- (Topic 4)
A 10-month-old infant??s mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse??s response is based on the knowledge that:

Correct Answer:D
(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.

- (Topic 7)
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, ??Nobody cares about the clients.?? The nurse??s most effective response would be:

Correct Answer:D
(A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the client??s ??splitting?? behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client??s emotions and the dynamics underlying ??splitting?? behavior. (D) By simultaneously acknowledging the client??s emotional intensity and gently challenging her ??splitting?? behavior, the nurse addresses the client??s current distortions and prepares for further interventions with angry or ambivalent feelings.

- (Topic 3)
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

Correct Answer:C
(A) This nursing action is too controlling and authoritative. It could increase the client??s anxiety level. (B) In her anxiety state, the client cannot rationally identify a problem. (C) This nursing action conveys a message of caring and security. (D) Giving the client a task would increase her anxiety. This would be a late nursing action.

- (Topic 4)
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

Correct Answer:B
(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.

- (Topic 1)
Hematotympanum and otorrhea are associated with which of the following head injuries?

Correct Answer:A
(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.

- (Topic 5)
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother??s discharge teaching plan?

Correct Answer:C
(A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.