1. a client, age 22, is a gavida 1, para 1. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior?
A. the client is experiencing postpartem depression
B. The client is questioning her role as a mother
C. The client is showing expected behaviors for the taking-in period
D. The client is failing to attach to the neonate

2. a Client is at risk for fluid volume exess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status?
A. Measuring and recording fluid intake and output
B. Weighing the client daily at the same time each day
C. assessing vital signs every 4 hours
D. checking the lungs for crackles every shift

3. A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. What is the nurse's overall goal when planning care for this client?
A. To help the client perform self-care activities
B. To help the client function effectively in her environment
C. To help control the client's symptoms
D. Top help the client participate in group therapy

4. A 36-year-old client with paranoid schizophrenia believes that his room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?
A. Autonomy versus shame and doubt
B. Generativity versus stagnation
C. Integrity versus despair
D. Trust versus mistrust

5.  A child, age 4, is taken to a clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal?
A. Light pink
B. Deep red
C. Pearly gray
D. Yellowish white

6. A client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 liters/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. metabolic acidosis

7. After being in remission from Hodgkin's Disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin's Disease and infection. 24 hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these findings result from:
A. Bleeding in the liver caused by the liver biopsy
B. Perforation of the colon caused by the liver biopsy
C. An allergic reaction to the contrast media used during the liver biopsy
D. Normal postprocedural pain, with a change in level of consciousness resulting from the preexisting fever

8. A client comes to the emergency department complaining of a fast and irregular heartbeat. After examining the client, the physician gives a verbal order for digoxin (Lanoxin), 0.25mg IV q6h over the next 24 hours, starting with the first dose stat. How should the nurse respond to this order?
A. Write and sign the order as dictated, then repeat it aloud for the physician's verification
B. Verbally repeat the order to the physician for verification
C. Insist that the physician write the order, then administer the drug
D. Refuse to carry out the order.