Nursing Semester 1 Final Study
3. A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? (P. 85) a. Testicular examination b. Blood glucose c. Fecal occult blood d. Prostate-specific antigen
A
4. A nurse is caring for client who has new prescription for anti hypertensive medication. Prior to the administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on the client. Which of the following components of critical thinking is the nurse using when he reviews the medication administration. A. Knowledge B. Experience C. Intuition D. Competence
A
A client asks the following responses is appropriate? nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 ft what visually unimpaired eyes see at 20 ft." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."
A
A mother tells the nurse that her 2-year-old child has temper tantrums. The child says "no" every time the mother tries to help her get dressed. The nurse explains that, developmentally, the toddler is a. trying to increase her independence. b. developing a sense of trust. c. manifesting an anger management problem. d. attempting to finish a project she started.
A
A nurse admits a client for abdominal surgery. The client's initial vital signs are temperature 37° C (98.6° F), pulse 98/min, respirations 20/min, and blood pressure 148/88 mm Hg. The client states, "I am really worried. This is the first surgery I have ever had." Which of the following is an appropriate use of a complementary alternative intervention? A. Offer information and ask the client if he is interested in trying a relaxation technique. B. Call the provider and get permission to use relaxation techniques with the client. C. Provide the client with reassurance and information about the procedure. D. Give the client a therapeutic back massage and tell him to try to relax.
A
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
A
A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? A. Presence of associated symptoms B. Location of the pain C. Pain quality D. Aggravating and relieving factors
A
A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity
A
A nurse is caring for a client who reports back pain and tells the nurse that a friend has recommended a chiropractor. She asks the nurse what a chiropractor does to relieve back pain. Which of the following responses by the nurse is correct? A. "Chiropractors use their hands to manipulate the spine to treat back pain." B. "Chiropractors insert needles or put pressure along meridians in the back." C. "Chiropractors use herbal remedies to treat back pain." D. "Chiropractors use their hands to balance the energy fields in the back."
A
A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? a. "My baby loved to play with his crib gym, but I took it away from him." b. "I just bought a soft mattress so my baby will sleep better." c. "My baby really likes sleeping on the fluffy pillow we just got for him." d. "I just bought a child-safety gate that folds like an accordion."
A
A nurse is instructing an AP about caring for a client who has a low platelet count as a result of chemo. Which of the following instructions is the priority for measuring VS for this client? A. "Do not measure the client's temp rectally" B. "Count the client's radial pulse for 30 sec and multiply it by 2" C. "Do not let the client know you are counting her respirations" D. "Let the client rest for 5 min before you measure her BP."
A
A nurse is planning care for a client who is on bed rest.. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hours B. Instruct the client to cough and deep breathe every 4 hours C. Restrict the clients fluid intake D. Reposition the client every 4 hours
A
A nurse is talking with parents of a school-age child who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? a. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." b. "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." c. "We think our son is trying too hard to excel in math just to get the top grades in his class." d. "Our son is always afraid the kids in school will laugh at him because he likes to sing and write little poems."
A
A nurse is talking with the parents of a toddler. Which of the following should the nurse suggest regarding discipline? a. Establish consistent boundaries. b. Place him in a room with the door closed. c. Have him learn by trial and error. d. Use favorite snacks as rewards.
A
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy
A
A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away." The instructor should inform the student that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
A
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? A. Reassess the client to determine the reasons for unsatisfactory pain relief. B. See whether the pain lessens during the next 24 hr. C. Change the plan to ensure that the client achieves adequate pain relief. D. Teach the client about the plan of care for managing his pain.
A
During evaluation, the nurse must gather information about the client to A. identify whether the client outcomes have been met. B. organize resources to proceed with implementing interventions. C. establish client-centered outcomes that are measurable and realistic. D. determine the priority of care and appropriate interventions.
A
a nurse is caring for a client who has a history of falls. which of the following actions is the nurses priority A. complete fall-risk assessment B. educate client and family about fall risks C. eliminate safety hazards from clients environment D. make sure the client uses assistive devices
A
A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits
A, B
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (select all that apply.) a. Make sure the surgeon obtained the client's consent. b. Witness the client's signature on the consent form. c. Explain the risks and benefits of the procedure. d. Describe the consequences of choosing not to have the surgery. e. Tell the client about alternatives to having the surgery
A, B
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? (Select all that apply.) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test
A, B
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are. B.Olderadultsneedthesameamountofmostvitaminsandmineralsasyoungeradultsdo. C. Many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.
A, B, C
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (select all) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate D. Count the rate for 30 sec if it is irregular E. Count and report any sighs the client demonstrates
A, B, C
A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for school-age children? (Select all that apply.) a. Building models b. Playing video games c. Reading books d. Using toy carpentry tools e. Shaping modeling clay
A, B, C
A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenza type B E. Polio
A, B, C
2. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (SATA) (P. 85) a. Help the client see the benefits of her actions. b. Identify the client's support systems. c. Suggest and recommend community resources. d. Devise and set goals for the client. e. Teach stress management strategies.
A, B, C, E
A nurse at an elementary school is planning a health promotion and primary prevention class. Which of the following topics are appropriate to include for the parents of school-age children? (Select all that apply.) a. Childhood obesity b. Substance us disorders c. Scoliosis screening d. Front-seat seatbelt use e. Stranger awareness
A, B, C, E
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks
A, B, C, E
A nurse is instructing a client who has an injury of the left lower extremity about the use of a cane. Which of the following instructions should the nurse include? Select all that apply A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the cane 38 cm (15 inches) in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the strong leg so that it aligns evenly with the cane
A, B, D
A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply.) a. Rolls from back to front b. Bears weight on legs c. Walks holding onto furniture d. Sits unsupported e. Sits down from a standing position
A, B, D
A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime.
A, B, D, E
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate
A, B, E
A nurse is preparing a wellness presentation for families at a community center. When discussing health screenings for adolescents, which of the following information about scoliosis should the nurse include? (Select all that apply.) A. Scoliosis is more common among girls than it is among boys. B. Loss of height is often the first sign of scoliosis. C. Scoliosis screening is essential during the adolescent growth spurt. D. Slouching is a common cause of scoliosis, especially in adolescents. E. Scoliosis is a forward curvature of the spine.
A, C
A nurse is coaching a group of nursing students in learning to use complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (Select all that apply.) A. Guided imagery B. Massage therapy C. Meditation D. Music therapy E. Therapeutic touch
A, C, D
A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) a. Keep toxic agents in locked cabinets. b. Keep toilet seats up. c. Turn pot handles toward the back of the stoves. d. Place safety gates across stairways. e. Make sure balloons are fully inflated.
A, C, D
A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply.) A. Does your lack of sleep interfere with your ability to function during the day? B. Do you feel confused in the late afternoon? C. Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day? D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? E. Tell me about any personal stress you are experiencing.
A, C, D, E
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
A, C, E
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."
A, C, E
A nurse is caring for an 82-year-old client in the ED who has an oral body temp of 38.3C or 101F, pulse 114/min, and RR 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all) A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently
A, C, E
A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretion D. Far vision E. Glomerular filtration
A, C, E
A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.) a. Assembling puzzles b. Pulling wheeled toys c. Using musical toys d. Using finger paints e. Coloring with crayons
A, C, E
A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply.) A. REM sleep provides cognitive restoration. B. REM sleep lasts about 90 min. C. It is difficult to awaken a person in REM sleep. D. Sleepwalking occurs during REM sleep. E. Vivid dreams are common during REM sleep.
A, C, E
A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following as mind-body therapies? (Select all that apply.) A. Art therapy B. Acupressure C. Yoga D. Therapeutic touch E. Biofeedback
A, C, E
A nurse in a provider's office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion
A, D, E
A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension of the trachea on both sides of the midline
A, D, E
A nurse is caring for a 5-year-old client whose parents report that she fears painful procedures, such as injections. Which of the following strategies should the nurse use to try to help ease the child's fear? (Select all that apply.) a. Invite the child to assist with mealtime activities. b. Cluster invasive procedures whenever possible. c. Assign caregivers which whom the child is familiar. d. Have the parents bring in a favorite toy from home. e. Engage the child in pre tent play with a toy medical kit.
A, D, E
A nurse is preparing to assess a clients skin as part of comprehensive physical exam. Which of following findings should the nurse expect? A. Cap refill in 2 seconds, B. 1+ pitting edema in both feet, C. Pale nail beds in both hands, D. Thick skin on soles of the feet, E. Numerous light brown macules on the face.
A, D, E
A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective? (Select all that apply.) A. Respiratory rate of 22/min with even, unlabored respirations B. "I can only walk three blocks before my legs start to hurt." C. Pain level 3 on a scale of 0 to 10 D. Skin pink, warm, and dry E. Urine output of 300 mL/8 hr F. Dressing clean, dry, and intact
A, D, E, F
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors
A. Presence of associated manifestations The nurse should attempt to identify manifestations that occur along with the client's pain, such as nausea, fatigue, or anxiety
2. A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers that she is allergic to antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk taking D. Creativity
B
4. A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? (P. 85) a. Cholesterol screening b. Nutrition presentation c. Medication therapy d. Cardiac rehabilitation
B
5. A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? (P. 85) a. "So I don't need the colon cancer procedure for another 2 or 3 years." b. "For now, I should continue to have a mammogram each year." c. "Because the doctor just did a Pap smear, I'll come back the next year for another one." d. "I had my blood glucose test last year, so I won't need it again till next year."
B
A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification and instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temperature of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed."
B
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. A facial will make you feel more attractive." D. "It's still too soon to expect to feel normal. Give it a little more time."
B
A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
B
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals.
B
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements is an appropriate response by the nurse? A. "Sounds like something you should discuss with her when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine."
B
A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to be discharged." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse displaying to enhance communication between the nurse and the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating
B
A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality
B
A nurse is caring for a school-age child who is seated. In order to facilitate effective communication, the nurse should A. touch the child. B. sit at eye level with the child. C. stand facing the child. D. stand with a relaxed posture.
B
A nurse is counseling a middle adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my son expects me to relive my parenting days."
B
A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A. This device will keep me from getting sores on my skin B. This thing will keep the blood pumping through my leg C. With this thing on, my leg muscles won't get weak D. This device is going to keep my joints in good shape
B
A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following client statements indicates understanding of the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."
B
A nurse is instructing a group of nursing students in the priorities of care in preforming an integumentary assessment of their clients. Which of the following findings should the student recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema
B
A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the Muslim client? A. "I will make sure the menu includes kosher options." B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer." C. "I will make sure to use direct eye contact when speaking with this client." D. "I will make sure daily communion is available for this client."
B
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? A. Ask the client's permission. B. Explain to the client that this therapy involves prayer. C. Request that the client participate actively. D. Encourage the client to relax for this therapy.
B
A nurse is reviewing car-seat safety with parents of a 1-month-old infant. When reviewing car-seat use, which of the following instructions should the nurse include? a. Use a car seat that has a three-point harness system. b. Postion the car seat so that the infant is rear-facing. c. Secure the car seat in the front passenger seat of the vehicle. d. Put soft padding in the car seat behind the infant's back and neck.
B
A nurse is talking with parents of a preschooler who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? a. "Our son will only eat a few things, like burgers and bananas, and pretty much refuses everything else." b. "Our son has these temper tantrums every time we tell him to do something he doesn't want to do." c. "We think our son truly believes that his toys have personalities and talk to him, especially at night." d. We feel bad when we see our son trying so hard to button his shirt. We just tell him this is something he'll just have to learn to do."
B
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my wife was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and he taught me a few things." D. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous."
B
A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "If I am having any discomfort, I'll just go to an urgent care center." D. "If I am feeling stressed, I will remind myself that this is something I should expect."
B
A nurse recognizes that a helping relationship is established with a client if the communication A. is equally reciprocal between the nurse and the client. B. encourages the client to express his thoughts and feelings. C. has no time limits. D. occurs spontaneously throughout the nurse-client relationship.
B
A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94. The client denies any history of HTN. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request prescription for an antianxiety med D. Return in 30 min to recheck the client's BP
B
a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. which of the following statements by a nurse requires further instruction A. i will place the client on his side B. i will go to the nurses station for assistance C. i will administer his meds D. i will prepare to insert an airway
B
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation
B, C, D
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home.
B, C, D
A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (all that apply) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. excessive dryness and wrinkles.
B, C, D
The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses by the nurse are appropriate? (Select all that apply.) a. "It might be good to add bananas, as they can help with loose stools." b. "Let's make a list of the foods he is eating so we can spot any problems." c. "Did the changes begin after you started one particular food?" d. Has he been vomiting since he started these new foods?" e. "Most babies react with a little indigestion when you start new foods."
B, C, D
A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test
B, C, D, E
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.
B, C, E
A nurse is caring for a client of is postoperative following knee surgery. Which of the following should the nurse examine to assess the clients peripheral vascular system? (all that apply) A. Range of motion B. Skin color C. Edema D. Skin Lesions E. Skin Temp.
B, C, E
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at high risk for body image disturbances? (Select all that apply.) A. 30-year-old male following laparoscopic appendectomy B. 45-year-old female following mastectomy C. 20-year-old female following left above-the-knee amputation D. 65-year-old male following cardiac catheterization E. 55-year-old male following stroke with right-sided hemiplegia
B, C, E
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that may result in contamination from secretions.
B, C, E
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.
B, C, E
A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of two preschoolers. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) a. Haemophilus influenzae type b b. Varicella c. Polio d. Hepatits A e. Seasonal influenza
B, C, E
nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a middle adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type b B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza
B, C, E
During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur
B, D
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions are appropriate? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape.
B, D, E
A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza
B, D, E
A nurse is using an interpreter to communicate with a client. Which of the following are appropriate when communicating with a client and his family? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Ask the family one question at a time. C. Look at the interpreter when asking the family questions. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk.
B, D, E
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? Select all that apply: A. Instruct the client not to perform the Valsalva movement B. Apply elastic stockings C. Review lab values for total protein levels D. Place pillows under the clients knees & lower extremities E. Assist the client to change position often
B, E
A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions are appropriate for this client? (Select all that apply.) A. Suggest that his parents room in with him. B. Provide a television and DVDs for him to watch. C. Limit visitors to immediate family. D. Devise a regular schedule for inpatient routines. E. Allow him to perform his own morning care.
B, E
1. A nurse is caring for a 20-year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? (P. 85) a. Measure vital signs. b. Encourage HIV screening. c. Determine risk factors. d. Instruct the client to use condoms.
C
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? a. alert the American Nurses Association. b. Fill out an incident report. c. Report the observations to the nurse manager on the unit. d. Leave the nurse alone to sleep
C
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? a. "I'd rather have my brother make decisions for me, but I know it has to be my wife." b. "I know they won't go ahead with the surgery unless I prepare these forms." c. "I plan to write that i don't want them to keep me on a breathing machine." d. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
C
A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of the client's pain by A. asking what precipitates the pain. B. questioning the client about the location of the pain. C. offering the client a pain scale to measure his pain. D. using open-ended questions to identify the sensation.
C
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sin
C
A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure ulcer D. Fecal impaction
C
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions is appropriate for the nurse to take? A. Contact the hospital's spiritual services. B. Ask him what is making him cry. C. Provide quiet times for these moments. D. Turn on the television for a distraction.
C
A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup
C
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."
C
A nurse is caring for a client who shares the same religious background. The nurse should recognize that A. members of the same religion share similar feelings about their religion. B. a shared religious background generates mutual regard for one another. C. the same religious beliefs may influence individuals differently. D. they should discuss the differences and commonalities in their beliefs.
C
A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub her back for 15 min before bedtime. B. Offer her warm milk and crackers at 2100. C. Allow her to take a bath in the evening. D. Ask the provider for a sleeping medication.
C
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."
C
A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.
C
A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
C
A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parents' statements should indicate to the nurse that they understand the feeding guidelines for this age group? a. "I should keep feeding my son whole milk until he is 3 years old." b. "It's okay for me to give my son a cup of apple juice with each meal." c. "I'll give my son about 2 tablespoons of each food at mealtimes." d. "My son loves popcorn, and I know it is better for him than sweets."
C
A nurse is talking with an adolescent who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I kind of like this girl in my class. She doesn't like me back, though, not that way." B. "I like hanging out with the guys in the science club, but the jocks pick on them." C. "I just don't seem to be any good at anything. I can't play any sports at all." D. "My dad wants me to be a lawyer like him, but I don't want to learn all that stuff."
C
A nurse is talking with the father of a 12-year-old boy who is concerned that he hasn't observed any indications that his son is approaching puberty. The nurse should explain that the first sign of sexual maturation in boys is A. the appearance of downy hair on the upper lip. B. hair growth in the axillae. C. enlargement of the testes and the scrotum. D. deepening of the voice.
C
A nurse is talking with the father of a 4-year-old child who states that his daughter goes to bed at 8:30pm and wakes up at about 7:30am, but she often lies in bed talking to herself or gets up a few times before falling asleep 40 min later. At her preschool, the children take a 2-hr afternoon nap. Which of the following recommendations should the nurse make to help improve the child's sleep behavior? a. Offer the child a snack of her favorite treat right before bedtime. b. Allow the child to watch an extra 30 min of TV in the evening. c. Change the child's bedtime to 9pm on days she napped. d. Request that the preschool staff limit her nap time to 1hr.
C
A nurse is talking with the parent of a 10-year-old child who express concern that their son is suddenly becoming secretive, for example, closing the door when he showers, dresses, and does his homework in his room. Which of the following responses by the nurse is appropriate? a. "Perhaps you should try to found out what is is doing behind those closed doors." b. "Suggest that he leave the door ajar for his own safety." c. "At this age, children tend to become more modest and value their privacy." d. "Tell him it's okay to close the door when he is undressed, but he has to do his homework where you can see him."
C
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between and being responsible for two generations
C
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias
C
a nurse observes smoke coming from under the door of the staffs lounge. which of the following actions is the nurses priority A. extinguish the fire B. activate the alarm C. move the clients who are nearby D. close all open doors on the unit
C
A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds
C, D, E
A nurse is caring for a client who is concerned about being discharged home with a new colostomy because he is an avid swimmer. Which of the following statements made by the nurse indicates use of an effective communication technique? (Select all that apply.) A. "You will do great! You just have to get used it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about your support system when you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."
C, D, E
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea
C, D, E
A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums
C, D, E
A nurse is planning diversionary activities for children on an inpatient unit. Which of the following should the nurse incorporate as appropriate play activities for a toddler? (Select all that apply.) a. Building simple models b. Working with clay c. Filling and emptying containers d. Playing with blocks e. Looking at books
C, D, E
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."
C, D, E
A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse‑initiated? (Select all that apply.) A. Give morphine sulfate 1 to 2 mg IV every 1 hr as needed for pain. B. Insert an NG tube to relieve a client's gastric distention. C. Show a client how to use progressive muscle relaxation. D. Perform a daily bath after the evening meal. E. Reposition a client every 2 hr to reduce pressure ulcer risk.
C, D, E
a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. which of the following actions should the nurse take to decrease the risk of another fall (select all that apply) A. place belt restraint on the client when he is sitting on the bedside commode B. keep bed in lowest position with all side rails up C. make sure clients call light is within reach D. proved nonskid footwear E. complete fall-risk assessment
C, D, E
A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following capabilities? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Feel frustrated that time is too short for attempting to start another life. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and activities.
C, E
Which of the following are behaviors of active listening? (Select all that apply.) A. Maintaining an open posture B. Writing down what the client says so that details are not forgotten C. Establishing and maintaining eye contact D. Nodding in agreement with the client throughout the conversation E. Responding positively when giving feedback
C, E
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statments indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button for my while I am sleeping."
C. "I should tell the nurse if the pain doesn't stop while I am using this device." PCA allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control, he should let the nurse know that she can initiate a reevaluation of the client's pain management and possible dosage change.
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. which of the following effects should the nurse anticipate? (select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea
C. Bradypnea Opioid analgesa can cause respiratory depression, which causes respiratory rates to drop to dangerously low levels. The nurse should monitor the client's respiratory rate, and administer naloxone if indicated D. Orthostatic hypotension Opioid analgesia cau causes orthostatic hypotension. The nurse should monitor the client for dizziness or lighheadedness when changing positions E. Nausea Opioid analgesia can cause nausea and vomiting the nurse should monitor and treat for these complications as needed
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure his pain. D. Use open-ended questions to identify the client's pain sensations.
C. Offer the client a pain scale to measure his pain. The nurse should use a pain rating scale to help the client report the intensity of his pain. The nurse should use a numeric, verbal, or visual analog scale appropriate to the client's individual needs.
1. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."
D
5. A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline
D
A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing."
D
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses by the nurse is appropriate? A. "I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. "Why does your religion mandate that you cannot receive any blood transfusions?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."
D
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster
D
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness
D
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30 cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand
D
A nurse is obtaining a history from a client who has pain. The nurse's guiding principle throughout this process should be that A. some clients exaggerate their level of pain. B. pain must have an identifiable source to justify the use of opioids. C. objective data are essential in assessing pain. D. pain is whatever the client says it is.
D
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy source? A. Fat B. Protein C. Glycogen D. Carbohydrates
D
A nurse is reviewing nutritional guidelines with the parents of an 11-year-old child. Which of the following parents' statements should indicate to the nurse that they understand the guidelines for school-age children? a. "She wants to eat as much as we do, but we're afraid she'll soon be overweight." b. "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." c. "We limit fast-food restaurant meals to three times a week now." d. "We reward her school achievements with a point system instead of a pizza or ice cream."
D
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence
D
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
D
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A. The client evaluates his behavior after a social interaction. B. The client states he is learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation.
D
a charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent falls, which of the following clients should be assigned to rooms closest to the nursing station A. a middle adult who is postop following a laparoscopic cholecystectomy B. a middle adult who requires telemetry for a possible myocardial infarction C. young adult who is postop following an open reduction internal fixation of the ankle D. an older adult who is postop following a below-the-knee amputation
D
discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.
D
A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles? ( all that apply ) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella.
D, E
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hours following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.
D. A client who has episodic back pain following a fall 2 years ago. A client who reports pain that lasts more tha 6 months and continues beyond tissue healing is experiencing chronic pain. The nurse should identify the client's pain as chronic and assist with planning interventions to relieve manifestations associated with the pain.