Nursing Process: Assessment

10. A client has delusions and hallucinations and refers to himself as "the man." He tells the nurse, "The man is bad." Which defense mechanism is the client demonstrating? a. Dissociation b. Splitting c. Displacement d. Identification

A

13. Which additional assessments should be conducted on an 18-year-old woman who was confused when found on the bathroom floor and her urinalysis tested positive for flunitrazepam? a. Assess for signs of sexual assult. b. Observe for hallucinations or delusions. c. Directly ask about suicidal intentions. d. Monitor for renal failure.

A

2. On which body system would the nurse focus when assessing a client with suspected Goodpasture syndrome? a. Renal b. Neurological c. Cardiovascular d. Musculoskeletal

A

23. Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. a. Asthma b. Hay fever c. Sarcoidosis d. Myasthenia gravis e. Rheumatoid arthritis

A, B

12. Which is true about prescriptive theory? a. It is nonspecific. b. It focuses on medication. c. It is seen in the Neuman systems model. d. It focuses on the phenomenon of an event.

B

17. Which thought in an individual corresponds to the society-maintaining orientation stage? Select all that apply. a. "I have to follow all state and federal laws." b. "I should avoid parties where alcohol is served." c. "I should avoid risky driving and follow traffic rules." d. "I should follow the rules or the teacher will punish me." e. "I should complete my homework so that the teacher will reward me."

B, C

19. A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks' gestation. Cervical examination reveal heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing? a. Missed b. Complete c. Inevitable d. Threatened

C

24. Which thought is common in an individual during the social contract orientation stage? a. "I should avoid parties where alcohol is served." b. "I should follow the rules or the teacher will punish me." c. "I should work to change a law to better society." d. "I should complete my homework so that the teacher will reward me."

C

11. An older adult client is admitted to the health care facility following a stroke. Which action is correct when the client's cousin asks to see the client's health record? a. Confirm the client's relationship first. b. Ask the client's primary health care provider. c. Inform the nurse manager and show the records. d. Explain that medical health records are confidential.

D

18. Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. a. Back of the neck b. Back of the hand c. Palm of the hand d. On the sternal area e. Back of the forearm

D, E

22. Which criteria in a client must be assessed to diagnose premenstrual dysphoric disorder (PMDD)? Select all that apply. a. Symptom-free period in the luteal phase b. Symptoms that resolve within a few days of menses onset c. Symptoms caused by the exacerbations of other disorder d. Symptoms such as irritability, anxiety, or depressed mood e. Symptoms that interfere with work or interpersonal relationships

D, E

16. The client says, "I want what I want." According to Freud's psychoanalytic theory, which aspect of personality development is the client displaying? a. Superego b. Id c. Healthy ego d. Unhealthy ego

B

6. Which question would the nurse ask while assessing a Hispanic woman with depression for the risk of self-harm? a. "When did you last spend time with friends?" b. "How do you express yourself when you're angry?" c. "When did you first notice that you were depressed?" d. "Do you have interests outside your work and home?"

B

3. A client with which condition would the nurse treat first according to a three-tiered triage system? a. Respiratory distress b. Multiple soft tissue injuries c. New onset of respiratory tract infection d. Skin rash and a simple lower limb fracture

A

7. During the initial assessment phase, which parameter would the nurse focus on for a client with panic disorder and agoraphobia? a. Easing the client's anxiety so further interviewing may be done b. Learning about the client's home life to facilitate the planning of future care c. Suggesting that the client rest for a while before taking the health history d. Helping the client identify the source of anxiety so the source may be avoided

A

9. Which potential complication is associated with ketonuria that can occur when clients severely restrict their calorie intake during pregnancy? a. Preterm labor b. Placenta previa c. Gestational diabetes d. Hyperemesis gravidarum

A

4. For a client with moderate dementia, which clinical manifestations are expected? Select all that apply. a. Restlessness b. Pessimism c. Short attention span d. Disordered reasoning e. Impaired motor activities

A, C, D, E

14. For which clinical manifestations would the nurse assess the client diagnosed with Alzheimer disease? Select all that apply. a. Loss of recent memory b. Focused attention span c. Perceptual disturbances d. Willingness to accept change e. Difficulty learning something new

A, C, E

20. According to the three-tiered triage system, which client condition requires urgent treatment? Select all that apply. a. Renal colic b. Strains and sprains c. Respiratory distress d. Severe abdominal pain e. Multiple displaced fractures

A, D, E

25. Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. a. Client with corneal arcus b. Client with periorbital edema c. Client with decreased skin turgor d. Client with paleness of conjunctivae e. Client with yellow lipid lesions on eyelids

A, E

5. A 50-year old client seen for a routine physical asks why a stool specimen for occult blood testing has been ordered. Which is the correct nursing response? a. "You will need to ask your health care provider; it is not part of the usual tests for people your age." b. "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." c. "It is performed routinely starting at your age as part of an assessment for colon cancer." d. "There must have been a positive finding after a digital rectal examination performed by your health care provider."

C

8. A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior would the nurse expect to observe? a. Making huge efforts to avoid "any kind of bug or spider" b. Experiencing flashbacks to an event that involved a sexual attack c. Spending hours each day worrying about something "bad happening" d. Becoming suddenly tachycardic and diaphoretic for no apparent reason

C

1. Which descriptions of play are developmentally normal in preschoolers? Select all that apply. a. Preschoolers hinder play of other children. b. Preschoolers follow set rules while playing. c. Preschoolers engage in pretend play. d. Preschoolers get engaged in associative play. e. Preschoolers need a temporary leader to play.

C, D, E

21. A primary health care provider orders a nucleic acid amplified test for an adolescent client who sustained a sexual assault. Which infections can be diagnosed with this test? Select all that apply. a. Syphilis b. Hepatitis B c. Chlamydia d. Gonorrhea e. Trichomoniasis

C, D, E

15. Which need would be essential in clients who have dementia? a. To relate in a consistent manner to staff b. To learn that the staff cannot be manipulated c. To accept controls that are concrete and fairly applied d. To have sameness and consistency in the environment

D