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Medical Examination CCNS .
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CCNS PDF DEMO:
QUESTION NO: 1
Rudy is a 55-year-old patient who was diagnosed with Hepatitis A.
After three weeks, the patient developed hepatic cirrhosis and ascites with an elevated serum ammonia level. What would be the
priority nursing intervention, considering that the patient has high ammonia levels?
A. Oral fluid intake restrictions
B. Obtaining a daily weight
C. Observe for signs of increasing confusion
D. Measurement of urine specific gravity
Answer: C
Explanation: The priority nursing intervention considering that the patient has a high ammonia level is to
observe for any signs of increasing confusion. The patient's safety will be the priority since the patient has
altered level of consciousness caused by an increased serum ammonia level that impairs the cranial nerve system.
QUESTION NO: 2
A nursing care plan has been created for a term small-for-gestational-age neonate who was admitted to
the NICU. A priority nursing diagnosis was: Imbalance nutrition: Less than body requirements. The goal
was for the newborn to reach 4 pounds by a specified date. On the specified date, the infant weighs 3 pounds and 2 ounces. The nurse should:
A. Increase the daily number of calories
B. Reassess the problem before altering the plan
C. Postpone the evaluation date for another month
D. Change the goal to a more realistic number
Answer: B
Explanation: The nurse should reassess the problem before altering the plan. Before further intervention,
the reason for the inadequate weight gain must be evaluated. Evaluation should be done before changing
the plan or altering the goal.
QUESTION NO: 3
When teaching a mother how to prevent accidents while caring for her 6-month-old, the nurse should
emphasize that this age child can usually:
A. Sit up
B. Roll over
C. Crawl lengthy distances
D. Stand while holding onto furniture
Answer: B
Explanation: Muscular coordination and perception are developed enough at 6 months so that infant can
roll over. If unaware of this ability of the infant, the mother could leave the child unattended for a moment
to reach for something and the child could roll off the crib.
QUESTION NO: 4
A nurse is coaching a group of student nurses about the anatomy and physiology of the head.
The nurse
asks one of the students what to do if she observes that there is blood coming from a patient's ear after a
head injury sustained following a motor vehicle collision. The correct response by the student nurse should be:
A. Cleanse the ear with sterile gauze
B. Put sterile cotton loosely in the external ear
C. Turn the patient to the unaffected side
D. Test the drainage with dextrostix
Answer: B
Explanation: The correct response by the student nurse should be to put sterile cotton loosely in the external ear. This will absorb the drainage without causing further trauma. Additionally, the nurse should
notify the attending physician immediately, as this could be a sign of a life threatening condition.
QUESTION NO: 5
To communicate effectively with the parents of a hospitalized child, the nurse should:
A. Understand that non-verbal communication is meaningful
B. Have empathy with the parents, but realize that the nurse should be in control of the situation
C. Acknowledge positive comments and ignore negative comments
D. Present policy and procedures in detail upon admission
Answer: A
Explanation: To communicate effectively with the parents of a hospitalized child, the nurse should understand that non-verbal communication is meaningful. Observation of non-verbal behavior will assist
the nurse in determining who the decision-maker is; enable the nurse to assess readiness to learn and
provide guidelines to follow in communication of complex clinical information.
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Updated: May 25, 2022