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

1. A. Abstract thinking
2. B. Ability to focus and concentrate thoughts
3. C. Judgment
4. D. Memory

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 4)
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:

1. A. Tetralogy of Fallot
2. B. Ventricular septal defect
3. C. Patent ductus arteriosus
4. D. Transposition of the great arteries

Correct Answer: A
(A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the reach the systemic circulation. (B) A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic circulation. (C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. (D) Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.

- (Topic 6)
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

1. A. Encourage him to drink plenty of fluids
2. B. Expect him to have nausea with vomiting
3. C. Keep him awake for the next 12 hours
4. D. Wake him up every 1–2 hours during the night

Correct Answer: D
(A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should know to notify the physician or hospital if they occur. (C) The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

- (Topic 6)
While the nurse is taking a male client??s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:

1. A. Politely tells the client, ??Keep your hands off ??
2. B. Ignores the remarks and hopes he will not try it again
3. C. Confronts the remarks but attempts not to reject the client
4. D. Leaves the room in order to compose herself

Correct Answer: C
(A) This response does not recognize normal feelings of attraction and rejects the client.
(B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.

- (Topic 4)
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?

1. A. Providing him with books, challenging puzzles, and games as diversionary activities
2. B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
3. C. Having a volunteer come in to sit with the client and to read him stories
4. D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client??s position frequently

Correct Answer: B
(A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility.