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Question 1 of 5

A young boy tells the nurse, 'I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.' The nurse recognizes this stage of growth and development as:

Correct Answer: B

Rationale: The Oedipus complex involves a young boy's erotic attachment to his mother and jealousy toward his father.

Question 2 of 5

Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?

Order the Items

Source Container

Circle the surgical site with a marker.
Verify patient information with a designated patient representative.
Designate operative site with a facility designated mark.
Include a copy of the Advanced Directives on the chart before surgery.
Verify patient information three times.
Observe pre-op time out before proceeding with surgery.

Correct Answer: C, E, F

Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.

Question 3 of 5

In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

Correct Answer: B

Rationale: Clay-colored stools indicate dysfunction of the liver or biliary tract. In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. Dark brown stools indicate normal passage through the colon. Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.

Question 4 of 5

A client is being admitted to the labor and delivery unit. She has had previous admissions for 'false labor.' Which clinical manifestation would be most indicative of true labor?

Correct Answer: B

Rationale: Contractions of true labor produce progressive cervical effacement and dilatation.

Question 5 of 5

The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?

Correct Answer: A

Rationale: Rales and distended neck veins suggest cardiotoxicity (e.g., heart failure), a serious doxorubicin side effect requiring immediate reporting. Red urine (
B) is expected, nausea/vomiting (
C) are common, and BUN/skin changes (
D) are less urgent.

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