. Weight loss of 2 lb in one day
B. Crackles in the lungs
C. Dry mucous membranes
D. Decreased blood pressure
B. Crackles in the lungs
A nurse is assessing a client in early labor. Which finding indicates true labor?
A. Contractions that decrease with rest
B. Irregular contractions
C. Cervical dilation and effacement
D. Pain relieved by hydration
C. Cervical dilation and effacement
A nurse is assessing a toddler. Which behavior is expected for this age group?
A. Shares toys easily with others
B. Engages in parallel play
C. Has a well-developed sense of time
D. Prefers abstract thinking
B. Engages in parallel play
Rationale: Toddlers typically engage in parallel play (playing alongside others without interacting much). Sharing comes later.
A nurse is teaching a client about Lisinopril. Which statement by the client indicates understanding?
A. “I will report a persistent dry cough.”
B. “I should take potassium supplements daily.”
C. “This medication will increase my heart rate.”
D. “I can stop this medication once I feel better.”
A. “I will report a persistent dry cough.”
Rationale: ACE inhibitors commonly cause a dry cough and can increase potassium levels—so supplements are not recommended.
A client with generalized anxiety disorder reports constant worrying. Which nursing intervention is most appropriate?
A. Encourage the client to avoid anxiety-provoking situations
B. Teach deep breathing exercises
C. Provide unlimited reassurance
D. Encourage decision-making without guidance
B.Teach deep breathing exercises
$200 – Mild
A nurse is caring for a client receiving a blood transfusion. Which action should the nurse take first if a transfusion reaction is suspected?
A. Notify the provider
B. Stop the transfusion
C. Administer antihistamines
D. Slow the infusion rate
B. Stop the transfusion
A nurse is caring for a postpartum client. Which finding is expected on day 1 after delivery?
A. Fundus firm and at the umbilicus
B. Foul-smelling lochia
C. Fundus displaced to the right
D. Heavy bright red bleeding with clots
A. Fundus firm and at the umbilicus
Rationale: On postpartum day 1, the fundus should be firm, midline, and at/near the umbilicus. The other findings suggest complications.
A nurse is caring for a child with dehydration. Which finding indicates moderate dehydration?
A. Sunken eyes and decreased urine output
B. Bradycardia
C. Bounding pulses
D. Hypertension
A. Sunken eyes and decreased urine output
Rationale: Moderate dehydration presents with sunken eyes, dry mucous membranes, and decreased urine output. Severe dehydration includes hypotension and poor perfusion.
A nurse is caring for a client taking Furosemide. Which electrolyte imbalance should the nurse monitor for?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypernatremia
C. Hypokalemia
Rationale: Loop diuretics cause potassium loss, putting the client at risk for hypokalemia and dysrhythmias.
A nurse is assessing a client experiencing a panic attack. Which finding is the priority?
A. Restlessness
B. Tachycardia
C. Sense of impending doom
D. Hyperventilation
D. Hyperventilation
A client with hypoglycemia (glucose 55 mg/dL) is conscious. What should the nurse do?
A. Administer glucagon IM
B. Give 15 g of fast-acting carbohydrates
C. Start IV insulin
D. Provide a high-protein snack
B. Give 15 g of fast-acting carbohydrates
A nurse is monitoring a client receiving oxytocin for labor induction. Which finding requires immediate action?
A. Contractions every 2–3 minutes
B. Fetal heart rate of 170 bpm
C. Mild uterine discomfort
D. Cervical dilation of 4 cm
B. Fetal heart rate of 170 bpm
Rationale: Fetal tachycardia
A nurse is caring for a child with Epiglottitis. Which intervention is the priority?
A. Inspect the throat with a tongue depressor
B. Obtain a throat culture
C. Prepare for intubation
D. Encourage oral fluids
C. Prepare for intubation
Rationale: Epiglottitis can cause sudden airway obstruction. Do not examine the throat—this can trigger complete airway collapse. Airway management is the priority.
A nurse is caring for a client receiving Heparin. Which lab value is used to monitor this medication’s therapeutic effect?
A. INR
B. Platelet count
C. aPTT
D. Hemoglobin
C. aPTT
Rationale: Heparin is monitored using aPTT (activated partial thromboplastin time). INR is used for warfarin.
A client with schizophrenia is experiencing auditory hallucinations. What is the nurse’s best response?
A. “The voices are not real.”
B. “What are the voices telling you?”
C. “Ignore the voices.”
D. “You shouldn’t be hearing things.”
B. “What are the voices telling you?”
A nurse is caring for a client post-thyroidectomy. Which finding requires immediate action?
A. Pain at incision site
B. Hoarseness
C. Difficulty swallowing
D. Neck swelling
D. Neck swelling
Rationale: This can indicate a hematoma → airway obstruction → emergency.
A nurse is caring for a client with preeclampsia. Which assessment finding requires immediate intervention?
A. Blood pressure 150/92 mmHg
B. 1+ proteinuria
C. Headache and visual disturbances
D. Mild edema in the lower extremities
C. Headache and visual disturbances
Rationale: These are signs of severe preeclampsia and possible impending eclampsia (seizures).
A nurse is assessing a child with Tetralogy of Fallot during a “tet spell.” What is the nurse’s first action?
A. Administer oxygen
B. Place the child in the knee-chest position
C. Start IV fluids
D. Notify the provider
B. Place the child in the knee-chest position
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting and improving oxygenation.
A client taking Digoxin reports nausea and visual changes (yellow halos). What is the nurse’s priority action?
A. Administer the next dose as scheduled
B. Check the apical pulse
C. Hold the medication and notify the provider
D. Encourage increased fluid intake
C. Hold the medication and notify the provider
Rationale: These are classic signs of digoxin toxicity. The medication should be held immediately to prevent serious dysrhythmias.
A nurse is caring for a client admitted after a suicide attempt. Which action is the priority?
A. Develop a safety plan
B. Place the client on one-to-one observation
C. Encourage family involvement
D. Administer antidepressants
B. Place the client on one-to-one observation
A nurse is caring for four clients. Which client should the nurse assess FIRST?
A. A client with COPD who has an oxygen saturation of 90% on 2 L nasal cannula
B. A client 1 hour post–cardiac catheterization with a small amount of bleeding at the insertion site
C. A client with diabetic ketoacidosis whose blood glucose decreased from 600 to 250 mg/dL in 2 hours
D. A client with sepsis who has a blood pressure of 86/50 mmHg and altered mental status
D. A client with sepsis who has a blood pressure of 86/50 mmHg and altered mental status
A nurse is assessing a fetal heart rate tracing. Which finding indicates the need for immediate intervention?
A. Early decelerations
B. Moderate variability
C. Late decelerations
D. Accelerations
C. Late decelerations
Rationale: Late decelerations indicate uteroplacental insufficiency → fetal hypoxia, requiring urgent intervention (e.g., reposition, oxygen, stop oxytocin).
A nurse is caring for four pediatric clients. Which child should the nurse assess FIRST?
A. A child with asthma with expiratory wheezing and O₂ saturation of 95%
B. An infant with bronchiolitis who has nasal flaring and retractions
C. A child with gastroenteritis and mild diarrhea for 2 days
D. A child with a fever of 38.2°C (100.8°F) and sore throat
B. An infant with bronchiolitis who has nasal flaring and retractions
Rationale: This is an airway/breathing priority. Retractions + nasal flaring = increased work of breathing → risk for respiratory failure. Infants decompensate quickly.
A nurse is caring for a client receiving Regular insulin IV for diabetic ketoacidosis. Which finding indicates the treatment is effective but requires immediate nursing action?
A. Blood glucose decreases from 600 to 250 mg/dL in 2 hours
B. Serum potassium level decreases from 4.5 to 3.2 mEq/L
C. Urine output increases
D. Client becomes more alert
B. Serum potassium level decreases from 4.5 to 3.2 mEq/L
Rationale: Insulin drives potassium into cells, causing hypokalemia, which can lead to life-threatening dysrhythmias. This requires immediate intervention (potassium replacement).