Core Module 2 Exam practice questions

The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding, which nursing action is most appropriate? 1. Document the temperature. 2. Notify the health care provider. 3. Retake the temperature by the rectal route. 4. Inform the client that the temperature is elevated and antibiotics may be required.

1) Document the temp. It is normal and there is no need to notify the provider

An 85-year-old client has impaired hearing. When creating the care plan, which intervention should have the highest priority? 1. Obtaining an amplified telephone. 2. Teaching the importance of changing his position. 3. Providing reading material with large print. 4. Checking expiration dates on food packages

1. Obtaining an amplified telephone; The amplified telephone helps with hearing and provides a means for communicating with others. Option 2 refers to a tactile impairment. Option 3 relates to a visual impairment, and option 4 an olfactory impairment.

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1. The client's body temperature is 98° F. 2. The client's fingers and toes are cool to touch. 3. The client remains in a fetal position when in bed. 4. The client complains of coolness in the hands and feet only.

1. The client's body temperature is 98° F.

Which statement indicates the client needs a sensory aid in the home? 1. "I tripped over that throw rug again." 2. "I can't hear the doorbell." 3. "My eyesight is good if I wear my glasses." 4. "I can hear the TV if I turn it up high."

2. "I can't hear the doorbell."; This client could use an assistive device that flashes a light when the doorbell rings.

The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? Select all that apply. A. Excessive sleeping B. Confusion at night C. Anger over minor issues D. Easily distracted E. Sitting quietly reading a book

A, B, C , D

In responding to visceral stimuli, the client would be most likely to experience which of the following? 1. Being aware train is coming because of hearing whistle 2. Being aware of which foot is forward when walking 3. Awareness of a full stomach 4. Being aware of an unpleasant smell

3. Awareness of a full stomach; Visceral refers to organs that may produce stimuli that make a person aware of them, e.g., a full stomach.

A client arrives on the unit after surgery. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the surgical site. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.

3. Cover the client with a warm blanket.

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket

Nurses can increase environmental stimuli for clients with sensory deficit by: 1. Keeping the radio on throughout the day to provide auditory stimulation 2. Keeping the bathroom light on at night to avoid complete darkness 3. Establishing a routine identified with each meal 4. Ensuring the client's safety

3. Establishing a routine identified with each meal; Regular meaningful stimuli will benefit the client. The radio can provide meaningful or meaningless stimuli. The nurse must carefully choose programming based on the client's preferences and expose the client to that programming only at appropriate times. Listening to the radio constantly can introduce meaningless stimuli that confuse the client. A 24-hour light may actually keep clients awake, leading to sleep deprivation. Safety is a priority diagnosis but is not an intervention to provide environmental stimuli.

A client is exhibiting signs and symptoms of acute confusion/delirium. Which strategy should the nurse implement to promote a therapeutic environment? 1. Keep lights in the room dimmed during the day to decrease stimulation. 2. Keep the environmental noise level high to increase stimulation. 3. Keep the room organized and clean. 4. Use restraints for client safety.

3. Keep the room organized and clean; A disorganized, cluttered environment increases confusion. Keeping the room well-lit during waking hours (option 1) promotes adequate sleep at night. It is important to eliminate unnecessary noise (option 2). Client does not meet the standard criteria for restraint application (option 4).

Which client is at greatest risk for experiencing sensory overload? 1. A 40-year-old client in isolation with no family. 2. A 28-year-old quadriplegic client in a private room. 3. A 16-year-old listening to loud music. 4. An 80-year-old client admitted for emergency surgery.

4. An 80-year-old client admitted for emergency surgery; A sudden, unexpected admission for surgery may involve many experiences (e.g., lab work, x-rays, signing of forms) while the client is in pain or discomfort. The time for orientation will thus be lessened. After surgery, the client may be in pain and possibly in a critical care setting. Options 1 and 2 would more likely be at risk for sensory deprivation. Option 3 is considered a normal activity for most teenagers.

A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure

4. Decreased heart rate and decreased blood pressure

The nurse documents that a client is fully conscious. What did the nurse assess in this client? Select all that apply. A. Client responded to verbal stimuli B. Client responded to written word C. Client oriented to time, place, and person D. Client demonstrated poor memory E. Client alert

A, B, C, E

The nurse is taking the vital signs of a client. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing intervention? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids.

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate (aspirin) in 4 hours. 4. Remove excess clothing and blankets from the child.

4. Remove excess clothing and blankets from the child.

A client is experiencing acute confusion. What nursing actions would be appropriate for this client? Select all that apply. A. Eliminate unnecessary noise B. Keep eyeglasses within reach C. Place a calendar in the room, and identify each day D. Keep the room well lit during waking hours E. Provide dark glasses

A, B, C, and D

A client with a minor head injury has a Glasgow Coma score of 15. What does this score indicate to the​ nurse? ​(Select all that​ apply.) A. Client uses appropriate words and phrases. B. Client spontaneously opens the eyes. C. Client is oriented to​ person, place, and time. D. Client withdraws to pain. E. Client withdraws to touch.

A, B, and C

A nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? Select all that apply A. Sleeplessness B. Anxiety C. Apathy D. Racing Thoughts E. Somatic complaints

A, B, and D

After a nursing​ assessment, the nurse documents that a client is confused. Which behaviors did the nurse assess to determine this client​'s level of​ consciousness? ​(Select all that​ apply.) A. Uses inappropriate words to describe situations B. Moans in response to painful stimuli C. Does not know why hospitalization is required D. Responds to verbal stimuli but quickly falls back asleep E. Does not remember home address

A, C, E Rationale: Confusion is the inability to think rapidly and clearly. Additional characteristics include easily​ bewildered, poor​ memory, short attention​ span, misinterprets stimuli and impaired judgment. Semicomatose is moaning in response to painful stimuli. Obtundation is responding to verbal stimuli but quickly falling asleep.

The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? Select all that apply. A. Ongoing pain B. Confusion at night C. Inability to sleep D. Easily angered E. Worrying about upcoming diagnostic tests

A, C, and E

A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that the treatment will include: A. Core rewarming with warm fluids B. Ambulation to increase metabolism C. Frequent oral temperature D. Gastric tube feedings to increase fluids

A. Core rewarming with warm fluids

The nurse wants to protect a client from developing an infection. What action should the nurse take to break a link in the chain of infection? A. Cover the mouth and nose when sneezing B. Place contaminated linens in a paper bag C. Use PPE sparingly D. Wear gloves at all time

A. Cover the mouth and nose when sneezing

A patient arrives in the emergency department with a swollen ankle after an injury occurred while playing soccer. Which action by the nurse is appropriate? A. Elevate the ankle above heart level B. Remove the patient's shoe and sock C. Apply a warm moist pack to the ankle D. Assess the ankle's range of motion (ROM)

A. Elevate the ankle above heart level

The nurse, surveying the assisted living facility regarding safety features for patients with sensory deficits, notes that accommodations that are most appropriate are A. Fire and smoke alarms with both sound and flashing lights B. Colorful throw rugs to designate the purpose of various rooms C. Alarms on all exit doors D. Steps painted with dark colors

A. Fire and smoke alarms with both sound and flashing lights Rationale: Sound and flashing lights for alarms are helpful for both visual and auditory deficits. Throw rugs, though colorful, present a mobility hazard. Exit door alarms are not required for sensory deficits but are more essential for patients with cognitive impairments. Steps painted with dark colors are a hazard to the elderly because their depth perception may be impaired.

A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this client's response to sensory stimuli as being due to which factor? A. Lifestyle B. Developmental stage C. Culture D. Illness

A. Lifestyle

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including: A. Stupor B. Erythema C. Increased anxiety D. Rapid respirations

A. Stupor

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate? a. Risk for falls related to dizziness or weakness b. Disturbed tactile sensory perception related to spinal cord damage c. Ineffective thermoregulation related to decreased vasomotor response d. Acute pain related to hyperreflexia and spasm

Answer: A Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia.

Neurologic testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, the nurse plans to a. insert an oral airway. b. withhold oral fluid or foods. c. provide highly seasoned foods. d. apply artificial tears every hour.

Answer: B Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

To assess the functioning of the optic nerve (CN II), the nurse should a. apply a cotton wisp strand to the cornea. b. have the patient read a magazine. c. shine a bright light into the patient's pupil. d. check for equal opening of the eyelids.

Answer: B Rationale: The optic nerve is responsible for visual fields and visual acuity. Trigeminal and facial nerve functions are tested by assessing the corneal reflex. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment? a. The new nurse tests for light touch before testing for pain. b. The new nurse has the patient close the eyes during testing. c. The new nurse tells the patient, "You may feel a pinprick now." d. The new nurse uses an irregular pattern to test for intact touch.

Answer: C Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to a. determine the patient's motivation for self-care. b. include the patient in health care decisions. c. use the information given by the patient to guide care. d. assess the patient's baseline cognitive abilities.

Answer: D Rationale: Appropriateness of the patient's response and the patient's use of language will help the nurse to assess the baseline cognitive abilities of the patient. A confused patient may not be able to participate in self-care or make informed health care decisions. The health history given by a confused patient should not be used to guide decisions about care unless it can be verified by another source.

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but does not respond to the nurse's questions. The nurse will suspect a. a temporal lobe lesion. b. injury to the cerebellum. c. a brainstem lesion. d. damage to the frontal lobe.

Answer: D Rationale: Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

When obtaining a health history from a patient with a neurologic problem, which question by the nurse will elicit the most useful response from the patient? A. "Do you ever have any nausea or dizziness?" B. "Does the pain radiate from your back into your legs?" C. "Do you have any sensations of pins and needles in your feet?" D. "Can you describe the sensations you are having in your chest?"

Answer: D. "Can you describe the sensations you are having in your chest?" Rationale: The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms. The other questions encourage the use of "yes" or "no" responses and may cause the patient to omit useful additional data.

A nursing instructor is reviewing sensory perception with the nursing students. The nursing instructor knows that the students have appropriately learned the information when he hears them make what comments regarding the sensory​ process? (Select all that​ apply.) A. ​"A receptor is not always necessary to process a stimulus to the​ brain." B. ​"The feeling of my stomach being full after a large meal is an example of a visceral​ sensation." C. ​"If a person can perceive stimuli in the​ environment, and​ respond, that person is exhibiting​ awareness." D. ​"When I am feeling around my purse with my hand trying to find my​ keys, I am using the process of​ stereognosis." E. ​"Kinesthetic is the sensation of​ touch."

B, C, D

The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? Select all that apply. A. Client has severe pain B. Client has impaired vision C. Client is unable to ambulate D. Client is on medication that alters sensory perception E. Client has no family in the immediate area

B, C, D, and E

Nursing diagnoses for patients with sensory perceptual variances might include (Select all that apply): A. Knowledge deficit for nutrition. B. Risk for injury. C. Impaired mobility. D. Altered nutrition that is less than the body requirements. E. Decreased cardiac output.

B, C, and D

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ? A. Schedule a Weber and Rinne test B. Observe the client's interaction with significant other C. Use an otoscope to examine the inner ear D. Confront the client with the nurse's suspicion

B. Observe the client's interaction with significant other

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? A. A diagnosis of AIDS and cytomegalovirus B. A positive PPD with an abnormal chest x-ray C. A tentative diagnosis of viral pneumonia D. Advanced carcinoma of the lung

B. A positive PPD with an abnormal chest x-ray

A client with a traumatic brain injury is intubated and placed on mechanical ventilation. What should the nurse use to evaluate the effectiveness of these respiratory​ interventions? A. Motor and sensory function B. Arterial blood gas results C. Cranial nerve function D. Glasgow Coma score

B. Arterial blood gas results

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck because the client is moved onto a stretcher B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish C. Place a cap over the client's head D. Administer a sedative as ordered

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish

The patient informs nurse that she is not able to recall her phone number or her address, and this is concerning to the patient. Nurse recognizes the inability to recall information is indicative of what sensory/ perception problem? A. Stupor B. Disorientation C. Semi-comatose D. Somnolent

B. Disorientation

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? A. Cut the needle off a syringe after using it to give a client an injection B. Dispose of the blood-contaminated materials in a biohazard container C. Gloves should not be worn for client care unless body fluids are seen D. Wear a mask when in direct contact with all clients

B. Dispose of the blood-contaminated materials in a biohazard container

The nurse assesses a patient the morning of the first post-op day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? A. Obtain a wound culture B. Document assessment C. Notify provider D. Assess the wound every 2 hours

B. Document assessment

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? A. Edema, rubor, heat, and pain B. Fever, malaise, anorexia, nausea, and vomiting C. Palpitations, irritability, and heat intolerance D. Tingling, numbness, and cramping of the extremities

B. Fever, malaise, anorexia, nausea, and vomiting

A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nurse assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? A. Masks should be worn with all client contact B. Gloves should be worn with all client contact C. Isolation gowns are not needed D. A private room is always indicated

B. Gloves should be worn with all client contact

A​ 78-year-old female client presents for an annual exam. The client admits to smoking a ​½ a pack of cigarettes per day for the last 50 years. The nurse would expect that the client would also complain of a deficit in what type of sensory​ stimuli? A. Visual B. Gustatory C. Tactile D. Auditory

B. Gustatory Rationale: The two most common sensory deficits associated with tobacco use are the sense of taste​ (gustatory) and the sense of smell​ (olfactory). ​Visual, auditory, and tactile senses are not affected.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle

B. Nail bed pressure

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? A. Increase fluid intake. B. Resume full activity level. C. Stay in a cool environment when possible. D. Monitor voiding for adequacy of urine output.

B. Resume full activity level.

A client is hospitalized for a treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the client's sensory perception function? A. Risk for sensory overload B. Social support network C. Mental status D. Environment

B. Social support network

The nurses assessing a patient's gustatory function. What approach by the nurse will assist in assessing this sensation? A. Close your eyes and tell me what you smell B. Tell me if the taste on your tongue is sweet, sour, bitter, or salty C. Repeat the words that I speak softly to you D. Please read this paragraph to me

B. Tell me if the taste on your tongue is sweet, sour, bitter, or salty

The nurse assesses that the patient who has acquired a nosocomial infection is most likely the patient with: A. an abdominal abscess following a ruptured appendix. B. a urinary infection after the insertion of a Foley catheter. C. lice and nits that have come from the Emergency Department. D. a 2-day postoperative hip replacement foot fungus.

B. a urinary infection after the insertion of a Foley catheter

The patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. The nurse responds that it is caused by: A. fecal-oral contamination. B. long-term antibiotic therapy. C. protozoal infection. D. inflammatory response.

B. long-term antibiotic therapy.

Mr. Fields is a resident of a long-term care facility who has moderate hearing loss. When communicating with Mr. Fields what should the nurse do? A: Use vocabulary and concepts that are as simple and unambiguous as possible. B: Minimize background noise and ensure that lighting adequate to see the nurses face. C: Repeat each direction or question in different terms in order to maximize understanding D: Use written communication whenever possible in order to minimize Mr. Fields frustration.

B: Minimize background noise and ensure that lighting adequate to see the nurses face.

A client with a traumatic brain injury is diagnosed as being brain dead. Which assessment finding supports this​ diagnosis? A. Complete unawareness of self B. Aware of environment but unable to communicate C. Absence of spontaneous respirations D. Neck extended and the jaw is clenched

C. Absence of spontaneous respirations

The patient brought to the emergency room is unconscious and cannot be aroused. The patient is breathing and has a heartbeat. What state of awareness is the patient exhibiting? A. Stupor B. Somnolence C. Coma D. Sleeping

C. Coma

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? A. Radiation B. Convection C. Conduction D. Evaporation

C. Conduction

During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client? A. Use the clock face as a format for describing the position of food on meal trays B. Provide all teaching materials in very large font C. Ensure that the client has assistance when ambulating D. Use only non-irritating soaps for bathing

C. Ensure that the client has assistance when ambulating

A client recovering from a stroke is unable to swallow and has an absent gag reflex. Which cranial nerve should the nurse suspect is affected in this​ client? A. Hypoglossal B. Trigeminal C. Glossopharyngeal D. Spinal accessory

C. Glossopharyngeal

The nurse is preparing to remove soiled gloves. What action should the nurse take first? A. Drop the gloves into the appropriate waste receptacle B. Ease the fingers into the gloves C. Grasp the outside of the non dominant glove D. Hook the bare thumb inside the other glove

C. Grasp the outside of the non dominant glove

Deep Tendon Reflexes would be a part of which assessment? A. Mental Assessment B. Physical Assessment C. Neurological Assessment D. Sensory Assessment

C. Neurological Assessment

The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? A. Adjust the diet so it contains more fruits and veggies B. Apply lubricating lotion to the edges of the wound C. Notify the physician of any edema, heat, or tenderness at the wound site D. Thoroughly irrigate the wound with hydrogen peroxide

C. Notify the physician of any edema, heat, or tenderness at the wound site

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this client's room? A. Cabinet stocked with gloves and gowns B. Cards and records C. Paper towels, sink, and BP cuff D. Sign on the door

C. Paper towels, sink, and BP cuff Rationale: The stocked cabinet (a) and sign on the door (d) are on the OUTSIDE of the pt's room

A patient has expressed great relief at the improvement in her hearing after irrigation of the ear canal yielding a large amount of impacted cerumen. The patient was experiencing a sensory alteration related to which of the following? A. Sensory transmission B. Sensory perception C. Sensory reception D. Sensory reaction

C. Sensory reception

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection A. Assess vital signs only once daily B. Raise the temp of the client's room C. Wash hands D. Wear a mask for all client care

C. Wash hands

The nurse explains that the difference between medical asepsis and surgical asepsis is that medical asepsis requires: A. hand washing with antimicrobial soap for 3 minutes. B. that no nonsterile product come into contact with the patient. C. elimination of all microorganisms. D. good hand washing technique.

C. elimination of all microorganisms.

The nurse assessing a neglected child brought into the emergency department the grandmother of the child reports that the child remains in the crib and removed only when the child is fed. During the time in the crib, what is the child most likely to have experienced? A . adaptation B. stereognosis C. sensory deprivation D. kinesthesia

C. sensory deprivation

What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment? A. A cotton ball B. A penlight C. An ophthalmoscope D. A tongue depressor and flashlight

D. A tongue depressor and flashlight Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.

What nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? A. Monitor WBC count B. Check the skin for areas of redness C. Check the temp every 2 hours D. Ask about fatigue or feelings of malaise

D. Ask about fatigue or feelings of malaise

A postoperative client has been placed on a clear-liquid diet. The nurse provides the client with which items that are allowed to be consumed on this diet? A. Vegetable juices. B. Custard. C. Sherbet. D. Bouillon

D. Bouillon

A 24 y/o patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8º F. Which action by the nurse is most appropriate? A. Apply a cooling blanket B. Notify the provider C. Give the prescribed PRN aspirin 650mg D. Check the patient's oral temp again in 4 hours

D. Check the patient's oral temp again in 4 hours

A special needs child has been placed in a classroom with other special needs children. The classroom is noisy with a high level of activity, and the child appears to have difficulty concentrating on his work. What is the child's likely experiencing? A. Sensory deprivation B. Sensory reception C. Sensory perception D. Sensory overload

D. Sensory overload

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure? A.. Cerebrum B. Cerebellum C. Hippocampus D. Hypothalamus

D. Hypothalamus

A client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? A. Speak loudly to the client B. Test the temperature of the shower water C. Check the temperature of the food on the delivery tray D. Provide a clear path for ambulation without obstacles

D. Provide a clear path for ambulation without obstacles Rationale: CN II is the optic nerve

A client who is recovering from a surgery has been ordered a change from a clear liquid diet to a full liquid diet. The nurse would offer which full liquid item to the client? A. Popsicle. B. Carbonated beverages. C. Gelatin. D. Pudding.

D. Pudding. Rationale: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding, and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. Options A, B, and C are clear liquid diet.

A priority nursing intervention for a patient with hyperthermia would be: A. Initiating seizure precautions B. Limiting oral intake C. Providing a blanket D. Removing excess clothing

D. Removing excess clothing

A client's baseline vital signs are as follows: temperature 98.8° F oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F. Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? A. Respiratory rate of 12 breaths/min B. Respiratory rate of 16 breaths/min C. Respiratory rate of 18 breaths/min D. Respiratory rate of 22 breaths/min

D. Respiratory rate of 22 breaths/min

The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client. A. Social isolation B. Risk for Impaired Skin Integrity C. Disturbed Sensory Perception D. Risk for Injury

D. Risk for Injury

A client can be aroused only with extreme or repeated stimuli. How should the nurse document the client's behavior? A. Somnolent B. Disoriented C. Comatose D. Semicomatose

D. Semicomatose

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased respirations B. Rapid pulse rate C. Red, sweaty skin D. Slow capillary refill

D. Slow capillary refill

The nurse has just received change-of-shift report about the following 4 patients. Which patient will the nurse assess first? A. The patient who has multiple back wounds on the feet and ankles B. The newly admitted patient with a stage IV pressure ulcer on the coccyx C. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change D. The patient who has been receiving immunosuppressant medications and has a temp of 102º F

D. The patient who has been receiving immunosuppressant medications and has a temp of 102º F

The nurse is removing PPE. Which nursing action demonstrates the appropriate technique for removing a mask? A. Bend the strip at the top of the mask B. Loop the ties over the ears C. Tie the strings in a bow D. Touch the mask by the strings only

D. Touch the mask by the strings only

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? A. Disinfecting an item before adding it to a sterile field B. Allowing sterile gloved hands to fall below the waist C. Suctioning the oral cavity of an unconscious client D. Touching only the inside surface of the first glove while pulling it onto the hand

D. Touching only the inside surface of the first glove while pulling it onto the hand

The nurse is preparing to leave a client's isolation room. What action should the nurse take first when removing a grossly soiled gown? A. Grasp the sleeve of the dominant arm, and remove with a gloved hand B. Release the neck ties of the gown and allow the gown to fall forward C. Untie the strings at the neck first D. Untie the strings at the waist first

D. Untie the strings at the waist first

The nurse is caring for a client with Hepatitis A. Which technique should the nurse use to promote proper hand washing technique with this client? A. Allow the water to splatter forcibly when it is turned on B. Clean the faucet after each use C. Hold the hands upward under the faucet D. Use approximately a teaspoon of soap

D. Use approximately a teaspoon of soap

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? A. Administering parenteral medications B. Changing a dressing C. Performing a urinary catheterization D. Using PPE

D. Using PPE

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Remove the patient's shoe and sock. c. Apply a warm moist pack to the ankle. d. Assess the ankle's range of motion (ROM).

a. Elevate the ankle above heart level.

Which strategy by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection? a) Provide a light blanket. b) Encourage a hot shower. c) Monitor temperature every hour. d) Turn up the thermostat in the patient's room.

b) Provide acetaminophen every 4 hours to maintain consistent blood levels. Rationale: Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

A patient had abdominal surgery last week. The patient calls the office and says the wound is now draining thick white material and it smells funny. How should the nurse document this drainage? a) Serous b) Purulent c) Fibrinous d) Catarrhal

b) Purulent

The patient has inflammation and is complaining of malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? a) Local response b) Systemic response c) Infectious response d) Acute inflammatory response

b) Systemic response

The nurse assess a patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound culture b. Document assessment c. Notify health care provider d. Assess the wound every 2 hours

b. Document assessment