Select All That Apply Practice Test #6: Mixed Review

Correct answers (A, C, E):
A. The client's code status and allergies.
C. The client's pain level, when the last pain medicine was given, and how well it worked.
E. Any change in the client's condition during the shift and what was done about it.

Rationale: A hand-off report passes on the information the next nurse needs to keep the client safe. Code status and allergies are basic safety information that must never be missed (A). Pain level, the time of the last dose and how well it worked tell the next nurse when more medicine can be given and whether the plan is working (C). Changes in condition and the actions taken, such as a new finding that was reported to the provider, let the next nurse watch for problems and follow up (E). A structured format such as SBAR, and giving report at the bedside when the facility uses that method, helps prevent missed information. Option B is wrong because personal opinions and judgmental labels about clients or families are not appropriate in report; the nurse describes facts and behaviors instead. Option D is wrong because lines, drains, the incision and other devices are part of a complete report, and leaving them out can delay care if something is wrong.

Correct answers (A, B, D):
A. Assess the client, including heart rate and blood pressure.
B. Notify the provider about the error.
D. Complete an incident (occurrence) report that describes the facts objectively.

Rationale: The client's safety comes first, so the nurse assesses the client right away. Metoprolol is a beta blocker, so the nurse checks for a slow heart rate, low blood pressure, dizziness and other effects (A). The provider is notified so that monitoring or treatment can be ordered (B). The nurse completes an incident or occurrence report as the facility policy directs, stating what happened in factual, objective terms without blame or guesses (D). The care given, such as the assessment findings and the provider notification, is documented in the medical record. Option C is wrong because the incident report is an internal quality and risk document, so the chart does not mention that it was filed. Option E is wrong for the same reason: the report is kept separate from the medical record and is not copied into it. Who tells the client about the error, and how, follows the facility's disclosure policy.

Correct answers (B, C, D):
B. Bruises in different stages of healing on both upper arms.
C. The son answers every question for the client and will not leave the room.
D. The client says money keeps disappearing from the bank account and bills are going unpaid.

Rationale: Elder abuse can be physical, emotional, sexual or financial, and it also includes neglect. Bruises in different stages of healing, especially on the upper arms where someone may grab, suggest injuries that happened at different times and do not match a single fall (B). A caregiver who answers for the client and will not let the client speak alone with the nurse may be controlling the client or hiding abuse (C). Missing money and unpaid bills can be signs of financial exploitation (D). The nurse interviews the client alone, documents findings objectively, and reports suspected abuse as state law and facility policy require; reporting rules for older adults vary by state. Option A is wrong because a correctly filled pill organizer suggests the client's medicines are being managed. Option E is wrong because up-to-date immunizations and follow-up visits suggest the client's health needs are being met.

Correct answers (A, C, D):
A. "I'll do the exam during or right after a warm shower, when the skin is relaxed."
C. "I'll gently roll each testicle between my thumb and fingers to feel for lumps."
D. "The soft, cord-like tube at the back of each testicle is a normal structure."

Rationale: Testicular cancer is most common in young men, and it is usually first noticed as a painless lump or swelling. Recommendations about routine self-exams vary, but many providers teach the exam so men learn what is normal for them and notice changes early. Warm water relaxes the scrotum, which makes the testicles easier to feel (A). Each testicle is rolled gently between the thumb and fingers to feel for lumps, hard spots or changes in size (C). The epididymis is a soft, cord-like structure at the back of each testicle and is a normal finding (D). Option B is wrong because it is normal for one testicle to be slightly larger or to hang lower than the other; a change in size is what matters. Option E is wrong because a hard, painless lump is the classic warning sign of testicular cancer and should be reported to a provider promptly.

Correct answers (B, C, E):
B. Keep the child in a rear-facing car seat until the child reaches the highest height or weight the seat maker allows.
C. Cut foods such as grapes and hot dogs into small pieces, and do not give whole nuts or hard candy.
E. Store medicines and cleaning products up high in a locked cabinet, and keep the poison control number handy.

Rationale: Toddlers move fast, explore with their mouths and cannot judge danger, so injury prevention is a key part of teaching at this age. Current child safety guidance is to keep children rear-facing in a car seat for as long as possible, until they reach the highest height or weight the seat maker allows (B). Round, firm foods such as whole grapes, hot dog slices, nuts and hard candy are a common cause of choking, so they are cut into small pieces or avoided (C). Medicines and household chemicals are kept up high and locked, and parents keep the poison control number (1-800-222-1222 in the US) where they can find it (E). Option A is wrong because baby walkers are linked with falls down stairs and burns, and many child health groups advise against using them. Option D is wrong because very hot tap water can scald a child's skin in seconds; a water heater set no higher than about 120°F (49°C) is commonly advised, and bath water is checked before the child gets in.

Correct answers (A, C, D, E):
A. Help the client choose a quit date, ideally within the next few weeks.
C. Explain that nicotine replacement or other quit-smoking medicines, used as prescribed or directed, raise the chance of success.
D. Help the client list triggers, such as coffee, alcohol or stress, and plan other ways to cope with them.
E. Refer the client to a quitline or a counseling program.

Rationale: A client who says they want to quit is ready for action, and the nurse helps the client make a plan. Setting a quit date gives the client a clear starting point and time to prepare (A). Quit-smoking medicines, such as nicotine patches, gum or lozenges and prescription medicines, reduce withdrawal and cravings and improve the chance of quitting, especially when combined with counseling; the choice and dose depend on the client's health and the provider's or product's directions (C). Knowing personal triggers lets the client plan new habits for those moments (D). Quitlines (1-800-QUIT-NOW in the US) and counseling programs give free support and raise quit rates (E). Option B is wrong because cravings are an expected part of nicotine withdrawal and usually ease with time. Many people need several attempts before they quit for good, so a slip is treated as a chance to learn, not a failure.

Correct answers (A, B, D):
A. Hand tremors.
B. Sweating and a fast heart rate.
D. Anxiety, irritability and trouble sleeping.

Rationale: Alcohol depresses the brain. When a person who drinks heavily every day suddenly stops, the nervous system becomes overactive. Early withdrawal often begins within about 6 to 24 hours after the last drink, although the timing varies. Tremors of the hands are a classic early sign (A). Sweating, a fast heart rate and a rise in blood pressure come from the overactive nervous system (B). Anxiety, irritability and trouble sleeping are also common early (D). Withdrawal can progress to hallucinations, seizures and delirium tremens, so the nurse reports the findings, uses the facility's withdrawal scale (such as the CIWA-Ar) as the protocol directs, and gives prescribed medicines such as benzodiazepines and thiamine. Option C is wrong because pinpoint pupils and slow breathing point to opioid effects, not alcohol withdrawal. Option E is wrong because drowsiness, slurred speech and an unsteady walk are signs of alcohol intoxication, not withdrawal.

Correct answers (B, D, E):
B. Speak in a calm, low voice using short, simple sentences.
D. Keep a safe distance, with a clear path to the door for both the nurse and the client.
E. Offer simple choices, such as moving to a quieter room or having something to drink.

Rationale: Verbal de-escalation is the first step with an agitated client who has not yet become violent. A calm, low voice and short, simple sentences are easier for an upset person to take in and help lower tension (B). Keeping a safe distance protects the nurse, and a clear path to the door for both people means no one feels trapped; a client who feels cornered is more likely to lash out (D). Offering simple choices gives the client a sense of control (E). The nurse also calls for help early, as the facility policy directs, and removes other people from the area if needed. Option A is wrong because threats increase anger and fear. Restraints are a last resort, used only when the client is an immediate danger and less restrictive measures have failed, and they require an order and follow facility policy. Option C is wrong because standing close or touching an agitated client can feel threatening and may lead to an assault.

Correct answers (B, C, E):
B. Stay with the client.
C. Use short, simple, calm statements.
E. Move the client to a quieter area and breathe slowly along with the client.

Rationale: During a panic attack the client feels intense fear and cannot think clearly or take in much information. Staying with the client gives a sense of safety and lets the nurse watch for changes (B). Short, simple, calm statements are easier to follow than long explanations (C). A quieter area reduces stimulation, and breathing slowly together helps the client slow down fast breathing that can cause dizziness and tingling (E). Option A is wrong because being left alone can make the fear worse, and the client still needs to be watched. Option D is wrong because learning complex coping skills, such as changing anxious thoughts, is not possible during the attack; this teaching is done later, when the client is calm. A first episode of chest pain, shortness of breath or a racing heart always needs a check for physical causes before it is treated as panic.

Correct answers (A, C, D, E):
A. Ask about abuse in private, when the partner is not in the room.
C. Ask direct questions in a calm, nonjudgmental way, such as, "Has someone hurt you?"
D. Document the injuries objectively, using the client's own words in quotes and a body diagram or photos as the facility policy directs.
E. Help the client make a safety plan, and give information about shelters and hotlines.

Rationale: Screening for intimate partner violence must be done in private, because asking in front of the partner can put the client in danger (A). Direct, caring questions show the client that the nurse is ready to listen and that abuse can be talked about (C). Clear, objective documentation, with the client's exact words in quotation marks and the size, color and location of injuries shown on a body diagram or in photos as the facility policy allows, can matter later for the client's safety and any legal case (D). A safety plan and information about shelters and hotlines, such as the National Domestic Violence Hotline in the US, give the client options (E). Option B is wrong because the decision to leave belongs to the client; the time of leaving can be the most dangerous, and pressure can damage trust. Rules on reporting abuse of adults vary by state, so the nurse follows state law and facility policy.