nclex SATA questions with correct answers
1.The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce
labor. The nurse should be prepared for which maternal adverse reactions?
Select all that apply:
- Hypertension
- Jaundice
- Dehydration
- Fluid overload
- Uterine tetany
- Bradycardia Answer✔✔ 1, 4, 5
- A client who is 29 weeks pregnant comes to the labor and delivery unit. She
states that she’s having contractions every 8 minutes. The client is also 3 cm
dilated. Which medications can the nurse expect to administer?
Select all that apply: - Folic acid (Folvite)
- Terbutaline (Brethine)
- Betamethasone
- Rho (D) immune globulin (Rhogam)
- I.V. fluids
- Meperidine (Demerol) Answer✔✔ 2, 3, 5
- The nurse is evaluating a client who is 34 weeks pregnant for premature rupture
of the membranes (PROM). Which findings indicate that PROM has occurred?
Select all that apply: - Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry
- Acidic pH of fluid when tested with nitrazine paper
- Presence of amniotic fluid in the vagina
- Cervical dilation of 6 cm
- Alkaline pH of fluid when tested with nitrazine paper
- Contractions occurring every 5 minutes Answer✔✔ 1, 3, 5
- What information should the nurse include when teaching postcircumcision care
to parents of a neonate before discharge from the hospital?
Select all that apply: - The infant must void before being discharged home.
- Petroleum jelly should be applied to the glans of the penis with each diaper
change. - The infant can take tub baths while the circumcision heals.
- Any blood noted on the front of the diaper should be reported.
- The circumcision will require care for 2 to 4 days after discharge. Answer✔✔ 1,
2, 5 - A 28-year-old client is admitted with inflammatory bowel syndrome (Crohn’s
disease). Which therapies should the nurse expect to be part of the care plan?
Select all that apply: - Lactulose therapy
- High-fiber diet
- High-protein milkshakes
- Corticosteroid therapy
- Antidiarrheal medications Answer✔✔ 4, 5
- The nurse is assisting in the discharge planning for a client with alcoholism.
Which of the following should be included in the discharge plan?
Select all that apply: - Strongly encourage participation in Alcoholics Anonymous (AA).
- Provide nutritional information and counseling.
- Establish an exercise program.
- Discuss relapse prevention.
- Have the client introduce himself slowly to people from his former lifestyle.
Answer✔✔ 1, 2, 3, 4 - The nurse receives a change-of-shift report for a 76-year-old client who had a
total hip replacement. The client is not oriented to time, place, or person and is
attempting to get out of bed and pull out an I.V. line that’s supplying hydration and
antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which
action by the nurse would be appropriate?
Select all that apply: - Assess and document the behavior that requires continued use of restraints.
- Tie the restraints in quick-release knots.
- Tie the restraints to the side rails of the bed.
- Ask the client if he needs to go to the bathroom and provide range-of-motion
exercises every 2 hours. - Position the vest restraints so that the straps are crossed in the back. Answer✔✔
1, 2, 4 - The nurse is performing a Denver Developmental Screening Test II on a 4 1/2-
year-old child. What behaviors should the nurse expect the child to demonstrate?
Select all that apply: - He balances on each foot for at least 6 seconds.
SATA nclex questions with correct answers
The nurse is preparing a teaching plan for a client who is undergoing cataract
extraction with intraocular
implant. Which home care measures will the nurse include in the plan? Select all
that apply.
- To avoid activities that require bending over
- To contact the surgeon if eye scratchiness occurs
- To place an eye shield on the surgical eye at bedtime
- That episodes of sudden severe
pain in the eye is expected - To contact the surgeon if a decrease in visual acuity occurs
- To take acetaminophen (Tylenol) for minor eye discomfort Answer✔✔ 1,3,5,6
Rationale:
After eye surgery, some scratchiness and mild eye discomfort may occur in the
operative eye and is
usually relieved by mild analgesics. If the eye pain becomes severe, the client
should notify the surgeon
because this may indicate hemorrhage, infection, or increased intraocular pressure.
The nurse would also
instruct the client to notify the surgeon of purulent drainage, increased redness, or
any decrease in visual
acuity. The client is instructed to place an eye shield over the operative eye at
bedtime to protect the eye
from injury during sleep and to avoid activities that increase intraocular pressure
such as bending over.
A nurse in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema.
The nurse immediately
notifies the registered nurse and expects which interventions to be prescribed?
Select all that apply.
- Administering oxygen
- Inserting a Foley catheter
- Administering furosemide (Lasix)
- Administering morphine sulfate intravenously
- Transporting the client to the coronary care unit
- Placing the client in a low Fowler’s side-lying position Answer✔✔ 1,2,3,4
Rationale:
Pulmonary edema is a life-threatening event that can result from severe heart
failure. In pulmonary
edema the left ventricle fails to eject sufficient blood, and pressure increases in the
lungs because of the
accumulated blood. Oxygen is always prescribed, and the client is placed in a high
Fowler’s position to
ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate
accumulated fluid. A Foley
catheter is inserted to accurately measure output. Intravenously administered
morphine sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of breathing.
Transporting the client to
the coronary care unit is not a priority intervention. In fact, this may not be
necessary at all if the client’s
response to treatment is successful
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant
suddenly becomes
cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions
that the nurse should
perform. Select all that apply.
- Call a code blue.
- Notify the registered nurse.
- Place the infant in a prone position.
- Prepare to administer morphine sulfate.
- Prepare to administer intravenous fluids.
- Prepare to administer 100% oxygen by face mask. Answer✔✔ 2,4,5,6
Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a
hypercyanotic episode.
Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and
they may occur among
infants whose heart defect includes the obstruction of pulmonary blood flow and
communication
between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a
knee-chest position
immediately. The registered nurse is notified, who will then contact the health care
provider. The kneechest position improves systemic arterial oxygen saturation by decreasing venous
return so that smaller
amounts of highly saturated blood reach the heart. Toddlers and children squat to
get into this position
and relieve chronic hypoxia. There is no reason to call a code blue unless
respirations cease. Additional
interventions include administering 100% oxygen by face mask, morphine sulfate,
and intravenous fluids,
as prescribed.
A client with carcinoma of the lung develops the syndrome of inappropriate
antidiuretic hormone
(SIADH) as a complication of the cancer. The nurse anticipates that which of the
following may be
prescribed? Select all that apply.
- Radiation
- Chemotherapy
- Increased fluid intake
- Serum sodium blood levels
- Decreased oral sodium intake
- Medication that is antagonistic to antidiuretic hormone (ADH) Answer✔✔
1,2,4,6
Rationale:
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts
of water are reabsorbed
by the kidney and put into the systemic circulation. The increased water causes
hyponatremia (decreased
SATA NCLEX SAUNDERS REVIEW
questions with correct answers
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium
complex (MAC) disease and tuberculosis. The nurse monitors for which side
effects of the medication? Answer✔✔ Signs of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
A nurse in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse
suspects pulmonary edema. The nurse immediately notifies the registered nurse
and expects which interventions to be prescribed? Answer✔✔ Administering
oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
Administering morphine sulfate intravenously
A client with coronary artery disease complains of substernal chest pain. After
checking the client’s heart rate and blood pressure, a nurse administers
nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, “My chest
still hurts.” Select the appropriate actions that the nurse should take. Answer✔✔
Assess the client’s pain level.
Check the client’s blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered nurse.
The nurse monitoring a client receiving peritoneal dialysis notes that the client’s
outflow is less than the inflow. The nurse should take which actions? Answer✔✔
Check the level of the drainage bag.
Reposition the client to his or her side.
Place the client in good body alignment.
Check the peritoneal dialysis system for kinks.
The nurse is preparing a teaching plan for a client who is undergoing cataract
extraction with intraocular implant. Which home care measures will the nurse
include in the plan? Answer✔✔ To avoid activities that require bending over
To place an eye shield on the surgical eye at bedtime
To contact the surgeon if a decrease in visual acuity occurs
To take acetaminophen (Tylenol) for minor eye discomfort
The nurse is preparing to administer eye drops. Select the interventions that the
nurse takes to administer the drops Answer✔✔ Wash hands.
Put on gloves.
Place the drop in the conjunctival sac.
Pull the lower lid down against the cheek bone.
A client is receiving meperidine hydrochloride (Demerol) for pain. Which of the
following are side effects of this medication Answer✔✔ Hypotension
Tremors
Drowsiness
A nurse is preparing a list of cast care instructions for a client who just had a
plaster cast applied to his right forearm. Which instructions should the nurse
include on the list? Answer✔✔ Keep the cast and extremity elevated.
The cast needs to be kept clean and dry.
Allow the wet cast 24 to 72 hours to dry.
A nurse is preparing a list of cast care instructions for a client who just had a
plaster cast applied to his right forearm. Which instructions should the nurse
include on the list? Answer✔✔ Symptom control during periods of emotional
stress
Normal white blood cell counts, platelet, and neutrophil counts
Radiological findings that show nonprogression of joint degeneration
An increased range of motion in the affected joints 3 months into therapy
Which interventions would apply in the care of a client at high risk for an allergic
response to a latex allergy. Answer✔✔ Use non-latex gloves.
Use medications from glass ampules
Keep a latex-safe supply cart available in the client’s area.
Do not puncture rubber stoppers with needles
Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Select the
interventions that the nurse includes when administering this medication
Answer✔✔ Monitor hepatic and liver function studies.
Instruct the client to avoid alcohol.
Instruct the client to avoid exposure to the sun.
A client with human immunodeficiency virus is taking nevirapine (Viramune). The
nurse should monitor for which adverse effects of the medication? Answer✔✔
Hepatotoxicity
Rash
The nurse in the mental health unit reviews the therapeutic and nontherapeutic
communication techniques with a nursing student. Which of the following are
therapeutic communication techniques? Answer✔✔ Restating
Listening
Maintaining neutral responses
Providing acknowledgment and feedback
Which nursing interventions are appropriate for a hospitalized client with mania
who is exhibiting manipulative behavior? Answer✔✔ Assist the client in
developing means of setting limits on personal behavior.
Follow through about the consequences of behavior in a nonpunitive manner.
Be clear with the client regarding the consequences of exceeding limits set
regarding behavior.
Communicate expected behaviors to the client.
Which of the following are appropriate interventions for caring for the client in
alcohol withdrawal Answer✔✔ Monitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
A nurse is preparing to care for a dying client, and several family members are at
the client’s bedside. Which therapeutic techniques should the nurse use when
communicating with the family. Answer✔✔ Extend touch and hold the client’s or
family member’s hand if appropriate.
Be honest and truthful and let the client and family know that you will not abandon
them
Encourage expression of feelings, concerns, and fears.
SATA questions with correct answers
Which best describes how a legal nurse consultant (LNC) would best prepare for
testifying in court as an expert witness? (Select all that apply.)
a. By carefully analyzing the client’s medical record and related documents
b. By creating a PowerPoint slide presentation to help educate the jury
c. By helping to examine all the witnesses in preparation for the court trial
d. By personally doing or observing the autopsy on the deceased
e. By preparing charts and tables illustrating the important legal points
f. By summarizing the literature regarding the standard of care Answer✔✔ a. By
carefully analyzing the client’s medical record and related documents
f. By summarizing the literature regarding the standard of care
CH. 21:1. A nurse is caring for an individual with intellectual and developmental
disabilities (IDD). Which findings would be most concerning to the nurse? (Select
all that apply.)
a. Poor skin turgor
b. Decreased appetite
c. Increased urination
d. No bowel movement for the past 3 days
e. Symptoms of choking after taking a sip of water
f. Recent seizure Answer✔✔ a. Poor skin turgor
d. No bowel movement for the past 3 days
e. Symptoms of choking after taking a sip of water
f. Recent seizure
CH. 21: Which are strategies the nurse should practice to provide effective care for
persons with disabilities? (Select all that apply.)
A. Apologize for slips of the tongue such as saying “Do you see?” to a blind
person.
B. Don’t assume the client has a physical or cognitive deficit until you have
validated it.
C. Allocate additional time for care.
D. Take hold of a blind person’s arm to assist them in dangerous situations, such as
crossing a busy street.
E. Volunteer the most recent research findings related to the person’s disability.
F. Adopt the client’s perspective as to what works best without bias. Answer✔✔ B.
Don’t assume the client has a physical or cognitive deficit until you have validated
it.
C. Allocate additional time for care.
F. Adopt the client’s perspective as to what works best without bias.
CH. 22: Which best describes the military culture? (Select all that apply.)
a. A strong sense of service
b. Altruism
c. Egalitarianism
d. A hierarchal class system
e. Problem-focused actions
f. Solutions-focused actions Answer✔✔ a. A strong sense of service
d. A hierarchal class system
f. Solutions-focused actions
CH. 22: A spouse of a veteran inquires as to if he will qualify for the Civilian
Health and Medical Program of the Department of Veteran’s Affairs (CHAMPVA).
Which describes what criteria will need to be met? (Select all that apply.)
a. The veteran has been rated permanently and totally disabled for aserviceconnected disability by a VA regional office
b. The spouse is a survivor of a veteran who died from a VA-rated serviceconnected disability
c, The veteran has been diagnosed with PTSD by a VA regional office
d. The spouse is a survivor of a veteran who died in the line of duty
e. The spouse has been diagnosed with a terminal illness
f. The veteran has been diagnosed with a terminal illness Answer✔✔ a. The
veteran has been rated permanently and totally disabled for aservice-connected
disability by a VA regional office
b. The spouse is a survivor of a veteran who died from a VA-rated serviceconnected disability
d. The spouse is a survivor of a veteran who died in the line of duty
CH. 22: A veteran has been diagnosed with a mild traumatic brain injury (mTBI).
Which symptoms would most likely be reported to the nurse? (Select all that
apply.)
a. Diarrhea
b. Headaches
c. Appetite loss
d. Dizziness
e. Increased thirst
f. Memory problems Answer✔✔ b. Headaches
d. Dizziness
f. Memory problems
SATA NCLEX Sample questions with
correct answers
- A patient is admitted to the same day surgery unit for liver biopsy. Which of the
following laboratory tests assesses coagulation? Select all that apply. - Partial thromboplastin time.
- Prothrombin time.
- Platelet count.
- Hemoglobin
- Complete Blood Count
- White Blood Cell Count Answer✔✔ Answers and Rationale
- Answer: 1, 2, and 3
Prothrombin time, partial thromboplastin time, and platelet count are all included
in coagulation studies. The hemoglobin level, though important information prior
to an invasive procedure like liver biopsy, does not assess coagulation. - A patient is admitted to the hospital with suspected polycythemia vera. Which of
the following symptoms is consistent with the diagnosis? Select all that apply. - Weight loss.
- Increased clotting time.
- Hypertension.
- Headaches. Answer✔✔ 2. Answer: 2, 3, and 4
Polycythemia vera is a condition in which the bone marrow produces too many red
blood cells. This causes an increase in hematocrit and viscosity of the blood.
Patients can experience headaches, dizziness, and visual disturbances.
Cardiovascular effects include increased blood pressure and delayed clotting time.
Weight loss is not a manifestation of polycythemia vera. - The nurse is teaching the client how to use a metered dose inhaler (MDI) to
administer a Corticosteroid drug. Which of the following client actions indicates
that he is using the MDI correctly? Select all that apply. - The inhaler is held upright.
- Head is tilted down while inhaling the medication
- Client waits 5 minutes between puffs.
- Mouth is rinsed with water following administration
- Client lies supine for 15 minutes following administration. Answer✔✔ 3.
Answer: 1 and 4. - The nurse is teaching a client with polycythemia vera about potential
complications from this disease. Which manifestations would the nurse include in
the client’s teaching plan? Select all that apply. - Hearing loss
- Visual disturbance
- Headache
- Orthopnea5. Gout6. Weight loss Answer✔✔ 4. Answers: 2, 3, 4 and 5.
Polycythemia vera, a condition in which too many RBCs are produced in the blood
serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity,
and hypertension. Subsequently, the client can experience dizziness, tinnitus,
visual disturbances, headaches, or a feeling of fullness in the head. The client may
also experience cardiovascular symptoms such as heart failure (shortness of breath
and orthopnea) and increased clotting time or symptoms of an increased uric acid
level such as painful swollen joints (usually the big toe). Hearing loss and weight
loss are not manifestations associated with polycythemia vera. - Which of the following would be priority assessment data to gather from a client
who has been diagnosed with pneumonia? Select all that apply. - Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of
chest pain.4. Presence of peripheral edema5. Color of nail beds Answer✔✔ 5.
Answer: 1, 3, 5.
A respiratory assessment, which includes auscultation of breath sounds and
assessing the color of the nail beds, is a priority for clients with pneumonia.
Assessing for the presence of chest pain is also an important respiratory assessment
as chest pain can interfere with the client’s ability to breathe deeply. - The nurse is teaching a client who has been diagnosed with TB how to avoid
spreading the disease to family members. Which statement(s) by the client
indicate(s) that he has understood the nurses instructions? Select all that apply. - “I will need to dispose of my old clothing when I return home.”2. “I should
always cover my mouth and nose when sneezing.”3. “It is important that I isolate
myself from family when possible.”4. “I should use paper tissues to cough in and
dispose of them properly.”5. “I can use regular plate and utensils whenever I eat.”
Answer✔✔ 6. Answer: 2, 4, 5. - The nurse is admitting a client with hypoglycemia. Identify the signs and
symptoms the nurse should expect. Select all that apply. - Thirst
- Palpitations
- Diaphoresis
- Slurred speech
- Hyperventilation Answer✔✔ 7. Answer: 2, 3, 4.
Palpitations, an adrenergic symptom, occur as the glucose levels fall; the
sympathetic nervous system is activated and epinephrine and norepinephrine are
secreted causing this response. Diaphoresis is a sympathetic nervous system
response that occurs as epinephrine and norepinephrine are released. Slurred
speech is a neuroglycopenic symptom; as the brain receives insufficient glucose,
the activity of the CNS becomes depressed. - Which adaptations should the nurse caring for a client with diabetic ketoacidosis
expect the client to exhibit? Select all that apply: - Sweating
- Low PCO2
- Retinopathy
- Acetone breath
- Elevated serum bicarbonate Answer✔✔ 8. Answer: 2, 4.
Metabolic acidosis initiates respiratory compensation in the form of Kussmaul
respirations to counteract the effects of ketone buildup, resulting in a lowered
PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is
elevated in ketoacidosis. - When planning care for a client with ulcerative colitis who is experiencing
symptoms, which client care activities can the nurse appropriately delegate to a
unlicensed assistant? Select all that apply. - Assessing the client’s bowel sounds
- Providing skin care following bowel movements
- Evaluating the client’s response to antidiarrheal medications
- Maintaining intake and output records
- Obtaining the client’s weight. Answer✔✔ 9. Answer: 2, 4, and 5.
The nurse can delegate the following basic care activities to the unlicensed
assistant: providing skin care following bowel movements, maintaining intake and
output records, and obtaining the client’s weight. Assessing the client’s bowel
sounds and evaluating the client’s response to medication are registered nurse
activities that cannot be delegated. - Which of the following nursing diagnoses would be appropriate for a client
with heart failure? Select all that apply.
Mental Health SATA questions with correct
answers
A nurse is discussing unit expectations with a newly admitted patient diagnosed
with poor impulse control. The nurse shows an understanding of the use of body
language to convey feelings when documenting that the patient is angry and
resistant to authority based on which of the following? Select all that apply.
a. Patients reluctance to make eye contact
b. Crossed-arm posture the patient assumes
c. Quizzical expression on the patients face
d. Sharp rapping of the patients fingers against the table
e. Patients tendency to lean forward when seated in the chair Answer✔✔ b.
Crossed-arm posture the patient assumes
d. Sharp rapping of the patients fingers against the table
The nurse is planning approaches to use to begin the establishment of the nursepatient relationship. Which therapeutic communication techniques will be most
useful to achieve this goal? Select all that apply.
a. Attentively listening as the patient describes their obsessive compulsive rituals
b. Asking the anxious patient if they have a plan for controlling their current
anxiety
c. Encouraging the depressed patient to come and talk with me whenever you want
d. Sitting quietly in the room while the non-communicating patient unpacks their
belongings
e. Responding to the patients feelings of loss by stating, I know that must have
made you very sad. Answer✔✔ a. Attentively listening as the patient describes
their obsessive compulsive rituals
c. Encouraging the depressed patient to come and talk with me whenever you want
d. Sitting quietly in the room while the non-communicating patient unpacks their
belongings
e. Responding to the patients feelings of loss by stating, I know that must have
made you very sad.
The nurse has been working for several weeks with a single mom who has been
both verbally and physically abused by her childrens father. Which nursing actions
are appropriate for this stage of treatment? Select all that apply.
a. Asking, How does it make you feel when he hits you?
b. Providing information regarding womens shelters in the local area
c. Assuring the patient that her children can visit when she wants to see them
d. Sharing that, I know leaving him is difficult but you need a plan if he abuses you
again.
e. Responding, Youve certainly become more assertive; dont be afraid to stand up
for yourself. Answer✔✔ a. Asking, How does it make you feel when he hits you?
b. Providing information regarding womens shelters in the local area
d. Sharing that, I know leaving him is difficult but you need a plan if he abuses you
again.
The nurse shows an understanding of an essential purpose of therapeutic
communication when (select all that apply):
a. Asking the patient, How did it make you feel when your son died?
b. Encouraging the patient to assume responsibility for the problems he or she has
c. Attentively listening as the patient describes the reasons he or she is seeking help
d. Providing the patient with feedback regarding how he or she is implementing
stress relief techniques
e. Sharing with the patient the details of several extremely stressful personal events
and how they were managed Answer✔✔ a. Asking the patient, How did it make
you feel when your son died?
SATA questions with correct answers
- The nurse is aware of the 2014 American Cancer Society Screening Guidelines
for colon cancer, which
include which testing modalities for people over the age of 50? (Select all that
apply.)
a. Colonoscopy every 10 years
b. Colonoscopy every 5 years
c. Computed tomography (CT) colonography every 5 years
d. Double-contrast barium enema every 10 years
e. Flexible sigmoidoscopy every 10 years Answer✔✔ ANS: A, C
Test Bank – Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 438
The options for colon cancer screening for people over the age of 50 include
colonoscopy every 10 years and
CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every
5 years. - A client had an endoscopic retrograde cholangiopancreatography (ERCP). The
nurse instructs the client and
family about the signs of potential complications, which include what problems?
(Select all that apply.)
a. Cholangitis
b. Pancreatitis
c. Perforation
d. Renal lithiasis
e. Sepsis Answer✔✔ ANS: A, B, C, E
Possible complications after an ERCP include cholangitis, pancreatitis, perforation,
sepsis, and bleeding. Kidney stones are not a complication of ERCP.
- The nurse working with older clients understands age-related changes in the
gastrointestinal system. Which
changes does this include? (Select all that apply.)
a. Decreased hydrochloric acid production
b. Diminished sensation that can lead to constipation
c. Fat not digested as well in older adults
d. Increased peristalsis in the large intestine
e. Pancreatic vessels become calcified Answer✔✔ ANS: A, B, C, E
Several age-related changes occur in the gastrointestinal system. These include
decreased hydrochloric acid
production, diminished nerve function that leads to decreased sensation of the need
to pass stool, decreased fat
digestion, decreased peristalsis in the large intestine, and calcification of pancreatic
vessels. - The nurse working in the gastrointestinal clinic sees clients who are anemic.
What are common causes for
which the nurse assesses in these clients? (Select all that apply.)
a. Colon cancer
b. Diverticulitis
c. Inflammatory bowel disease
d. Peptic ulcer disease
e. Pernicious anemia Answer✔✔ ANS: A, B, C, D
In adults, the most common cause of anemia is GI bleeding. This is commonly
associated with colon cancer, diverticulitis, inflammatory bowel disease, and
peptic ulcer disease. Pernicious anemia is not associated with
GI bleeding.
- The nurse working with clients who have gastrointestinal problems knows that
which laboratory values are
related to what organ dysfunctions? (Select all that apply.)
a. Alanine aminotransferase: biliary system
b. Ammonia: liver
c. Amylase: liver
d. Lipase: pancreas
e. Urine urobilinogen: stomach Answer✔✔ ANS: B, D
Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase
are related to the pancreas. Urobilinogen evaluates both hepatic and biliary
function. - The nurse is caring for a client with sialadenitis. What comfort measures may
the nurse delegate to the
unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Applying warm compresses
b. Massaging salivary glands
c. Offering fluids every hour
d. Providing lemon-glycerin swabs
e. Reminding the client to avoid speaking Answer✔✔ ANS: A, C
The UAP can apply warm compresses and offer fluids. Massaging salivary glands
can be done, but not by the
SATA Questions with correct answers
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and
has developed amenorrhea. For which physical manifestations of anorexia nervosa
should a nurse assess? Select all that apply.
a. Peripheral edema
b. Parotid swelling
c. Constipation
d. Hypotension
e. Dental caries
f. Lanugo Answer✔✔ A, C, D, F
A patient diagnosed with anorexia nervosa is hospitalized for treatment. What
features should the milieu provide? Select all that apply.
a. Flexible mealtimes
b. Unscheduled weight checks
c. Adherence to a selected menu
d. Observation during and after meals
e. Monitoring during bathroom trips
f. Privileges correlated with emotional expression Answer✔✔ C, D, E
The admission note indicates a patient diagnosed with major depressive disorder
has anergia and anhedonia. For which measures should the nurse plan? Select all
that apply.
a. Channeling excessive energy
b. Reducing guilty ruminations
c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardation Answer✔✔ C, D, E
A student nurse caring for a patient diagnosed with major depressive disorder reads
in the patient’s medical record, “This patient shows vegetative signs of depression.”
Which nursing diagnoses most clearly relate to the vegetative signs? Select all that
apply.
a. Imbalanced nutrition: less than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia Answer✔✔ A, C, D, F
A patient diagnosed with major depressive disorder will begin electroconvulsive
therapy tomorrow. Which interventions are routinely implemented before the
treatment? Select all that apply.
a. Administer pretreatment medication 30 to 45 minutes before treatment.
b. Withhold food and fluids for a minimum of 6 hours before treatment.
c. Remove dentures, glasses, contact lenses, and hearing aids.
d. Restrain the patient in bed with padded limb restraints.
e. Assist the patient to prepare an advance directive. Answer✔✔ A, B, C
A patient diagnosed with major depressive disorder shows vegetative signs of
depression. Which nursing actions should be implemented? Select all that apply.
a. Offer laxatives, if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
d. Eliminate all daily caffeine intake.
e. Restrict the intake of processed foods. Answer✔✔ A, B, C
A patient being treated with paroxetine (Paxil) 50 mg/day orally for major
depressive disorder reports to the clinic nurse, “I took a few extra tablets earlier in
the day and now I feel bad.” Which aspects of the nursing assessment are most
critical? Select all that apply.
a. Vital signs
b. Urinary frequency
c. Increased suicidal ideation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness Answer✔✔ A, D, E
A patient diagnosed with bipolar disorder is being treated as an outpatient during a
hypomanic episode. Which suggestions should the nurse provide to the family?
Select all that apply.
a. Provide structure
b. Limit credit card access
c. Encourage group social interaction
d. Limit work to half days
e. Monitor the patient’s sleep patterns Answer✔✔ A, B, E
A nurse prepares the plan of care for a patient having a manic episode. Which
nursing diagnoses are most likely? Select all that apply.
a. Imbalanced nutrition: more than body requirements
b. Disturbed thought processes