- (Topic 1)
A client is 6 weeks pregnant. During her first prenatal visit, she asks, ??How much alcohol is safe to drink during pregnancy??? The nurse??s response is:

1. A. Up to 1 oz daily
2. B. Up to 2 oz daily
3. C. Up to 4 oz weekly
4. D. No alcohol

Correct Answer: D
(A, B, C) No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. (D) The recommended safe dosage of alcohol consumption during pregnancy is none.

- (Topic 7)
A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client??s:

1. A. Level of insight
2. B. Thought processes
3. C. Mood and affect
4. D. Abstracting abilities

Correct Answer: C
(A) Assessing the client??s level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client??s thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client??s mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client??s abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.

- (Topic 6)
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client??s best choice from the items below would be:

1. A. Liver and onions, macaroni and cheese, tea with sugar
2. B. Baked chicken, baked potato with bacon bits, milk
3. C. Waffles with butter and honey, orange juice
4. D. Cheese omelette with ham and mushrooms, milk

Correct Answer: C
(A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.

- (Topic 4)
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer??s disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:

1. A. Allowing the client to perform activities of daily living as much as possible unassisted
2. B. Confronting confabulations
3. C. Reality testing
4. D. Providing a highly stimulating environment

Correct Answer: A
(A) This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. (B) This answer is incorrect. Confrontation tends to increase anxiety. (C) This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. (D) This answer is incorrect. A highly stimulating environment increases distractibility and anxiety.

- (Topic 4)
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

1. A. Lower lip to the shoulder to the upper sternum
2. B. Tip of the nose to the lower lip to the umbilicus
3. C. End of the tube to the first measurement line on the tube
4. D. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

Correct Answer: D
(A) This measurement is _50 cm (48–49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (47–48 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client??s nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.