medsurg cumulative

A client is learning how to perform Kegel exercises. Which statement by the client indicates a need for additional teaching?

"I need to hold the position for at least 15 seconds."

Which priority issue should the nurse choose when caring for a client with long-standing hypertension?

Altered tissue perfusion

What clinical manifestations does the nurse recognize would be associated with a diagnosis of hyperthyroidism? Select all that apply.

An elevated systolic blood pressure Muscular fatigability Weight loss.

The nurse advises the patient with chronic pyelonephritis that he should:

Increase fluids to 3 to 4 L/24 hours to dilute the urine.

A client presents at the walk-in clinic reporting diarrhea and vomiting. The client has a documented history of adrenal insufficiency. Considering the client's history and current symptoms, the nurse should anticipate that the client will be instructed to do which of the following?

Increase their intake of sodium until the gastrointestinal (GI) symptoms improve.

A nurse is preparing to administer an antiretroviral medication to a client who is positive for HIV. The nurse identifies the drug as a nucleoside reverse transcriptase inhibitor (NRTI). What drug will the nurse administer?

Lamivudine

The nurse is assessing a new client with reports of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder?

Megaloblastic anemia

A number of pharmacologic agents are used to treat hyperthyroidism. Which of the following drugs is one of the most commonly prescribed and acts by blocking synthesis of the thyroid hormones?

Methimazole

A creatinine level has been ordered. The nurse prepares to:

Obtain a blood specimen.

A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include

adrenal suppression.

The nurse is caring for a client who is scheduled to have an upper endoscopy. Which type of medication(s) might be provided during the procedure? Select all that apply.

analgesic agent anticholinergic agent sedative

Which allergic reaction is potentially life threatening?

angioedema

The nurse is caring for a client with a new onset of gout. What medication does the nurse anticipate will be ordered by the health care provider?

colchicine

When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of:

encouraging fluids.

A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of:

hypoglycemia

The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response?

"A PFT measures how much air moves in and out of your lungs when you breathe."

A nurse is teaching a client with immunodeficiency about the signs and symptoms of infection to report. The nurse determines that the teaching was successful when the client makes which statement?

"Any change, however subtle, might mean that I have an infection."

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?

"Are you allergic to seafood or iodine?"

The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question?

"Are you allergic to shellfish?"

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client?

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications?

"Do you feel any muscle twitches or spasms?"

The nurse cares for a client who is post op bariatric surgery whose bowel sounds have returned and is tolerating oral intake. What teaching will the nurse provide the client about the nutrition required at this time? Select all that apply.

"Eat slowly." "You will have six small meals per day." "You need to drink plenty of water in between meals."

While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?

"Echocardiography is a way of determining the functioning of the left ventricle of your heart."

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes based on which statement(s)? Select all that apply.

"Exercise will need to be a regular part of my daily routine." "I will make sure to follow the weight loss plan designed by the dietitian."

A nurse cares for a client who wants to know more information about bariatric surgery. The client asks the nurse, "What weight loss can I expect?" What is the nurse's best response?

"Expect to lose 10-35% of total body weight 2 to 3 years postoperatively."

A nurse is completing an assessment of a client with suspected acromegaly. To assist in making the diagnosis, which question should the nurse ask?

"Has your shoe size increased recently?"

During a routine medical evaluation, a client is found to have a random blood glucose level of 210 mg/dL. Which client statement(s) made by the client are concerning to the nurse? Select all that apply.

"I have lost 10 pounds without even trying." "At times my vision is blurry." "I have to void nearly every hour." "I cannot seem to quench my thirst."

A client with type 2 diabetes has recently been prescribed acarbose, and the nurse is explaining how to take this medication. The teaching is determined to be effective based on which statement by the client?

"I will take this medication in the morning, with my first bite of breakfast."

The nurse is educating a client just diagnosed with human immunodeficiency virus (HIV) about the use of condoms to prevent sexual transmission. Which statement made by the client indicates the education provided is understood? Select all that apply.

"If I use condoms consistently, they are very effective in preventing transmission." "Latex condom use is recommended during vaginal or anal intercourse."

A client with Cushing syndrome is admitted to the hospital. During the initial assessment, the client tells the nurse, "The worst thing about this disease is how awful I look. I want to cry every time I look in the mirror." Which statements by the nurse is the best response?

"If treated successfully, the major physical changes will disappear with time."

A nurse is conducting a class on how to self-manage insulin regimens. A client asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer?

"If you are going to use up the vial within 1 month, it can be kept at room temperature."

A nurse is caring for a client who will undergo bariatric surgery. Which nutritional recommendation will the nurse include in the client teaching?

"Increase your intake of plant-based proteins."

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

"Ketones will tell us if your body is using other tissues for energy."

A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate?

"Make sure to eat enough fiber to prevent constipation."

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer?

"My pain resolves when I have something to eat."

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse?

"OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

The nurse is educating a client regarding macrovascular complications of diabetes. Which statement(s) made by the client indicates. the education is effective? Select all that apply.

"There is a higher risk that I will have a heart attack." My risk for stroke is higher with diabetes."

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control.

A nurse catheterized an elderly client and confirmed the presence of residual urine. What residual urine volume would be considered abnormal for an elderly client?

150 mL

A client is infected with human immunodeficiency virus (HIV) after sharing needles with another intravenous (IV) drug abuser. Upon infection with HIV, the immune system responds by making antibodies against the virus, usually within how many weeks after infection?

3 to 12 weeks

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?

30 minutes

Calculate the BMI of a client who is 180 pounds and is 5 feet 2 inches tall. Round to one decimal point.

32.9

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 p.m.

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.

6

A health care provider prescribes one tablet of ferrous sulfate daily for a 15-year-old girl who experiences heavy blood flow during her menstrual cycle. The nurse advises the patient and her parent that this over-the-counter preparation must be taken for how many months before stored iron replenishment can occur?

6 to 12 months

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled?

6.5%

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

7:45 AM

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube

The nurse is caring for several older clients. For which client would the nurse be especially alert for signs and symptoms of pyelonephritis?

A client with urinary obstruction

Which of the following is a clinical manifestation of hypothyroidism?

A pulse rate below 60 beats/minute.

A patient with sickle cell disease is brought to the emergency department by a parent. The patient has a fever of 101.6°F, heart rate of 116, and a respiratory rate of 32. The nurse auscultates bilateral wheezes in both lung fields. What does the nurse suspect this patient is experiencing?

Acute chest syndrome

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply.

Administer Diphenhydramine. Insert an intravenous line. Have respiratory therapy provide an albuterol treatment.

After a thyroidectomy, the client develops a carpopedal spasm while the nurse is taking a BP reading on the left arm. Which action by the nurse is appropriate?

Administer IV calcium gluconate as ordered.

Before discharge, what should a nurse instruct a client with Addison's disease to do when exposed to periods of stress?

Administer hydrocortisone I.M.

The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that which risk factors and cardiovascular problems are related to hypertension? Select all that apply.

Age ≥65 in women Overweight/obesity Smoking

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?

Airway clearance

A nurse is teaching a client and the client's family about chronic pancreatitis. Which are the major causes of chronic pancreatitis?

Alcohol consumption and smoking

The triage nurse in the emergency department is assessing a client who reports pain and swelling in the right lower leg. The client's pain became much worse last night and appeared along with fever, chills, and sweating. The client states, "I hit my leg on the car door 4 or 5 days ago, and it has been sore ever since." The client has a history of chronic venous insufficiency. Which intervention should the nurse anticipate for this client?

Antibiotics to treat cellulitis

The patient has been diagnosed with urge incontinence. What classification of medication does the nurse expect the patient will be placed on to help alleviate the symptoms?

Anticholinergic agents

A client is brought to the ED reporting fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the client has been treated for a sore throat three times in the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client's diagnosis?

Aplastic anemia

A child has been transported to the emergency department (ED) after a severe allergic reaction. How will the nurse evaluate the client's respiratory status? Select all that apply.

Assess breath sounds. Measure the client's oxygen saturation. Monitor the client's respiratory pattern. Assess the client's respiratory rate.

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?

Assess for signs and symptoms of anaphylaxis.

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)

Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complication(s)? Select all that apply.

Atelectasis Pneumonia Metabolic imbalances

The nurse is teaching a client about the correct use of topical concentrated corticosteroids. The nurse includes which statement(s)? Select all that apply.

Avoid applying to the face. Avoid prolonged use.

The nurse is caring for a client who is scheduled for a urea breath test to detect for Helicobacter pylori as a reason for gastric distress. Which instruction(s) will the nurse provide to the client to prepare for this test? Select all that apply.

Avoid bismuth subsalicylate before the test. Do not take proton pump inhibitors before the test.

The nurse is educating a client with chronic venous insufficiency about the prevention of complications related to the disorder. What should the nurse include in the information given to the client? Select all that apply.

Avoid constricting garments. Elevate the legs above the heart frequently throughout the day. Sleep with the foot of the bed elevated.

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. Which health education related to this medication will the nurse provide? Select all that apply.

Avoid drinking alcohol while taking the drug. May produce a metallic taste.

A young adult client is prescribed misoprostol to prevent gastric ulcers caused by frequent use of nonsteroidal anti-inflammatory agents for an autoimmune disorder. For which reason will the nurse question giving the client a dose of this medication?

Awaiting the results of a pregnancy test

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan?

Bed rest lowers the metabolic rate and reduces enzyme production.

A client presents to the emergency room with a possible diagnosis of appendicitis. The health care provider asks the nurse to assess for tenderness at McBurney's point. The nurse knows to palpate which area?

Between the umbilicus and the anterior superior iliac spine

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Bleeding

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications?

Bleeding and perforation

To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment?

Blood levels of the drug must be monitored.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.

Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply.

Blood pressure control Weight loss Smoking cessation

A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.

Blurred or deteriorating vision Fatigue and irritability Polyuria and polydipsia Wounds that heal slowly or respond poorly to treatment

A nurse cares for a client with obesity who is also diagnosed with depression. Which medication does the nurse expect the health care provider will prescribe, which also aids in weight loss?

Bupropion

A nurse is providing an educational class to a group of older adults at a community senior center. To prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrient(s)? Select all that apply.

Calcium Vitamin D

The nurse is to check residual urine amounts for a client experiencing urinary retention. Which of the following would be most important?

Catheterize the client immediately after the client voids.

The nurse is performing an assessment on a patient to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.)

Character of apical and peripheral pulses Heart rhythm Heart rate

What finding by the nurse may indicate that the client has chronic hypoxia?

Clubbing of the fingers

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents

A client who has been taking corticosteroids for several months has been experiencing muscle wasting. The client has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend? Select all that apply.

Consume a high-protein diet. Increase consumption of vitamin D and calcium sources. Limit sodium consumption.

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse? (Select all that apply.)

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins

A nurse is teaching a client about hormones within the endocrine system. Which hormones would be included as the hypothalamic hormones? Select all that apply.

Corticotropin-releasing hormone Thyrotropin-releasing hormone Gonadotropin-releasing hormone

A patient with hypertension is waking up several times a night to urinate. The nurse knows that what laboratory studies may indicate pathologic changes in the kidneys due to the hypertension? (Select all that apply.)

Creatinine Blood urea nitrogen (BUN)

A nurse is performing the admission assessment of a client who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.

Current medication regimen Identification of client's support system Immune system function History of sexual practices

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

The nurse is performing an assessment of a clients peripheral pulses and indicates that the pulse quality is +1 on a scale of 0-4. What does this documented finding indicate?

Difficult to palpate and is obliterated with pressure.

A diabetes nurse educator is educating a group of clients with type 1 diabetes about "sick day rules." Which guidelines apply to periods of illness in a diabetic client? Select all that apply.

Do not eliminate insulin when nauseated and vomiting. Report elevated glucose levels greater than 300 mg/dL. Eat 6 to 8 smaller meals a day. Assess blood glucose every 3 to 4 hours

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?

Dorsiflex the foot while the leg is elevated to check for calf pain.

You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client?

Drink at least 8 glasses of water every day.

A high school student who was injured in a football game presents with knee pain with internal rotation of the foot. Which interventions are appropriate nursing actions? Select all that apply.

Elevate the affected leg. Apply ice packs to the affected knee. Apply a knee brace or wrap the affected knee.

A major goal when caring for a catheterized patient is to prevent infection. Select all the nursing actions that apply.

Empty the collection bag at least every 8 hours to reduce bacterial growth. Suspend the drainage bag off the floor. Wash the perineal area with soap and water at least twice daily.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake.

The nurse is caring for a client receiving insulin isophane suspension (NPH) at breakfast. What is an important dietary consideration for the nurse to keep in mind?

Encourage midday snack.

A nurse is caring for a client who has a magnetic resonance imaging (MRI) scheduled. Which action(s) by the nurse would be a priority prior to this diagnostic procedure? Select all that apply.

Ensure that there are no metal objects on the client Confirm whether or not the client has a pacemaker

The nurse is caring for a client who requires enteral nutrition. For which reasons will the nurse anticipate the client having a gastrostomy tube inserted? Select all that apply.

Enteral support needed for over 6 weeks Client is comatose

The nurse assesses a client returning from the post anesthesia unit with a new onset of sinus tachycardia with a heart rate of 138 beats per minute and a blood pressure of 128/80mmHg after elevating the head of the bed. What intervention does the nurse consider?

Evaluating laboratory values

A client is brought by ambulance to the ED after experiencing what the family thinks is a stroke. The nurse caring for this client is aware that which is an absolute contraindication for thrombolytic therapy?

Evidence of hemorrhagic stroke

A patient with sickle cell anemia is to begin treatment for the disease with hydroxyurea. What does the nurse inform the patient will be the benefits of treatment with this medication? Select all that apply.

Fewer painful episodes of sickle cell crisis Lower incidence of acute chest syndrome Decreased need for blood transfusions

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?

Fruity breath

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?

Frustration around changes in function and communication

A client who is postoperative bariatric surgery is diagnosed with bile reflux. Which conditions are associated with bile reflux? Select all that apply.

Gastritis Esophagitis

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Group A, beta-hemolytic streptococci

A student with diabetes reports feeling nervous and hungry. The school nurse assesses the student and finds the child has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?

Half of a cup of juice, followed by cheese and crackers

Which of the following precautions would be most appropriate when caring for a client being treated with radioactive iodine (RAI) for a thyroid tumor?

Handle body fluids carefully.

A client is brought into the ED by family members who tell the nurse the client grabbed their chest and reported substernal chest pain. What form of monitoring should the nurse anticipate being implemented?

Hardwire continuous electrocardiogram (ECG) monitoring

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?

High sugar pulls fluid into the bloodstream, which results in more urine production.

What information should the nurse include in client discharge teaching for a client as a way to prevent epistaxis?

Humidify the indoor environment.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

Hypercapnia

When administering benazepril with spironolactone, the nurse should be aware that which electrolyte imbalance may occur?

Hyperkalemia

A client has had a thyroidectomy. Which of the following would lead the nurse to suspect that the client is developing thyrotoxic crisis?

Hyperthermia

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?

Hypoglycemia

A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply.

Hypotension Hypoventilation Hypothermia

The nurse has performed a thorough nursing assessment of the care of a client with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply.

Identification of mobility limitations Comparison of temperature in the client's legs Bilateral comparison of peripheral pulses Location and type of pain

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

An older adult client reports experiencing hemorrhoids of increasing severity in recent months. Which education will the nurse provide to reduce the severity of occurrence? Select all that apply.

Increased fluid intake Increased fiber intake

The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The nurse should plan interventions to address which priority issue?

Ineffective tissue perfusion

A client with a long-standing diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the client for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis?

Infection

The nurse and urologist have both been unsuccessful in catheterizing a client with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the health care provider will use to drain the client's bladder?

Insertion of a suprapubic catheter

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options.

Inspection Auscultation Percussion Palpation

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.

Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly. Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals.

During a routine physical examination, the nurse assesses a blood pressure reading of 150/90 mm Hg. The patient's blood work indicates several abnormal results. The health care provider informs the nurse that he suspects that the patient has metabolic syndrome. The nurse knows that this diagnosis is associated with three classic signs/symptoms. Select all that apply.

Insulin resistance Dyslipidemia and/or abdominal obesity A blood pressure reading greater than 130/85 mm Hg

The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. This pain is relieved with rest and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address which health problem?

Intermittent claudication

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5.

A client admitted to the hospital in preparation for a splenectomy to treat autoimmune hemolytic anemia asks the nurse about the benefits of splenectomy. Which statement best explains the expected effect of splenectomy?

It will remove the major site of red blood cell (RBC) destruction.

The nurse knows to advise the patient with hyperparathyroidism that he or she should be aware of signs of the common complication of:

Kidney Stones

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?

Limit the use of indwelling urinary catheters.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen)

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment?

Loss of voluntary control of movement

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis?

Low serum calcium and low phosphorus level

The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?

Lowering the limb so that it is dependent

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Lung sounds

A client comes to the walk-in clinic with reports of pain in the foot following stepping on a roofing nail 4 days ago. The client has a visible red streak running up his foot and ankle. Which health problem should the nurse suspect?

Lymphangitis

A client is newly diagnosed with a peptic ulcer. For which medications will the nurse prepare teaching for this client? Select all that apply.

Metronidazole Bismuth subsalicylate Omeprazole

The student nurse is preparing a teaching plan for a client being discharged status post MI. What should the nurse include in the teaching plan? Select all that apply.

Need for dietary modifications Need for carefully regulated exercise Need for careful monitoring for cardiac symptoms

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply.

Normal bedtime blood glucose Increase in blood glucose from 3:00 AM until breakfast Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM

A nurse is assessing a client and notes a blood pressure (BP) of 205/115. The client has had BP's within normal limits up until this time. The client reports a sudden onset severe headache. The nurse recognizes this as probable malignant hypertension. What would be the nurse's first action?

Notify the health care provider.

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

Nuchal rigidity

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Oxygen toxicity

A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.

P wave P-R interval T wave

A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply.

Pain Gastrointestinal symptoms Changes in voiding

The nurse is performing an assessment for a patient who may have peripheral neurovascular dysfunction. What signs does the patient present with that indicate circulation is impaired? (Select all that apply.)

Pale, cyanotic, or mottled color Cool temperature of the extremity More than 3-second capillary refill

A client postoperatively reports to the nurse the need to urinate, but is unable to void. What should the nurse expect the healthcare provider to order? Select all that apply.

Perform a bladder scan. Complete a straight catheterization.

DDiagnostic imaging and physical assessment have revealed that a client diagnosed with peptic ulcer disease has experienced a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication?

Peritonitis

A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, which finding would be most consistent with this platelet level? Select all that apply.

Petechiae Bleeding gums

The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.)

Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Discontinue the transfusion. Administer oxygen.

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention?

Positioning the client to avoid intercranial pressure (ICP)

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?

Potassium-rich foods

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

A client newly diagnosed with type 1 diabetes asks the nurse why injection site rotation is important. What is the nurse's best response?

Promote absorption.

A nurse is developing a teaching plan for a client with an immunodeficiency. What would the nurse need to emphasize? Select all that apply.

Prophylactic medication regimens Need to interrupt therapy for short periods Maintenance of a well-balanced diet

The nurse is administering a medication to a client with hyperthyroidism to block the production of thyroid hormone. The client is not a candidate for surgical intervention at this time. What medication should the nurse administer to the client?

Propylthiouracil

The nurse is caring for a client with low back pain. Which education about body mechanics will the nurse provide the client? Select all that apply.

Push objects Avoid twisting the spine Lift with the leg muscles

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

Rapid, jerky, involuntary movements

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?

Raynaud's disease

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?

Related to bone demineralization resulting in pathologic fractures

The nurse is caring for a client with chronic gastritis. Which interventions will the nurse add to this client's plan of care? Select all that apply.

Remind to avoid alcohol intake. Review actions to reduce stress. Provide omeprazole as prescribed. Instruct to avoid foods that aggravate the condition.

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize which of the following actions?

Removing all metal-containing objects

A nurse is caring for a client with Cushing's syndrome. Which interventions would the nurse include in the client's plan of care? Select all that apply.

Report systolic BP greater than 139 mm Hg or diastolic BP greater than 89 mm Hg. Examine extremities for pitting edema. Administer prescribed diuretics. Monitor weight.

A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works?

Restricts the client's ability to eat.

A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of which condition?

Retinal blood vessel damage

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments?

Reviewing the client's creatinine and BUN levels

The nurse is completing the intake assessment of a client new to the allergy clinic. The client states reports taking nose drops six times a day to relieve nasal congestion. The nasal congestion increased, causing the client to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client is experiencing which condition?

Rhinitis medicamentosa

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?

Rhonchi

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?

Rovsing sign

The client asks the nurse about the functions of the kidney. Which should the nurse include when responding to the client? Select all that apply.

Secretion of prostaglandins Regulation of blood pressure Vitamin D synthesis

The client with diabetes asks the nurse why shoes and socks are removed at each office visit. The nurse gives which assessment finding as the explanation for the inspection of feet?

Sensory neuropathy

The nurse is preparing a teaching tool on the functions of the skin. Which information about the skin will the nurse include on this tool? Select all that apply.

Serves as a sensory organ Aids in maintaining fluid balance Helps regulate body temperature Protects the body from microorganisms

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem?

Severe pancreatitis with possible peritonitis

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.

Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow

What should the nurse assess for to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? Select all that apply.

Skin atrophy Striae Telangiectasia

The nurse is instructing a client on the self-administration of insulin. Place in order the steps that the nurse will instruct the client to take.

Stabilize the skin by pinching an area. Hold the syringe as if holding a pencil. Insert the needle straight into the skin. Push the plunger of the syringe. Pull the needle straight out of the skin. Press a cotton ball over the injection site. Discard the syringe into a hard container.

During an adult client's last two office visits, the nurse obtained BP readings of 130/88 mm Hg and 132/88 mm Hg, respectively. How would this client's BP be categorized?

Stage 1 hypertensive

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs).

Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction.

A client has a decreased level of thyroid hormone being excreted. What will the feedback loop do to maintain the level of thyroid hormone required to maintain homeostatic stability?

Stimulate more hormones using the negative feedback system

The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply.

Stoma is pink and shiny Continuous liquid flows from the stoma

A client who has been experiencing changes in bowel function is scheduled for a barium enema. Which instruction will the nurse provide for postprocedural recovery? Select all that apply.

Stool may be light colored for 3 days Increase fluid intake to evacuate the barium.

A client receiving a unit of packed red blood cells develops hives and generalized itching. Which actions will the nurse take to help this client? Select all that apply.

Stop the transfusion Notify the primary health care provider Administer diphenhydramine as prescribed

A client diagnosed with type 2 diabetes achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what as the likely cause for this short-term change in treatment?

Stress has likely caused an increase in the client's blood sugar levels.

A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply.

Stroke Myocardial infarction Coronary artery disease

A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response?

Surgery is delayed until the acute symptoms subside.

A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply.

Tachycardia Hypotension A rigid, board-like abdomen

A client is diagnosed with dumping syndrome after bariatric surgery. Which findings on the nursing assessment correlate with this diagnosis? Select all that apply.

Tachycardia Sweating Dizziness

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer?

The client has a rigid, "board-like" abdomen that is tender.

The nurse is gathering data from laboratory studies for a client who has HIV. The client's CD4+ cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse?

The client has converted from HIV infection to AIDS.

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received insulin.

A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy?

The client is at an increased risk for developing infection.

The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply.

The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours).

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family?

The client should mobilize as soon as physically able.

Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply.

The client should sit quietly while BP is being measured. The client's arm should be positioned at the level of the heart. Using a BP cuff that is too small will give a higher BP measurement.

An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. Which intervention(s) will be included in the client's subsequent care? Select all that apply.

The foot should be elevated to prevent edema. The toes should be monitored for temperature and sensations.

The nurse is caring for a client with essential hypertension. The nurse reviews lab work and assesses kidney function. Which action of the kidney would the nurse evaluate as the body's attempt to regulate high blood pressure?

The kidney excretes sodium and water.

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?

The short-acting insulin is withdrawn before the intermediate-acting insulin.

The nurse is assessing the client's ileal conduit stoma in the clinic. Which assessment finding would be of greatest concern to the nurse?

The stoma is dusky red.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?

They can be heard during inspiration and expiration.

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?

They increase the need for insulin.

A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?

This insulin has no peak action and does not cause a hypoglycemic reaction.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?

This is significant for poor neurologic outcomes.

A nurse cares for a client with anemia after having a total gastrectomy a year ago. Which unique assessment findings will the nurse likely find when assessing this client that may not be present in another client with anemia? Select all that apply.

Tingling in the fingers Poor coordination

A client in a clinic setting has just been diagnosed with hypertension. When the client asks what the end goal is for treatment, what is the nurse's best response?

To prevent complications/death by achieving and maintaining a blood pressure of 140/90 or less

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium

A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer her a complex carbohydrate snack as soon as possible?

To restore liver glycogen and prevent secondary hypoglycemia

Which clinical manifestation would the nurse recognize as an indicator of peripheral neurovascular dysfunction? Select all that apply.

Toes mottled and cool Complaints of pins and needles in feet

The nurse is caring for a client experiencing a severe nosebleed. A nasal sponge has been inserted and needs to remain in place up to 6 days before it is removed. The nurse should discuss the risk of what complication with the client?

Toxic shock syndrome

Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder? Select all that apply.

Tremor Rigidity Bradykinesia Postural instability

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

A client is admitted to a surgical unit after a thyroidectomy. The nurse takes and maintains the inflated blood pressure cuff on the client and observes a carpopedal spasm. What does this result indicate?

Trousseau sign and overt tetany

The nurse is caring for a client with symptoms of gallbladder disease. Which diagnostic test will the nurse anticipate preparing the client for to confirm the diagnosis?

Ultrasound

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

Unequal pupils Pinpoint pupils Absence of pupillary response

The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications?

Urinary tract infections

A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.

Urine output that decreased from 60 to 40 mL/hr Heart rate that increased from 82 to 98 beats/min within 2 hours Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?

Urine retention or incontinence

A nurse is assessing a new client who is diagnosed with peripheral artery disease. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment?

Use Doppler ultrasound to identify the pulses.

The nurse is caring for a client with Bell's palsy. Which of the following teaching points is a priority in the management of symptoms for this client?

Use ophthalmic lubricant and protect the eye.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

The nurse is preparing a teaching tool about the development of a venous thromboembolism. Which information about Virchow triad will the nurse include? Select all that apply.

Venous stasis Endothelial damage Altered coagulation

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?

Ventricular fibrillation

The nurse reviews laboratory results requested to track HIV. What laboratory test measures HIV RNA levels and is the best predictor of HIV disease progression?

Viral load

A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest?

Walking

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.

Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times.

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply.

Weigh the client every day. Check blood glucose level every 6 hours. Document intake and output.

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply.

Weight loss Limiting exercise Avoiding purine-rich foods

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply.

Weight loss Regular exercise Smoking cessation

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply.

Wheezes Decreased airflow Compromised gas exchange

An adult with a darker skin tone is admitted to the medical unit with a diagnosis of cirrhosis of the liver. To correctly assess this client for jaundice, which body area will the nurse initially look for a yellow discoloration? Select all that apply.

Whites of the eyes Oral cavity

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply.

Wound size Periwound skin Wound bed

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply.

Younger than 30 years of age Ketosis-prone Little or no endogenous insulin

A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:

has type 2 diabetes.

The nurse is performing an assessment for an older adult client and auscultates an S3 heart sound. What condition does the nurse determine may correlate with this finding?

heart failure

A client with adrenal insufficiency is gravely ill and presents with nausea, vomiting, diarrhea, abdominal pain, profound weakness, and headache. The client's family reports that the client has been doing strenuous yard work all day and was sweating profusely. Nursing management of this client would include observation for signs of:

hyponatremia and hyperkalemia.

The nurse establishes a learning contract with an overweight client. The contract is best if it

includes an incremental goal of 1-2 pound weight loss this week

A nurse is providing care to a client diagnosed with iron deficiency anemia who has been prescribed iron supplements. Which information should the nurse include in health education regarding the medication therapy? Select all that apply.

iron will cause the stools to darken in color. Increase vitamin C intake through diet and/or supplement.

The nurse is completing discharge teaching with a client with hyperthyroidism who has been treated with radioactive iodine at an outpatient clinic. The nurse instructs the client to

monitor for symptoms of hypothyroidism.

What lifestyle factors will the nurse discuss with the client who has a blood pressure of 130/88? Select all that apply.

physical activity dietary sodium weight reduction the DASH diet alcohol moderation

A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in:

serum glucose level.

The nurse is caring for a client in the emergency department. The client reports dyspnea, headache, and tinnitus. The client's blood pressure is 210/126 mm Hg. What should the nurse expect the health care provider to order?

short-acting intravascular antihypertensive agents

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

sit upright, leaning slightly forward.

The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management?

strategies for remaining active

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?

type I

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.