NCLEX- RN Practice Exam 2

Questions

1. A patient informs you that they have noticed a change in their urine color. Assuming this alteration is a result of medication, which of the patient’s medications is not known to cause urine discoloration?

A. Amoxicillin
B. Levodopa
C. Phenolphthalein
D. Aspirin

2. You have been assigned the task of inspecting the nursing unit’s refrigerator. Which of the following medications, if found, should be removed from the refrigerator?
A. Corgard
B. Humulin (injection)
C. Urokinase
D. Epogen (injection)

3. A woman aged 34 has been diagnosed with an autoimmune disorder and has found out that she is expecting a baby. Which sole immunoglobulin type will offer protection to the unborn child within the uterus?

A. IgA
B. IgD
C. IgE
D. IgG

4. A nursing student has just experienced a needlestick injury while attending to a patient who has tested positive for AIDS. What is the most crucial step the nursing student should take?

A. Consult a social worker right away
B. Initiate prophylactic AZT therapy
C. Begin prophylactic Pyrimethamine treatment
D. Pursue counseling services

5. A 37-year-old male has been an insulin-dependent diabetic for five years and is now unable to urinate. Which of the following is the most likely cause?

A. Arteriosclerosis
B. Diabetic nephropathy
C. Autonomic neuropathy
D. Peripheral neuropathy

6. You are taking the history of a 14-year-old girl with a BMI of 18. She reports difficulty eating, self-induced vomiting, and severe constipation. Which of the following conditions is most likely?

A. Multiple sclerosis
B. Anorexia nervosa
C. Bulimia nervosa
D. Systemic sclerosis

7. A 24-year-old female is admitted to the ER for confusion. She has a history of myeloma diagnosis, constipation, severe abdominal pain, and polyuria. Which of the following conditions is most likely?

A. Diverticulitis
B. Hypercalcemia
C. Hypokalemia
D. Irritable bowel syndrome

8. RhoGAM is most commonly administered to ____ mothers with a ____ infant.

A. Rh-positive, Rh-positive
B. Rh-positive, Rh-negative
C. Rh-negative, Rh-positive
D. Rh-negative, Rh-negative

9. A new mother has a few inquiries concerning Phenylketonuria (PKU). Which of these statements provided by a nurse is inaccurate in relation to PKU?

A. The Guthrie test is utilized to assess the essential lab values for PKU.
B. High levels of phenylpyruvic acid are present in the urine of individuals with PKU.
C. Mental impairments are frequently associated with PKU.
D. PKU’s effects can be reversed.

10. A patient has ingested an excessive amount of aspirin. During the acute management of this patient, which symptom should a nurse primarily observe for?

A. Hypoventilation
B. Hypertension
C. Constipation
D. Tachypnea

11. A 52-year-old patient who is both blind and deaf has been admitted to your ward. As the charge nurse, what is your primary responsibility for this patient?

A. Inform other staff members of the patient’s sensory limitations.
B. Share your concerns about the patient’s sensory deficits with your supervisor.
C. Keep the patient constantly informed about the social environment.
D. Ensure a safe and secure environment for the patient.

12. A patient with a history of severe COPD and PVD is being discharged from a skilled nursing facility. Their main concern is maintaining ease of breathing. Which of the following recommendations is most suitable for this patient?

A. Practice deep breathing techniques to enhance oxygen levels.
B. Cough frequently and deeply to clear airway passages.
C. Cough after using a bronchodilator.
D. Lower CO2 levels by increasing oxygen intake during meals.

13. A nurse is attending to an infant recently diagnosed with a congenital heart defect. Which of the following clinical indicators would most likely be observed?
A. Reduced pulse rate
B. Increased weight
C. Lowered systolic pressure
D. Instant development of perfect pitch in hearing

14. A mother has been notified that her child has Down syndrome, and you will be responsible for the child’s care during the next shift. Which of the following characteristics is not typically linked to Down syndrome?

A. Simian crease
B. Brachycephaly
C. Oily skin
D. Hypotonicity

15. A patient has recently suffered a myocardial infarction (MI) within the last 4 hours. Which of the following medications is most likely to be administered?

A. Streptokinase
B. Atropine
C. Acetaminophen
D. Antacid tablets

16. A patient inquired of a nurse, “My doctor advised me to increase my folic acid intake. What kinds of foods are rich in folic acid?”

A. Green vegetables and liver
B. Yellow vegetables and red meat
C. Carrots
D. Fried chicken and french fries

17. A nurse is preparing a presentation on meningitis. Which of the following microorganisms is not associated with meningitis in humans?

A. S. pneumoniae
B. M. rainbowii
C. N. meningitidis
D. Cl. difficile

18. A nurse is giving blood to a patient with low hemoglobin levels. The patient inquires about the lifespan of red blood cells (RBCs) in their body. The correct response is:

A. The life span of RBCs is 7 days.
B. The life span of RBCs is 60 days.
C. The life span of RBCs is 90 days.
D. The life span of RBCs is 120 days.

19. A 67-year-old man has been admitted to the hospital for spinal stenosis surgery. When should discharge training and planning commence for this patient?

A. After the surgery
B. Upon admission
C. Only after the patient requests it
D. During the preoperative discussion

20. In light of Erikson’s developmental stages, which stage is a 5-year-old child most likely to be in?

A. Trust vs. mistrust
B. Initiative vs. guilt
C. Autonomy vs. shame
D. Identity vs. role confusion

21. Considering Erikson’s developmental stages, which stage would a 16-month-old toddler likely be in?

A. Trust vs. mistrust
B. Initiative vs. guilt
C. Autonomy vs. shame and doubt
D. Identity vs. role confusion

22. In the context of Erikson’s developmental stages, which stage corresponds to a 20-year-old young adult?

A. Trust vs. mistrust
B. Initiative vs. guilt
C. Industry vs. inferiority
D. Intimacy vs. isolation

23. A nurse is assessing vital signs of various patients. Which of the following sets of vital signs appears to be abnormal?

A. 11-year-old male – 90 bpm, 22 resp/min, 100/70 mm Hg
B. 13-year-old female – 105 bpm, 22 resp/min, 105/60 mm Hg
C. 8-year-old male – 85 bpm, 18 resp/min, 95/65 mm Hg
D. 10-year-old female – 95 bpm, 20 resp/min, 100/65 mm Hg

24. While obtaining a patient’s history, she mentions experiencing depression and anxiety. Which medication is the patient most likely to be prescribed?

A. Elavil
B. Calcitonin
C. Lisinopril
D. Furosemide

25. In which of the following conditions should a nurse avoid administering erythromycin?

A. Streptococcal infection
B. Legionnaire’s disease
C. Pneumonia
D. Multiple Sclerosis

Answers and Rationales

1. Correct answer:

D. Aspirin. Aspirin is not known to cause urine discoloration. It is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for pain relief, fever reduction, and preventing blood clot formation. Aspirin typically does not have an impact on urine color.

Incorrect answer options:

A. Amoxicillin. Amoxicillin, a penicillin antibiotic, can cause urine discoloration. It is used to treat bacterial infections and may cause urine to turn brown or dark yellow.

B. Levodopa. Levodopa, a medication used in the treatment of Parkinson’s disease, can cause urine discoloration. It may lead to darkening of the urine, turning it brown or even black in some cases.

C. Phenolphthalein. Phenolphthalein, a chemical compound found in some laxatives, can cause urine discoloration. It may cause the urine to turn red or pink.

2. Correct answer:

A. Corgard. Corgard, also known as nadolol, is a beta-blocker medication used to treat high blood pressure and angina. It does not require refrigeration and should be stored at room temperature. If found in the refrigerator, it should be removed.

Incorrect answer options:

B. Humulin (injection). Humulin is a type of insulin used to manage blood sugar levels in individuals with diabetes. Insulin injections, including Humulin, should be stored in the refrigerator at a temperature between 36°F to 46°F (2°C to 8°C) to maintain their efficacy.

C. Urokinase. Urokinase is a thrombolytic medication used to dissolve blood clots. It is typically stored in the refrigerator at a temperature between 36°F to 46°F (2°C to 8°C) to maintain its efficacy.

D. Epogen (injection). Epogen, also known as epoetin alfa, is a medication used to treat anemia caused by chronic kidney disease or chemotherapy. It should be stored in the refrigerator at a temperature between 36°F to 46°F (2°C to 8°C) to maintain its efficacy.

3. Correct answer:

D. IgG. Immunoglobulin G (IgG) is the only immunoglobulin type that can cross the placenta, offering protection to the unborn child within the uterus. IgG antibodies provide passive immunity to the fetus, protecting it from various infections during pregnancy and after birth until the baby’s immune system starts producing its antibodies.

Incorrect answer options:

A. IgA. Immunoglobulin A (IgA) is primarily found in mucous membranes, saliva, tears, and breast milk. It plays a crucial role in protecting mucosal surfaces from infections but does not cross the placenta to offer protection to the unborn child.

B. IgD. Immunoglobulin D (IgD) is found on the surface of B cells and functions as an antigen receptor. Its exact role in the immune system is not well understood, and it does not cross the placenta.

C. IgE. Immunoglobulin E (IgE) is associated with allergic reactions and defense against parasites. It does not cross the placenta to offer protection to the unborn child.

4. Correct answer:

B. Initiate prophylactic AZT therapy. If a healthcare worker, including a nursing student, experiences a needlestick injury involving a patient who has tested positive for AIDS, the most crucial step is to initiate post-exposure prophylaxis (PEP) treatment as soon as possible. PEP typically includes a combination of antiretroviral medications, such as AZT (zidovudine), which can help reduce the risk of HIV infection following potential exposure. The sooner PEP is initiated, the more effective it is, ideally within 1-2 hours and no later than 72 hours after exposure.

Incorrect answer options:

A. Consult a social worker right away. While a social worker can provide support and resources, the most immediate concern after a needlestick injury is to minimize the risk of infection. Initiating PEP treatment should be the priority.

C. Begin prophylactic Pyrimethamine treatment. Pyrimethamine is an antiprotozoal medication used to treat infections like toxoplasmosis and malaria. It is not an appropriate treatment for potential HIV exposure from a needlestick injury.

D. Pursue counseling services. Counseling services can be beneficial for coping with the psychological impact of a needlestick injury, but the priority should be to initiate PEP treatment to reduce the risk of HIV infection.

5. Correct answer:

C. Autonomic neuropathy. Autonomic neuropathy is a type of nerve damage that affects the autonomic nervous system, which controls various involuntary functions in the body, including bladder control. In a person with diabetes, high blood sugar levels can damage the nerves over time, leading to autonomic neuropathy. This can cause urinary problems such as difficulty in urinating, urinary retention, or incontinence.

Incorrect answer options:

A. Arteriosclerosis. Arteriosclerosis is the hardening and narrowing of the arteries due to plaque buildup. While it can be a complication of diabetes, it is not the most likely cause of urinary problems in this case.

B. Diabetic nephropathy. Diabetic nephropathy is a kidney-related complication of diabetes. It can cause kidney damage and lead to kidney failure over time. Although diabetic nephropathy can lead to kidney dysfunction, it is not the most likely cause of an inability to urinate in this case.

D. Peripheral neuropathy. Peripheral neuropathy is a type of nerve damage that affects the nerves in the extremities, such as the hands and feet. It is a common complication of diabetes but is not directly related to urinary problems.

6. Correct answer:

B. Anorexia nervosa. Based on the symptoms described, anorexia nervosa is the most likely condition in this 14-year-old girl. Key symptoms include difficulty eating, a low BMI of 18 (suggesting severe weight loss and malnutrition), self-induced vomiting (indicating purging behavior), and severe constipation, which can occur due to low calorie intake and dehydration. Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight, a distorted body image, and self-imposed food restrictions, leading to extreme weight loss.

Incorrect answer options:

A. Multiple sclerosis. Multiple sclerosis is a neurological disorder that affects the central nervous system, causing symptoms such as muscle weakness, vision problems, and difficulty with coordination and balance. It is not primarily characterized by the reported symptoms in this case.

C. Bulimia nervosa. Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by compensatory behaviors such as self-induced vomiting, excessive exercise, or laxative use to prevent weight gain. Although bulimia nervosa shares some similarities with anorexia nervosa, the difficulty eating and low BMI are more indicative of anorexia nervosa in this case.

D. Systemic sclerosis. Systemic sclerosis, also known as scleroderma, is a rare autoimmune disorder that causes the body’s connective tissues to harden and tighten. It can affect various organs and systems, including the skin, blood vessels, and internal organs, but it is not primarily characterized by the reported symptoms in this case.

7. Correct answer:

B. Hypercalcemia. The combination of symptoms and the patient’s history of myeloma suggest that hypercalcemia is the most likely condition. Hypercalcemia is an elevated calcium level in the blood, which can cause various symptoms, including confusion, constipation, severe abdominal pain, and polyuria (increased urine production). Multiple myeloma, a type of cancer that affects plasma cells, can lead to hypercalcemia due to bone destruction and release of calcium into the bloodstream.

Incorrect answer options:

A. Diverticulitis. Diverticulitis is an inflammation of small pouches (diverticula) in the colon, which can cause abdominal pain and changes in bowel habits. While constipation and abdominal pain are present in this case, the patient’s history of myeloma and other symptoms make hypercalcemia a more likely diagnosis.

C. Hypokalemia. Hypokalemia is a low potassium level in the blood, which can lead to muscle weakness, cramps, and irregular heartbeat. While constipation can be a symptom of hypokalemia, the patient’s history of myeloma and other symptoms point toward hypercalcemia as the most likely cause.

D. Irritable bowel syndrome. Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain and changes in bowel habits, such as constipation or diarrhea. Although constipation and abdominal pain are present in this case, the patient’s history of myeloma and additional symptoms make hypercalcemia a more probable diagnosis.

8. Correct answer:

C. Rh-negative, Rh-positive. RhoGAM (Rh immune globulin) is most commonly administered to Rh-negative mothers who have an Rh-positive infant. This is done to prevent the development of Rh isoimmunization, a condition where the mother’s immune system produces antibodies against the Rh factor present on the surface of the infant’s red blood cells. If left untreated, Rh isoimmunization can lead to hemolytic disease of the newborn in subsequent pregnancies, which can cause severe anemia, jaundice, and other complications in the affected infant.

Incorrect answer options:

A. Rh-positive, Rh-positive. There is no need for RhoGAM in this case, as both the mother and infant share the same Rh factor, and there is no risk of Rh isoimmunization.

B. Rh-positive, Rh-negative. RhoGAM is not needed in this case either, as the Rh-positive mother will not develop antibodies against the Rh-negative infant’s red blood cells.

D. Rh-negative, Rh-negative. In this case, both the mother and infant share the same Rh factor, so there is no risk of Rh isoimmunization, and RhoGAM is not necessary.

9. Correct answer:

D. PKU’s effects can be reversed. This statement is inaccurate in relation to Phenylketonuria (PKU). PKU is a genetic disorder in which the body cannot properly metabolize the amino acid phenylalanine, causing a buildup of phenylalanine and its byproducts, such as phenylpyruvic acid, in the blood and urine. If untreated, PKU can lead to intellectual disabilities, seizures, and other neurological problems. While early diagnosis and proper dietary management can help prevent or reduce the severity of these complications, the effects of PKU cannot be reversed once they have occurred.

Incorrect answer options:

A. The Guthrie test is utilized to assess the essential lab values for PKU. This statement is accurate, as the Guthrie test, also known as the Guthrie bacterial inhibition assay, is a commonly used screening test for detecting elevated levels of phenylalanine in the blood, which is indicative of PKU.

B. High levels of phenylpyruvic acid are present in the urine of individuals with PKU. This statement is accurate, as phenylpyruvic acid is a byproduct of phenylalanine metabolism and accumulates in the blood and urine of individuals with PKU.

C. Mental impairments are frequently associated with PKU. This statement is accurate, as untreated PKU can lead to intellectual disabilities and other neurological problems due to the toxic effects of accumulated phenylalanine and its byproducts on the developing brain.

10. Correct answer:

D. Tachypnea. Tachypnea, or rapid breathing, is a common symptom of aspirin (salicylate) overdose. Aspirin can disrupt the body’s acid-base balance, leading to metabolic acidosis. To compensate for this acidosis, the body increases its respiratory rate to expel more carbon dioxide, which is an acid when dissolved in blood. This results in tachypnea.

It’s like when you’re running – your body needs to get rid of excess carbon dioxide, so you start breathing faster.

Incorrect answer options:

A. Hypoventilation. Hypoventilation, or slow and shallow breathing, is not typically associated with aspirin overdose. In fact, the opposite is true – aspirin overdose usually leads to hyperventilation (rapid and deep breathing) as the body tries to compensate for metabolic acidosis.

B. Hypertension. While aspirin overdose can affect many body systems, it does not typically cause hypertension, or high blood pressure. The primary effects of aspirin overdose are on the gastrointestinal, respiratory, and central nervous systems.

C. Constipation. Constipation is not a typical symptom of aspirin overdose. Aspirin overdose can cause a variety of gastrointestinal symptoms, but these more commonly include nausea, vomiting, and abdominal pain.

11. Correct answer:

D. Ensure a safe and secure environment for the patient. As the charge nurse, your primary responsibility for a patient who is both blind and deaf is to ensure a safe and secure environment for them. This includes taking measures to prevent falls, accidents, and other safety hazards. It is essential to address the patient’s unique needs and adapt the care plan accordingly.

Incorrect answer options:

A. Inform other staff members of the patient’s sensory limitations. While this is an important aspect of care, ensuring the safety and security of the patient should be the primary responsibility. Informing staff members is a crucial step in achieving a safe environment but is secondary to the main goal.

B. Share your concerns about the patient’s sensory deficits with your supervisor. While communicating with your supervisor is important, your primary responsibility is to ensure the patient’s safety and well-being.

C. Keep the patient constantly informed about the social environment. Although keeping the patient informed is important for their emotional well-being and social interaction, your primary responsibility is to ensure their safety and security within the healthcare environment.

12. Correct answer:

C. Cough after using a bronchodilator. For a patient with a history of severe COPD and PVD, the most suitable recommendation to maintain ease of breathing is to cough after using a bronchodilator. Bronchodilators help relax the muscles around the airways, making it easier to breathe. Coughing after using a bronchodilator can help clear mucus and other secretions, further improving airflow and reducing breathing difficulties.

Incorrect answer options:

A. Hold their breath for extended periods to improve lung capacity. This recommendation is not suitable for a patient with severe COPD, as holding their breath for extended periods can lead to increased shortness of breath and discomfort.

B. Engage in high-intensity aerobic exercise without supervision. This recommendation is not appropriate for a patient with severe COPD and PVD, as high-intensity aerobic exercise can worsen their condition and may even be dangerous. Any exercise program for such patients should be carefully planned and supervised by a healthcare professional.

D. Lower CO2 levels by increasing oxygen intake during meals. This recommendation is not suitable for a patient with severe COPD. Although increasing oxygen intake can help improve oxygenation, it should be done under medical supervision and not specifically during meals. In some cases, supplemental oxygen may be prescribed, but this should only be used as directed by a healthcare professional.

13. Correct answer:

C. Lowered systolic pressure. In an infant with a congenital heart defect, one of the clinical indicators that may be observed is lowered systolic pressure. Congenital heart defects can affect the heart’s structure and function, which may lead to problems in blood flow and circulation. This can result in lowered blood pressure, particularly systolic pressure, as the heart struggles to pump blood efficiently.

Incorrect answer options:

A. Reduced pulse rate. While a congenital heart defect can affect the infant’s pulse rate, this is not the most likely clinical indicator. The heart rate may be increased, decreased, or irregular, depending on the specific defect and its severity.

B. Increased weight. Infants with congenital heart defects may have difficulty gaining weight due to inadequate oxygenation and circulation, which can affect their overall growth and development. Increased weight is not a typical clinical indicator of a congenital heart defect.

D. Instant development of perfect pitch in hearing. This option is not related to a congenital heart defect. A congenital heart defect affects the structure and function of the heart, not the development of hearing abilities.

14. Correct answer:

C. Oily skin. Oily skin is not typically associated with Down syndrome. Down syndrome is a genetic disorder caused by the presence of an extra 21st chromosome and is characterized by various physical and developmental features.

Incorrect answer options:

A. Simian crease. A single palmar crease, also known as a simian crease, is a characteristic commonly associated with Down syndrome. It is a single crease that runs across the palm, instead of the typical two creases.

B. Brachycephaly. Brachycephaly, or a flattened head shape, is another characteristic commonly associated with Down syndrome. This occurs due to the abnormal shaping of the skull bones.

D. Hypotonicity. Hypotonicity, or low muscle tone, is a common feature in individuals with Down syndrome. This can result in delayed motor development and difficulties with physical activities.

15. Correct answer:

A. Streptokinase. Streptokinase is a thrombolytic medication that helps dissolve blood clots and can be used in the treatment of an acute myocardial infarction (MI). By dissolving the clot, it restores blood flow to the heart muscle and can limit the extent of the heart damage. Thrombolytic therapy is most effective when administered as soon as possible after the onset of MI symptoms, ideally within the first few hours.

Incorrect answer options:

B. Atropine. Atropine is an anticholinergic medication that is not used as a primary treatment for MI. It may be used in cases of symptomatic bradycardia, but it is not a first-line therapy for an acute MI.

C. Acetaminophen. Acetaminophen is a pain reliever and fever reducer. While it may help alleviate some discomfort associated with an MI, it does not address the underlying cause of the condition and is not the most effective treatment option.

D. Antacid tablets. Antacid tablets neutralize stomach acid and are not used as a primary treatment for MI. Although MI symptoms can sometimes mimic heartburn, antacids do not treat the cause of an MI.

16. Correct answer:

A. Green vegetables and liver. Folic acid, also known as vitamin B9, is essential for various bodily functions, including DNA synthesis and cell growth. Foods that are rich in folic acid include green leafy vegetables (e.g., spinach, kale, and collard greens), liver, and other organ meats. Other good sources of folic acid include legumes, such as lentils, beans, and peas, as well as fortified cereals and breads.

Incorrect answer options:

B. Yellow vegetables and red meat. While some yellow vegetables and red meat may contain small amounts of folic acid, they are not considered the richest sources of this vitamin.

C. Carrots. Although carrots are nutritious and provide several essential vitamins and minerals, they are not a particularly rich source of folic acid.

D. Fried chicken and french fries. These foods are not good sources of folic acid. They tend to be high in unhealthy fats and may contribute to a poor diet if consumed in excess.

17. Correct answer:

D. Cl. difficile. Clostridium difficile (Cl. difficile) is a bacterium that can cause severe diarrhea and inflammation of the colon. It is not associated with meningitis, an infection of the membranes surrounding the brain and spinal cord. Cl. difficile infections typically occur when the balance of bacteria in the gut is disrupted, often due to antibiotic use.

Incorrect answer options:

A. S. pneumoniae. Streptococcus pneumoniae is a common cause of bacterial meningitis in humans, particularly in children, the elderly, and people with compromised immune systems.

B. M. rainbowii. Mycobacterium rainbowii is not a typical cause of meningitis in humans. However, other Mycobacterium species, such as Mycobacterium tuberculosis, can cause meningitis, particularly in people with weakened immune systems.

C. N. meningitidis. Neisseria meningitidis is another common cause of bacterial meningitis in humans, particularly in young adults and adolescents.

18. Correct answer:

D. The life span of RBCs is 120 days. Red blood cells (RBCs), also known as erythrocytes, have a life span of approximately 120 days in the human body. During this time, they circulate through the bloodstream, delivering oxygen to tissues and organs and removing carbon dioxide. After around 120 days, RBCs are removed from circulation by specialized cells in the spleen, liver, and bone marrow.

Incorrect answer options:

A. The life span of RBCs is 7 days: This is incorrect because the lifespan of red blood cells is much longer than 7 days. They typically survive for about 120 days in the circulation before they are removed by the spleen and liver.

B. The life span of RBCs is 60 days: This is incorrect as the average lifespan of red blood cells is 120 days, not 60 days. The 60-day estimate is significantly shorter than the actual duration.

C. The life span of RBCs is 90 days: This is also incorrect. Although 90 days is closer to the actual lifespan of red blood cells, it is still not accurate. Red blood cells have a lifespan of approximately 120 days.

19. Correct answer:

D. During the preoperative discussion. Discharge planning and training should begin during the preoperative discussion for patients who will undergo spinal stenosis surgery. This will allow the healthcare team to assess the patient’s needs, address any concerns, and provide information on what to expect after surgery. The patient and their family should be informed about the expected length of hospital stay, any necessary equipment or services needed after discharge, and any potential complications or limitations that may affect their recovery. By starting the planning and training process early, patients can be better prepared for the postoperative period, which can improve their overall outcome.

Incorrect answer options:

A. After the surgery – Discharge planning and training should not start after surgery, as it may delay the patient’s discharge and increase the risk of complications.

B. Upon admission – While it is important to begin assessing the patient’s needs upon admission, discharge planning and training should start during the preoperative discussion to ensure adequate time to prepare the patient for postoperative recovery.

C. Only after the patient requests it – Waiting for the patient to request discharge planning and training may result in delays and missed opportunities to provide necessary information and resources for their recovery.

20. Correct answer:

B. Initiative vs. guilt. According to Erikson’s theory of psychosocial development, a 5-year-old child is most likely in the stage of initiative vs. guilt. During this stage, children begin to assert their independence and take initiative in their actions and decisions. They develop a sense of purpose and responsibility, but also may experience feelings of guilt and anxiety if their efforts are not successful or do not meet expectations. This stage is characterized by a balance between initiative and guilt, as children learn to navigate their environment and establish a sense of self-efficacy.

Incorrect answer options:

A. Trust vs. mistrust – This stage occurs during infancy, where the primary task is to develop a sense of trust in the world and caregivers.

C. Autonomy vs. shame – This stage typically occurs during early childhood, around 2-3 years old, where children learn to assert their independence and develop a sense of autonomy.

D. Identity vs. role confusion – This stage occurs during adolescence, where individuals develop a sense of identity and establish a sense of self.

21. Correct answer:

C. Autonomy vs. shame and doubt. According to Erikson’s theory of psychosocial development, a 16-month-old toddler is most likely in the stage of autonomy vs. shame and doubt. During this stage, children develop a sense of independence and begin to explore their environment. They learn to do things for themselves, such as feeding themselves and walking, which contributes to a sense of self-confidence and autonomy. However, if caregivers are overly critical or restrict the child’s autonomy, they may develop a sense of shame and doubt in their abilities.

Incorrect answer options:

A. Trust vs. mistrust – This stage occurs during infancy, where the primary task is to develop a sense of trust in the world and caregivers.

B. Initiative vs. guilt – This stage typically occurs during early childhood, around 3-6 years old, where children begin to assert their independence and take initiative in their actions and decisions.

D. Identity vs. role confusion – This stage occurs during adolescence, where individuals develop a sense of identity and establish a sense of self.

22. Correct answer:

D. Intimacy vs. isolation. According to Erikson’s theory of psychosocial development, a 20-year-old young adult is most likely in the stage of intimacy vs. isolation. During this stage, individuals seek to form intimate relationships with others, such as romantic partnerships and close friendships. They develop a sense of identity and establish a sense of self, which allows them to form meaningful connections with others. However, if they are unable to form these intimate relationships, they may experience feelings of isolation and loneliness.

Incorrect answer options:

A. Trust vs. mistrust – This stage occurs during infancy, where the primary task is to develop a sense of trust in the world and caregivers.

B. Initiative vs. guilt – This stage typically occurs during early childhood, around 3-6 years old, where children begin to assert their independence and take initiative in their actions and decisions.

C. Industry vs. inferiority – This stage occurs during middle childhood, around 6-12 years old, where children begin to develop a sense of competence and mastery in their abilities and skills.

23. Correct answer:

B. 13-year-old female – 105 bpm, 22 resp/min, 105/60 mm Hg. This set of vital signs appears to be abnormal. While there can be variations in normal vital sign ranges, a heart rate of 105 bpm may be considered high for a 13-year-old female. Additionally, a blood pressure of 105/60 mm Hg may be considered low for this age range.

Incorrect answer options:

A. 11-year-old male – 90 bpm, 22 resp/min, 100/70 mm Hg – These vital signs appear to be within the normal range for an 11-year-old male.

C. 8-year-old male – 85 bpm, 18 resp/min, 95/65 mm Hg – These vital signs appear to be within the normal range for an 8-year-old male.

D. 10-year-old female – 95 bpm, 20 resp/min, 100/65 mm Hg – These vital signs appear to be within the normal range for a 10-year-old female.

24. Correct answer:

A. Elavil. The patient who mentioned experiencing depression and anxiety is most likely to be prescribed Elavil. Elavil, also known as amitriptyline, is a tricyclic antidepressant that is commonly used to treat symptoms of depression, anxiety, and other mood disorders. It works by increasing the levels of certain neurotransmitters in the brain, such as serotonin and norepinephrine, which can help regulate mood.

Incorrect answer options:

B. Calcitonin – Calcitonin is a hormone that regulates calcium levels in the body and is used to treat conditions such as osteoporosis and Paget’s disease.

C. Lisinopril – Lisinopril is an ACE inhibitor that is used to treat high blood pressure and heart failure.

D. Furosemide – Furosemide is a loop diuretic that is used to treat fluid retention and high blood pressure.

25. Correct answer:

D. Multiple Sclerosis. A nurse should avoid administering erythromycin in patients with a history of QT prolongation or ventricular arrhythmias, as erythromycin can exacerbate these conditions. Patients with multiple sclerosis may be at increased risk of developing QT prolongation or ventricular arrhythmias, and therefore, erythromycin should be used with caution or avoided altogether.

Incorrect answer options:

A. Streptococcal infection – Erythromycin is an antibiotic that is commonly used to treat streptococcal infections, such as strep throat and skin infections.

B. Legionnaire’s disease – Erythromycin is one of the antibiotics of choice for treating Legionnaire’s disease, a severe form of pneumonia caused by Legionella bacteria.

C. Pneumonia – Erythromycin is also used to treat other types of pneumonia, including community-acquired pneumonia and mycoplasma pneumonia.