Learning System PN

A nurse is caring for a client following a fetal demise. The client crying and says I tried to get pregnant for so long. My partner and I wanted this baby so much. Now what will I do? Which of the following responses should the nurse make?

"Are you feeling overwhelmed?"

A nurse is caring for a client who is a sexual assault survivor. The client says, "I feel so humiliated. I dont want anyone to know what happened to me" Which of the following respones should the nurse make?

"Are you saying that you are fearful about what others will think?"

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery"

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older"

An older adult client tells a nurse at a health fair "I am always forgetting things. I cannot even remember where I parked my car! Do you think I have Alzheimer's disease?" Which of the following is a therapeutic response by the nurse?

"That must be very upsetting. Can you tell me about your forgetfulness?"

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?

Confirm unresponsiveness

A nurse on a med surg unit is admitting a client. Which of the following information should the nurse document in the clients record first?

Data collection for the client

A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiologic changes contribute to the development of type 2 diabetes?

Decreased sensitivity to the circulating insulin

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?

Donate autologous blood before the surgery

A nurse is assisting with planning care for an older adult client following abdominal surgery for a bowel obstruction. Which of the following information about pain management should the nurse include in the plan of care?

Older adult clients are sensitive to the analgesic effects of opiates.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the clients hand

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the clients

A nurse is reinforcing discharge teaching about calcium supplements with an older adult female client who has osteoporois and a recent repair of a fracture in her right hip. Which of the following instructions should the nurse include?

You should take your calcium supplement with a large glass of water.

A nurse is caring for a client who has MDD. The client tells the nurse, "Dont bother me. Find someone else to talk to. I dont have anything worth saying. Go find someone you can help." Which of the following statements should the nurse make?

"I would like to sit quietly with you for a while."

A nurse is caring for a client who had a spontaneous miscarriage at 9 weeks of gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following statements should the nurse make?

"It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend"

A nurse is caring for an older adult client who dies during the night while his partner is at his side. The partner says, I cant believe he is gone. Which of the following responses should the nurse make?

"It must be hard to accept that this has happened"

A nurse is making morning rounds when a client says "I almost died last night." Which of the following responses should the nurse make?

"That must have been frightening. Tell me more about it."

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

Absent bowel sounds with distention

A nurse is reinforcing teaching with a group of older adult females clients who are postmenopausal about dietary requirements. Which of the following statements about the role of folic acid should the nurse make?

Adequate folic acid intake is associated with a reduced risk for heart disease.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is reinforcing teaching with an older adult client who has anemia. Which of the following foods should the nurse recommend to increase the clients iron intake?

Dried fruit

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers

A nurse in a long-term care facility is promoting reminiscence among older adult clients. Which of the following actions should the nurse take?

Insitute a daily storytelling hour

A nurse is reinforcing teaching with an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae. Which of the following statements by the client indicates an understanding of the teaching?

To relieve the pressure on my hip, I can use a cane while ambulating

A nurse is planning to administer diphenhydramine hydrochloride to an older adult client. Which of the following actions should the nurse plan to take prior to administration?

Review the medical record for a client history of glaucoma.

A nurse is caring for a 13-year-old female client who is admitted for an emergency appendectomy. While the nurse is reinforcing preop teaching, the client asks, will i have a large scar from the surgery? Which of the following responses should the nurse make?

"It will be small enough that it wont show when youre wearing a bathing suit"

A nurse is caring for a client who has a suspected brain tumor and is scheduled for a CAT. When the procedure is explained, the client expresses fear about entering the enclosed space of the scanner. Which of the following statements should the nurse make?

"Let me review some breathing exercises with you"

A nurse is caring for a client who has leukemia. The client says, "The doctor told me that my condition is too severe to be treated successfully. I guess I don't have long to live." Which of the following responses should the nurse make?

"Lets talk about how you are feeling with this information"

An emergency department nurse takes a telephone call from a client who states. "I have just taken 100 amitriptyline tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live" Which of the following responses should the nurse make?

"Please stay on the phone with me so we can talk about your feelings"

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections"

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take?

Raise the level of the bed

A client is scheduled for a lumbar puncture to rule out bacterial meningitis. She tells the nurse that she is fearful of becoming paralyzed from the needle being placed into her spinal column. Which of the following responses should the nurse make?

"The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends"

A nurse is caring for a client who has been recently dignosed with cancer. The client says I would rather be dead than go through the treatment for cancer. Which of the following responses should the nurse make?

"What is it that concerns you about the cancer treatment?"

A nurse is reinforcing teaching with a client about how to perform personal ileostomy care prior to discharge. The client says, "I dont think that I am going to be able to take care of this myself" Which of the following responses should the nurse make?

"What part of the ileostomy care are you having trouble with?"

The adult child of a client has come to take his parent home from the facility following a colon resection. The client's son tells the nurse, "I dont know how I am going to take care of my mom now." Which of the following responses should the nurse make?

"Which part of your mother's care are you concerned about?"

A nurse is caring for an older adult client who is to undergo surgery for a hip fracture. The client says, "I guess I've lived long enough, and its my time" Which of the following responses should the nurse make?

"You feel that your life is ending?"

A nurse is caring got an adolescent client who has a positive hCG test. She tells the nurse "I dont think I can tell my parents that i am pregnant" Which of the following responses should the nurse make?

"You seem frightened to tell your parents"

A nurse is caring for an adolescent client who was recently diagnosed with testiculat cancer. When a nurse asks the client a question, he angrily spits in the nurse's face. Which of the following responses should the nurse make?

"You seem to be very upset."

A nurse is caring for a client who has recently found out that she is pregnant. The clients say "I dont think I should tell my partner about the pregnancy." Which of the following responses should the nurse make?

"You seem uncertain about teling your partner"

An assistive personnel is bathing a client who is unconscious and is talking to him about current events and the weather. The clients partner says to the nurse, Why does the AP talk to my husband? He's unconcious. Which of the following responses should the nurse make?

"Youe husband is unconcious but might still be able to hear"

A nurse is collecting data from an older adult client. Which of the following actions should the nurse take to collect subjective data?

Allow sufficient time for the client to respond to the questions.

A nurse is caring for a client who has Alzheimer's disease and refuses to take her morning antihypertensive med. The client is oriented to name and place and is able to perform ADLs with a minimal supervision. Which of the following actions should the nurse take?

Ask the client to express her reasons for refusing the medication and document the event.

A nurse is contributing to the plan of care for a client who had a recent stroke and a history of gastroesophageal reflux disease (GERD). For which of the following disorders should the nurse plan to monitor this client?

Aspiration pneumonia

A nurse is planning weight loss strategies for a group of client who are obese. Which of the following actions by the nurse will improve the clients commitment to a long-term goal of weight loss?

Attempt to increase the clients self-motivation

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute and describe the rhythm in the chart.

A nurse in the clinic is assessing an older adult client for the second time this week. The client reports a decreased energy level, insomnia, and anorexia. Diagnostic tests are within the expected reference ranges. For which of the following conditions should the nurse screen the client?

Depression

A nurse is caring for a client who is unstable and has vital signs meaured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 minutes

A nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis. The client has a new prescription for alendronate sodium. Which of the following findings in the clients history should the nurse recognize is a contraindication to this medication?

Esophageal stricture

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is collecting data from an older adult client during an annual physical. Which of the following findings should the nurse report to the provider?

Fasting blood glucose level of 160 mg/dL

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take tp determine if the client is dehyrdated?

Grasp a skin fold on the client under the clavicle, release it, and note whether it springs back

A nurse is collecting data for an adult client. Identify the correct sequence of steps used for data collection of the abdomen.

Inspection Auscultation Percussion Palpation

A nurse is participating on a committee that is developing age-appropriate care standards for older adult clients. Which of the following of Erikson's developmental tasks should the nurse recommend as the focus?

Integrity vs. despair

A nurse is caring for an older adult client who has gout and refuses to eat. The clients provider has approved the family to bring food from home. Which of the followinf foods should the nurse recommend that the client not eat?

Lentil soup

A nurse is reinforcing dietary teaching with an older adult client who is on bedrest following development of DVT about methods to increase peristalsis. Which of the following high-fiber food choices should the nurse recommend?

Navy bean soup

A nurse is preparing a client who is scheduled for a hysterectomy for a transport to the operation room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the clients decision

A nurse on a medical-surg unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Perform hand hygiene

A nurse is obtaining the blood pressure in a client lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh Auscultate BP at the popliteal artery Measure BP in prone position Position cuff 2.5cm above popliteal

A nurse is assisting with the care of an older adult client who has dementia. The client becomes agitated and confused at night and wanders into the hallway. Which of the following actions should the nurse take?

Place the clients mattress on the floor

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed

A nurse is caring for an older adult client who is violet and attempting to disconnect her IV lines. The provider prescibes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?

Screening groups of older adults in nursing care facilities for earlt influenza manifestations.

A nurse is screening clinic is collecting data for a client who report a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse at a long-term facility is assisting with planning care for a group of older adult clients. When planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following?

Short-term memory

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

Sit on the toilet 30 minute after eating a meal

A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2 C(102.6 F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperture?

Temporal

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain

A nurse is contributing to the plan of care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client?

The clients airway will remain clear, as evidenced by clear breath sounds.

A nurse on a medical-surg unit is washing her hands prior to assisting with an surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes with her hands held higher than her elbows

A nurse is instructing an AP about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands

A nurse is drawin blood for lab testing from client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene

A nurse is reinforcing teaching with a newly hired AP about her role in helping older adult clients with activities of ADLs. The nurse should explain that which of the following is the most common factor that affects a clients ability to perform ADLs

Chronic physical disability

A nurse is assisting with the admission of an older adult client who fell at home 3 days ago. The client has a fractured hip, malnutrition, and dehydration. Which of the following lab values, noted on admission, should indicate to the nurse prolonged malnutrition?

Decreased albumin

A nurse is collecting data from an older adult client for signs of dehydration. Which of the following findings should the nurse consider an expected part of the aging process?

Decreased creatinine clearance

A nurse is caring for an older adult client. Which of the following physiologic changes associated with aging can affect medication dosage in thsi client?

Decreased gastric motility

A nurse is caring for an older adult client who has pneumonia. Which of the following physiologic changes associated with aging places the client at a greater risk for pneumonia?

Decreased number of cilia

A nurse is collecting data from an older adult client who states he is homeless. Which of the following findings should the nurse document as comorbidities(medical conditions known to co-exist in a client) for this client?

Dementia and tuberculosis

A nurse at an ophthalmology clinic is collecting data from a client referred by the provider for a potential cataract. Which of the following client reports should the nurse recognize is consistent with cataracts?

Halos when looking at lights

A nurse is receiving a client from a PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher

A nurse at an assisted living center is conducting an orientation session for a group of newly hired AP. Which of the following instructions should the nurse include regarding clients who are hearing impaired?

Maintain eye contact with the clients

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse observes an AP preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

Using a cuff that is too small will result in an accurately high reading

A nurse is reinforcing teaching with a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend that the clients complete annually?

Visual acuity

A nurse is caring for a client who has Type 1 diabetes mellitus and is to receive hemodialysis. The client says. "I don't even know why I'm doing this. There is no cure." Which of the following statements should the nurse make?

"It sounds as though you have given up"

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying