1. 1. Question
A 4-year old child is brought by her grandmother in the emergency room due to
fever, chills, and difficulty walking. The nurse tries to remove the excessive
clothing of the child but is reluctant. After a thorough assessment, the nurse also
noted bruises around the genital area. Which of the following interventions
should the nurse do first?
o A. Collect the clothing and underwear of the child
o B. Provide privacy and disregard the behavior of the child
o C. Inform the law enforcement for a possible child abuse
o D. Record all the findings
Incorrect
Correct Answer: C. Inform the law enforcement for a possible child abuse
o Option C: Calling law enforcement is a priority action and a legal
responsibility of the nurse in cases of suspected child abuse. Signs of
sexual abuse in children 0-5 years of age include unexplained genital injury,
avoidance to remove clothing, insist on wearing multiple garments,
difficulty walking or sitting due to genital or anal pain, and signs of sexually
transmitted infections.
o Options A and D: Documenting and collecting evidence is an important
aspect of a suspected child sexual abuse but is not the first action.
o Option B: It is the responsibility of the nurse to protect the welfare of the
child.
2. 2. Question
A client receiving hydrochlorothiazide is instructed to increase her dietary intake
of potassium. The best snack for the client requiring increased potassium is:
o A. Pear
o B. Apple
o C. Orange
, o D. Avocado
Incorrect
Correct Answer: D. Avocado
o Option D: The fruit which packs the most potassium among the choices is
the avocado which contains 487 mg per half serving of the fruit.
o Option A: A pear contains 280 mg of potassium.
o Option B: An apple contains 165 mg of potassium.
o Option C: An orange contains 235 mg of potassium.
3. 3. Question
The nurse is caring for a client following the removal of the thyroid. Immediately
post-op, the nurse should:
o A. Maintain the client in a semi-Fowler’s position with the head and
neck supported by pillows
o B. Encourage the client to turn her head side to side, to promote drainage of
oral secretions
o C. Maintain the client in a supine position with sandbags placed on either
side of the head and neck
o D. Encourage the client to cough and breathe deeply every 2 hours, with the
neck in a flexed position
Incorrect
Correct Answer: A. Maintain the client in a semi-Fowler’s position with the
head and neck supported by pillows.
o Option A: Following a thyroidectomy, the client should be placed in semi-
Fowler’s position to decrease swelling that would place pressure on the
airway.
o Options B, C, and D: These positions would increase the chances of post-
operative complications that include bleeding, swelling, and airway
obstruction.
4. 4. Question
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer.
Which of the following is associated with an increased incidence of gastric
cancer?