75 items MS Random Questions with Answers and Rationale
1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A)Chronic vessel plaque formation
B)Pulmonary embolism
C)Occlusions at the vessel bifurcations
D)Coronary artery aneurysms
The correct answer is D: Coronary artery aneurysms
Kawasaki Disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.
2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
A)"I cannot give this medication as it is written. I have no idea of what you mean."
B)"Would you please clarify what you have written so I am sure I am reading it correctly?"
C)"I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D)"Please print in the future so I do not have to spend extra time attempting to read your writing."
The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?"
Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.
3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
A)Reprimand the child and give a 15 minute "time out"
B)Maintain a permissive attitude for this behavior
C)Use patience and a sense of humor to deal with this behavior
D)Assert authority over the child through limit setting
The correct answer is C: Use patience and a sense of humor to deal with this behavior
The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.
4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A)"Have you had a recent heart attack?"
B)"Do you become short of breath during your normal daily activities?"
C)"How many pillows do you use at night to sleep comfortably?"
D)"Do you smoke?"
The correct answer is B: "Do you become short of breath during your normal daily activities?"
These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure.
