C3
The nurse is caring for a client with a dlagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sian the will and requests that the nurse act as a witness. Which is the most appropriate nursing response to the client?
"A nurse caring for a client cannot serve as a witness to a living will.
The nurse is caring for several clients with respiratory disorders. Which clients are at the highest risk for developing a tuberculosis infection? Select all that apply. One, some, or all may be correct.
*A 4-year old child from a low-income family * An older woman with immunodeficiency *A woman living in a nursing home
The nurse is monitoring several older adults for adverse drug effects. Which client requires closest monitoring for drug toxicity?
A client who consumes a high-carbohydrate, low-protein diet
The nurse is providing information to assistive personnel (AP) regarding caring for an older adult. The nurse determines the AP understands the information provided if the AP identifies which situation portrays ageism?
Advising older adults to forgo aggressive treatment
The nurse is assisting with preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child?
Encourage the child to eat in the playroom.
Which instructions would be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?
Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.
A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifles which responses by the husband as indicative of effective individual coping?
*He expresses his anger at God and the primary healthcare providers for allowing this to happen. *He tells the nurse he has prayed that God wll allow his wife to live long enough to watch their children's high school graduation. *He has asked his wife and chlldren to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.
Which assessment findings help confirm a diagnosis of Down syndrome? Select all that apply. One, some, or all may be correct.
*High-arched, narrow palate *Protruding tongue *Transverse palmar crease
The nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documents which intervention in the plan?
Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry.
A client in labor is experiencing dystocia. In delivering care to this client, the nurse would place the highest priority on which ongoing nursing interventions?
Monitoring the status of both mother and fetus
When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution would the nurse institute before making contact with the client?
Put on a gown and gloves.
Nurse suspects that a coworker is substance impaired and is self administering
Report the Information to a supervisor.
A client has just been treated with cardioversion. The nurse should check which measure first?
Status of airway
Nurse gathering data regarding an older client, which indicator of fluid imbalance are they likely to be reliable for a client in this age group?
Thirst
An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected, and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action?
Transport the client to the operating room immediately.
The nurse prepares to take a blood pressure (BP) on a school-age chld. Where would the nurse place the blood pressure cuff to obtain an accurate measurement?
Two-thirds the distance between the antecubital fossa and the shoulder
The nurse is caring for an 8-year old child in the late stage of a terminal illness. The child is semiconscious. The nurse notices that the child has a dry mouth, and the family believes the child is thirsty. The family is attempting to give the child a large glass of apple juice. Which actions would the nurse take? Select all that apply. One, some, or all may be correct.
*Perform frequent oral care with mouth swabs. *Encourage the famlly to participate in oral care as much as desired. *Give the chld small sips of water or Ice chips If alert and requested by the chld.
The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply. One, some, or all may be correct.
*Suicide Is a frequent cause of death among the older population. *Some Indications of dementia may actually originate as depression. *Depression in an older person is likely to have physical manifestations.
