NCLEX Practice Test
about Health Promotion and Maintenance

1. A five-year-old child with terminal illness is talking to the nurse. Which of the following best reflects a 5-year-old’s understanding of death?

a. “I’ll see grandma in heaven.”
b. “Will it hurt when I die?”
c. “Can Mommy go with me?”
d. “It isn’t fair. Why me? I’m too young to die.”

2. A woman who is 6-months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to:

a. Increase her fluid intake to 3 liters/day
b. Request a prescription for a laxative from the physician
c. Stop taking iron supplements
d. Take 2 tablespoon of mineral oil daily

3. The nurse has been discussing promotion of growth and development with a family whose 15-month-old son has a cyanotic heart defect. Which statement by the father indicates a need for further teaching?

a. “I need to feed him slowly and allow frequent rest periods.”
b. “I need to play quiet games and activities with my son.”
c. “I need to provide highly nutritious foods.”
d. “I need to limit my son’s interactions with other children.”

4. The mother of a two-year-old tells the nurse that her son has temper tantrums, demanding cookies in the supermarket, and asks how she can best handle these temper tantrums. The nurse should suggest to the mother that she:

a. Buy one box of cookies for each shopping trip
b. Leave him home while she goes shopping
c. remain calm and ignore his behavior
d. Discipline the child immediately when he demands cookies

5. A woman with severe pregnancy-induced hypertension (PIH) has delivered 2 hours ago. Which nursing action should be included in the plan of care fro her postpartum hospital stay?

a. Continuing to monitor blood pressure, respirations and reflexes.
b. Encouraging frequent family visitors
c. Keeping her NPO
d. Maintaining an IV access to the circulatory system

6. The nurse assesses a neonate’s respiratory rate at 46 breaths/minute 6 hours after birth. Respirations are shallow, with periods of apnea lasting up to 5 seconds. Which action should the nurse take next?

a. Attach an apnea monitor
b. Continue routine monitoring
c. Follow respiratory arrest protocol
d. Call the pediatrician immediately to report findings

7. Before a well check-up in the pediatrician’s office, an 8-month-old infant is sitting contentedly on the mother’s lap, chewing a toy. When preparing to examine this infant, which of the following steps should the nurse do first?

a. Obtain birth weight
b. Ausculate heart and breath sounds
c. Check pupillary response
d. Measure the head circumference

8. The nurse is watching two siblings, ages 7 and 9 years, verbally arguing over a toy. The nurse has counseled the mother before about how to handle this situation. The nurse would judge that the teaching has been effective when the mother does which of the following?

a. Tells the siblings to stop arguing and shake hands
b. Ignores the arguing and continues what she is doing
c. Tells the children they will be punished when they go home
d. Says they will not go out to lunch now since that have argued

9. A nulligravid client in the second stage of labor has had no anesthesia or analgesia. Anatomically, which of the following would be the most effective position for the client to begin pushing?

a. Squatting with body curved in a C shape
b. side-lying while keeping the head elevated
c. in the knee-chest position while keeping the head down
d. Squatting with back arched

10. A nurse is observing all of the following babies in the clinic. Which baby may be experiencing a developmental delay?

a. A 1-month-old who does not coo
b. A 3-month-old who does not crawl
c. An 8-month-old who does not walk
d. A 10-month-old who does not sit

11. An adolescent client makes an unprovoked rude gesture to a staff member. In a staff conference the nurse explains that the reason for this is that:

a. The client is exhibiting antisocial behavior
b. The client is psychotic
c. The client is testing limits the staff will set
d. The client is a threat to others

12. A 14-year-old female is to be admitted for the insertion of rods to straighten her spine. Because she is a 14-year-old female, you can predict which of the following about her postoperative course?

a. This client is likely to need some sense of control, but will want the nurse to do things for her
b. This client will not cry
c. Friends will probably be important to her recovery and return to school
d. There will be physical, psychological and social dimensions recovery

13. The vital signs of a 56-year-old client are: temperature, 98.6F (37C) orally: pulse, 80 bpm; and respirations, 30 breaths/minute. Which of the following interpretations of these values is correct?

a. Pulse is above normal range
b. Temperature is above normal range
c. Respirations are above normal range
d. Respirations and pulse are above normal range

14. Which of the following actions is an example of developmentally based care?

a. Provide books to a 9-year-old client
b. Walk a 10-year-old according to written orders
c. Provide a pureed diet to a postoperative 13-year-old client
d. Change a surgical dressing on a 15-year-old client every 4 hours as ordered

15. During prenatal classes, a pregnant woman asks the nurse when is the best time to start breastfeeding her infant if she decides to do so. The nurse is aware that the ideal time for the mother to breastfeed her baby is:

a. 15 – 30 minutes after birth
b. 1 -2 hours after birth
c. 3-4 hours after birth
d. After the baby has its first bath

16. The nurse can anticipate a 23-year-old client with ulcerative colitis would benefit from counseling in order to assist in fulfilling the psychosocial stage of:

a. Integrity vs. despair
b. Intimacy vs. isolation
c. Generativity vs. stagnation
d. Autonomy vs. shame and doubt

17. The nurse observes that the electronic fetal monitor strip of a laboring woman indicates that a fetal heart rate (FHR) baseline is 170 bpm. This value would be interpreted as:

a. Within normal range, requiring no intervention
b. Fetal tachycardia, which possibly a sign of hypoxia
c. Fetal Bradycardia that may respond to oxygen
d. A normal FHR for a preterm fetus

18. The nurse’s discharge teaching plan for the client with congestive heart failure would stress the significance of which of the following?

a. Maintaining a high-fiber diet
b. Walking 2 miles every day
c. Obtaining daily weights at the same time each day
d. remaining sedentary for most of the day

19. An adult client has hypertension. The nurse takes his blood pressure in lying and standing positions. The nurse explains to him that this is a test for:

a. Central nervous system depression
b. Malignant hypertension
c. Orthostatic hypotension
d. Vascular insufficiency

20. An 80-year-old man has closed-angle glaucoma. He tells the nurse that he has heard that glaucoma may be hereditary. He is concerned about his children, a son age 45 and a daughter age 38. The most appropriate response by the nurse is to ask,

a. “Are your children complaining of eye problems?”
b. “There is no need for concern because glaucoma is not a hereditary disorder.”
c. “There may be a genetic factor with glaucoma and your children should be screened.”
d. “Your son should be evaluated because he is over 40.”

21. An adult comes to the clinic because she has a productive cough. She smokes two packs of cigarette per day and has a family history of lung cancer and emphysema. Using the principles of health promotion, the nurse would make what interpretation of the client’s behavior? She is:

a. Using denial to deal with being at high risk for lung cancer
b. Not assuming self-responsibility for her health
c. Exhibiting a laissez-faire attitude toward smoking and her risk of cancer
d. Demonstrating passive suicidal tendencies

22. During the clinical breast examination, which of the following is a normal finding?

a. pronounced unilateral venous pattern
b. Peau d’orange breast tissue
c. Long-term, bilateral nipple inversion
d. Breast tissue that is darker than the areolae

23. The nurse who is stuck by a used needle but has not completed the hepatitis B immunization should receive:

a. Both active and passive immunization
b. Active immunization
c. Passive immunization
d. Immunization only after a blood titer has been drawn

24. The Dietary Approaches to Stop Hypertension (DASH) diet, includes ensuring the adequate intake of very specific nutrients. These specific nutrients include:

a. Magnesium, potassium, vitamin C, and calcium
b. Vitamins B6, B12, E, and A
c. Iron. Zinc, vitamin D and vitamin K
d. Biotin, protein, riboflavin, and panthotenic acid

25. The nurse teaches girls 10 to 12 years of age about self-care during menses. The nurse emphasizes that a risk factor for toxic shock syndrome (TSS) is:

a. Changing tampons every 3 hours
b. Avoiding use of deodorized tampons
c. Alternating tampons with sanitary pads
d. Using only tampons at night

26. Which of the following statements would be helpful in teaching a family about caring for an HIV-positive infant at home?

a. The virus cannot be transmitted by casual contact
b. Everyone in the house should receive an oral polio vaccine
c. Sterilize all toys and utensils after the child has used them
d. Wash the client’s clothes separately from the rest of the family

27. A child has a positive sweat test for cystic fibrosis (CF). The nurse is teaching the family about the implications of the cystic fibrosis diagnosis on family life. Which of the following would the nurse include in the teaching plan?

a. The life expectancy is about 20 years
b. Management of cystic fibrosis is aimed at preventing infection and promoting good nutrition
c. Pregnancy will not be a possibility
d. Parents should have genetic counseling so that they can make decisions about subsequent pregnancies

28. The nurse learns from a 17-year-old adolescent client in the high school health office that she is sexually active. Which of the following interventions is appropriate for the nurse to do next?

a. Call her mother immediately
b. Give her pamphlets regarding abstinence
c. Find out who her boyfriend is
d. Find out what measures are being taken to prevent the spread of communicable disease

29. While teaching a health promotion class, the nurse informs the group that which of the following clients has the highest risk for developing brain cancer?

a. An Anglo-American male with a history of smoking and ingestion of alcohol daily
b. An African American female with advanced breast cancer
c. An Asian male who is malnourished and has chronic constipation
d. A Hispanic male with gastroesophageal reflux and pyrosis

30. The nurse reviews the cardinal danger signs of pregnancy with a woman who is 24-weeks pregnant. The woman should be instructed to contact her health care provider when she experience which of the following symptoms?

a. Nasal stuffiness and headache
b. Dependent edema of feet and ankles
c. Continuous backache and fatigue
d. Vaginal bleeding or fluid discharge

31. During a family discussion, a client who has been diagnosed with Alzheimer’s disease begins to act out. Which of the following is the most appropriate course of action for the nurse to take?

a. Restrain the client
b. Provide the client with some distraction
c. Administer IM haloperidol (Haldol) immediately
d. Focus upon the client and try to correct it

32. When advising parents about poison prevention, which of the following should the nurse include in the teaching plan?

a. In order to encourage children to take medicine, refer to it as candy
b. If a child ingests a poison, administer syrup of ipecac immediately
c. Post the telephone number for the poison control center near the phone
d. If a child ingests a poison, administer milk immediately

33. Developmentally, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with:

a. Mastering his environment
b. Identifying with the male role
c. Developing meaningful relationships
d. Differentiating himself from the environment

34. A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, “It will be difficult for my wife to care for a helpless old man.” These comments by the client regarding himself are an example of Erikson’s conflict of:

a. Initiative vs. guilt
b. Integrity v. despair
c. Industry vs. inferiority
d. Generativity vs. stagnation

35. When correcting myths about aging, the nurse should teach that older adults normally have:

a. An inflexible attitude
b. Periods of confusion
c. A slower reaction time
d. Some senile dementia

36. When nurses are conducting health assessment interviews with elderly clients, they should:

a. Leave a written questionnaire for clients to complete at their leisure
b. Ask family members rather than the clients to supply the necessary information
c. Keep referring to previous questions to ascertain that the information given is correct
d. 4. Spend time in several short sessions to elicit more complete information from the clients

37. Three days after a below-the-knee amputation, a client is refusing to eat, talk, or perform rehabilitative activities. The best initial nursing approach would be to:

a. Frequently why there is a need to quickly increase his activity
b. Emphasize repeatedly that with a prosthesis there will be a return to a normal lifestyle
c. Appear cheerful and noncritical regardless of the client’s response to attempts at intervention
d. Accept and acknowledge that the client’s withdrawal is a normal and necessary part of initial grieving

38. The nurse examines a woman in labor and determines that the cervix is fully dilated and effaced, with the fetus at +1 station and intact membranes. Contractions are strong in intensity and are coming every 2 minutes and lasting 60-90 seconds. The nurse records that the woman is in which stage of labor?

a. Active
b. First
c. Second
d. Transition

39. The nurse uses nitrazine paper to determine if a laboring woman’s membranes have ruptured. If the membranes have ruptured, the nurse can expect that the color of the nitrazine paper will turn:

a. Green
b. Orange
c. Yellow
d. Blue

40. The mother of a 4-year-old child calls the clinic, saying that her child has been wetting the bed at night. What would be an appropriate response by the nurse?

a. “There is probably a physical problem causing the bedwetting.”
b. “Stress is probably contributing to your child’s bedwetting.”
c. “Children of this age are not expected always to be dry at night.”
d. “Please talk with your child’s teacher to see if this is happening at preschool.”

41. Which of the following histories given by the mother would alert the nurse to a potential problem with a child?

a. Using gestures to communicate at 18 months of age
b. Cooing at 2 months of age
c. Saying first at 18 months of age
d. Pointing to body parts at 15 months of age

42. A mother of an infant asks the nurse when she can expect her baby to sit up. The nurse informs the mother that an infant can generally sit up without support at:

a. 4 months
b. 6 months
c. 8 months
d. 10 months

43. Following delivery of an infant who weighed 9+ lbs and who experienced shoulder dystocia, the nurse should assess the infant for which of these signs associated with shoulder dystocia?

a. Diminished Moro reflex
b. Absent sucking reflex
c. Altered glucose levels
d. Increased bilirubin levels

44. A 65-year-old client who has just retired, expresses concerns of loneliness due to the loss of his job and co-workers. Which response by the nurse is most therapeutic?

a. “You need to take a vacation.”
b. “Do you know about the local senior citizen group?”
c. “But now you can finally relax and enjoy life.”
d. “Why don’t you go in to work and visit with your old friends?”

45. A woman who had a normal spontaneous vaginal delivery 5 hours ago has not been able to void since delivery. The nurse’s actions should be based on which of these understandings about the most likely cause of her problem:

a. The urinary catheterization at the time of delivery
b. The dehydration that follows delivery
c. The decreased bladder sensation that results from birth trauma
d. The sluggish renal blood flow postpartum

46. Which of the following information about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?

a. Take a mild analgesic for the menstrual pain
b. Avoid cold foods if menstrual pain persists
c. Stop exercise while menstruating
d. Avoid sexual intercourse

47. A 21-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. The nurse would include which of the following instructions in the use of condoms as a method for family planning?

a. Using a spermicide with the condom offers added protection against pregnancy.
b. Natural skin condoms protect against sexually transmitted diseases
c. The typical failure rate for couples using condoms is about 25%
d. Condom users frequently report penile gland sensitivity

48. Using the Nagele’s rule for a client whose last normal menstruation began on May 10, the nurse determines that the client’s estimated date of delivery would be:

a. January 13
b. January 17
c. February 13
d. February 17

49. Which of the following methods would be appropriate when assessing for pain in toddler?

a. Ask the child about pain
b. Observe the child for restlessness
c. Use a numeric pain scale
d. Assess for changes in vital signs

50. The mother asks the nurse for advice about discipline for her 18-month-old child. Which would the nurse recommend that the mother use first?

a. Structured interactions
b. Spanking
c. Reasoning
d. Time out

51. A nurse is conducting a screening clinic. A client visits the clinic to be screened for prostatic cancer. Which laboratory measure is used to screen for prostatic cancer?

a. Creatinine kinase (CK)
b. Aspartate aminotransferase (AST)
c. Blood urea nitrogen (BUN)
d. Prostate-specific antigen (PSA)

52. The client is instructing a client regarding skin test for hypersensitivity reactions. The nurse should teach the client to:

a. Keep skin test areas moist with a mild lotion
b. Stay out of direct sunlight until tests are read
c. Wash the sites daily with a mild soap
d. Have the sites read on the correct date

53. A client is scheduled to perform a 24-hour urine test beginning at 8:00 a.m. on the first day. The nurse should instruct the client to:

a. Discard the second-day 8:00 a.m. sample
b. Discard the first and last samples
c. Discard the first day 8:00 a.m. sample
d. Retain all samples collected

54. A client is scheduled for myelogram which requires administration of an IV radio-opaque dye. The nurse informs the client that during the procedure he may experience:

a. Chest tightness
b. Burning at the IV site
c. Flushing of the face
d. Increased salivation

55. Which of the following diets is most commonly associated with colon cancer?

a. Low-fiber, high fat
b. Low fat, high fiber
c. Low protein, high carbohydrate
d. Low carbohydrate, high protein

56. A client is at risk for aspiration pneumonia. Which of the following nursing interventions will aid in the prevention of aspiration?

a. Maintaining the head of the bed elevated for at least 30 minutes after delivering, feeding, or medications via the NG tube
b. Auscultating breath sounds bilaterally daily
c. Providing pulmonary toilet weekly
d. Performing mouth care with the client in a supine position

57. When counseling the parents of an infant with AIDS about immunization, which of the following vaccines should the nurse explain to the parents as being safe for infants with AIDS?

a. DTaP, OPV
b. MMR, OPV
c. IPV, DtaP
d. MMR, HIB

58. The nurse is aware that when teaching a class on health promotion, the major problem in the treatment of hypertension is:

a. There no good medications
b. Clients do not comply with their prescriptions
c. Weight gain is a frequent complication
d. Headaches persist despite treatment

59. The nurse determines that a client has knowledge deficit about the diagnosis of tuberculosis (TB), its treatment, and follow-up care. When teaching, which of the following points should the nurse emphasize?

a. Combination drug therapy is the most effective treatment
b. Drug therapy will continue for a short period of time
c. Family members need not worry about acquiring TB
d. There are few side effects with TB drugs

60. Medicare will pay for a limited number of home care visits for clients with hypertension. The nurse visiting an elderly hypertensive client must assess the client regularly for:

a. Ability to ambulate
b. Dehydration
c. Effectiveness of medication
d. Awareness of advanced directives

61. Women should be informed that they are more susceptible to urinary tract infections than males because:

a. Vaginal secretions provide a good medium for bacteria growth
b. Candida affects females more than males
c. Most males are circumcised, which protects them
d. The urethra in females is shorter than that of males

62. Which of the following is not a risk factor for hearing loss in children?

a. Family history of hearing loss
b. Birthweight of more than 1,500 g
c. Hyperbilirubinemia
d. Maternal rubella syndrome

63. A 2-month-old child is seen at the clinic. After checking the previous immunization record, the nurse would probably give which of the following immunizations?

a. MMR, DPT, OPV
b. Td, OPV, DPT
c. Td, MMR
d. DPT, OPV, HIB

64. A 31-year-old client has been diagnosed with breast cancer. The client and her husband express their desire to have children. What is the most important reason that a client should not become pregnant while receiving chemotherapy?

a. To avoid the increased physical stress of pregnancy on the client while receiving chemotherapy
b. The emotional changes of pregnancy are not optimally experienced while receiving chemotherapy
c. The potential teratogenic effects on the fetus
d. The client will not be able to adequately support herself and the fetus nutritionally while receiving chemotherapy

65. A 4-year-old child with a new arm cast is going back to the day care center. Which of the following age-appropriate instructions should the nurse give this child?

a. “Don’t chew the cast edges.”
b. “Be careful. Your cast can break if you fall on it.”
c. “Don’t use the cast to hammer pegs into holes.”
d. “Other people won’t see the cast if you wear long sleeves.”

66. The nurse is aware that the most reliable indicator of pain in a 4-year-old child is:

a. Crying and sobbing
b. Changes in behavior
c. Decreased heart rate
d. Verbal reports of pain

67. The nurse is caring for the mother of a newborn. The nurse recognizes that the mother needs more teaching regarding cord care because:

a. Keeps the cord exposed to the air
b. Washes her hands before sponge bathing the baby
c. Washes the cord and surrounding area well with water at each diaper change
d. Checks it daily for bleeding and drainage

68. During a neonate’s assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian creases and epicanthal folds. Which of the following actions would be most appropriate?

a. Notify the physician immediately
b. Ask the mother to consent to genetic studies
c. Explain these deviations to the newborn’s mother
d. Document these findings as minor deviations

69. The nurse understands that most accidental scalding of young children occurs:

a. On the back of the body
b. On the front of the body
c. In a circular or glove pattern
d. On the buttocks

70. A 28-year-old woman is learning about breast self-exam (BSE). The nurse teaches the women that the best time of each month to examine her breasts is during:

a. The week before menstruation
b. The week that menstruation occurs
c. The first week after menstruation
d. The week that ovulation occurs

71. A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. The best response for the nurse to make is which of the following?

a. “Birth weight doubles by 6 months of age.’
b. “Birth weight doubles by 3 months of age.”
c. “The baby will eat what he needs.”
d. “You need to make sure the baby finishes each bottle.”

72. The nurse observes a group of 2-year-old children at play. The nurse would expect to see:

a. Four children playing dodge ball
b. Three children playing tag
c. Two children playing sandbox building castles side by side
d. One child digging a hole

73. The nurse is caring for an 11-year-old client with renal failure. The nurse should expect the child to make which of the following statements?

a. “My girlfriend means everything to me.”
b. “No one understands me.”
c. “My favorite thing is to be a boy scout.”
d. “I don’t know my place in the world.”

74. The mother of a 13-year-old boy confides to the physician’s office nurse that she is concerned because her son has recently become clumsy and coordinated. The most likely interpretation of this behavior is that the boy:

a. Has attention deficit hyperactivity disorder
b. Has a subtle motor dysfunction
c. Is acting normally for his age
d. May have an early sign of depression

75. The mother of a 10-year-old boy with the mental age of 4 asks the clinic nurse, “What should I expect my child to be able to do?” which of the following is the best response by the nurse?

a. “Your child should be able to choose and dress himself with assistance.”
b. “Your child should be able to take care of his dog by himself”
c. Your child should be able to join the local soccer team.”
d. “Your child should be able to load and start the dishwasher after dinner.”

76. A 24-year old woman at 10 weeks gestation becomes nauseated each around 4 PM. Which of the following interventions is most appropriate for the nurse to suggest to the client?

a. Limit lunch to soft and fruit before 2 PM
b. Eat several pretzels around 3:30 PM
c. Take an antacid around 3:30 PM
d. Lie down and rest around 2 PM

77. During the induction of labor, the patient’s uterine contractions occur every 2-3 minutes and last 90 seconds. During a contraction, the fetal heart rates initially drop to 100 bpm, and then remain between 100-110 bpm. The nurse should:

a. Administer oxygen at 10 L/min
b. Stop the infusion of Pitocin
c. Change the patient’s position
d. Increase the IV infusion rate

78. When assessing a 2-year-old child brought by his mother to the clinic for a routine check-up. The nurse would expect the child is able to do which of the following?

a. Ride a tricycle
b. Tie his shoelaces
c. Kick a ball forward
d. Use blunt scissors

79. Depression in an older adult differs from depression in a younger person because:

a. Sadness of mood is usually present but it is masked by other symptoms
b. Impairment of cognition usually is not present
c. Psychosomatic tendencies do not tend to dominate
d. Traditional antidepressant therapies are less effective

80. A primary concern of the hospitalized adolescent would be:

a. Respect for the need for privacy
b. Allowing friends to visit after hours
c. Wearing a hospital gown
d. The fear of loss of control when in pain

81. A 15-month-old is admitted to the pediatric unit with the diagnosis of pneumonia and is placed in a mist tent. Which of the following toys would be appropriate for this child?

a. A pull toy
b. Story books
c. Crayons and paper
d. Plastic blocks

82. The vital signs of a 56-year-old client are: temperature, 98.6F (37C) orally: pulse, 80 bpm; and respirations, 30 breaths/minute. Which of the following interpretations of these values is correct?

a. Pulse is above normal range
b. Temperature is above normal range
c. Respirations are above normal range
d. Respirations and pulse are above normal range

83. The nurse is assessing a client admitted to the unit who has developed a “runny nose” following a motor vehicle accident. How should the nurse proceed regarding the nasal discharge?

a. Obtain a specimen for culture and sensitivity
b. Test for occult blood
c. Test for glucose
d. Perform a Gram stain test

84. When a nurse is giving discharge teaching instructions for a client with pyelonephritis, the nurse should give information on how to prevent recurrence. This would include instruction on:

a. Maintenance of perineal hygiene
b. Discontinuing antibiotic therapy when the patient feels better
c. Limiting fluid intake to 1 liter per day
d. Monitoring urine output

85. When planning teaching for the parents of a child with Tetralogy of Fallot, who are both employed full time, the nurse should:

a. Schedule a whole evening for teaching
b. Insist both parents attend the teaching session
c. Provide written and oral information in short sessions
d. Point things out to them when they are visiting their child

86. A 5-month-old infant is admitted to the hospital with a fever and history of vomiting for 48 hours. In view of this infant’s responses, the assessment by the nurse that would initially influence the child’s care is:

a. Inspecting the baby’s skin for poor turgor
b. Determining the baby’s vital signs and weight
c. Checking the baby’s neurological status and urinary output
d. Asking the mother whether the baby is breastfed or bottle-fed

87. The nurse is teaching s client about the treatment for gonorrhea. The nurse explains that follow-up cultures will be taken after treatment has been completed to:

a. Evaluate for complications
b. Check the lab’s work
c. Validate eradication of the infection
d. Provide an opportunity for sexual counseling

88. In assessing clients for early signs of cancer, which of the following findings reported to the nurse would indicate a priority for follow up?

a. Bowel movements twice a day for the past five years
b. Monthly breast self-exam
c. Lingering cough one week after a cold
d. Mole that has become larger in the past 4 weeks

89. The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?

a. Use of alcohol
b. Frequent use of mouthwash
c. Lack of vitamin B12
d. Lack of regular teeth cleansing by a dentist

90. A client with hydrocephalus complains of a headache in the morning on arising, but it disappears later in the day. The nurse is aware that intracranial pressure is highest in:

a. The early morning
b. The late afternoon
c. The evening
d. The middle of the night

91. Which of the following groups is more likely to develop severe hypertension?

a. Asian
b. African American
c. European
d. American Indian

92. A 70-year-old, previously well client asks the nurse, “I have noticed I have tremors. Is this just normal for my age?” the best response for the nurse to make is which of the following?

a. “I would not be worried, because this is common with aging.”
b. “You should report this to the physician, because it may indicate a problem.”
c. “You should drink orange juice when this occurs.”
d. “You should have you blood pressure checked when this occurs.”

93. An adult is undergoing screening for stomach cancer. It is most important for the nurse to ask which of the following questions?

a. “How much coffee do you drink per day?”
b. “Do you drink carbonated beverages?”
c. “How often do you eat smoked food?”
d. “Do you eat beef that is rare?”

94. Which of the following diagnostic tests may be performed to determine if a client has gastric cancer?

a. Barium enema
b. Colonoscopy
c. Gastroscopy
d. Serum chemistry level

95. While assessing the fetal heart rate of a woman in labor who is 9-cm dilated the nurse notes a pattern of early decelerations of the fetal heart rate. Which of the following interventions should the nurse implement?

a. Continue routine observation
b. Place the woman on her left side
c. Place the woman in a knee-chest position
d. Administer oxygen by nasal cannula at 6 liters per minute

96. A client has been diagnosed with Alzheimer’s disease. During the family discussion in which the diagnosis was presented, the client’s wife asks, “How long will it be until my husband gets better?” What will be the best response for the nurse?

a. “He will not get better; you should put him in a nursing home now.”
b. “There is no cure, but many options are available to you and your husband.”
c. “Let’s not worry about that now.”
d. “Your husband probably will not get any worse.”

97. Developmentally, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with:

a. Mastering his environment
b. Identifying with the male role
c. Developing meaningful relationships
d. Differentiating himself from the environment

98. A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, “It will be difficult for my wife to care for a helpless old man.” These comments by the client regarding himself are an example of Erikson’s conflict of:

99. When correcting myths about aging, the nurse should teach that older adults normally have:

a. An inflexible attitude
b. Periods of confusion
c. A slower reaction time
d. Some senile dementia

100. When nurses are conducting health assessment interviews with elderly clients, they should:

a. Leave a written questionnaire for clients to complete at their leisure
b. Ask family members rather than the clients to supply the necessary information
c. Keep referring to previous questions to ascertain that the information given is correct
d. Spend time in several short sessions to elicit more complete information from the clients





ANSWERS AND RATIONALE

1) C
- children ages 3 to 5 often think of death as sleep or a departure. To them, death is reversible. Option 1, Children ages 5 to 9 begins to view death as irreversible and permanent. They develop generalizations based on observable facts. Option 2, children ages 7 to 10 view death as inevitable, universal and final. Death becomes associated with pain. Option 4, teenagers view death as final, universal and personal experience. Adolescent view life in the present and can become very angry at the injustice of death.

2) A
- in pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to 3 liters a day will help prevent constipation.

3) D
- the parents should be encouraged to foster normal socialization of their child. Parents may need additional information regarding fears they may have. Feeding slowly and allowing frequent rest periods helps reduce energy expenditure and are appropriate activities. Playing quiet games and activities help reduce energy expenditure and are appropriate activities. Maintaining a good diet fosters growth and development.

4) C
- the best technique for handling temper tantrums includes being consistent, remaining and ignoring the behavior. Bribery is not appropriate. Rewards may be given on occasion for good behavior. Leaving the child home is not the best action. It does not give the child a chance to learn impulse control. Disciplining the child in a public place is difficult. No matter what from of discipline the mother uses, the child is getting additional attention. This will reinforce the child’s behavior.

5) A
- post delivery management of the mother with severe PIH includes close observation for blood pressure elevation, CNS irritability and respiratory function. The client is at risk for seizures for 24 hours after delivery.

6) B
- the normal respiratory rate is 30 to 60 breaths/minute. Attaching an apnea monitor, following a respiratory arrest protocol, and notifying the pediatrician of findings aren’t necessary, as listed findings are normal respiratory patterns in neonates.

7) B
- heart and lung auscultation shouldn’t distress the infant, so it should be done early in the assessment. Placing a tape measure on the infant’s head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the rest of the examination more difficult.

8) B
- the best approach by the mother is not to interfere. The children need to learn how to solve their disagreements on their own. If the parent always intervenes, then the children do not learn how to do this. Siblings will disagree and argue as part of normal development. Punishment, including telling the children that they will not go out to lunch, is not warranted.

9) A
- anatomically, the squatting position enlarges the pelvic outlet and uses the force of gravity during the pushing. The mother should curve her body into a C shape for the greatest effectiveness.

10) D
- an infant should be able to sit unsupported by 7 or 9 months. Therefore, further assessments should be made of the 10-month-old. Cooing begins around 2 months of age. Crawling begins around 7 or 8 months of age. At about 9 months, infants begin to cruise and walk around furniture.

11) C
- adolescent frequently test social limits as a normal manifestation of their process of individualization.

12) D
- this is the more global statement, which incorporates the need for friends. The client at 14 years old will want some control while hospitalized. The nurse should encourage self-care. Though many adolescents would prefer not to cry, surgery is a major stressor and this procedure is painful. The nurse cannot predict how the adolescent will react to stress.

13) C
- normal vital signs for an adult client are: temperature, 96.9 to 99F (36 to 37C); pulse 60 to 100 bpm; respirations, 16 to 20 breaths/ minute. Client needs: Health promotion and maintenance

14) A
- providing books to a 9-year-old girl facilitate her reading skills and helps her grow developmentally. Changing a surgical dressing, walking a client, and providing a pureed diet are routine care tasks, which don’t necessarily promote further development of the individual.

15) A
- In the event of a delivery without complications, and if the baby is in good condition, 15-30 minutes after delivery is the best time to start breastfeeding because the baby is alert. This will also stimulate the production of milk in the mother.

16) B
- The object during this psychosocial stage is for the young adult to develop a lasting commitment to another person while pursuing a career and/or education; the onset and chronicity of this disease may interfere with the individual’s progress through this stage of development.

17) B
- Tachycardia is a FHR greater than 160 bpm. Anything outside the normal range may be an indicator of fetal distress caused by hypoxia. Two other causes of tachycardia may be maternal fever and administration of terbutaline, a tocolytic, to the mother.

18) C
- CHF is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 pounds or more. This may indicate fluid overload and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life-threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with CHF. Prescribing an exercise program for the client, such as walking 2 miles every day, would not be appropriate at discharge.

19) C
- assessment made of lying and standing blood pressures to detect orthostatic, which is characterized by a decrease in systolic blood pressure when the client moves from a lying to standing position. Malignant hypertension is characterized by severely elevated blood pressure in both standing and lying positions. Malignant hypertension commonly damages the intima of small vessel, the brain, retina, heart and kidneys.

20) C
- there is a strong hereditary factor in glaucoma. Therefore, family members should have intraocular pressures measured yearly. Client needs: Health promotion and maintenance

21) B
- there are 4 principles of health promotion: self-responsibility, nutrition, stress management, and exercise. Self-responsibility includes avoiding high risk behaviors such abusing alcohol or drugs, overeating, driving while intoxicated, engaging in sexual practices put the client at risk for disease and smoking. Although any of the answers could be true, this is the only answer which addresses the question of health promotion principles.

22) C
- it is normal variation for women to have long-term, bilateral nipple inversion. A woman who has unilateral nipple inversion that is a new change is at risk for a tumor; the weight of the tumor causes pulling on the nipple. A pronounced unilateral venous pattern, peau d’ orange breast tissue, and breast tissue darker than the areolae are definite warning signals for breast cancer that must be reported to the physician immediately.

23) A
- when a nurse have been stuck by a used needle and has not completed the hepatitis B vaccination, he or she should receive both active and passive immunization.

24) A
- this diet is experimental research indicating that diets low in potassium are often associated with hypertension. Higher-potassium diets appear to prevent and correct hypertension. Magnesium deficiency causes artery walls and capillaries to constrict and therefore raises blood pressure. Magnesium intake within the normal range lowers blood pressure. Vitamin C helps to normalize blood pressure. Calcium lowers blood pressure in healthy people and in those with hypertension.

25) D
- risk factors for TSS include the use of tampons at night, when tampon would be in place for 7 to 9 hours. TSS can occur in other situation, but it is most often associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk for TSS.

26) A
- the virus cannot be transmitted through casual contact. This must be reinforced so that the child is not deprived of touch. Oral polio vaccine should not be taken by others in the household. It is not necessary to sterilize toys and utensils after the child uses them. The child’s clothes do not have to be washed separately.

27) B
- the goal of treatment of CF is to provide optimal nutrition and prevent infections that cause fatal complications of CF. life expectancy is now longer than 20 years.

28) D
- collecting data is the first step of nursing process. Making an assessment of the client’s knowledge regarding safe sex and sexually transmitted diseases would be the priority.

29) B
- metastatic lesions most commonly come from the breast or lung cancer. An Anglo-American male with a history of smoking is more likely to be at risk for lung cancer but the female breast cancer is at higher risk for developing brain cancer.

30) D
- Vaginal bleeding could indicate either abruption placenta or placenta previa.

31) B
- Distraction may be the most successful way to interrupt the behavior. Focusing on the client’s behavior will most likely serve only to increase his agitation.

32) C
- The telephone number for the poison control center should be posted near every telephone in the house. The poison control center should be contacted first and their instructions followed.

33) C
- this is the young-adult task associated with intimacy vs. isolation. Option 1 and 4 are toddler’s task associated with autonomy vs. shame and doubt. Option 2 is a school-ager’s task associated with initiative vs. guilt.

34) B
- according to Erikson, poor self-concept and feelings of despair are conflicts manifested in the 65-and-older groups.

35) C
- a decrease in neuromuscular function slows reaction time. The ability to be flexible has nothing to do with age but with character. Confusion is not a normal process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. The majority of older adults do not have organic mental disease.

36) D
- spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the elderly.

37) D
- the withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body.

38) C
- because the cervix is already fully dilated and effaced, the woman must be in the second stage of labor. The second stage of labors begins with complete dilatation of the cervix and ends with the birth of the infant.

39) D
- amniotic fluid is alkaline. Amniotic fluid will turn nitrazine paper dark blue.

40) C
- children achieve night time bladder control after daytime bladder control. Night time bladder control may not be until 5-7 years of age.

41) C
- a child should say the first word between 8 and 14 months of age. Using gestures to communicate at 18 months of age is normal. Cooing at 2 months of age is normal. Pointing to body parts at 15 months of age is normal.

42) C
- at 8 months of age a child can usually sit alone without support. At 4 months of age, the child can sit with support. At 6 months, a child can sit with one hand for support.

43) A
- shoulder dystocia, often experienced during the delivery of a large infant, is associated with an increased risk of fracture of the clavicle. A broken clavicle may lead to decreased arm movement on the affected side.

44) B
- becoming involved in an organization assists the retired adult in resocialization, which is beneficial to clients who depended on their employment for social interaction.

45) C
- normal spontaneous vaginal delivery puts pressure on both the bladder and urethra. Forceps delivery and/or excessive manipulation may exaggerate this trauma, causing swelling of the urethra and lower bladder, contributing to urinary retention.

46) A
- The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or “cramps” are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases abdominal tone. Avoiding cold foods will not decrease dysmenorrheal. Sexual intercourse is not prohibited during menstruation, but the male partner should wear condom to prevent exposure to blood.

47) A
- The typical failure rate of a condom is approximately 12% to 14%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy. Natural skin condoms do not offer the same protection against STD caused by viruses as latex condoms do. Unlike latex condoms, natural skin (membrane) condoms do not prevent the passage of viruses. Most condom users report decreased penile gland sensitivity. However, some users report an increased sensitivity or allergic reaction (such as rash) to latex, necessitating the use of another method of family planning or a switch to a natural skin condom.

48) D
- When using Nagele’s rule to determine the estimated date of delivery, the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days. This means the client’s estimated date of delivery is February 17.

49) B
- Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. Numeric pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.

50) D
- Time out is the most appropriate discipline for toddlers. It helps to remove them from the situation and allows them to regain control. Structuring interactions with 3-years-old helps minimize unacceptable behavior. This approach involves setting clear and reasonable rules and calling attention to unacceptable behavior as soon as it occurs. Physical punishment, such as spanking, does cause a dramatic decrease in behavior but has serious negative effects. However, slapping a child’s hand is effective when the child refuses to listen to verbal commands. Reasoning is more appropriate for older children, such as preschooler and those older, especially when moral issues are involved.

51) D
- PSA measurement is widely used as a screening test for prostatic cancer. CK measurement is most associated with myocardial damage, the AST measurement provides information about her liver damage and BUN measurement provides information about kidney function.

52) D
- an important facet of evaluating skin tests is to read the skin test results at the proper time. Evaluating the skin too late or too early will give inaccurate and unreliable results. The sites should be kept dry. There is no requirement to wash the site with soap, and direct sunlight isn’t prohibited.

53) C
- in a 24-hour urine test, the first sample is discarded and the last sample is retained.

54) C
- a typical response to IV radio-opaque dye is the sensation of flushing of the face. Chest tightness is associated with a hypersensitive reaction and isn’t an expected response. Neither burning at the IV site nor increased salivation is associated with administration of radio-opaque dye.

55) A
- a low fiber, high fat diet reduces motility and increases the chance to constipation. The metabolic end-products of this type of diet are carcinogenic. A low-fat, high fiber diet is recommended to help avoid colon cancer. Carbohydrates and protein aren’t necessarily with colon cancer.

56) A
- keeping the head of the bed elevated following feeding or medication administration will decrease the incidence of regurgitation and aspiration. Regular respiratory assessment will help to identify an at-risk patient before aspiration occurs and should occur at least with every 8-hour shift. Vigorous pulmonary toilet is critical when caring for a client at risk for aspiration

57) C
- DTaP is safe and IPV (inactivated polio vaccine) is also safe because it is not a live vaccine. OPV is a live vaccine and is therefore contraindicated for infants with AIDS. Measle vaccines are sometimes contraindicated if the child is severely immunocompromised. HIB is safe for infants with AIDS.

58) B
- lack of symptoms, troublesome side effects of the medications, complex regimens result in noncompliance. There are effective medications for hypertension. Weight gain is not a frequent complication of hypertension. Headaches are not the primary problem.

59) A
- Isoniazid (INH), the most common drug used in the treatment of TB, is usually given in combination with one or two other drugs. Treatment for Tb lasts at least 6 months. TB is communicable and thus precautions should be taken with family members. There are side effects that occur with drugs taken for TB.

60) C
- in clients with cardiovascular disease, the effectiveness of medication, as well as side effects, should be monitored. This is the highest priority. Other options are not specifically related to management of hypertension.

61) D
- the female urethra is about 3.5-4.0 cm long while the male urethra is about 15-20 cm long. The short female urethra reduces the distance between the bladder and the external environment. The location of the external meatus makes it very vulnerable to vaginal and fecal contamination

62) B
- A birthweight of less than 1,500 g is not a risk factor for hearing loss. The other options are known risk factors for hearing loss

63) D
- The DPT, OPV, and HIB would be administered to a 2-month-old infant. MMR is usually not given until 12-15 months. Pertussis should never be administered after age seven, but is usually include in the primary series. Td and MMR would not be administered to a 2-month-old child.

64) C
- The client’s ovaries could be damaged by the chemotherapy and teratogenic effects on the fetus are probable. This is, therefore, the primary purpose in advising the client not to become pregnant while receiving chemotherapy, although the other options may also be of concern.

65) B
- there is a fear for pre-schoolers that if an injury occurs, all their “insides” can leak out. Reminding the child of this age group of safety factors is important.

66) B
- although none of the choices is always indicative of pain, a change in behavior is the indicator that occurs most often in children.

67) C
- washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection. Exposure to air helps dry the cord. Good handwashing is the prime mechanism for preventing infection.

68) A
- a large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the physician immediately. The physician should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise.

69) B
- accidental scalding is usually splash-related and occurs on the front of the body. Any burns on the back of the body or in a well-defined or glove pattern may indicate physical abuse. Immersion burns on the buttocks are also suspicious injuries.

70) C
- it is recommended that a woman examine the breast during the first week after menstruation. During this period, the breast are least likely to be tender or swollen, because the secretion of estrogen, which prepares the uterus for implantation, is at its lowest level.

71) A
- a general growth parameter is that the birth weight doubles in 6 months and triples in a year. Telling the mother that the baby will eat what he needs is not appropriate. The nurse needs to investigate whether the baby’s weight is within the normal parameters of infant weight gain.

72) C
- parallel play are seen with toddlers. Cooperative play is seen with school-age children while associative play is seen with preschool children. Solitary play is seen with infants.

73) C
- this indicates industry; 6-12 years; aspires to be best; learns social skills, how to finish tasks; sensitive about school expectations; may be impaired due to absences from school, growth retardation, and emotional difficulties.

74) C
- the child is characteristically awkward due to rapid growth of long bones.

75) A
- the child should be able to perform activities of daily living with supervision; moderate level of mental retardation- IQ ranges 35-40 to 50-55; can learn self-help activities and simple manual skills.

76) B
- the woman should eat dry carbohydrate food ½ to 1 hour before getting out of bed; remain in bed until the feeling nausea subsides; alternate dry carbohydrate with fluids such as hot tea, milk, or coffee; avoid eating fried, spicy, or gas-forming foods; eat small frequent meals.

77) B
- this allows uterus to relax and increases placental perfusion correcting fetal hypoxia.

78) C
- A 2-year-old usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old. Tying shoelaces is a behavior to be expected of a 5-year-old. Using blunt scissors is characteristic of a 3-year-old.

79) A
- elderly are a high-risk group for depression. The classic symptoms of depression frequently are masked and depression present differently in the aging population. Depression in late life is under diagnosed because the symptoms are incorrectly attributed to aging or medical problems. Impairment of cognition in previously well elderly or psychosomatic complaints may be the presenting symptom of depression. Traditional therapies are usually effective.

80) D
- fears of the adolescent include body changes and loss of control. The young adolescent is typically concerned about the inability to control body changes and feelings and about embarrassment. The typical adolescent is more concerned about being separated from the peer group than from the family and schoolwork and is realistically worried about experiencing pain and loss of control.

81) D
- plastic blocks are the most appropriate toy for a toddler in a croup tent. Because the blocks are plastic, they can be washed. For the pull toy to be used, the child would need to leave the tent, any paper, including story books, would become damp, crumble and provide an environment for the growth of microorganisms.

82) C
- normal vital signs for an adult client are: temperature, 96.9 to 99F (36 to 37C); pulse 60 to 100 bpm; respirations, 16 to 20 breaths/ minute.

83) C
- glucose will be definitive determination as to whether the discharge is CSF. Glucose levels of CSF are normally 40-70 mg/dl. Levels are decreased if there is bacterial infection of the CSF. CSF will also leave a slight pink halo if drained onto a white bandage or bed linen. Leakage of CSF should be reported immediately to the physician, since it places the client at high risk of infection of the CNS and is evidence of the severity of the trauma.

84) A
- good perineal hygiene will prevent the introduction of microorganisms into the urinary tract. This is the most important component of prevention

85) C
- the parents will probably be anxious and will benefit from most short teaching sessions and written material to review at their leisure. The most effective teaching and learning sessions occur in an area with minimal distractions; being in the room with their child at this time would present a major distraction to the parents.

86) B
- the degree of dehydration is correlated with weight loss; continued fever aggravates losses through evaporation. Poor skin turgor may not occur after only 48 hours of vomiting.

87) C
- a repeat culture is important to validate eradication of disease, thus preventing spread of the infection. Repeat culture also documents successful treatment.

88) D
- obvious changes in moles are a cancer warning signal and would be a priority for follow up. Breast self-exam is a recommended action to detect early signs of breast cancer.

89) A
- chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless ate other significant risk factors. Additional risk factors include chronic irritation such as broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin B12, and lack of regular teeth cleansing appointments have not been implicated as primary risk factors.

90) A
- intracranial pressure is highest in the early morning. If the client has a headache on arising, this should be reported to the physician. The client with hydrocephalus may be experiencing signs of increased ICP that need to be treated.

91) B
- epidemiologic and experimental research studies indicate that African Americans are more likely to develop severe hypertension.

92) B
- fine tremors are the first symptom reported in 70% of clients with Parkinson’s disease. A new onset of tremors needs to be investigated by the physician. Tremors are not an expected change in aging.

93) C
- the ingestion of smoked foods with sodium nitrates has been linked to the development of cancer in laboratory animals. The ingestion of rare beef, coffee and carbonated drinks has not been linked to the development of stomach cancer.

94) C
- a gastroscopy will allow direct visualization of the tumor. A colonoscopy or a barium enema would help to diagnose colon cancer. Serum chemistry levels don’t contribute data useful to the assessment of gastric cancer.

95) A
- Early decelerations are generally benign and are seen in late labor when the fetal head is on the perineum. Beginning at the onset of a contraction and ending as the contraction ends, the nadir (lowest point) occurs at the peak of the contraction. Early decelerations occur when increased intracranial pressure causes local changes in cerebral blood flow, which in turn results in stimulation of vagal centers, which then slows the FHR. Early decelerations are not associated with loss of variability, tachycardia or fetal hypoxia, acidosis or low Apgar scores. Early decelerations are viewed as a reassuring FHR pattern unless seen in early labor or with lack of deceleration of the fetal head.

96) B
- Alzheimer’s disease is progressive and incurable. There are many options available to families who have a member with this disease.

97) C
- this is the young-adult task associated with intimacy vs. isolation. Option 1 and 4 are toddler’s task associated with autonomy vs. shame and doubt. Option 2 is a school-ager’s task associated with initiative vs. guilt.

98) Integrity vs. despair
- According to Erikson, poor self-concept and feelings of despair are conflicts manifested in the 65-and-older groups

99) C
- a decrease in neuromuscular function slows reaction time. The ability to be flexible has nothing to do with age but with character. Confusion is not a normal process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. The majority of older adults do not have organic mental disease.

100) D
- spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the elderly.

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