Comprehensive Online Practice 2020 review questions
A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?
Decreased bowel sounds *The greatest risk to this client is bowel necrosis or perforation due to bowel obstruction or strangulation. This is a surgical emergency. Therefore, decreased bowel sounds are the priority finding to report to the provider.
A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. The nurse should report which of the following to the provider after hearing this sound? (Click on the audio button to listen to the clip.)
Fine crackles {audio}
A nurse is preparing to administer medications to a client who is PO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?
Metoprolol ER 50 mg per NG tube BID
Complete the following sentence by using the lists of options. A nurse is caring for a client in an outpatient setting.
The client is exhibiting manifestations of heart failure as evidenced by the client's drop BNP level When analyzing cues, the nurse should determine that the client is exhibiting manifestations of heart failure as evidenced by the client's NP level. The client is experiencing dyspnea and fatigue, which might be manifestations of decreased cardiac output. Auscultation of S3 is an early indication of heart failure. A BNP level greater than 400 pg/mL is associated with heart failure. Chronic hypertension leads to myocardial hypertrophy and decreased ability of the heart to fill during diastole and is a common cause of heart failure.
Complete the following sentence by using the lists of options. A nurse is reinforcing teaching with a client who is pregnant.
When prioritizing hypotheses, the nurse should recognize that the client is at risk for developing metabolic acidosis due to excessive weight loss. The intake and retention of food is not meeting the client's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue, which increases the release of nonvolatile acids into the blood stream.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. A nurse is assisting with the care of a client who is postoperative.
When recognizing cues, the nurse should identify that restlessness, dyspnea, chest pain, blood-tinged sputum, hypotension, tachypnea, and D-dimer results are findings that require immediate follow-up. These findings are manifestations of a pulmonary embolus, which is a potentially life-threalening postoperative complication. The nurse should initiate a rapid response and continue to monitor for other changes in respiratory status
Which of the following 4 client findings should the nurse report to the charge nurse? A nurse is assisting in the care of a client who is postoperative following an appendectomy.
When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings br a client who is postoperative following an appendectomy. Therefore, these findings should be reported to the charge nurse.
A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?
Apply the prosthesis immediately upon waking each day
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the A demonstrates an understanding of how to perform this skill?
Applying the stockings before the client gets out of bed
A nurse is reinforcing teaching with a client who has left-sided weakness and is learning how to ambulate with a cane. The nurse should identify that the client understands the teaching when the client places the cane in which of the following positions when advancing forward? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
B is correct. The client should hold the cane on the stronger side of the body; in this scenario, it would be in the right hand. When ambulating forward, the client should move the cane forward first (in front of right foot) and then advance the weaker leg forward next so that the client's body weight is evenly distributed between the cane and stronger leg.
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective?
Cardiac workload decreases
A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take?
Gently close the patient's eyelids. *The nurse should hold the client's eyelids closed for a few seconds to ensure that they remain closed.
A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?
Hydrogen peroxide *The nurse should identify that sterile hydrogen peroxide solution is used to loosen secretions from the inner cannula during cleaning. If the client skin becomes irritated, the nurse should choose 9% sodium chloride solution.
A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?
Hydrogen peroxide Rationale: The nurse should identify that sterile hydrogen peroxide solution is used to loosen secretions from the inner cannula during cleansing. If the client's skin becomes irritated, the nurse should choose 9% sodium chloride solution.
A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of the following responses should the nurse make?
I can't see that you are feeling overwhelmed. I will come back when you are ready
A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?
Informing a client that the nurse is going to administer an injection even though the client refuses
A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?
Instruct the client not to get out of the bed. *Lorazepam causes sedation, placing the client at risk for injury due to falling. Therefore, the nurse should instruct the client not to get out of bed.
A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
Lack of sleep *The greatest risk for this client is exhaustion or death from lack of sleep; therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day.
A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
Lack of sleep. rationale: The greatest risk for this client is exhaustion or death from lack of sleep: therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day.
A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?
Place the client in a 30 degree lateral position
A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?
Poor lighting in the learning setting RAT: The nurse should recognize that the physical learning setting is an external factor that can affect the participants' learning ability. Environmental factors that affect learning include lighting, comfort of seating, and the temperature of the room. INCORRECT: The nurse should recognize that anxiety is an internal factor that can impede learning ability. The nurse should use therapeutic communication to decrease anxiety and promote learning for the participants. The nurse should recognize that developmental ability is an internal factor that affects learning ability. The nurse should recognize that belief in one's ability to learn, or self-efficacy, is an internal factor that affects learning ability. The nurse can foster self-efficacy in the participants by providing encouragement about their ability to learn the information.
A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis (CF). Which of the following findings is the priority for the nurse to report to the provider?
Reports lack of appetite *The nurse should identify that the greatest risk to a child who has a decreased appetite is pulmonary infection. Anorexia, along with other manifestations, such as loss of weight and lethargy, are commonly seen in children who have CF which an infection exacerbation. Typical manifestations of pulmonary infection, such as fever and tachypnea, might now be seen in a child who has CF. Additionally, a child who is anorexic is at increased risk for diminished lung function.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. A nurse is assisting in the care of a client who is postoperative following administration of general anesthesia.
Upon collecting data, the nurse should note the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm. The nurse should determine that this client is most likely experiencing malignant hyperthermia, and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should assist the RN with the administration of dantrolene and oxygen. The nurse should also assist the RN to monitor the PCOz level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.
For each data collection finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process. A nurse is caring for a school-age child.
When analyzing cues, the nurse should identify that manifestations of ADHD include losing necessary things, interrupting others, social functioning deficit, and hyperreactivity to sensory input. In ADHD, the client often loses necessary things in daily life like pencils, erasers, and books. The client often interrupts others and has difficulty waiting for their turn in conversation. The client might have a social functioning deficit, which can lead to difficulties with socialization. The client might exhibit hyperreactivity or hyporeactivity to stimuli. When analyzing cues, the nurse should identify that manifestations of ID include impaired language skills and social functioning deficit. The client can exhibit difficulty with communication, as well as deficits with problem-solving, judgment, and academic ability.
Complete the following sentence by using the lists of options. A nurse in the emergency department (ED) is assisting in the care of a client
When analyzing cues, the nurse should identify that the client is likely experiencing serotonin syndrome. Serotonin syndrome is a potentially life-threatening adverse effect of an interaction of an SSRI with an MAOI. Manifestations include tachycardia, fever, hypertension, delirium, abdominal pain, incoordination, and death. A client should discontinue an SSRI at least 2 weeks before starting an MAOI,
Drag words from the choices below to fill in each blank in the following sentence. A nurse is assisting with the care of a client who has bulimia nervosa.
When recognizing cues, the nurse should determine that the client is at the greatest risk of developing cardiovascular abnormalities and electrolyte imbalance due to chronic vomiting. When chronic vomiting occurs, abnormal electrolytes result in hypokalemia, hypochloremia, and hyponatremial Cardiovascular abnormalities such as bradycardia, arrhythmias, and electrocardiograph changes can occur.
Select the 6 actions the nurse should take.
When taking action for the client, the nurse should firmly massage the uterine fundus, administer methylergonovine, weigh the perineal pads, provide emotional support, insert an indwelling urinary catheter, and administer oxygen at 12 L/min via nonrebreather face mask. The nurse should identify that the client is experiencing a postpartum hemorrhage, which requires immediate intervention to prevent hemorrhagic shock.
A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.)
[1] determine the facts related to the dilemma. [2] identify possible solution [3]consider the client wishes
A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
[1] expose the glans of the penis [2] cleanse the penis using and antiseptic swab. [3]Begin urination [4] pass the cup into the urine stream [5] move the cup out of the urine stream. [6] replace the foreskin
A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
[1] expose the glans of the penis [2] cleanse the penis using and antiseptic swab. [3]Begin urination [4] pass the cup into the urine stream [5] move the cup out of the urine stream. [6] replace the foreskin
A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?
List of potential complications to report
A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?
Maintain a sequential compression device. *Sequential compression devices promote venous return by providing intermittent periods of compression on the legs.
A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
Moist mucus membranes. Rationale: The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy.
A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?
Muscle weakness *The nurse should expect a client who has hypokalemia to have bilateral muscle weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness, cramping, and paralysis.
A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?
Offering general leads *Offering general leads is therapeutic and will enhance positive interaction with the client because it demonstrates to the client that the nurse is listening and is interested in what the client is sharing.
A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?
Place your babies crib away from heat vents
A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?
Platelet count 95,000 mm3
A nurse is preparing to discharge a client who is immunocompromised. Which of the following vaccines should the nurse plan to administer?
Pneumococcal polysaccharide (PPSV). varicella vaccine consists of a live virus and is contraindicated for a client who is immunocompromised.
A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?
Potassium chloride 20 mEq PO every morning *This prescription is accurately transcribed by the nurse and does not include any error-prone abbreviations.
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?
Prepare a new dose of insulin for injection
A nurse is receiving change-of-shift report for a group of clients. The nurse should plan to implement which of the following time-management strategies?
Prepare a priority list of client needs for the shift. *The nurse should prepare a client priority to-do list, which could include administering time-critical medications. This will allow the nurse to determine which clients should receive care first.
A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the Foliowing information should the nurse include?
Prolonged use of corticosteroids is a risk factor for infection.
A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?
Putting a glove on their dominant hand first. *The nurse is demonstrating sterile technique when they put a glove on their dominant hand first. Using the dominant hand to apply the second glove helps prevent contamination because the nurse's dominant hand is more likely to have better dexterity than their non dominant hand.
A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity?
Scan the client facility identification board
A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?
The facility had 12% fewer UTI over the past 6 months Quality improvement relates to improving outcomes for clients, staff, or the facility. The nurse should document a reduction in urinary tract infections as an improvement in care quality.
Complete the following sentence by using the lists of options. A nurse is assisting with the care of a client who is postoperative following coronary artery bypass surgery (CABG).
The nurse should assist to analyze cues to determine if the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilution, it is important for the nurse to closely monitor electrolytes.
For each finding, click to specify if the finding requires follow-up or does not require follow-up. A nurse in an urgent care setting is assisting with the care of a client.
When analyzing cues for follow-up, the nurse should recognize that the client's heart rate and blood pressure are above the expected reference range, A BMI greater than 30 is classified as obese. An HbA1 c measures glucose control over a 120-day period. The client's glucose control is 8%, which indicates fair diabetic control and requires follow-up. The nurse should identify increased heart rate and blood pressure along with type 2 diabetes mellitus and a BMI greater than 30 are risk factors for coronary heart disease
A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?
client reports burning with urination. rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse should identify this as the priority finding to report to the provider.
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?
open the outer package flap of the catheterization kit away form the body
A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?
your oncologist might prescribe a cold cap to war during treatment to reduce hair loss The nurse should inform the client that cold caps cause vasoconstriction, which can help to decrease hair loss by reducing the ability of the chemotherapy medication to reach the hair follicles.
A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?
"I will receive the nutrients I need through my IV fluid."
A school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parents?
"We can't decide whether to try to homeschool our child or move her to a private school."
A nurse is reinforcing teaching with the adult children of a client who is dying. Which of the following statements should the nurse make?
"You can continue talking to your partner until they are gone."
A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?
"You will need to take the medication for the rest of your life."
A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack?
Albuterol *The nurse should instruct the client to use albuterol, a bronchodilator, to relieve the bronchospasms of an acute asthma attack.
A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?
Allow the weights to hang freely. nurse should ensure the weights hang freely to provide the appropriate counterweight to facilitate reduction and alignment of the client's fracture.
A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?
As soon as the client awakens in the morning *Sputum from the base of the lungs provides the best specimen for collection. The AP should obtain the specimen early in the morning because overnight fluid accumulates in the base of the lungs while the client is sleeping.
A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?
Avoid massaging the site after injecting the vaccine. *The nurse should not massage the site following an intradermal injection because this can spread the vaccine into the tissue or out through the needle insertion site.
A nurse is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
BMI
A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the following foods should the nurse include in the plan as having the highest amount of iron?
Boiled spinach
A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?
C. the guy with one drooping eye and has a unibrow Rationale: This is an example of ptosis, in which there is abnormal drooping of the upper eyelid. Ptosis, along with diplopia, are early manifestations of MG.
A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?
Change the appliance two times each week. *The nurse should change the appliance two times each week to maintain an effective seal around the stoma. The nurse should remove the appliance carefully and cleanse the client's stoma.
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
Check the client's gag reflex
A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?
Cherry tomatoes *The nurse should include cherry tomatoes in the teaching because they contain 141 g of water per 1 cup serving.
A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?
Consumption of contaminated food *The nurse should include that hepatitis A is spread via fecal-oral route direct contact with stool or consumption of contaminated food and water.
A nurse is reviewing laboratory reports for a client who has an Escherichie coll infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose?
Creatinine 2.5 mg/dL The nurse should report the creatinine level of 2.5 mg/dl to the provider prior to administering any further doses of the medication because gentamicin is nephrotoxic and can result in acute tubular necrosis. A creatinine level above the expected reference range is an indication of kidney impairment.
A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 ml orally three times a day at home. Which of the following components of the prescription should the nurse question?
Dosage. The nurse should question client about the actual prescribed dosage of the med to ensure proper med reconciliation. While the client has stated the amount taken, they have not specified the medication strength of the liquid
A nurse is working with an interpreter to assist the provider with explaining a diagnostic procedure to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Ensure the interpreter is culturally compatible with the client.
A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?
Have a supply of prescribed medications. *In a disaster situation, it could be difficult to obtain addition prescribed mediation. Therefore, the nurse should recommend clients have a backup supply of prescribed medication to prevent a potentially harmful interruption in dosing.
A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of the following manifestations should the nurse expect?
Hematemesis. The nurse should expect hematemesis, or vomiting blood, in a client who was recently diagnosed with bulimia nervosa. Hematemesis is a result of esophageal tears caused by purging. Neuropathy is a finding consistent with anorexia nervosa,
A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?
If I forget to take a dose, I can take it later on the same day."
A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?
Instruct the client to use a sitz bath at least twice a day. *The nurse should instruct the client to use a sitz bath for at least 20 min twice per day. For the first 24 hr following delivery, the sitz bath should contain cool water to reduce edema and pain. After 24 hr following delivery, the sitz bath should contain warm water to promote circulation and reduce pain.
A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?
Lack of change in pupil size when the client looks from a far to a near object. The nurse should expect the client's pupils to constrict when looking from a far to a near object. Lack of change in pupil size can indicate brain injury or increased intracranial pressure.
A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?
Discuss this behavior with the AP while reinforcing expectaions.
A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?
"I am so frustrated. I cannot even open my milk carton for breakfast."
A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?
"Advance directives are written instructions regarding end-of-life care."
A nurse is reinforcing teaching with a female client who requests information about how to lose weight. Which of the following statements should the nurse take?
"Consume 1,800 calories per day."
A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?
"I will apply diaper cream to my baby's skin during each diaper change."
A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions?
"I will give our baby sponge baths until the cord falls off."
A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?
"My son took my wallet so he can keep track of what I'm spending." The nurse should identify taking the client's wallet and controlling the client's spending as possible indicators of financial maltreatment. The nurse should collect further data about this situation to determine if abuse is present.
A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?
Determine the client's mobility status. *The first action the nurse should take when using the nursing process is to determine the client's mobility status. The nurse should begin collecting data about the client's ability to move freely within their environment while preventing injury. The nurse should begin by placing the client in the position providing the most support, then moving in increments to positions requiring less support and higher levels of tolerance.
A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?
Gastric ulcer formation *The nurse should monitor the client for indications of a gastric ulcer formation, which is a common adverse effect of prednisone.
A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?
Nurse administered insulin lispro to a pt who has DM & is NPO. Lispro is a rapid-acting insulin given with or just after meals because onset of action is 15 to 30 min after admin. A client who is NPO will not receive a meal & can have a potentially serious drop in blood glucose levels. Therefore, the nurse should complete an incident report after ensuring safety of the client & notifying the client's provider.
A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?
Report the situation to the provider who obtained the informed consent.
For each body system below, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than 1 potential nursing intervention. A nurse is assisting in the care of a client who is in the emergency department (ED).
The nurse should take action by administering naloxone, an opioid antagonist for opioid toxicity. The nurse should monitor the client for hypotension and observe the client for pinpoint pupils, which are findings tilat suggest opioid toxicity.
A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
You weight gain should be the same as for someone without diabetes.
A marse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent understanding of the teaching?
" should offer my child yogurt that has a probiotic as a snack."
A nurse assisting with a childbirth class is discussing nopharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?
"I should use counterpressure for back pain during labor."
A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching?
"I will imagine myself in a calm place when I can't concentrate."
A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?
"I will rinse my mouth after taking this medication"
A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2 mL
A nurse is caring for a client who has a prescription for famotidine 160 mg PO every 6 hr. Available is famotidine oral suspension 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
20 mL
A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?
A client who has pneumonia and a new onset of conditions
A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client?
Chlordiazepoxide rationale: The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal.
A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?
Decreased bowel sounds
A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, "I don't think I can go through this again." Which of the following actions is the nurse's priority?
Determine if the client is experiencing psychotic thinking.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching?
I should offer my child yogurt that has a probiotic as a snack.
A nurse is preparing to administer a medication to a client. The client states, "I'm sick of all these medications, and I'm not taking any more today!" Which of the following actions should the nurse take?
Inform the client of the possible consequences of the medication refusal.
A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?
Irrigate the bladder using sterile technique
Complete the following sentence by using the lists of options.
The nurse should determine that the priority hypothesis is that the adolescent is developing compartment syndrome as evidenced by severe pain following the administration of pain medication. When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is severe pain. This can indicate compartment syndrome, which requires immediate intervention. Therefore, this finding is the highest priority.
Complete the following sentence by using the lists of options. The nurse is continuing to care for the adolescent.
The nurse should determine that the priority hypothesis is that the adolescent is developing compartment syndrome as evidenced by severe pain following the administration of pain medication. When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is severe pain. This can indicate compartment syndrome, which requires immediate intervention. Therefore, this finding is the highest priority.
For each nursing action, click to specify if the nursing action is anticipated or contraindicated for the client. A nurse on a mental health unit is caring for a client.
While taking action for this client, the nurse should identify that initiating suicide precautions, encouraging the client to attend group therapy, and frequently offering high calorie snacks are anticipated. The client expresses feelings of guilt, exhibits a flat affect, and expresses thoughts of self-harm, which increase the risk for suicidal behavior. The client should be encouraged to attend individual and group therapy to promote participation in the treatment plan. Frequent high calorie and high protein snacks can increase the client's intake and might be better tolerated than larger meals. The nurse should identify that allowing the client to sleep with their Hands out of view is contraindicated due to the risk of self-harm.
A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
Wipe the drainage port with an antiseptic wipe after emptying urine from bag.
A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?
Yankauer catheter
A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?
Zolipedem
A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (Select all that apply.)
[1] a pharmacist. [2] package inserts. [3] American diabetes association.
A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client?
acetylcysteine Acetaminophen toxicity can result in liver damage or death and requires treatment with acetylcysteine as an antidote. The nurse should plan to mix the medication with water, juice, or cola and administer an oral dose every 4 hr for up to 72 hr.
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?
applying the stocking before the client gets out of bed
A nurse is reinforcing teaching with a client who has tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching?
the people i live with should be tested for TB
A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client?
chlordiazepoxide
A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. The nurse should report which of the following to the provider after hearing this sound? (Click on the audio button to listen to the clip.)
fine crackles
A nurse is reinforcing teaching with a client who has asthma and a new prescription for an ipratropium inhaler. Which of the following statements by the client indicates an understanding of the teaching?
i should wait 1 minute before taking a second puff of the medication
A nurse is assisting with the admission of a client who has a latex allergy. The nurse should identify that which of the following supplies has the potential to contain latex?
indwelling urinary catheter
A nurse is speaking with the partner of a client who has Alzheimer's disease. The partner states, "I love him, but caring for him is wearing me out." Which of the following responses should the nurse make?
lets discuss how caring for your partner is affecting your health The nurse should use the therapeutic communication technique of offering self and giving broad openings to support the partner. This facilitates the caregiver in determining whether the current situation is having a negative effect on the partner's health.
A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?
place the client in a 30 lateral position. The nurse should place the client in a 30° lateral position to alleviate pressure over bony prominences.
For each potential postoperative complication below, click to specify the nursing intervention that the nurse should implement. A nurse is caring for a client who is postoperative following a perineal prostatectomy.
postoperative following a perineal prostatectomy, the nurse should assist the client with a sit bath, encourage the dient to drink prune juice, and instruct the cient to perform calf pump and foot crite evercises. The nurse should offer the dient a sitz bath to relieve gain and promote healing. The nurse should encourage the dient to difink prune e should instruct the dient to perform evercises to promote venous return and reduce the risk of dvt.
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?
purchase beef that is a loin cut.
A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
tomatoes. Rationale: They are high in vit C apricots= vit A avocados= vit E Carrots= Vit A
A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?
yankeurs catheter rationale: A Yankauer catheter is a clean suction catheter used when performing oral and oropharyngeal suctioning to remove secretions from the client's mouth to facilitate breathing or obtain a sample for diagnostic evaluation.
A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?
Take up to three tablets during a single angina episode
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
The AP reports client information to the oncoming AP in the hallway
The nurse is assisting with preparing the adolescent for a fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?
The adolescent's parents have concerns regarding the surgery.
The nurse is assisting with preparing the adolescent for a fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?
The adolescent's parents have concerns regarding the surgery.
A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take?
Discuss how each AP's actions measure against the job description.
A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will secure the car seat in the car by using the seatbelt." *The nurse should instruct the guardian to secure the car seat in the car by using the seatbelt.
A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?
"Where is your pain located?"
A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?
"You should depress the button on the handheld marker when you feel your baby move."
A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?
"You will need to schedule a bone density test." *Long-term use of corticosteroids, such a prednisone, can induce osteoporosis. Therefore, the client should schedule a bone density test to establish a baseline evaluation.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?
"You will need to schedule a bone density test." *Long-term use of corticosteroids, such a prednisone, can induce osteoporosis. Therefore, the client should schedule a bone density test to establish a baseline evaluation.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include?
Eat a bedtime snack *The symptoms described by the client indicate hypoglycemia. Eating a snack at bedtime will help prevent hypoglycemic episodes during the night.
A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?
Maintain the drainage system below the level of the client's chest.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
A client who's urinary output was 100 mL for the past 12 hr *When using the urgent vs. non urgent approach to client care, the nurse should determine that the priority finding is a urine output of less than 30 mL/hr due to the risk for fluid imbalance Therefore the nurse should see this client first.
A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention?
A school-aged child who has allergic rhinitis and is taking diphenhydramine
A charge nurse on a long-term care unit is preparing to delegate tasks to a licensed practical nurse (LP) and an assistive personnel (AP). Which of the following tasks should the charge nurse delegate to the LPN?
Administering an initial NG tube feeding to a client who had a stroke.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent.
Anticipated: - Prepare the adolescent for surgery - Remove the splint. Contraindicated: -elevating the right leg above heart level -applying ice to the affected extremity
A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?
Apply the external fetal heart rate monitor.
A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following Instructions should the nurse include?
Apply the prosthesis immediately upon waking each day
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include?
Eat a bedtime snack *The symptoms described by the client indicate hypoglycemia. Eating a snack at bedtime will help prevent hypoglycemic episodes during the night.
A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?
Ensure the injection produces a wheal on the skin. *The nurse should ensure that the injection of the PPD produces a wheal, or bleb, on the skin. This indicates the medication has been injected into the dermis of the skin.
A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?
Establish a regular exercise routine 2 hr or more before bedtime.
A nurse is reinforcing teaching with a client who is bottle feeding their full-term newborn with formula. Which of the following instructions should the nurse include in the teaching?
Feed the newborn at least every 3 to 4 hr. *Although it is unnecessary to be rigid about feeding times, six to eight feedings every 24 hr should support a full-term newborn's nutrition needs adequately. Fewer feedings in the initial weeks could delay the establishment of an adequate weight-gain pattern.
A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?
Place the client in a lateral position. *Late decelerations occur due to utero-placental insufficiency. The nurse should assist the client into a lateral position to improve uterine perfusion and oxygen transfer to the fetus.
A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?
Place the client in the lateral position.
A nurse is transferring a client from a bed to a wheelchair. The client has right-sided weakness following a recent stroke. Which of the following actions should the nurse take?
Place the wheelchair on the client's left side. *The nurse should place the wheelchair on the client's stronger side to reduce the risk of falling.
A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse recommend?
Position the head of the bed at 30 angle. The nurse should elevate the head of the bed to a 30° to 45° angle to reduce the risk of ventilator-acquired pneumonia.
A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse recommend?
Position the head of the bed at 30 angle. The nurse should elevate the head of the bed to a 30° to 45° angle to reduce the risk of ventilator-acquired pneumonia.
A nurse manager is providing an in-service on hand hygiene to assistive personnel Which of the following information should the nurse manager include in the in service?
Remove reigns when washing hand with soap and water.
A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which of the following information should the nurse manager include in the in-service?
Remove reigns when washing hand with soap and water.
A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which of the following information should the nurse manager include in the in-service?
Remove rings when washing hands with soap and water
A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?
Report the observations about the ap to the unit's nurse manager.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider?
The client has absent bowel sounds. *Absence of bowel sounds can indicate absence of peristalsis, which is a manifestation of an ileus. The nurse should report this finding to the provider for reconsideration of the diet prescription.
A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurs recommend as being high in vitamin C?
Tomatoes
A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?
Use one finger to insert the suppository past the anal sphincters.
A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?
Wear a surgical mask within 3 feet of the client. *The nurse should wear a surgical mask within 3 feet of the client to prevent exposure to meningitis.
Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply.
When analyzing cues for a postoperative adolescent, actions the nurse should take include elevating the adolescent's affected limb at chest level, monitoring neurovascular status every hour, and removing the indwelling urinary catheter when it is no longer indicated. The nurse should elevate the affected limb at chest level to reduce edema. Neurovascular monitoring should be performed every hour for the first 24 hr post-surgery for immediate recognition of neurovascular compromise. For clients who have an indwelling urinary catheter, evidence-based practice indicates the catheter should be removed as soon as possible or within 24 hr if no longer indicated.
Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply.
When analyzing cues for a postoperative adolescent, actions the nurse should take include elevating the adolescent's affected limb at chest level, monitoring neurovascular status every hour, and removing the indwelling urinary catheter when it is no longer indicated. The nurse should elevate the affected limb at chest level to reduce edema. Neurovascular monitoring should be performed every hour for the first 24 hr post-surgery for immediate recognition of neurovascular compromise. For clients who have an indwelling urinary catheter, evidence-based practice indicates the catheter should be removed as soon as possible or within 24 hr if no longer indicated.
Complete the following sentence by using the lists of options. A nurse is assisting with the care of a client who is 24 hr postoperative following a cesarean birth.
When analyzing cues, the nurse should recognize that the client is at risk for developing seizures as evidenced by the presence of severe features of preeclampsia. The client is reporting a new onset of headache, blurred vision, and nausea. The client has significantly elevated blood pressure, hyperreflexia, and clonus. These findings indicate central nervous system irritability, which increases the risk for seizures, also known as eclampsia.
Click to highlight the findings below that indicate an improvement in the adolescent's condition.
When evaluating outcomes, the nurse should identify the adolescent's extremity pulse, capillary refill, extremity warm to the touch, no numbness or tingling, and a decrease in pain are all findings that indicate the fasciotomy was effective.
Select the 4 findings that require follow-up.
When recognizing cues, the nurse should identi ify the findings that require follow up in an adolescent who has an injury to the right leg include capillary refill, pedal pulse, skin temperature, and pain. The adolescent rates their pain as 10 on a scale of 0 to 10, which requires follow up by the nurse. A capillary refill of 4 seconds is ourtle the expected reference range of less than 2 seconds. A pedal pulse of +1 is diminished and is outside the expected reference range Skin temperature of the right extremity is cool to the touch, which is an unexpected finding, These findings are Indicative of decreased perfusion to the extremity and require follow up by the nurse.
Select the 4 findings that require follow-up by the nurse. A nurse is assisting in the care of an adolescent.
When recognizing cues, the nurse should identify the findings that require follow-up in an adolescent who has an injury to the right leg include capillary refill, pedal pulse, skin temperature, and pain. The adolescent rates their pain as 10 on a scale of 0 to 10, which requires follow-up by the nurse. A capillary refill of 4 seconds is outside the expected reference range of less than 2 seconds. A pedal pulse of +1 is diminished and is outside the expected reference range. Skin temperature of the right extremity is cool to the touch, which is an unexpected finding. These findings are indicative of decreased perfusion to the extremity and require follow-up by the nurse.
The nurse is reinforcing discharge teaching with the client. For each discharge instruction, click to specify if each action is recommended or contraindicated for the client. A nurse is assisting in the care of a client who is pregnant.
When taking action and reinforcing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein and low in fat. Warm ginger ale or ginger tea can also decrease nausea.
A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?
purchase beef that is a loin cut.
A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?
separate the Childs used washcloth form those of others. Due to the contagious nature of the infection, it is necessary to separate the washcloth of a child who has conjunctivitis from those of others to prevent the spread of infection.
A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following methods should the nurse use when communicating with the client?
Provide a picture board. *A client who has expressive aphasia has difficulty expressing needs or wants through verbalization or writing. The use of a picture board provides an alternative means of communication that might be less frustrating for the client.
A nurse is reinforcing teaching with a client about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?
The client attempts to elevate the cylinder by inhaling deeply.
Select the 2 findings the nurse should report to the provider. A nurse is assisting with the care of a client.
When analyzing cues, the nurse should identify that the dient's heart rate and dressing status should be reported to the provider. These findings could be an indication that the dient is experiencing a postoperative hemorrhage.
A nurse is reviewing a client's electronic medical record and finds that an assistive personnel (AP) recorded the client's temperature as 35.3° C (95.5° F) 2 hr earlier. Which of the following actions should the nurse take first?
Check the client's temperature.
A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
Obtaining a client's vital signs prior to discharge Obtaining vital signs does not require use of the nursing process and is within the range of function for an AP, Therefore, the nurse should delegate this task to the AP.
A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?
Report the suspected abuse to the appropriate agency It is the nurse's legal and professional responsibility to immediately report suspected abuse to the proper child protective service agency.
A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?
The child was born at 34 weeks of gestation *The nurse should identify that children born prematurely are at an increased risk for physical maltreatment. This increased risk is due to possible impairment of bonding during infancy and an increased need for care due to medical concerns as a result of their premature delivery.
Complete the following sentence by using the lists of options. A nurse is assisting in the care of a client who is 1 day postoperative following a total thyroidectomy.
The client is at greatest risk for developing hypocalcemia evidenced by report of numbness around the lips
Complete the following sentence by using the lists of options. A nurse on the medical-surgical unit is assisting with the care of a client who was admitted from the emergency department (ED).
The client is at risk for developing confusion due to sodium level Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should assist in monitoring the client's level of consciousness and place the client on fall and seizure precautions.
For each potential assessment finding, click to specify if the finding is consistent with schizophrenia or bipolar 1 disorder. Each finding may support more than 1 disease process. A nurse is assisting with the care of a client who was admitted to the emergency department (ED).
When analyzing cues, the nurse should distinguish between positive and negative manifestations of schizophrenia and bipolar 1 disorder. The client is displaying positive manifestations of schizophrenia, when compared to the assessment findings of a client who has bipolar 1 disorder.
