Masteries

The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? 1. Intravenous administration of regular insulin 2. Administer insulin glargine subcutaneously at hour of sleep 3. Maintain nothing prescribed orally (NPO) status 4. Intravenous administration of 10% dextrose

1. Intravenous administration of regular insulin

What should the nurse expect the healthcare provider to prescribe if a client exhibits clinical indicators of warfarin overdose? 1. Heparin 2. Vitamin K 3. Iron dextran 4. Protamine sulfate

2. Vitamin K

A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect does a nurse monitor the client? 1. Torticollis 2. Oculogyric crisis 3. Tardive dyskinesia 4. Pseudoparkinsonism

3. Tardive dyskinesia

Which cognitive development is seen in early adolescence? 1. Having established abstract thoughts 2. Developing capacity for abstract thinking 3. Exploring the ability to attract opposite sex 4. Exploring a newfound ability for limited abstract thoughts

4. Exploring a newfound ability for limited abstract thoughts

What does that nurse state that is true about language development in preschoolers? 1. They start questioning events. 2. They realize that words have arbitrary meanings. 3. They distinguish between phonetically similar sounds. 4. They use 2,000 to 8,000 words to express their desires.

1. They start questioning events.

Which screening report will help the nurse determine skeletal growth in a child? 1. Electroencephalogram reports 2. Radiographs of the hand and wrist 3. Magnetic resonance imaging (MRI) 4. Denver Developmental Screening Test

2. Radiographs of the hand and wrist

A person is badly disfigured by the lawnmower blade when mowing a lawn. According to Erikson's theory, which age at the time of injury will be associated with the greatest risk of long-term psychologic effects? 1. 11 years 2. 35 years 3. 55 years 4. 70 years

1. 11 years

A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent? 1. Clients with mental illness are not allowed to give consent. 2. Clients with mental illness have the right to refuse treatment. 3. Family members of the client need to give consent for all procedures. 4. Primary healthcare providers may perform procedures without consent.

2. Clients with mental illness have the right to refuse treatment.

A high cleansing enema is prescribed for a client. What is the maximum height at which the container of fluid should be held by the nurse when administering this enema? 1. 30 cm (12 inches) 2. 37 cm (15 inches) 3. 51 cm (20 inches) 4. 66 cm (26 inches)

2. 37 cm (15 inches)

The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. 1. Pruritus 2. Sedation 3. Constipation 4. Respiratory rate 5. Nausea and vomiting

2. Sedation 4. Respiratory rate

According to Erikson's theory of psychosocial development, which attribute plays an important role in the development of a healthy personality from birth to 1 year of age? 1. Initiative versus guilt 2. Trust versus mistrust 3. Autonomy versus shame 4. Industry versus inferiority

2. Trust versus mistrust

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis? 1. Wear snug-fitting pants 2. Sit with the knees flexed 3. Apply warm soaks to the legs daily 4. Put on elastic stockings before arising

4. Put on elastic stockings before arising

While caring for a client with urinary tract infection, the nurse manager delegated the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. 1. Registered nurse (RN) 2. Patient care associate (PCA) 3. Licensed practical nurse (LPN) 4. Licensed vocational nurse (LVN) 5. Unlicensed assistive personnel (UAP)

3. Licensed practical nurse (LPN) 4. Licensed vocational nurse (LVN)

A client has a diagnosis of schizoid personality disorder. During the assessment what should the nurse expect of the client's behavior? 1. Rigid and controlling 2. Dependent and submissive 3. Detached and socially distant 4. Superstitious and socially anxious

3. Detached and socially distant

A nurse communicates with a mother about the cognitive changes that her child will exhibit after becoming an adolescent. Which statements made by the mother indicate adequate learning? Select all that apply. 1. "My child will think in terms of the future." 2. "My child will be able to deal with hypothetical problems." 3. "My child will consider a limited variety of causes and solutions." 4. "My child will be able to imagine multiple outcomes of a situation." 5. "My child will be unable to understand the influence of an individual's ideas on others."

1. "My child will think in terms of the future." 2. "My child will be able to deal with hypothetical problems." 4. "My child will be able to imagine multiple outcomes of a situation."

When teaching the parents of a toddler-age client about normal growth and development, which statements should the nurse include in the teaching session regarding learning through the senses? Select all that apply. 1. "The toddler often puts new objects in the mouth." 2. "The toddler may inspect a new toy by turning it over." 3. "The toddler will touch a new object only once during exploration." 4. "The toddler will shake a new toy when it is first introduced to the play area." 5. "The toddler rarely uses the sense of smell to learn about something new introduced within the environment."

1. "The toddler often puts new objects in the mouth." 2. "The toddler may inspect a new toy by turning it over." 4. "The toddler will shake a new toy when it is first introduced to the play area.

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? 1. 70 mL 2. 60 mL 3. 50 mL 4. 40 mL

1. 70 mL

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1. A 59-year-old who had a knee replacement 2. A 60-year-old who has bacterial pneumonia 3. A 68-year-old who had emergency dental surgery 4. A 76-year-old who has a history of thrombocytopenia

1. A 59-year-old who had a knee replacement

The children of adolescent mothers experience more cognitive developmental problems than children of adult mothers. What could be the possible reasons for this observation? Select all that apply. 1. Adolescent mothers may view the infant as a play thing. 2. Adolescent mothers may be reluctant to seek medical care. 3. Adolescent mothers may lack parental competence. 4. Adolescent mothers are younger than adult mothers. 5. Adolescent mothers usually conceive before they have pelvic adequacy.

1. Adolescent mothers may view the infant as a play thing. 3. Adolescent mothers may lack parental competence.

An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse? 1. Allowing the resident to reminisce about the past and listening with interest 2. Involving the resident in interesting diversional activities with a small group 3. Reminding the resident that those "good old days" are past and that the client should focus on the present 4. Introducing the resident to other residents with the same diagnosis so that they can share their past experiences

1. Allowing the resident to reminisce about the past and listening with interest

The registered nurse assists other registered nurses when there are no safety issues. While assisting, the registered nurse uses the strategy of asking. What is the benefit of this strategy? Select all that apply. 1. Allows the registered nurse to reassess 2. Allows the delegator to examine the situation differently 3. Demonstrates a specific task or behavior to improve client care 4. Opens lines of communication between delegator and the delegatee 5. Helps to make a suggestion to facilitate the achievement of a desirable client care outcome

1. Allows the registered nurse to reassess 2. Allows the delegator to examine the situation differently 4. Opens lines of communication between delegator and the delegatee

What are the "four As" for which nurses should assess clients with suspected Alzheimer disease? 1. Amnesia, apraxia, agnosia, aphasia 2. Avoidance, aloofness, asocial, asexual 3. Autism, loose association, apathy, affect 4. Aggressive, amoral, ambivalent, attractive

1. Amnesia, apraxia, agnosia, aphasia

While playing with a toy car, a toddler accidentally hits the wall and falls down. The toddler then gets angry at the wall for making him fall. Which characteristic of preoperational thought does this behavior indicate? 1. Animism 2. Centration 3. Egocentrism 4. Irreversibility

1. Animism

A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record? 1. Anomia 2. Apraxia 3. Dysarthria 4. Dysphagia

1. Anomia

A client on duloxetine therapy ingests ibuprofen for pain relief. Which adverse effect does the nurse anticipate with this combination of medications? 1. Bleeding 2. Hepatotoxicity 3. Serotonin syndrome 4. Cardiac dysrhythmias

1. Bleeding

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? 1. Cognitive response 2. Emotional response 3. Perceptual response 4. Physical response

1. Cognitive response

A client in the mental health clinic has a phobia about closed spaces. Which desensitization method should the nurse expect to be used successfully with this client? 1. Imagery 2. Contracting 3. Role playing 4. Assertiveness training

1. Imagery

During chest physiotherapy (CPT) a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next? 1. Interrupt the therapy. 2. Encourage deep breathing. 3. Place the client in the low-Fowler position. 4. Have the client complete the therapy before resting.

1. Interrupt the therapy.

A blood donor whose blood type is O negative is known as a "universal donor." What does the nurse consider about O negative blood that accounts for this classification? 1. It does not have any of the antigens that can cause a reaction. 2. The donor can donate blood more frequently than other people. 3. More people have this blood type, so it is more universally available. 4. It is more frequently administered when compared with other blood types.

1. It does not have any of the antigens that can cause a reaction.

Which statement is correct regarding delegation? Select all that apply. 1. It involves transfer of authority. 2. The delegator retains accountability for the outcome. 3. The delegatee retains accountability for the outcome. 4. It is the transfer of both responsibility and accountability. 5. Principles of delegation outline what nurses need to know about the task.

1. It involves transfer of authority. 2. The delegator retains accountability for the outcome 5. Principles of delegation outline what nurses need to know about the task.

The goal of a particular nursing theory is to use communication to help a client re-establish positive adaptation to environment, and the framework for the nursing practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the healthcare system. Which nursing theory are these points related to? 1. King's theory 2. Neuman's theory 3. Nightingale's theory 4. Benner and Wrubel's theory

1. King's theory

A group of clients who sustained severe injuries in an earthquake received a full continuum of trauma services. Which level of trauma center provided these services to the clients? 1. Level I 2. Level II 3. Level III 4. Level IV

1. Level I

A nurse is assisting a primary healthcare provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare the skin? Select all that apply. 1. Mask 2. Gown 3. Betadine 4. Checklist 5. Sterile gloves

1. Mask 2. Gown 4. Checklist 5. Sterile gloves

During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

The nurse is listing the major developmental characteristics of hearing in infants. Which characteristics appear for the first time at 24 to 32 weeks? Select all that apply. 1. Responding to own name 2. Locating sounds by turning head in a curving arc 3. Locating sound by turning head to side, then looking up or down 4. Locating sound by turning head to side and looking in same direction 5. Localizing sounds by turning head diagonally and directly toward sound

1. Responding to own name 2. Locating sounds by turning head in a curving arc

What is a constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome? 1. Role experimentation 2. Adherence to peer standards 3. Sublimation through schoolwork 4. Development of dependence on parents

1. Role experimentation

The nurse is admitting a confused 80-year-old client to the mental health unit. Which is one factor associated with the aging process? 1. Slowing of responses 2. Changing of personality 3. Lowering of intelligence 4. Diminution of long-term memory

1. Slowing of responses

According to Piaget's theory, what are the cognitive or moral developmental changes in children aged 6 to 12 years? Select all that apply. 1. The child develops logical thinking. 2. The child is in the sensorimotor period. 3. The child is in the preoperational period. 4. The child is in the concrete operations period 5. There is a progress from reflex activity to simple activity.

1. The child develops logical thinking 4. The child is in the concrete operations period

While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? Select all that apply. 1. "I have difficulty judging things." 2. "I forget to take medicines." 3. "I am unable to do financial calculations." 4. "I get confused about the proper date and time." 5. "I am unable to recall words during conversations with my family."

1. The child is in the conventional level. 4. The child develops a good boy-nice girl orientation

Which behavior of a 3-year-old child indicates delayed development? Select all that apply. 1. The child is unable to feed himself. 2. The child is unable to climb the stairs. 3. The child is unable to name the colors. 4. The child is unable to count when asked. 5. The child is unable to tie his or her shoes.

1. The child is unable to feed himself. 2. The child is unable to climb the stairs.

To prepare for hemodialysis, a client with end-stage kidney disease is scheduled for surgery, specifically for the creation of an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm. When considering care for these sites, which difference will the nurse consider? 1. The graft is more subject to hemorrhage, clotting, and infection than the fistula is. 2. Blood pressure readings can be taken in the arm with the fistula but not the one with the shunt. 3. Intravenous (IV) fluids can be administered in the arm with the shunt but not the one with the fistula. 4. The fistula should be covered with a light dressing, and the shunt should be covered thoroughly with a heavy dressing.

1. The graft is more subject to hemorrhage, clotting, and infection than the fistula is.

What professional responsibility does the nurse display as a client's advocate? 1. The nurse protects the client's human and legal rights and provides assistance in asserting said rights. 2. The nurse actively collaborates with other healthcare professionals to follow the best treatment plan for a client. 3. The nurse explains concepts and facts about health, describes the reason for routine care activities, and demonstrates procedures. 4. The nurse establishes an environment for collaborative client-centered care to provide safe, quality care with positive client outcomes

1. The nurse protects the client's human and legal rights and provides assistance in asserting said rights.

What important step should the community nurse take when dealing with older adults with a confusional states problem? Select all that apply. 1. The nurse should provide a protective environment. 2. The nurse should monitor blood pressure and weight. 3. The nurse should recommend applicable community resources. 4. The nurse should demonstrate proper hygiene to the primary caretaker. 5. The nurse should educate about polypharmacy and drug-drug and drug-food interactions.

1. The nurse should provide a protective environment. 3. The nurse should recommend applicable community resources. 4. The nurse should demonstrate proper hygiene to the primary caretaker.

What points regarding the Good Samaritan Act of 1997 should the nurse remember? Select all that apply. 1. The nurse should provide care that is consistent with his or her level of expertise. 2. After providing emergency care, the nurse is not required to remain with the client. 3. Good Samaritan laws limit liability and offer legal immunity if a nurse helps at an accident scene. 4. The nurse is not liable for injuries resulting from performing procedures for which he or she is not trained. 5. Good Samaritan laws were enacted to encourage healthcare workers to provide assistance during emergencies.

1. The nurse should provide care that is consistent with his or her level of expertise. 3. Good Samaritan laws limit liability and offer legal immunity if a nurse helps at an accident scene. 5. Good Samaritan laws were enacted to encourage healthcare workers to provide assistance during emergencies.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. 1. Vomiting 2. Irritability 3. Hypotension 4. Increased respirations 5. Decreased level of consciousness

1. Vomiting 2. Irritability 5. Decreased level of consciousness

An older adult, accompanied by family members, is admitted to a long-term care facility with symptoms of dementia. What initial statement by the nurse during the admission procedure would be most helpful to this client? 1. "You're a little disoriented now, but don't worry. You'll be all right in a few days." 2. "Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you." 3. "I'm the nurse on duty today. You're in the hospital. Your family can stay with you for a while." 4. "Let me introduce you to the staff here first. In a little while I'll get you acquainted with our unit routine."

2. "Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you."

The nurse is assessing a client for recall memory. Which statements made by the client indicate that the client's recall memory is intact? Select all that apply. 1. "I was born in New York city." 2. "I came to the hospital in a car." 3. "You asked me to repeat the words apple, street, and chair." 4. "I was admitted on the 24th of September at 5 in the evening." 5. "I had an appointment with a neurophysician last month."

2. "I came to the hospital in a car." 3. "You asked me to repeat the words apple, street, and chair." 4. "I was admitted on the 24th of September at 5 in the evening." 5. "I had an appointment with a neurophysician last month."

A nurse is educating a client about the Uniform Determination of Death Act. What information should the nurse provide? Select all that apply. 1. "Nurses are not required to have an understanding of the legal definitions of death." 2. "Nurses have a specific legal obligation to treat a deceased person's remains with dignity." 3. "According to the act, multiple standards are used to determine of death." 4. "Different definitions regarding death are in place to facilitate recovery of organs for transplantation." 5. "The cardiopulmonary standard of determining death sets an irreversible cessation of circulatory and respiratory functions as the criterion."

2. "Nurses have a specific legal obligation to treat a deceased person's remains with dignity." 4. "Different definitions regarding death are in place to facilitate recovery of organs for transplantation." 5. "The cardiopulmonary standard of determining death sets an irreversible cessation of circulatory and respiratory functions as the criterion."

A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of this pregnancy? 1. Recognize her ambivalence 2. Accept that she is pregnant 3. Prepare for the birth of the baby 4. Recognize the fetus as an individual separate from the mother

2. Accept that she is pregnant

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? 1. Defibrillate 2. Assess the client's pulse 3. Initiate advanced cardiac life support 4. Check another lead to confirm asystole

2. Assess the client's pulse

What is the priority nursing action when caring for a client with disseminated intravascular coagulation? 1. Monitor for Homans sign. 2. Avoid giving intramuscular injections. 3. Take temperatures via the rectal route. 4. Apply sequential compression stockings.

2. Avoid giving intramuscular injections

While caring for clients with injuries after a terrorist attack, the nurse observed ear bleeding, conjuctival hemorrhage, and severe lacerations in a client and provided mechanical ventilation. Which tag would be appropriate for this client according to the disaster triage tag system? 1. Red tag 2. Black tag 3. Green tag 4. Yellow tag

2. Black tag

The nurse is caring for a client with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of what symptom? 1. Pruritus 2. Bleeding 3. Flatulence 4. Hypokalemia

2. Bleeding

A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain? 1. Polycythemia 2. Cor pulmonale 3. Compensated acidosis 4. Left ventricular failure

2. Cor pulmonale

A nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. How should the nurse respond? 1. Answer the questions softly so other people will not hear. 2. Decline to discuss the friend's medical condition. 3. Give the coworker the name of the client's primary healthcare provider, so the coworker can contact the provider instead. 4. To provide reassurance, tell the coworker of the friend's test results that are within normal limits.

2. Decline to discuss the friend's medical condition.

The nurse is caring for a client who is confused and delirious. What is the most therapeutic intervention when the nurse is interacting with this client? 1. Reassuring the client that the client will get better 2. Directing the client's daily activities on the unit 3. Helping the client clarify the client's experience and gain insight into personal behavior 4. Providing the client with solutions to past and current problems that have been experienced

2. Directing the client's daily activities on the unit

A nursing instructor asks a nursing student about the formal operations stage of Piaget's theory of cognitive development. Which of these statements by the student indicate a need for further teaching? Select all that apply. 1. During this stage, the individual engages in risk-taking. 2. During this stage, there's an absence of egocentric thought. 3. During this stage, reversibility in thought is the primary characteristic. 4. During this stage, the individual's thinking moves toward abstract theory. 5. During this stage, the individual develops the capacity to reason with respect to possibilities.

2. During this stage, there's an absence of egocentric thought. 3. During this stage, reversibility in thought is the primary characteristic.

What should the nurse include when planning activities for an older nursing home resident with a diagnosis of dementia? 1. Varied activities that will keep the resident occupied 2. Familiar activities that the resident can complete successfully 3. Challenging activities to maintain the resident's contact with reality 4. Ways to ensure that the resident actively participates in the unit's daily activities

2. Familiar activities that the resident can complete successfully

A nurse is caring for a community-dwelling older adult with dementia. What interventions should the nurse take to ensure the client's well-being? Select all that apply. 1. Obtain the client's drug history and educate the older adult about safe medication storage 2. Foster human dignity and maintain the best possible functioning, protection, and safety 3. Teach the client to be cautious of false advertisements that promise a cure for the disease 4. Show the caregiver techniques to dress, feed, and toilet the older adult 5. Protect the client's rights and provide support to maintain the physical and mental health of family members

2. Foster human dignity and maintain the best possible functioning, protection, and safety 4. Show the caregiver techniques to dress, feed, and toilet the older adult 5. Protect the client's rights and provide support to maintain the physical and mental health of family members

A frail, depressed client who frequently paces the halls becomes physically tired from the activity. What action should the nurse take to help reduce this activity? 1. Restrain the client in a chair. 2. Have the client perform simple, repetitive tasks. 3. Ask the client's primary healthcare provider to prescribe a sedative. 4. Place the client in a single room to limit pacing to a smaller area.

2. Have the client perform simple, repetitive tasks.

What should a nurse do when caring for a client whose behavior is characterized by pathologic suspicion? 1. Protect the client from environmental stress. 2. Help the client feel accepted by the staff on the unit. 3. Ask the client to explain the reasons for the feelings. 4. Help the client realize that the suspicions are unrealistic.

2. Help the client feel accepted by the staff on the unit.

An underweight client has autoimmune hemolytic anemia that has been unresponsive to corticosteroids, and a splenectomy is scheduled. For what complication should the nurse assess the client in the immediate postoperative period? 1. Dehiscence 2. Hemorrhage 3. Wound infection 4. Abscess formation

2. Hemorrhage

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1. Apply negative pressure while inserting the suction catheter. 2. Hyperoxygenate with 100% oxygen before and after suctioning. 3. Suction two to three times in succession to effectively clear the airway. 4. Use rapid movements of the suction catheter to loosen secretions

2. Hyperoxygenate with 100% oxygen before and after suctioning.

A nursing home resident with dementia of the Alzheimer type, stage 2, who has been receiving donepezil is engaging in numerous acting-out behaviors. On what should the nurse base the initial plan of care? 1. Assessing the client's level of consciousness 2. Identifying the stressors that precipitate the client's behavior 3. Observing the client's performance of activities of daily living 4. Monitoring the side effects associated with the client's medications

2. Identifying the stressors that precipitate the client's behavior

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1. Fatigue related to weight loss secondary to COPD 2. Imbalanced nutrition: less than body requirements, related to fatigue 3. Imbalanced nutrition: less than body requirements, related to COPD 4. Ineffective breathing pattern, related to alveolar hypoventilation

2. Imbalanced nutrition: less than body requirements, related to fatigue

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? 1. Pregnancy 2. Inactivity 3. Aerobic exercise 4. Tight clothing

2. Inactivity

A client is returned to the surgical unit after an abdominal cholecystectomy. What is the main reason why the nurse should assess for clinical indicators of respiratory complications? 1. Length of time required for surgery is prolonged. 2. Incision is in close proximity to the client's diaphragm. 3. Client's resistance is lowered because of bile in the blood. 4. Bloodstream is invaded by microorganisms from the biliary tract.

2. Incision is in close proximity to the client's diaphragm.

A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response? 1. Reduces pain 2. Induces sedation 3. Produces amnesia 4. Limits oral secretions

2. Induces sedation

A nurse is assessing a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group? 1. Trust versus mistrust 2. Intimacy versus isolation 3. Industry versus inferiority 4. Generativity versus stagnation

2. Intimacy versus isolation

A client who was admitted to the psychiatric unit because of a major depressive disorder is exhibiting increasingly withdrawn behavior. The nurse understands that eventually the client will experience what feelings? 1. Hedonia 2. Isolation 3. Paranoia 4. Ambivalence

2. Isolation

A nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. What area of the body should the nurse include as the most common site for bleeding? 1. Brain 2. Joints 3. Kidneys 4. Abdomen

2. Joints

An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation? 1. Minimize environmental stress to reduce confusion 2. Let the client continue to think in his or her own way 3. Prompt the client to recognize the correct date and time 4. Ask the client to recall the past to understand the present situation

2. Let the client continue to think in his or her own way

The primary healthcare provider prescribes a rectal suppository for a client with severe constipation. Which healthcare professional would be delegated the task of administering the suppository? 1. Patient care associate 2. Licensed practical nurse 3. Unlicensed assistive personnel 4. Unlicensed nursing personnel

2. Licensed practical nurse

Which item the nurse discusses is true about the brain maturation and cognitive development of preschoolers? 1. Preschoolers are least concerned about bodily harm. 2. Preschoolers are aware of the cause and effect relationship. 3. Most rapid growth occurs in the temporal lobes of the brain. 4. Preschoolers are inept at classifying objects according to size.

2. Preschoolers are aware of the cause and effect relationship.

A 54-year-old has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After the person is found disoriented and semi-naked while walking down a street, the diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety upon admission to a long-term care facility. What is the best nursing intervention in light of the client's diagnosis? 1. Exploring the reasons for the concerns 2. Reassuring the client with the frequent presence of staff members 3. Providing the client with a written schedule of planned interactions 4. Explaining to the client why the admission to the facility is necessary

2. Reassuring the client with the frequent presence of staff members

What would be the nurse's first step in efficiently tackling a situation of moral dilemma? 1. Helping the client make a moral decision 2. Recognizing one's own moral development level 3. Abiding by the decision of the hospital authority 4. Having one's own opinion that differs from the healthcare team

2. Recognizing one's own moral development level

What are the roles and responsibilities of a senior nurse leader while implementing strategies for improving the quality of the organization? Select all that apply. 1. Participating actively in the quality improvement activities 2. Setting priorities for staff effectiveness and client health outcomes 3. Providing support systems for staff who have been involved in a sentinel event 4. Building infrastructure, providing resources, and removing barriers for improvement 5. Meeting regularly with staff to monitor their progress and help them improve their work

2. Setting priorities for staff effectiveness and client health outcomes 3. Providing support systems for staff who have been involved in a sentinel event 4. Building infrastructure, providing resources, and removing barriers for improvement

A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess? 1. Quality of the cry 2. Signs of dehydration 3. Coughing up of feedings 4. Characteristics of the stool

2. Signs of dehydration

A nursing student notes information regarding restorative care. Which points noted by the nursing student are accurate? Select all that apply. 1. The restorative healthcare team is an interdisciplinary group of health professionals. 2. Success depends on effective and early collaboration with clients and their families. 3. Clients and families follow treatment plans better when they are involved in restorative care. 4. Clients who are disabled or are suffering from terminal diseases need restorative care. 5. Restorative care is provided through home healthcare, rehabilitation, or extended care facilities.

2. Success depends on effective and early collaboration with clients and their families. 3. Clients and families follow treatment plans better when they are involved in restorative care. 5. Restorative care is provided through home healthcare, rehabilitation, or extended care facilities.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1. Limit the client's fluid intake. 2. Teach the client how to exercise the legs. 3. Encourage use of the incentive spirometer. 4. Maintain the knee gatch position at an angle.

2. Teach the client how to exercise the legs.

During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding? 1. The nurse restores the client's sense of reality. 2. The nurse builds self-esteem by asking about a client's previous achievements. 3. The nurse agrees to a confused client's incorrect statement. 4. The nurse meets the expressed and unexpressed needs of the client.

2. The nurse builds self-esteem by asking about a client's previous achievements.

An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client? 1. Chlorpheniramine needs to be stopped immediately. 2. These are common side effects of chlorpheniramine. 3. Hydroxyzine needs to be taken with chlorpheniramine. 4. The chlorpheniramine prescription needs to be changed.

2. These are common side effects of chlorpheniramine.

After assessing the behavior of team members, the nurse leader concludes that the team is ineffective. Which activities by the team members might have led to this conclusion? Select all that apply. 1. They are involved in open discussions. 2. They are unclear about their assignments. 3. They are uncomfortable with disagreement. 4. They share discussion with almost everyone. 5. They frequently use formal voting to make decisions.

2. They are unclear about their assignments. 3. They are uncomfortable with disagreement. 5. They frequently use formal voting to make decisions.

A nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning discharge accompanied by a burning sensation and lower abdominal pain. After an examination the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she has been sexually active and asks the nurse whether her parents will be contacted. What should the nurse explain regarding informing the client's parents? 1. They need to know about and sign a consent form for testing and treatment. 2. They will not be contacted, because treatment at the clinic is confidential. 3. They will be notified when the insurance company is billed for testing and treatment. 4. They will remain uninformed if the adolescent ensures that her sexual contacts will come for testing.

2. They will not be contacted, because treatment at the clinic is confidential.

While assessing a neonate who was born at 42 weeks of gestation via vaginal delivery, the nurse finds that the neonate has a birth weight of 9 lb (4.1 kg). The nurse also assesses for Moro reflex and focal swelling or tenderness in the neonate. Why does the nurse perform these interventions? 1. To evaluate for facial paralysis 2. To evaluate for clavicle fracture 3. To evaluate for ophthalmia neonatorum 4. To evaluate for erythema toxicum neonatorum

2. To evaluate for clavicle fracture

What is the priority discharge criterion for a client who is using ritualistic behaviors? 1. Verbalizes positive aspects about self 2. Follows the rules of the therapeutic milieu 3. Able to intervene when increasing levels of anxiety occur 4. Recognizes that hallucinations occur at times of extreme anxiety

3. Able to intervene when increasing levels of anxiety occur

A healthcare team is caring for a client with food poisoning. Which task is most suitable to be delegated to licensed practical nurse (LPN)? 1. Collecting vital signs 2. Performing a stomach wash 3. Administering oral antiemetic medication 4. Administering intravenous replacement fluids

3. Administering oral antiemetic medication

The nursing leader stated, "The reimbursed cost is less than the full charge for a service in the hospital." Which type of health reimbursement does the nurse leader describe? 1. Contractual allowance 2. Value-based purchasing 3. Cost-based reimbursement 4. Prospective payment system

3. Cost-based reimbursement

What is the priority nursing action for a client with delirium? 1. Maintaining skin integrity 2. Planning for behavioral interventions 3. Creating a calm and safe environment 4. Maintaining personal contact through touch

3. Creating a calm and safe environment

A disturbed client is brought to the emergency department by the police. What should be included in the nurse's initial mental assessment? 1. Recollection of past events 2. Previous methods of coping with stress 3. Current behavior, cognitive function, and orientation 4. Cultural background, developmental level, and verbal skills

3. Current behavior, cognitive function, and orientation

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? 1. Occipital headache 2. Periorbital crepitus 3. Expectoration of blood 4. Changes in vocalization

3. Expectoration of blood

A client suspected of carcinoma of the liver is scheduled for a liver biopsy. For which procedural contraindication should the nurse assess the client? 1. Confusion and disorientation 2. Presence of any infectious disease 3. International normalized ratio (INR) greater than 4.5 4. Inclusion of foods high in vitamins E and phytonadione in the client's diet

3. International normalized ratio (INR) greater than 4.5

After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1. Observing the suprapubic dressing for drainage 2. Maintaining the client in the semi-Fowler position 3. Monitoring for bright red blood in the drainage bag 4. Encouraging fluids by mouth as soon as the gag reflex returns

3. Monitoring for bright red blood in the drainage bag

A client with a gunshot wound has severe hemiplegia associated with abnormal body posturing and fixed and dilated pupils. What is the nursing priority in this condition? 1. Monitoring skin integrity 2. Monitoring bowel patterns 3. Monitoring respiratory rate 4. Monitoring nutritional status

3. Monitoring respiratory rate

Which agency's operations would the registered nurse consider to be most in need of incident command system (ICS) training? 1. WHO (World Health Organization) 2. DHS (Department of Homeland Security) 3. NIMS (National Incident Management System) 4. FEMA (Federal Emergency Management Agency)

3. NIMS (National Incident Management System)

An infant is admitted to the pediatric unit with the diagnosis of heart failure. What should the nurse include in the infant's plan of care? 1. Increase the infant's fluid intake. 2. Position the infant flat on the back. 3. Offer the infant small, frequent feedings. 4. Measure the infant's head circumference.

3. Offer the infant small, frequent feedings

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? 1. Meet the clients' family. 2. Read the clients' medical reports. 3. Participate in the bedside rounds. 4. Visit the clients and introduce self.

3. Participate in the bedside rounds.

What instructions should the nurse give to an overweight adolescent to help him or her lose weight? Select all that apply. 1. Skip breakfast. 2. Sleep for long hours to reduce stress. 3. Perform physical activities regularly. 4. Eat small frequent meals throughout the day. 5. Reduce the intake of sugar and sweetened beverages.

3. Perform physical activities regularly. 4. Eat small frequent meals throughout the day. 5. Reduce the intake of sugar and sweetened beverages.

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances? 1. Restrict family visits 2. Withhold analgesic medications 3. Plan for maximum periods of rest 4. Keep the room light on most of the time

3. Plan for maximum periods of rest

Which should the nurse include in the plan of care to decrease the risk for drown injury for a school-age client? 1. Securing seatbelts properly 2. Using a low heat setting when cooking 3. Recommending enrollment in swimming lessons 4. Making sure smoke detectors are installed in the home

3. Recommending enrollment in swimming lessons

When evaluating a task performed by a delegatee, the registered nurse finds that the delegatee fails to provide appropriate feedback. Which right of delegation is compromised in this situation? 1. Right task 2. Right person 3. Right supervision 4. Right communication

3. Right supervision

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? 1. Provide small, frequent meals 2. Encourage pursed-lip breathing 3. Schedule nursing activities to allow for rest 4. Encourage bed rest until energy level improves

3. Schedule nursing activities to allow for rest

After giving birth to her third child, a client tearfully says to the nurse, "How much more can I give of myself?" Which principle should the nurse consider in the care of any new mother? 1. It is easier to adjust to the first child than to later ones. 2. Feeling anger and resentment toward a child is pathologic. 3. Some parents experience feelings of being overwhelmed by multiple children. 4. Parents usually have inborn feelings of love and acceptance of their children.

3. Some parents experience feelings of being overwhelmed by multiple children.

During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care? 1. Client's orientation to time, place, and person 2. Ability to perform daily activities without assistance from others 3. Stressors that appear to precipitate the client's disruptive behavior 4. That cognitive impairments will increase until adjustment to the home is accomplished

3. Stressors that appear to precipitate the client's disruptive behavior

The American parents of an adopted Spanish preschooler inform the nurse that the child often stutters while speaking. Upon assessment, the nurse finds that there is no hearing impairment, brain injuries, or developmental disorders in the child. What does the nurse suspect is the cause for the stuttering? 1. The child is pressured to speak English well. 2. The child is not comfortable with the new environment. 3. The change in language exposure has caused stuttering. 4. The parents do not provide a happy environment for the child.

3. The change in language exposure has caused stuttering

After assessing the behavior of a 3-year-old child, the nurse concludes that the child is slow to warm up. Which behavior helps the nurse reach this conclusion? 1. The child has predictable habits in different environments. 2. The child responds enthusiastically to a new environment. 3. The child adapts gradually to a new environment with repeated contact. 4. The child consistently expresses a negative mood in various environments.

3. The child adapts gradually to a new environment with repeated contact.

Which statement is true according to Piaget's theory of cognitive or moral development in the adolescent? Select all that apply. 1. The child is egocentric. 2. The child uses symbols. 3. The child develops abstract thinking. 4. The child is in the formal operations period. 5. The child is in the pre-operational period.

3. The child develops abstract thinking. 4. The child is in the formal operations period.

An 80-year-old client with dementia of the Alzheimer type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand the aging process? 1. "Most people at that age should be careful about weight gain." 2. "This is typical of older adults; they really don't eat well." 3. "It looks as though the frequent tanning has taken its toll." 4. "As we age, we lose the tissue that helps puff out the skin."

4. "As we age, we lose the tissue that helps puff out the skin."

A registered nurse (RN) delegates the task of oral care of a client with stomatitis, to an unlicensed assistive personnel (UAP). Which instruction should be given by the RN to the UAP? 1. "Use a mouthwash containing alcohol with the client." 2. "Teach the client to rinse the mouth once every 4 to 5 hours." 3. "Avoid using toothpaste containing sodium lauryl sulfate with the client." 4. "Be certain to use mouthwash containing sodium bicarbonate with the client."

4. "Be certain to use mouthwash containing sodium bicarbonate with the client."

A nurse is evaluating scenarios that are based on the responses of several clients. Which statement of a client confirms that he or she has reached the Intimacy versus Isolation stage according to Erikson's theory of psychosocial development? 1. "I donate a large sum of money to the local school every year." 2. "I want to enjoy my motherhood and that's why I am leaving the job." 3. "In the winter of my life, I feel that I do not have anyone to take care of me." 4. "I did so much for my partner but I was dumped for someone more attractive."

4. "I did so much for my partner but I was dumped for someone more attractive."

A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? 1. "How do you feel about the voices, and what do they mean to you?" 2. "You're the only one hearing the voices. Are you sure you hear them?" 3. "The health team members will observe your behavior. We won't leave you alone." 4. "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"

4. "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"

A registered nurse teaches a student nurse about delegation. Which statement made by the student nurse indicates appropriate learning? 1. "Licensed practical nurses are accountable for the tasks they perform." 2. "Complete client care can be delegated to the licensed practical nurse." 3. "Professional aspects of care can be carefully delegated to the licensed practical nurse." 4. "Licensed practical nurses can be expected to perform tasks with which they have experience."

4. "Licensed practical nurses can be expected to perform tasks with which they have experience."

The parents inform the nurse that their child often engages in 'doctor play' with other kids, with an aim to learn more about the sexual organs. The parents have often expressed their disapproval to the child, but it has no effect on the child's behavior. What does the nurse suggest to the parents? 1. "Offer a reward for not engaging in such activities." 2. "Encourage the child to engage in some sports activity." 3. "Tell the child it is dangerous to engage in such activities." 4. "Tell the child to talk with you about any questions related to sexuality."

4. "Tell the child to talk with you about any questions related to sexuality."

The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback? 1. "Nice job." 2. "Well done." 3. "Your performance was good." 4. "You performed that procedure safely and professionally."

4. "You performed that procedure safely and professionally."

A nurse educates parents about how to communicate with their 14-year-old. Which statement should the nurse make? 1. "You should ask your child closed-ended questions." 2. "You should avoid involving other individuals and resources." 3. "You should avoid discussing sensitive issues with your child." 4. "You should look for the meaning behind your child's words or actions."

4. "You should look for the meaning behind your child's words or actions."

A nurse is evaluating various scenarios related to the basic codes of ethics set forth by the American Nurses Association. Which situation is an example of following the principle of accountability? 1. A nurse carefully monitors all tasks that have been delegated to nursing assistive personnel. 2. At the client's request, a nurse refrains from telling the client's caregivers about the client's condition. 3. A nurse explains to a client's caregivers why the client requires a particular emergency procedure to be done. 4. A nurse ensures that all nursing actions performed during care can be explained to the client and the hospital.

4. A nurse ensures that all nursing actions performed during care can be explained to the client and the hospital.

The parents of a boy born with hypospadias ask the nurse at what age the repair of this congenital defect is performed. What is the most appropriate response by the nurse? 1. Shortly after birth 2. Between 4 and 5 years of age 3. Just before the onset of puberty 4. After 6 months and before 1 year of age

4. After 6 months and before 1 year of age

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action? 1. Provide the client with information about the usefulness of herbal therapies 2. Inform the client about taking supplemental vitamins rather than herbs 3. Teach the client about herbal supplements 4. Ask the client which herbs have been taken

4. Ask the client which herbs have been taken

The nurse is caring for an infant undergoing laser therapy for port-wine stain. Which instruction does the nurse give to the infant's parents? 1. Avoid trimming the fingernails during the laser therapy. 2. Use salicylate pain medications for the infant during the laser therapy. 3. Apply sunscreen to the infant while going in sunlight during the therapy. 4. Avoid any trauma to the lesion such as picking at the scab during the therapy.

4. Avoid any trauma to the lesion such as picking at the scab during the therapy.

What intervention should a nurse perform during a chest examination of a female client with a suspected lung disorder? 1. Perform the test in a dark room 2. Examine only the anterior chest 3. Observe for any evidence of respiratory distress 4. Begin the chest examination on the posterior chest

4. Begin the chest examination on the posterior chest

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports that the client has increasing restlessness and agitation accompanied by nausea. What does the nurse advise the partner to do? 1. Give the medication with food. 2. Administer the medication to the partner at bedtime. 3. Omit one dose today and start with a lower dose tomorrow. 4. Bring the partner to the clinic for testing and a physical examination.

4. Bring the partner to the clinic for testing and a physical examination.

A client who is receiving a cardiac glycoside, a diuretic, and a vasodilator has been placed on bed rest. The client's apical pulse rate is 44 beats per minute. The nurse concludes that the decreased heart rate most likely is a result of which drug? 1. Diuretic 2. Vasodilator 3. Bed rest regimen 4. Cardiac glycoside

4. Cardiac glycoside

A client is to receive donepezil for treatment of dementia of the Alzheimer type. The nurse sits down with the primary caregiver and the client and reviews the purpose of the drug, its dosage, and the usual side effects. What side effect identified by the caregiver leads the nurse to conclude that further teaching is needed? 1. Nausea 2. Dizziness 3. Headache 4. Constipation

4. Constipation

Which nursing intervention is indicated for aging clients with decreased bone density? 1. Teaching the client isometric exercises 2. Advising the client to take a moist heat shower 3. Providing supportive armchairs to the client 4. Demonstrating weight-bearing exercises to the client

4. Demonstrating weight-bearing exercises to the client

A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status? 1. Diminished remote memory resulting from anoxia 2. Loss of abstract thinking related to emotional state 3. Inability to concentrate related to decreased stimuli 4. Difficulty recalling recent events related to cerebral hypoxia

4. Difficulty recalling recent events related to cerebral hypoxia

A client is admitted to the emergency department after a train derailment. The primary health care provider orders staff members to monitor vital signs, perform basic wound care, and ensure spinal immobilization. Which emergency staff member should provide this care for the client's condition? 1. Paramedics 2. Prehospital care providers 3. Emergency medicine physician 4. Emergency medical technicians

4. Emergency medical technicians

A client states, "I get down on myself when I make a mistake." In a cognitive therapy approach, which nursing interventions are most appropriate? Select all that apply. 1. Teaching the client relaxation exercises to diminish stress 2. Exploring with the client past experiences that have caused distress 3. Providing the client with mastery experiences designed to boost self-esteem 4. Encouraging the client to replace these negative thoughts with positive thoughts 5. Helping the client modify the belief that anything less than perfection is unacceptable

4. Encouraging the client to replace these negative thoughts with positive thoughts 5. Helping the client modify the belief that anything less than perfection is unacceptable

The disaster management team is working to manage the aftermath of an accidental explosion in a fertilizer plant and has started evacuating the injured and uninjured victims from danger as first line of action. Which team member most likely engages in this action? 1. Nurse 2. Paramedic 3. Volunteers 4. Firefighter

4. Firefighter

What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? 1. Helping the client relate to others 2. Making the hospital atmosphere more homelike 3. Helping the client become accepted in a controlled setting 4. Maintaining the highest level of safe, independent function

4. Maintaining the highest level of safe, independent function

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? 1. Restricting gross motor activity 2. Preventing further deterioration 3. Keeping the client oriented to time 4. Managing the client's unsafe behaviors

4. Managing the client's unsafe behaviors

A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning? Select all that apply. 1. "I should examine the client in noise-free areas." 2. "I should use latex gloves during the physical examination." 3. "I should perform a physical examination in a cool room." 4. "I should leave a combative client alone during a physical examination." 5. "I should wear eye shields while examining a client with excessive drainage."

1. "I should examine the client in noise-free areas." 5. "I should wear eye shields while examining a client with excessive drainage."

A nurse is interviewing a client with the diagnosis of dementia of the Alzheimer type. What question should the nurse ask to assess the client's orientation to place? 1. "Where are you?" 2. "Who brought you here?" 3. "Do you know where you are?" 4. "How long have you been here?"

1. "Where are you?"

A nurse finds that an older adult has reduced consciousness and fatigue and imagines something that is unreal. Which condition does the nurse suspect in the client? 1. Delirium 2. Dementia 3. Depression 4. Alzheimer's disease

1. Delirium

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1. Mental confusion 2. Increased cholesterol 3. Brown-colored stools 4. Flapping hand tremors 5. Musty, sweet breath odor

1. Mental confusion 4. Flapping hand tremors 5. Musty, sweet breath odor

A nursing instructor asks a nursing student about language development in toddlers. Which statement by the student indicates a need for further learning? 1. "A 24-month-old child uses pronouns." 2. "An 18-month-old child uses approximately 25 words." 3. "A 24-month-old child has a vocabulary of up to 300 words." 4. "36-month-old child can use simple sentences and follow some grammatical rules."

2. "An 18-month-old child uses approximately 25 words."

The registered nurse (RN) is teaching a novice RN about delegating tasks to licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). Which statement made by the novice RN indicates a need for further teaching? 1. "I will delegate the task of reinforcing client teaching to the LPN." 2. "I will delegate the task of assisting the client with bathing to the LPN." 3. "I will delegate the task of recording vital signs of the client to the UAP." 4. "I will delegate the task of administering intramuscular injections to the LPN."

2. "I will delegate the task of assisting the client with bathing to the LPN."

What instructions should the nurse give to the parents of a toddler? Select all that apply. 1. "You should direct the actions of your child." 2. "You should serve finger foods to your child." 3. "You should give 5 cups of milk to your child daily." 4. "You should give graded independence to your child." 5. "You should use television to keep the child entertained."

2. "You should serve finger foods to your child." 4. "You should give graded independence to your child."

Which nursing actions are developmentally appropriate when caring for a hospitalized preschool-age child? Select all that apply. 1. Providing brochures regarding home care options 2. Using toys for distraction during a painful procedure 3. Knocking on the child's hospital room door prior to entering 4. Offering medical equipment to play with prior to a procedure 5. Providing clear instructions about details of a procedure that will occur near discharge

2. Using toys for distraction during a painful procedure 4. Offering medical equipment to play with prior to a procedure

Donepezil is prescribed for a senior client who has mild dementia of the Alzheimer type. What information does the nurse include when discussing this medication with the client and family? 1. Fluids should be limited to four large glasses per day. 2. Constipation should be reported to the primary healthcare provider immediately. 3. Blood tests that reflect liver function will be performed routinely. 4. The client's medication dosage may be self-adjusted according to the client's response.

3. Blood tests that reflect liver function will be performed routinely.

After assigning a specific work to the unlicensed nursing professional, the registered nurse does a critical analysis of the work to determine if the actions taken were appropriate and provides a detailed explanation of what occurred. Which action related to delegation is the nurse performing? 1. Supervision 2. Responsibility 3. Accountability 4. Legal authority

3. Accountability

The nurse is caring for a client newly diagnosed with diabetes. What symptom of hypoglycemia is most common and should be taught to the client? 1. Kussmaul respirations 2. Tachycardia 3. Confusion 4. Anorexia

3. Confusion

During a client's immediate postoperative period after a laryngectomy, what is a nursing priority? 1. Provide emotional support 2. Observe for signs of infection 3. Keep the trachea free of secretions 4. Promote a means of communication

3. Keep the trachea free of secretions

A 1-year-old exhibits a runny nose and cough after being administered a vaccine via the intranasal route. Which vaccine may have been administered to the child? 1. Rotavirus 2. Inactivated influenza 3. Live attenuated influenza 4. Haemophilus influenzae type b

3. Live attenuated influenza

An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? 1. The nurse should wait for the court's order to give blood to the client. 2. The nurse should proceed with the transfusion in order to save the client's life. 3. The nurse should inform the primary healthcare provider and not give blood to the client. 4. The nurse should explain to the family member that the client needs this transfusion.

3. The nurse should inform the primary healthcare provider and not give blood to the client.

Why would a nurse question an adolescent about his or her future education plans? 1. To help identify an adolescent who feels socially isolated 2. To give an adolescent the opportunity to talk about his or her strengths 3. To give an adolescent a chance to talk through significant sources of stress 4. To allow an adolescent to discuss items related to physical development

3. To give an adolescent a chance to talk through significant sources of stress

A nurse's best approach when caring for a confused older client is to provide an environment with what? 1. Space for privacy 2. Group involvement 3. Trusting relationships 4. Activities that are varied

3. Trusting relationships

A nursing instructor asks a nursing student about the warning signs that may be seen in an adolescent one month before suicide is attempted. What statement indicates a need for further education? 1. "A suicidal adolescent may sleep for long hours." 2. "A suicidal adolescent may have an increased appetite." 3. "A suicidal adolescent may lose interest in daily activities." 4. "A suicidal adolescent may avoid speaking about suicidal thoughts."

4. "A suicidal adolescent may avoid speaking about suicidal thoughts."

Which pulmonary risk may be increased in a postoperative client due to anesthesia? 1. Rhonchi 2. Fremitus 3. Dyspnea 4. Atelectasis

4. Atelectasis

A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client? 1. Acute pain 2. Impaired mobility 3. Impaired swallowing 4. Hematoma formation

4. Hematoma formation

A client is admitted in the primary healthcare center for treatment of electrical burns. Which technology should the nurse expect will be used for the treatment? 1. Skin substitutes 2. Electrical stimulation 3. Topical growth factors 4. Hyperbaric oxygen therapy

4. Hyperbaric oxygen therapy

Which would the nurse claim is a cardiovascular manifestation of alkalosis? 1. Anxiety 2. Seizures 3. Hyperreflexia 4. Increased digitalis toxicity

4. Increased digitalis toxicity

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change? 1. Decreased afterload 2. Decreased heart rate 3. Increased stroke volume 4. Increased intravascular volume

4. Increased intravascular volume

The nurse is preparing a care plan for a client who is to undergo an electromyography. Which nursing intervention should the nurse add to the care plan? 1. Encourage the client to sleep quietly during the procedure 2. Prepare the client to stay in a sitting position during the procedure 3. Inform the client that the procedure is both painless and noninvasive 4. Instruct the client to avoid drinking coffee or tea 24 hours before the procedure

4. Instruct the client to avoid drinking coffee or tea 24 hours before the procedure

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? 1. Libel 2. Slander 3. Negligence 4. Invasion of privacy

4. Invasion of privacy

A pregnant woman reports severe headaches, chest pain, and fatigue. Upon diagnosis, the woman has hypertension. Which drug can be prescribed to reduce hypertension? 1. Lithium 2. Miglitol 3. Calcium gluconate 4. Magnesium sulfate

4. Magnesium sulfate

A client who had abdominal surgery 24 hours ago reports pain in the left calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do first? 1. Elevate both legs. 2. Keep both legs dependent. 3. Administer the prescribed analgesic. 4. Administer the prescribed antipyretic.

1. Elevate both legs.

A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is prescribed. After the liver biopsy, how often and for how long should the nurse take the client's vital signs? 1. Every 15 minutes for two hours 2. Every 30 minutes for four hours 3. Every hour for 8 hours 4. Every 2 hours for 12 hours

1. Every 15 minutes for two hours

A nurse is counseling the parents of a 13-year-old child. Which of these behaviors will the nurse include in the discussion? Select all that apply. 1. Animism 2. Egocentrism 3. Logical reasoning 4. Concrete thinking 5. Imaginary audience

2. Egocentrism 3. Logical reasoning 5. Imaginary audience

A nurse has opted to work in a rural hospital. Which competencies are most important in this work setting? Select all that apply. 1. Spiritual values 2. Emergency care 3. Family dynamics 4. Physical assessment 5. Clinical decision-making

2. Emergency care 4. Physical assessment 5. Clinical decision-making

A client presents to the physician with a rash. The physician orders the application of a topical medication. Which healthcare team member will most likely carry out this order? 1. Nurse manager (NM) 2. Registered nurse (RN) 3. Licensed practical nurse (LPN) 4. Unlicensed assistive personnel (UAP)

3. Licensed practical nurse (LPN)

Which Institute of Medicine Report attempted to help interprofessional teams work more effectively together? 1. To Err Is Human 2. Preventing Medication Errors 3. Health Professions Education: A Bridge to Quality 4. Keeping Patients Safe: Transforming the Work Environment of Nurses

3. Health Professions Education: A Bridge to Quality

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? 1. Provides the greatest comfort 2. Restores circulating blood volume 3. Helps stop bleeding if any should occur 4. Reduces the fluid trapped in the biliary ducts

3. Helps stop bleeding if any should occur

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing? 1. Allergic 2. Pyrogenic 3. Hemolytic 4. Anaphylactic

3. Hemolytic

Which cranial nerve emerges from the client's medulla? 1. Trochlear 2. Trigeminal 3. Hypoglossal 4. Oculomotor

3. Hypoglossal

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses? 1. Bladder spasms 2. Polycythemia vera 3. Hypovolemic shock 4. Pulmonary hypertension

3. Hypovolemic shock

The nurse is implementing measures to reorient a confused client post earthquake and suggests that a family member accompany the client. Which safety consideration is the nurse demonstrating? 1. Patient identification 2. Injury prevention for staff 3. Injury prevention for clients 4. Risk for errors and adverse events

3. Injury prevention for clients

During a clinical assessment, what secondary sex characteristics does the nurse observe in a teenage client? Select all that apply. 1. Change in voice 2. Enlargement of breasts 3. Development of facial hair 4. Beginning of menstruation 5. Completion of skeletal growth

1. Change in voice 3. Development of facial hair

Which symptoms indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. 1. Decreased urine 2. Hypotension 3. Dyspnea 4. Dry mucous membranes 5. Pulmonary edema 6. Poor skin turgor

1. Decreased urine 2. Hypotension 4. Dry mucous membranes 6. Poor skin turgor

A nurse is caring for a client with hypothyroidism. Which clinical manifestations should the nurse anticipate when assessing this client? Select all that apply. 1. Dry skin 2. Brittle hair 3. Weight loss 4. Resting tremors 5. Heat intolerance

1. Dry skin 2. Brittle hair

Which question does the registered nurse recognize as related to the right of circumstance when delegating? 1. "Is the delegation appropriate to the situation?" 2. "Is the task within the delegatee's scope of practice?" 3. "Is the prospective delegate a willing and able employee?" 4. "Is the delegator able to monitor and evaluate the client appropriately?"

1. "Is the delegation appropriate to the situation?"

Which belief should a nurse expect a preschooler to hold regarding the concept of death? 1. A temporary condition 2. Results from certain illnesses 3. Something that happens in the hospital 4. An event that eventually happens to everyone

1. A temporary condition

Which language characteristics should the nurse expect when assessing a preschool-age client during a scheduled health maintenance visit? Select all that apply. 1. Explaining opposites 2. Defining simple objects 3. Describing the use of an object 4. Verbalizing simple classifications 5. Using deviations from grammar rules

1. Explaining opposites 2. Defining simple objects 3. Describing the use of an object 4. Verbalizing simple classifications

An infant with a diagnosis of failure to thrive has been receiving enteral feedings for 3 days. All feedings have been retained, but the skin and mucous membranes are dry, and the infant has lost weight. What should the nurse do first in light of these findings? 1. Notify the practitioner 2. Document the assessment findings 3. Increase the fluid component in the feeding 4. Increase the calorie component of the feeding

1. Notify the practitioner

According to Erikson, what will happen to an individual who fails to master the maturational crisis of adolescence? 1. Role confusion 2. Interpersonal isolation 3. Rebellion against parental orders 4. Feelings of inferiority on comparing the self to others

1. Role confusion

In order to prolong a hospitalization stay, the nurse documents in a client's electronic health record (EHR) that there are no signs of recovery. However, in reality, the client appears to be cured of the illness. What legal implication does the nurse's action have? 1. The nurse may be charged with libel. 2. The nurse may be charged with slander. 3. The nurse may be charged with malpractice. 4. The nurse may be charged with invasion of privacy.

1. The nurse may be charged with libel.

A client with a supratentorial tumor is scheduled for external radiation therapy to the brain. What should the nurse plan to teach the client? 1. A low-residue diet will be prescribed. 2. Feelings of extreme tiredness will occur. 3. The standard amount of radiation is given. 4. Loss of memory will occur after therapy begins.

2. Feelings of extreme tiredness will occur.

During a community health survey, the nurse is conducting a survey about the language development in preschoolers. What behavior is the nurse able to document in preschoolers? Select all that apply. 1. Preschoolers start to understand riddles and jokes. 2. Preschoolers want to know the reason behind an event. 3. Preschoolers have a vocabulary of 8,000 to 14,000 words. 4. Preschoolers know that words may have arbitrary meanings. 5. Preschoolers cannot distinguish between phonetically similar words.

2. Preschoolers want to know the reason behind an event. 3. Preschoolers have a vocabulary of 8,000 to 14,000 words. 5. Preschoolers cannot distinguish between phonetically similar words.

What is the most therapeutic nursing intervention to help a late-middle-aged individual cope with the emotional aspects of aging? 1. Focusing on the individual's past experiences 2. Having the individual attend lectures on aging 3. Assisting the individual with plans for the future 4. Encouraging the individual to focus on his or her career

3. Assisting the individual with plans for the future

A nursing instructor asks a nursing student to provide information about adolescents. Which statement made by the student indicates the need of further teaching? 1. "Adolescents have risk-taking behaviors." 2. "Adolescents accept their society and its values." 3. "Adolescents consider themselves invincible." 4. "Adolescents think of their parents as materialistic."

2. "Adolescents accept their society and its values."

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? 1. "I should encourage fluid intake." 2. "I should provide conditional positive support." 3. "I should promote social interaction based on abilities." 4. "I should provide ongoing assistance to family caregiver."

2. "I should provide conditional positive support."

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother shares that she is 4 weeks pregnant and questions as to whether this pregnancy will result in a child with hemophilia. What is the best response by the nurse? 1. Probably not, because there is a 50% risk of a mother who is a carrier transmitting the disease, and one child already has the condition. .2. With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child 3. Definitely, because the one child has hemophilia, all future pregnancies will result in children with the condition. 4. If if the father has the condition and the mother is a carrier, the child automatically will have hemophilia.

2. With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child

The nurse is caring for a client with dementia whose expression of emotions is altered. Which behavior is unexpected with this client? 1. Lability 2. Passivity 3. Curiosity 4. Withdrawal

3. Curiosity

A nurse educates a group of parents about the psychosocial changes of adolescents. Which statement made by parents indicates inadequate learning? 1. "Adolescents search for personal identity." 2. "Adolescents establish close peer relationships." 3. "Adolescents love their parents in every situation." 4. "Adolescents wish to be independent while keeping good family ties."

3. "Adolescents love their parents in every situation."

The registered nurse is teaching a newly hired nurse about communicating with delegatees during delegation. Which statement made by the newly hired nurse indicates the need for further learning? 1. "I should identify priorities." 2. "I should specify deviations." 3. "I should provide examples of each delegation." 4. "I should specify any performance limitations to the delegatee."

3. "I should provide examples of each delegation."

A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any risks after the procedure. Which response by the nurse is the best? 1. "There are relatively no risks associated with this procedure." 2. "The major risk is infection at the biopsy site." 3. "The major risk is bleeding postprocedure." 4. "The major risk is liver failure postprocedure.

3. "The major risk is bleeding postprocedure."

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? 1. Hypertension 2. Tenacious sputum 3. Altered mental status 4. Slow rate of breathing

3. Altered mental status

When working with a client who has a phobia of black cats, what problem does the nurse anticipates for this client? 1. Denying that the phobia exists 2. Anger toward the feared object 3. Anxiety when discussing the phobia 4. Distortion of reality when completing daily routines

3. Anxiety when discussing the phobia

A nurse notes that a client with dementia tries to cope with anxiety by using confabulation. What does the nurse plan to teach the family about confabulating? 1. The client may fantasize about past experiences. 2. The client has poor control of disorganized thoughts. 3. The client will make up what cannot be remembered. 4. The client experiences opposing feelings simultaneously.

3. The client will make up what cannot be remembered.

The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1. Boggy uterus 2. Hypovolemic shock 3. Multiple vaginal clots 4. Bleeding at the venipuncture site

4. Bleeding at the venipuncture site

A nursing instructor asks a nursing student about the development of adolescents according to Piaget's theory. Which statement made by the student indicates a need for further education? Select all that apply. 1. "Adolescents exhibit risk-taking behaviors." 2. "Adolescents consider their thoughts to be unique." 3. "Adolescents have a prevalence of egocentric thought." 4. "Adolescents emphasize using knowledge to achieve a goal." 5. "Adolescents have the ability to recognize different answers for different situations."

4. "Adolescents emphasize using knowledge to achieve a goal." 5. "Adolescents have the ability to recognize different answers for different situations."

A client is brought to emergency services after a motor vehicle accident. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. Based on this information, the nurse assesses the client for which early response to decreased arterial pressure? 1. Warm and flushed skin 2. Confusion and lethargy 3. Increased pulse pressure 4. Reduced peripheral pulses

4. Reduced peripheral pulses

The nurse manager has delegated tasks to a registered nurse (RN) and unlicensed assistive personnel (UAP) who are paired to provide care for a client with substance abuse. Which hospital care setting uses this model to deliver care to the clients? 1. Hospice care 2. Extended care 3. Long term care 4. Rehabilitative care

4. Rehabilitative care

Which initiative demonstrated by the registered nurse is an effective art of communication of a leader? 1. Keeping the information broad 2. Ignoring the loss involved in the change 3. Being sensitive to verbal communication 4. Reinforcing the values behind the change

4. Reinforcing the values behind the change

A client is admitted with severe burns, is obese, and has pre-existing respiratory problems. Which complication should the nurse anticipate? 1. Necrosis 2. Pneumonia 3. Dysrhythmias 4. Venous thromboembolism

4. Venous thromboembolism

A client who is receiving medication for an eye disorder reports bleeding in the eye. Which drug will the nurse most likely observe written in the medication administration record? 1. Ketorolac 2. Trifluridine 3. Natamycin 4. Ciprofloxacin

1. Ketorolac

The nurse is teaching a group of adolescents about the calendar method of contraception. Which statement made by an adolescent indicates effective learning? 1. "This type of contraception requires a regular menstrual cycle." 2. "This contraceptive method is 100% effective to prevent pregnancy." 3. "This contraception may decrease sensation and reduce spontaneity." 4. "This type of contraception is simple, must fit correctly, and is reusable."

1. "This type of contraception requires a regular menstrual cycle."

After a prostatectomy the client reports that the urinary catheter tubing is pulling too tightly on the leg. The nurse observes that the indwelling catheter tubing is taut and is taped properly to the thigh. Which action should the nurse take? 1. Explain that the traction helps control bleeding. 2. Adjust tension on the catheter to relieve pressure. 3. Untape the catheter and retape it closer to the urinary meatus. 4. Assess the degree of tension on the catheter and contact the primary healthcare provider.

1. Explain that the traction helps control bleeding.

An 84-year-old widow with dementia who had been living with her daughter before hospitalization is being discharged with a referral to the visiting nurse. When the nurse visits, the client is in bed sleeping at 10:00 am. Her daughter states that she gives her mother sleeping pills to stop her wandering at night. How should the nurse respond? 1. Explore hiring a home health aide to stay with the client at night. 2. Discuss the possibility of having the client placed in a nursing home. 3. Suggest moving the client among family members on a monthly basis. 4. Empathize with the daughter but suggest that wrist restraints would be preferable.

1. Explore hiring a home health aide to stay with the client at night.

Which fears should the nurse include in a teaching session for the parents of a preschool-age client during a scheduled health maintenance visit? Select all that apply. 1. Ghosts 2. The dark 3. Large dogs 4. Poor academic performance 5. Objects associated with pain

1. Ghosts 2. The dark 3. Large dogs 5. Objects associated with pain

What does the registered nurse consider to be the roles and functions of a medical command physician during implementation of an emergency preparedness and response plan? Select all that apply. 1. Identifying the need for and calling in specialty trained providers 2. Recruiting paid or volunteer staff to ensure availability of medical supplies 3. Determining the clients who require a higher level of care and relocating them 4. Directing the physical therapy department to convert the space into a minor treatment area 5. Dictating that all clients due to be discharged from an inpatient unit be moved to a lounge area

1. Identifying the need for and calling in specialty trained providers 3. Determining the clients who require a higher level of care and relocating them

A client comes to the mental health clinic with the complaint of a progressing inability to be in enclosed spaces. The primary healthcare provider makes the diagnosis of claustrophobia and prescribes desensitization therapy. The nurse recalls that desensitization therapy is used successfully with clients experiencing phobias because it is focused on what technique? 1. Imagery 2. Modeling 3. Role-playing 4. Assertiveness training

1. Imagery

A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco 2 is 35 mm Hg, and HCO 3 - is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information? 1. Muscle weakness improving after a period of rest 2. Symptoms worse in the morning upon awakening 3. Periods of hyperactivity 4. Slow, insidious onset of muscle weakness

1. Muscle weakness improving after a period of rest

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin. Which clinical adverse effect should the nurse identify as a reason for the client to seek medical consultation regarding an adverse effect of the drug? 1. Presence of blood in urine 2. Increased swelling of the ankles 3. Diminished ability to concentrate 4. Occurrence of transient ischemic attacks

1. Presence of blood in urine

After a large-scale disaster event, a client reports a feeling of numbness for 1 month. On assessment, the nurse notes a high score of all subscales of the impact of event scale—revised (IES-R) tool. Which healthcare professional should the nurse refer the client to for further evaluation? 1. Psychiatrist 2. Triage officer 3. Social worker 4. Mental health counselor

1. Psychiatrist

After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves? 1. Removing the dilated superficial veins 2. Bypassing the varicosities with artificial veins 3. Stripping the cholesterol deposits from the veins 4. Creating fistulas between superficial and deep veins

1. Removing the dilated superficial veins

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death? 1. Revising the client's will and planning a visit to a friend 2. Alternately crying and talking openly about death 3. Getting second, third, and fourth medical opinions 4. Refusing to follow treatments and stating they won't help anyway

1. Revising the client's will and planning a visit to a friend

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in phytonadione and that should be avoided. What should the nurse include on the list? Select all that apply. 1. Spinach 2. Oranges 3. Broccoli 4. Chicken breast 5. Sweet potatoes

1. Spinach 3. Broccoli

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include? 1. Keep the stockings on 2 hours and off 2 hours. 2. Wear the stockings only at bedtime when activity decreases. 3. Put the stockings on before rising in the morning. 4. Leave the stockings in place until the primary healthcare provider advises otherwise.

3. Put the stockings on before rising in the morning.

Which condition may a 4-year-old child develop due to a failure in mastering sensorimotor integration? 1. Obesity 2. Dyslalia 3. Sleep disturbance 4. Developmental stuttering

4. Developmental stuttering

A nurse is creating a therapy group for low-functioning clients. Which client is the most appropriate member? 1. A 77-year-old man with anxiety and mild dementia 2. A 52-year-old woman with alcoholism and an antisocial personality 3. A 38-year-old woman whose depression is responding to medication 4. A 28-year-old man with bipolar disorder who is in a hypermanic state

1. A 77-year-old man with anxiety and mild dementia

A registered nurse is educating a student nurse regarding the role of value clarification in the resolution of ethical dilemmas. What information should the nurse provide? 1. "Value clarification involves tolerating differences of opinions." 2. "Value clarification involves reinforcing or challenging family values." 3. "Value clarification involves accepting strong values by individuals as facts." 4. "Value clarification involves relating values to facts when dealing with ethical issues."

1. "Value clarification involves tolerating differences of opinions."

What is important when the nurse plans care for a client with paranoid ideation? 1. Avoiding placing demands on the client 2. Eliminating stress so that the client can relax 3. Giving the client difficult tasks to provide stimulation 4. Providing the client with opportunities for nonthreatening social interaction

4. Providing the client with opportunities for nonthreatening social interaction