NCLEX questions

A nurse is making an occupied bed. Which is the most important nursing action? A. Place a pad on the draw sheet. B. Keep the client covered C. Raise both bed rails D. Use new linen

Keep the client covered

A dying client says, "all my life I was fairly religious, but I am still worried about what happens after death." Which is the nurse's best response? A. "The unknown is often frightening." B. "Devout people know that god is forgiving." C. "You must feel good about being faithful all your life." D. "People with near-death experiences say it is peaceful."

"The unknown is often frightening."

A nurse identifies that a usually talkative client is withdrawn. Which is the nurse's best response? A. "What is bothering you?" B. "You are very quiet today." C. "Tell me what you're upset about." D. "Why are you so withdrawn today?"

"You are very quiet today."

A nurse identifies that a client has offensive breath. Which is the most effective interventions that the nurse should encourage the client to do? A. Brush the teeth and tongue after meals B. Eat the foods that do not generate odors C. Rinse the mouth with mouthwash every shift D. Flush the mouth with peroxide and baking soda

Brush the teeth and tongue after meals

A nurse is examining the literature regarding the cause of accidents in the hospital setting. Which does the nurse conclude is the main reason for accidents in hospitals? A. Safety precautions always take extra time. B. Clients do not recognize hazards C. Equipment breaks unexpectedly D. People sneak cigarettes

Clients do not recognize hazards

A female client talks about her children when they were young and states, "I was a very strict mother." Which response by the nurse exhibits the technique of paraphrasing? A. "It must have been difficult to be a disciplinarian." B. "Sometimes we are sorry for our past behaviors." C. "You don't seem like a very strict person." D. "You believe you were a firm parent."

"You believe you were a firm parent."

A client is being discharged to a nursing home. While preparing the discharge summary, the client says, "I feel that nobody cares about me." Which is the nurse's best response? A. "You feel as if nobody cares." B. "We are all concerned about you." C. "It's hard to be angry at your family." D. "Your family doesn't have the skills to care for you."

"You feel as if nobody cares."

A client says to the nurse, "lately I've been having a hard time sleeping." Which should the nurse encourage the client to do to promote sleep? Select all that apply. A. Exercise lightly B. Drink a cup of tea C. Eat only light meals D. Review the day's events E. Follow a bedtime routine

A, E

A nurse is caring for an older adult on bedrest. Which should the nurse provide to best prevent a pressure ulcer in this client? A. An air mattress B. A daily bed bath C. A high protein diet D, An indwelling urinary catheter

An air mattress

A nurse left a bedside rail down of a client who was premedicated with an opioid in preparation for surgery. The client was found on the floor. The client was examined by the rapid response team and no injury was identified as a result of the fall. The client was returned to the bed. Place a check in the box in front of the most appropriate category in the "occurrence category" section of the unusual occurrence report that relates to this event.

"Fall" box

A client tells the nurse, "the doctor just told me I have cancer" and then begins to cry. Which is the best response by the nurse? A. "Try to focus on something else." B. "Sometimes it helps to talk about it." C. "Deep breathing may help you regain control." D. "Tears are good because it gets it out of your system."

"Sometimes it helps to talk about it."

A nurse is collecting information to prepare a teaching plan for a client with type I diabetes. Which question asked by the nurse is associated with collecting information in the cognitive domain of learning? A. "How do you inspect your feet each day?" B. "Can you measure a serum glucose level?" C. "What do you know about diabetes mellitus?" D. "Are you able to perform a subcutaneous injection?"

"What do you know about diabetes mellitus?"

A dying client says to the nurse, "I was much more religious when I was young." How should the nurse respond to the client's statement? A. "Do you still believe in god?" B. "Do you want us to pray for you?" C. "Would you like me to call a chaplain?" D. "Are you concerned about live after death?"

"Would you like me to call a chaplain?"

Alprazolam 0.5 mg PO three times a day is prescribed for a client with generalized anxiety disorder. It is supplied in an oral solution of 1 mg/mL. How much solution should the nurse administer? Record your answer using one decimal place.

0.5 mL

Which temperature should the water be when the nurse gives a client a bed bath? A. 80-85 B. 90-95 C. 100-105 D. 110-115

110-115

A client has difficulty sleeping and the nurse secures a prescription for zolpidem (ambien) extended-release tablets 12.5 mg PO at bedtime. The medication supplied by the pharmacy is 6.25 mg/tablet. How many tablets should the nurse administer? Record your answer using a whole number.

2 tablets

An older adult has been taking 20 mg of furosemide by mouth twice a day along with an antihypertensive medication. The client's blood pressure has progressively decreased and the client has experienced several episodes of lightheadedness. The primary healthcare provider changes the furosemide prescription to 15 mg by mouth twice a day. An oral solution is prescribed because the client has difficulty swallowing pills. The furosemide solution states that there are 10 mg/1 mL of solution. How many mL's of furosemide should the nurse administer over 24 hours? Record your answer using a whole number.

3 mL

A nurse is caring for a client who is experiencing lower back pain. The muscle relaxant cyclobenzaprine 10 mg three times a day by mouth is prescribed. Cyclobenzaprine is available in 5 mg tablets. How many tablets of cyclobenzaprine will the client be taking in 24 hours? Record your answer using a whole number.

6 tablets

A nurse is planning to provide personal health care information to several clients. Which client should the nurse anticipate will be most motivated to learn? A. A 55 year old woman who had a mastectomy and is very anxious about her body image B. A 56 year old man who had a heart attack last week and is requesting information about exercise C. An 18 year old man who smokes two packs of cigarettes and is in denial about the dangers of smoking D. A 47 year old woman who has a long leg cast after sustaining a broken leg and is still experiencing severe pain

A 56 yer old man who had a heart attack last week and is requesting information about exercise

After reviewing the client's clinical record and completing a physical assessment, which type of bath should the nurse provide? A. Partial bath with total assistance B. Partial bath with partial assistance C. Complete bath with total assistance D. Complete bath with partial assistance

A complete bath with partial assistance

Which of the following clients' level of wellness does the nurse determine best represents the placement of X on Dunn's Health Grid? A. A person with emphysema and a history of a brain attack with left-sided weakness who lives in a nursing home while receiving respiratory rehabilitation B. A relatively healthy person who is recovering from the birth of a stillborn and who shares a small apartment with several other unrelated individuals C. A teenager who recently recovered from a fractures femur who lives with caring parents in a middle-class family home D. A person who is receiving treatment at the local clinic for cirrhosis of liver and who lives in an abandoned van

A person who is receiving treatment at the local clinic for cirrhosis of liver and who lives in an abandoned van

A client who usually is verbal appears sad and withdrawn. Which should the nurse do? Select all that apply. A. Use open-ended questions B. Describe the behavior to the client C. Continue to observe the client's behavior D. Ensure that the client has time to be alone E. Attempt to engage the client in cheerful conversation

A, B

A nurse is providing perineal care for a female client. Which should the nurse do during this procedure? Select all that apply. A. Use a new area of the washcloth for each stroke B. Wash from the pubis toward the rectum C. Use a circular motion with each stroke D. Clean the dirtiest area first E. Use only cool tap water

A, B

A nurse is admitting the child in this photo to the hospital for testing and treatment. Which should the nurse implement when caring for this child? Select all that apply. A. Explain to the child that an intervention may "hurt" but that medicine can be given to make the hurt go away B. Use a doll to explain what is going to be done and why in terms that the child can understand C. Encourage the parent to stay with the child as much as possible D. Examine the child while she is sitting on her mother's lap E. Remind the child that she is a big girl

A, B, C, D

A client who is hearing impaired tells the nurse, "I have difficulty hearing what people say to me." Which should the nurse do? Select all that apply. A. Face the client directly when talking B. Provide pencil and paper for communication C. Enunciate clearly when speaking with the client D. Shout with a loud voice in the client's better ear E. Ask the client questions that require a yes or no answer F. Encourage the client to use gestures and facial expressions when talking

A, B, C; Face the client directly when talking, provide pencil and paper for communication, enunciate clearly when speaking with the client

A client with one-sided weakness (hemiparesis) has a prescription to be transferred out of bed to a chair twice a day. Which should the nurse plan to do? Select all that apply. A. Place rubber-soled shoes on the client's feet B. Position the hands on the client's scapulae C. Support the client on the affected side D. Pivot the client on the unaffected leg E. Keep the client's feet together

A, B, D

A nurse is caring for the toddler in the photograph. Which nursing actions support the emotional needs of this child? Select all that apply. A. Demonstrating to the child how the pen light works before using it. B. Maintaining a smiling expression when talking with the child. C. Placing oneself within several inches of the child. D. Encouraging the child to hold a soft, cuddly toy. E. Allowing the child to sit on the mother's lap.

A, B, D, E; Demonstrating to the child how the pen light works before using it, Maintaining a smiling expression when talking with the child, Encouraging the child to hold a soft & cuddly toy, Allowing the child to sit on the mother's lap

Which client factors does the nurse consider are relevant when assessing a client's readiness to learn about smoking cessation? Select all that apply. A. Perceived positive outcomes B. Lack of barriers to actions C. Previous experiences D. Identified need E. Flexibility

A, B, D; perceived positive outcomes, lack of barriers to actions, identified need

A hospitalized client dies after a long illness. Which should the nurse do as part of postmortem care? Select all that apply. A. Remove tubes if an autopsy is not required. B. Attach an identification tag to the body C. Raise the head of the bed slightly D. Remove both dentures if present E. Tie the wrists together firmly F. Close the eyelids gently

A, B, F

A mentally disadvantaged adult client is learning self-care. What should the nurse do to help the client increase learning? Select all that apply. A. Verbally recognize when goals are met B. Use demonstration as a teaching strategy C. Offer candy as a reward when learning occurs D. Disregard the behavior when goals are not met E. Set a variety of short-term objectives to be met F. Conduct several short teaching sessions for each skill

A, B, F; verbally recognize when goals are met, use demonstration as a teaching strategy, conduct several short teaching sessions for each skill

According to Maslow's Hierarchy of Needs, which most clearly reflects physiological needs? Select all that apply. A. Fever B. Trauma C. Puberty D. Restraints E. Menopause

A, B; fever, trauma

Warm, dry heat to be applied via an aquathermia pad to a client's lower back is prescribed to ease muscle spasms resulting from a fall. Which should the nurse do? Select all that apply. A. Set the pad 98-104 degrees farenheit B. Apply the pad directly to the client's skin C. Remove the pad 20 to 30 minutes after it is applied D. Moisten the liner between the pad and the cover of the bed E. Put the pad under the client after the client is placed in the supine position

A, C

Which developmental factors specific to adolescents influence their ability to remain safe? Select all that apply. A. Believe they are invincible B. Use tools and household items C. Engage in risk-taking behaviors D. Tend not to wear seat belts in cars E. Are exposed to increased peer relationships

A, C, D, E

A client verbally communicates with the nurse while exhibiting nonverbal behavior. How should the nurse confirm the meaning of the nonverbal behavior? Select all that apply. A. Look for similarity in meaning between the client's verbal and nonverbal behavior B. Ask family members to help interpret the client's behavior C. Validate inferences by asking the client direct questions D. Recognize that what a client says is most important E. Point out the behavior to the client

A, C, E

A primary healthcare provider prescribes alprazolam 0.5 mg PO tid for a client experiencing panic attacks. What should the nurse do when caring for this client? Select all that apply. A. Assess for signs of alprazolam misuse B. Ensure that naloxone is readily available C. Teach the client to provide for personal safety D. Encourage the intake of grapefruit juice during therapy E. Advise the client not to abruptly discontinue the medication F. Encourage the client to take an additional prn dose when experiencing high-anxiety situations

A, C, E

Which events require a nurse to complete an incidence (variance) report? Select all that apply. A. A client who falls in the bathroom but who is not injured B. A nurse who refuses to be floated to a unit other than the usual unit assigned C. A visitor who faints when seeing an ill family member in the intensive care unit D. A resident physician who is angry because of being awakened to examine a client E. A nurse's aide working in a hospital who applies a topical fungicide cream to a client's perineal area

A, C, E

Which should the nurse do to provide emotional comfort when administering perineal care to a client? Select all that apply. A. Drape areas that are not being washed. B. Place the client in a supine position C. Pull a curtain around the bed D. Use warm water for washing E. Call the client by name

A, C, E

A nurse is performing a self-appraisal concerning the use of statements that do not support a client's needs. Which statements by the nurse are nontherapeutic? Select all that apply. A. "This is minor surgery." B. "You're smiling this morning." C. "A lot of people hate injections." D. "It is difficult to cope with pain." E. "You'll walk better after you have physical therapy."

A, C, E; "This is minor surgery." & "A lot of people hate injections." & "You'll walk better after you have physical therapy."

A nurse is caring for a group of clients. Which clients are at the greatest risk of developing a pressure ulcer? Select all that apply. A. Those who have a paraplegia B. Those who have a colostomy C. Those who use crutches to ambulate D. Those who use a reclining wheelchair E. Those who are ambulatory but confused F. Those who are on bedrest but able to move

A, D

Which should the nurse do to promote rest and sleep for all hospitalized clients? Select all that apply. A. Keep talking in the hall to a minimum B. Provide a backrub at bedtime C. Turn room lights off at night D. Encourage usual routines E. Administer a sedative

A, D

A nurse is preparing a teaching plan for a client who was just diagnosed with type I diabetes. Which are the most effective teaching strategies that can be used in the cognitive domain? Select all that apply. A. Explanation B. Demonstration C. Group discussion D. Written materials E. Individual practice

A, D; explanation, written materials

Which concepts are important for the nurse to consider when interacting with others? Select all that apply. A. Personal appearance can be a source of information about a person B. Progress notes are a form of nonverbal communication C. Clients with expressive aphasia cannot communicate D. Touch has various meanings to different people E. Words have the same meaning for all people

A, D; personal appearance can be a source of information about a person, touch has various meanings to different people

A nurse is caring for a client who has a fungal infection of the feet. Which should the nurse teach the client to employ to reduce the incidence of a fungal infection of the feet? Select all that apply A. Wear flip flops to protect the feet when walking in a locker room B. Soak the feet in a medicated solution during hygiene care C. Apply body lotion to the feet to avoid cracks in the skin D. Increase circulation to the feet by encouraging exercise E. Dry well between the toes of the feet after bathing

A, E

A nurse is caring for a variety of clients on a medical unit in the hospital. In which order should the nurse perform the following actions using Maslow's Hierarchy of Needs as a basis for prioritizing care? A. Administering two liters of oxygen via a nasal cannula B. Encouraging a family member to visit as often as desired C. Arranging for a minister to visit when requested by a client D. Asking a client about personal preferences before beginning care E. Placing the call bell within easy reach after a client is transferred to a chair

A, E, B, D, C

A client who is incontinent of urine becomes upset. Which are the best responses by the nurse while changing the client's gown and linens? Select all that apply. A. "This must be difficult for you." B. "I am a nurse. This is part of my job." C. "This doesn't bother me. It happens often." D. "This occurs all the time. Try not to feel bad." E. "I am your nurse. I will change your gown and linens."

A, E; "This must be difficult for you" and "I am your nurse. I will change your gown and linens."

A nurse is interviewing an adolescent during a yearly physical examination about preferred activities. Which activities are associated with the developmental task of adolescence? Select all that apply. A. Texting friends B. Reading a book C. Learning how to use a computer D. Helping parents with household chores E. Attending a high school basketball game

A, E; texting friends, attending a high school basketball game

Which is the most therapeutic exercise that can be done by a client confined to bed? A. Isometric exercises B. Active-assistive exercises C. Active range of motion exercises D. Passive range of motion exercises

Active range of motion

Which factor has the most significant influence on pain perception that is important for the nurse to consider when assessing a client's pain? A. Duration of the stimulus B. Activity of the cerebral cortex C. Characteristics of the stimulus D. Level of endorphins in the blood

Activity of the cerebral cortex

A client asks the nurse why cold compress were prescribes to treat a recent muscle sprain. Which is the reason why old is effective in reducing the discomfort associated with a local inflammatory response that the nurse should include when answering the client's question? A. Anesthetizes nerve endings and causes vasoconstriction B. Stimulates nerve endings and causes vasoconstriction C. Anesthetizes nerve endings and causes vasodilation D. Stimulates nerve endings and causes vasodilation

Anesthetizes nerve endings and causes vasoconstriction

A client asks for advice regarding a personal problem. Which is the most appropriate response by the nurse? A. Explain that nurses are not permitted to give advice to a client. B. Encourage the client to speak with a family member. C. Ask the client what would be the best thing to do. D. Offer an opinion after listening to the client

Ask the client what would be the best thing to do

A nurse reviews a client's clinical record. Which should the nurse do first in response to the change in the client's behavior? A. Initiate the bed alarm on the bed. B. Administer the prescribed sedative C. Place a vest restraint on the client and notify the primary healthcare provider D. Assign a staff member to stay with the client and notify the primary healthcare provider

Assign a staff member to stay with the client and notify the primary healthcare provider

A client is admitted to the hospital with multiple health problems. Which nursing intervention is least effective in meeting the client's psychosocial needs? A. Addressing the client by name B. Assisting the client with meals C. Identifying achievement of client goals D. Explaining care before it is to be given to the client

Assisting the client with meals

A nurse is interviewing a client who is terminally ill. Which is an unexpected behavior associated with the usual process of grieving? A. Talking about the illness B. Seeking alternative therapies C. Becoming angry with people D. Attempting to commit suicide

Attempting to commit suicide

A nurse is caring for a client who is coping with chronic pain. Which psychological reactions to chronic pain may occur? Select all that apply. A. Dyspnea B. Despression C. Self-splinting D. Hypertension E. Compromised relationships

B, E

A nurse in the emergency department is caring for several clients who are anxious. Place the following clients in the order that reflects the levels of anxiety progressing. A. Client who has vocal pitch changes, is focusing on one topic, and is exhibiting slight muscle tremors B. Client who has normal vital signs, is asking numerous questions, and is exhibiting slight muscle tension C. Client who has distorted perception, is hyperventilating, and is exhibiting erratic behavior D. Client who has increased motor activity, is irritable, and is exhibiting dilated pupils

B, A, D, C

A hospice nurse is working with several dying clients. Place the following clients' statements in the order that reflect the stage of Kubler-Ross's grieving theory progressing from diagnosis to impending death. A. "I am going to fight this disease with every ounce of energy I've got." B. "I don't always trust my doctor's diagnosis that I have an inoperable cancer." C. "I always wore a condom. How could I have gotten AIDS?" D. "I can't fight anymore. Please tell my family to let me go." E. "I am not going to grow old with my wife."

B, C, A, E, D

A client has difficulty communicating verbally (expressive aphasia) because of a brain attack (stroke). Which should the nurse do when caring for this client? Select all that apply. A. Anticipate needs to reduce frustration B. Teach the client how to use a picture board C. Encourage the client to elaborate with gestures D. Be patient when the client is attempting to speak E. Ask the client questions that require a yes or no response

B, C, D

A nurse is cleansing the perineal area of an uncircumcised male client. Which are important actions by the nurse when performing this procedure? Select all that apply. A. Handling the penis always with a light touch B. Washing the shaft of the penis before the scrotum C. Repositioning the foreskin after washing the penis D. Cleaning the length of the penis down the shaft towards the glans E. Washing the glans of the penis with a circular motion from the urinary meatus outwards

B, C, E

A nurse provides preoperative teaching for a client scheduled for surgery. What should the nurse do to ensure that the client understands the content of the teaching session? Select all that apply. A. Use simple vocabulary B. Obtain a return demonstration C. Ask the client what was learned D. Speak distinctly when giving directions E. Talk slowly when speaking with the client

B, C; obtain a return demonstration, ask the client what was learned

A nurse is caring for a client who was newly diagnoses with a latex allergy. Which information should the nurse include in the teaching plan? Select all that apply. A. Wear clothing labeled hypoallergenic B. Carry injectable epinephrine or keep it within easy reach C. Avoid clothing with spandex because spandex contains rubber D. Examine tags on clothing to ensure that they do not contain latex E. Have someone remove plants such as poinsettias, ficus, and rubber tree plants from the home

B, D, E

A nurse is positioning a client in a lateral position. Which actions by the nurse contribute to the client's functional alignment? Select all that apply. A. Utilizing a trochanter roll B. Putting a pillow under the upper leg C. Placing a small pillow under the waist D. Using a pillow to support the upper arm E. Positioning a pillow behind the client's back

B, D, E

A client has a history of verbally aggressive behavior. One afternoon the client starts to shout at another client in the lounge. Which are appropriate responses by the nurse? Select all that apply. A. "Stop what you are doing." B. "Let's go talk in your room." C. "Sit down until you are calm." D. "Come with me for a walk in the hall." E. "Do not raise your voice in a hospital."

B, D; "Let's go talk in your room." & "Come with me for a walk in the hall."

A nurse is caring for an eleven-year-old child who was recently diagnosed with type I diabetes. In addition to encouraging the child to practice with the equipment associated with diabetes, which additional interventions should the nurse implement to support this client? Select all that apply. A. Identify non-age-appropriate behavior and gently suggest corrective actions B. Explain that expressing feelings of sadness and anger is acceptable C. Provide honest, concrete, and detailed answers to questions D. Assign the client to a private room is available E. Encourage visits from peers and siblings

B, E; explain that expressing feelings of sadness and anger is acceptable, encourage visits from siblings and peers

What should the nurse do to meet a client's basic physiological needs? Select all that apply. A. Raise the side rails B. Provide a bed bath C. Converse with the client D. Explain procedures to the client E. Ambulate the client to the bathroom

B, E; provide a bed bath, ambulate the client to the bathroom

A nurse is completing a health history for a 90 year old woman being admitted to a home healthcare program. The client has Parkinson disease and stage 3 lung cancer that currently is in remission. The client said that she is able to get around alright as long as she stops frequently to catch her breath. She further explained that, other than knowing she has cancer, she felt that :healthwise I'm in pretty good shape." She said her children insisted that she get help with bathing several mornings a week but said, "I don't feel that I need any help." The primary healthcare provider's history and physical stated that the client's activities of daily living are significantly impaired as a result of the Parkinson disease and she may have less than 6 months to live. Where should the nurse place an X on the Health-Illness Continuum to reflect the client's perception of her health?

Between 7-8

A primary healthcare provider prescribes crutches for a person who has a left lower leg injury. The nurse is teaching the person how to rise from a chair without bearing weight on the left leg. Place the following steps in the order in which they should be implemented. A. Put one crutch under each arm B. Slide the buttocks toward the edge of the chair C. Hold both crutches together on the hand bars with the left hand D. Push down on the arm of the chair on the unaffected side while bearing weight on the hand bars of the crutches E. Extend the right leg while keeping the right foot flat on the floor, elevate the body to a standing position, and then check balance

C, B, D, E, A

A nurse is planning a turning schedule for a client with limited mobility. Which positions that contribute to the development of a pressure ulcer in the sacral area should be avoided in this client's plan of care? Select all that apply. A. Sims B. Prone C. Contour D. High-fowler E. Dorsal recumbent

C, D, E

For which behavioral responses should the nurse assess the client when the client is experiencing pain? Select all that apply. A. Rapid, irregular breathing B. Increased muscle tension C. Facial grimacing D. Self-splinting E. Groaning F. Fatigue

C, D, E

A client who is withdrawn says, "when I have the opportunity, I am going to kill myself." Which are appropriate responses by the nurse? Select all that apply. A. "You have a lovely family. They need you." B. "Let's explore the reasons you have for living." C. "Do you have a plan on how to commit suicide?" D. "You must feel overwhelmed to want to kill yourself." E. "Suicide does not solve problems. Can you tell me what is wrong?"

C, D; "Do you have a plan on how to commit suicide?" & "You must feel overwhelmed to want to kill yourself."

A nurse obtains a health history from a client with a chronic illness. Which behaviors support the nurse's conclusion that the client may be depressed? Select all that apply. A. Wishing to attend a nephew's wedding B. Seeking multiple medical opinions C. Evading activities of daily living D. Lacking interest in appearance E. Being sarcastic to caregivers

C, D; evading activities of daily living, lacking interest in appearance

When providing physical hygiene, the nurse identifies that a female client's hair is tangled and matted. Which should the nurse do? Select all that apply. A. Braid the hair in sections B. Use a comb instead of a hairbrush C. Comb a small section of the hair at a time D. Encourage the client to get a shorter haircut E. Brush the hair starting from the ends progressing towards the roots

C, E

When the home care nurse places an egg-crate pad under a client the spouse asks, "what is the purpose of that pad?" Which are the purposes of an egg-crate pad that should be included in a response to the spouse's question? Select all that apply. A. Absorbs moisture B. Limits perspiration C. Prevents pressure ulcers D. Supports the body in alignment E. Distributes pressure over a larger area

C, E

Which statements are associated with the task of generativity versus stagnation according to Erikson's developmental theory? Select all that apply. A. "I want to do it myself." B. "I will be getting married next week." C. "I enjoy mentoring the new employees." D. "I am pleased with the decisions I have made." E. "I am teaching my children how to manage their money."

C, E; "I enjoy mentoring the new employees", "I am teaching my children how to manage their money"

A nurse is considering the principles of stress and adaptation. Which words describe the concept of adaptive capacity? Select all that apply. A. Safety B. Health C. Restore D. Imbalance E. Reestablish

C, E; restore, reestablish

A nurse identifies that a client has been exposed to the stress of air pollution caused by a wood-burning fireplace in the home. Which classification of stress is air pollution? A. Physical B. Chemical C. Physiological D. Microbiological

Chemical

A nurse is caring for a client diagnosed with pediculosis. Lindane shampoo is prescribed to treat this condition. Which grooming device should the nurse use after washing the client's hair and scalp with lindane shampoo?

D (shorter comb)

Which are the reasons why restraints are used when caring for clients? Select all that apply. A. Limit movement B. Reduce agitation C. Immobilize clients D. Prevent client injury E. Prohibit a client from hurting others

D, E

Place the following statements made by a client with a terminal illness in order according to Kubler-Ross's five stages of Grief in Death and Dying. A. "I will never see my grandchildren grown up and married." B. "I will give up my cigars to see my grandchild born this summer." C. "I'm working on a tape recording that I'm making for my grandchildren." D. "I'm getting another opinion because I was told 3 months ago that everything was fine." E. "I cannot believe the doctor missed the tumor 3 months ago when I was last examined."

D, E, B, A, C

A dying client is withdrawn and depressed. Which are the most therapeutic actions by the nurse? Select all that apply. A. Explaining the fact that client goals still can be accomplished. B. Assisting the client to focus on positive thoughts. C. Offering the client advice when appropriate D. Accepting the client's behavioral responses E. Telling the client you are available to talk

D, E; accepting the client's behavioral responses, telling the client you are available to talk

A nurse is teaching a client about self-injection with insulin. Which is the most effective approach to use in this situation? A. Book B. Video C. Discussion D. Demonstration

Demonstration

A client is readmitted to the hospital because of complications resulting from nonadherence to the prescribed healthcare regimen. Which should the nurse do first? A. Encourage healthy behaviors B. Develop a trusting relationship C. Use educational aids to reinforce teaching D. Establish why the therapeutic plan is not being followed

Develop a trusting relationship

A newly admitted client appears upset and agitated. Which should the nurse do to best assist this client? A. Arrange for the client to remain on bedrest B. Encourage the client to share feelings C. Keep the patient as active as possible D. Point out the behavior to the client

Encourage the patient to share feelings

The nurse refers to Maslow's Hierarchy of Human Needs when assessing a client's needs. Place the following client statements that reflect basic needs in order from the most to least basic. A. "How soon are visiting hours so that my family can visit me?" B. "Promise me that someone will answer my call bell when I ring." C. "I would like you to help me with the arrangements for my funeral." D. "Can you please close the door when you help me to the bathroom?" E. "I am sitting here a long time and I am very thirsty. Can I have a glass of water?"

E, B, A, D, C

Lawrence Kohlberg's theory of stages of moral development is based on the ability to think at progressively higher levels as one matures. Place the following motivations for thinking in the order as one advances from a basic to a higher level of moral development. A. Adhering to societal standards while individualizing values and beliefs B. Using abstract reasoning based on universal ethical principles C. Pleasing others based on what they expect D. Performing actions based on rules E. Fearing negative consequences F. Wanting positive consequences

E, F, C, D, A, B

A nurse is providing a client with a backrub after a bed bath. Which massage technique is most effective in promoting relaxation? A. Tapotement B. Effleurage C. Petrissage D. Friction

Effleurage

A nurse is assessing a client coping with multiple stresses and knows that one body system has a major impact on how a client responds to stress. Which body system should the nurse assess first because it primarily controls the general adaptation syndrome? A. Endocrine B. Respiratory C. Integumentary D. Cardiovascular

Endocrine

A nurse uses a cotton blanket when bathing a client. Which principle is the basis for using a blanket to prevent the loss of body heat during a bed bath? A. Evaporation B. Conduction C. Diffusion D. Osmosis

Evaporation

A client with type 2 diabetes mellitus and restrictive airway disease comes to the emergency department of the hospital because of a productive cough and fever. The client is diagnosed with pneumonia and is admitted for treatment. During the admission health history the client tells the nurse, "I work full time as a high school english teacher and I am very healthy." Which is the most important intervention by the nurse during the client's hospitalization? A. Explain why the client really is not well B. Identify the client's perception of the sick role C. Foster client independence concerning self-care D. Give the client written materials about the identified illness

Foster client independence concerning self-care

A nurse is caring for a female client who is dying and the client's family members. The nurse has verbal interactions, listed below, with the client and several family members, who tend to hover around the client. Which is the best nursing action based on client and family member statements? A. Reinforce with the client the son's desire for his mother to keep on fighting B. Explain to the granddaughter that she should focus on her grandmother C. Help family members to understand the client's need to withdraw D. Tell the husband about rebeavement counseling that is available

Help family members understand the client's need to withdraw

A client is upset and rambles about an incident that occurred earlier in the week. Which should the nurse do first? A. Ask the client what is wrong B. Identify the client's concerns C. Recognize the client is confused D. Encourage the client to focus on the present

Identify the client's concerns

A nurse is transferring a client from the bed to a chair using a mechanical lift. As the nurse begins to raise the lift off the bed, the client begins to panic and scream. Which should the nurse do? A. Immediately lower the client back onto the bed B. Say "relax" and slowly continue the procedure C. Quickly continue and say "be calm, it's almost over" D. Stop the lift from rising until the client regains control

Immediately lower the client back onto the bed

A client who is confused and disoriented is wearing a restraint that was applied following the manufacturer's directions. The client struggles against the restraint. Which does the nurse conclude is the primary reason for this behavior? A. Response to discomfort B. Attempt to gain control C. Effort to manipulate the staff D. Inability to understand what is occurring

Inability to understand what is occurring

A prescription is written to apply a warm soak to the client's extremity. Which information should the nurse include when teaching the client how a warm soak reduces discomfort at a local inflammation site? A. Decreases local circulation and limits capillary permeability B. Decreases tissue metabolism and increases local circulation C. Increases local circulation and promotes muscle relaxation D. Provides local anesthesia and decreases local circulation

Increases local circulation and promotes muscle relaxation

Which describes the pattern of the process of growth and development? A. Uncertain B. Nonpredictable C. Based on motivation D. Influenced by the previous steps

Influenced by the previous steps

A nurse is teaching a client with diabetes how to self-monitor blood glucose levels. What is the most important factor when predicting the success of a teaching program regarding the learning of this skill? A. Interest of the learner B. Extend of family support C. Amount of reinforcement D. Level of learner's cognitive ability

Interest of the learner

A nurse educator is teaching a class on the concepts of stress and adaptation and reinforced the content using the following illustration. Which is the most important reason why the nurse educator presented this illustration? A. It appeals to the participants of the class B. It employs the concept of positive reinforcement C. It stimulates learning in those with an internal locus of control D. It improves students conceptual understanding of presented content

It improves students conceptual understanding of the presented content

A nurse is changing the linens for a client on bedrest. Which should the nurse do to prevent pressure (decubitus) ulcers when putting a bottom sheet on a bed? A. Cover it with a draw sheet B. Make it with a toe pleat C. Change it everyday D. Keep it wrinkle free

Keep it wrinkle free

A nurse is conducting an intake interview with a client. Which should the nurse do to best facilitate therapeutic communication with this client? A. Talk about expectations B. Using probing questions C. Ask direct questions D. Listen attentively

Listen attentively

A client comes to the emergency department reporting pain, nausea, vomiting, and a low-grade fever. Rovsing's sign is elicited when the primary health-care provider palpates the client's left lower quadrant. Place an X over the site where the client felt an increase in pain.

Lower left quadrant

While walking, a client becomes weak and the client's knees begin to buckle. Which should the nurse do? A. Hold up the client B. Walk the client to the closest chair C. Call for assistance to help the client D. Lower the client to the floor carefully

Lower the client to the floor carefully

A client has a nasogastric tube. Which is a daily nursing intervention that contributes to hygeine? A. Instilling the system with one ounce of water B. Replacing the fixation tube C. Suctioning the oral pharynx D. Lubricating the nares

Lubricating the nares

Which is the most important principle of body mechanics when the nurse positions a client? A. Making the client comfortable B. Elevating the client's arms on pillows C. Maintaining the client in functional alignment D. Keeping the client's head higher than the heart

Maintaining the client in functional alignment

Several times a day, every day, a client who is experiencing short-term memory loss asks when medication is to be given. The client receives medication at the same time every day. Which is the most therapeutic nursing intervention? A. Inform the client when the time for medication has arrived B. Tell the client to go to the nurse when it is time for medication C. Encourage the client to remember when it is time for medication D. Make the client a sign to hang on a wall indicating the times for medication

Make the client a sign to hang on the wall indicating the times for medication

A nurse is obtaining the psychosocial history of a client. Which event generally precipitates the highest degree of stress when considering theories of stress? A. Marriage B. Pregnancy C. Relocation D. Retirement

Marriage

Which word best describes the feelings associate with an infant in Erikson's stage of trust versus mistrust? A. Me B. We C. You D. They

Me

A nurse identifies that a client sitting in a wheelchair begins to have a tonic-clonic seizure. Which should the nurse do? A. Transfer the client to an empty room to provide privacy B. Return the client to bed to provide a soft surface C. Move the client to the floor to prevent injury D. Secure the client to prevent falling

Move the client to the floor to prevent injury

A school nurse is teaching a group of high school students about health promotion and sleep. Which age group should the nurse explain requires the least amount of sleep? A. Adolescents 2. Older adults 3. Young adults 4. Middle aged adults

Older adults

A client is afraid of falling when it is time to get out of bed to a chair. Which is the best action by the nurse to reduce the client's fear? A. Permit the client to set the pace of the transfer B. Transfer the client using a mechanical lift C. Inform the client that a fall will not occur D. Allow the client to decide when to get up

Permit the client to set the pace of the transfer

A nurse is assessing a client with a severe sunburn. In which classification of stress should the nurse place the sun that caused the sunburn? A. Physical B. Chemical C. Physiological D. Microbiological

Physical

A nurse is planning interventions to facilitate a client's ability to sleep. Which action minimizes the most common cause of insomnia? A. Promoting a comfortable position B. Decreasing environmental noise C. Exploring emotional concerns D. Regulating room temperature

Promoting a comfortable position

A nurse is providing oral hygiene for client with dentures. Which should the nurse do to support the client's dignity? A. Provide a cup for the client's teeth B. Pull the curtain around the client's bed C. Support the client in high-fowler position D. Resist looking at the client while the teeth are out

Pull the curtain around the client's bed

A client who had a brain attack (stroke, cerebrovascular accident) 3 days earlier has left-sided hemiparesis. Which should the nurse plan to do when dressing the client? A. Put the client's left sleeve on first B. Encourage the client to dress independently C. Instruct the client to wear clothes with zippers D. Tell the client to get clothes with buttons in the front

Put the client's left sleeve on first

Which know should the nurse use when attaching the strap of a restraint to a bed frame?

Quick release slip knot

Which developmental task according to Erikson should the nurse assist older adult clients to achieve? A. Assisting grown children B. Reconciling one's life C. Becoming dependent D. Establishing trust

Reconciling one's life

A client asks a nurse, "What is health?" Which concept basic to most definitions of health should the nurse consider when answering the client's question? A. A progressive state B. The absence of disease C. Relative to one's value system D. An extreme of the wellness-illness continuum

Relative to one's value system

A nurse is assessing clients who are coping with multiple stresses to identify the use of defense mechanisms as coping behaviors. Which type of behavior is related to defense mechanisms? A. Relief B. Conscious C. Somatizing D. Manipulative

Relief

A nurse is planning to give a client a backrub to promote comfort and rest. Which is the reason why a backrub promotes comfort and rest? A. Causes vasodilation B. Stimulates circulation C. Relieves muscular tension D. Increases oxygen to tissues

Relieves muscular tension

A nurse identifies that the electrical cord on a client's radio is frayed near the plug. Which should the nurse do? A. Report the problem to the supervisor B. Unplug it and put it in the client's closet C. Remove it from the client's room and send it home with a family member D. Ask the maintenance department to apply nonconductive tape to the damaged section

Remove it from the client's room and send it home with a family member

Which is the reason why the nurse rinses the client after washing with soap and water during a bed bath? A. Increases circulation B. Minimize pressure ulcers C. Remove residue and debris D. Promote comfort and relaxation

Removes residue and debris

A nurse is interviewing the wife of a client who died 2 weeks ago. The wife states, "I go to the cemetery every day and say several prayers." Which stage of grieving according to Engel's model of grieving is the client exhibiting? A. Developing awareness B. Resolving the loss C. Idealization D. Restitution

Restitution

A client's spouse has died 1 week ago. When reminiscing about their life together, the client begins to cry. Which is the nurse's best response? A. Stay while reorganizing the client's unit B. Say, "things will get better as time passes." C. Encourage the client to get grief counseling D. Say, "this must be a very difficult time for you."

Say, "this must be a very difficult time for you"

An older adult reminisces extensively and attempts to keep the nurse from leaving the room. Which nursing action is a therapeutic response? A. Encouraging the client to focus on the present B. Limiting the amount of time the client talks about the past C. Setting aside time to listen to the stories about the client's past D. Suggesting that the client reminisce with other clients of the same age

Setting aside time to listen to the stories about the client's past

Which level anxiety is the client currently experiencing based on the information in the client's clinical record? A. Mild B. Moderate C. Severe D. Panic

Severe

A nurse makes the assessment that a client's feet are dirty. Which is the most effective nursing intervention when planning to clean the client's feet? A. Ask the client to take a shower B. Lubricate feet with lotion to soften dirt C. Soak feet for a few minutes in a basin with soap and water D. Use an antifungal medication to prevent a fungal infection

Soak feet for a few minutes in a basin with soap and water

A nurse identifies the illustrated ulcer when completing a skin assessment for a newly admitted client. Which stage ulcer should the nurse indicate on the pressure ulcer flow sheet? A. Stage I B. Stage II C. Stage III D. Stage IV

Stage IV

A nurse is working in an assisted-living facility that has designated smoking areas. Which is the best nursing intervention to prevent accidents associated with smoking? A. Removing cigarettes from individuals who smoke B. Supervising individuals when they want to smoke C. Encouraging individuals who smoke to give up smoking D. Asking family members of individuals who smoke not to bring cigarettes to the facility

Supervising individuals who want to smoke

A client becomes upset whenever anyone mentions an upcoming birthday and does not want to talk about age. Which does this behavior reflect? A. Denial B. Sorrow C. Loneliness D. Suppression

Suppression

A client's son has just died. The client states, "I can't believe that I have lost my son. Can you believe it?" Which is the nurse's best response? A. Touch the client's hand and say, "I am very sorry." B. Leave the room and allow the client to grieve in private C. Encourage a family member to stay and provide support D. Assume a serious facial expression and say, "I can't believe it either."

Touch the client's hand and say, "I am very sorry."

A client is confused and disoriented. Which route of communication used by the nurse if most effective in this situation? A. Touch B. Talking C. Writing D. Pictures

Touch

While a client is lying in the dorsal recumbent position, the client's legs externally rotate. Which equipment should the nurse use to prevent external rotation? A. Bed cradle B. Trochanter roll C. Elastic stockings D. High top sneakers

Trochanter roll

A nurse on the evening shift in the hospital is caring for a slightly confused client. Which is the most effective nursing intervention to prevent disorientation at night? A. Check on the client regularly B. Place a call bell on the client's bed C. Turn on a night-light in the client's room D. Describe the physical environment to the client

Turn on a night-light in the client's room

A nurse is caring for a client positioned in the left lateral position. Place an X over the bony prominence that the nurse should be most concerned about regarding development of a pressure ulcer.

Upper left leg

A newly admitted client is being oriented to the hospital unit. Which is the most important information that the nurse should review with the client? A. Name of the nurse in charge B. Potential date of discharge C. Daily routine on the unit D. Use of the call bell

Use of the call bell

A nurse is responding to a fire alarm within the hospital. Which should the nurse do when transporting a fire extinguisher to a fire scene on a different level of the building than the one on which the nurse is working? A. Use the stairs B. Pull the safety pin C. Keep it from touching the floor D. Always run as quickly as possible

Use the stairs

During a clinic visit an older adult reports having cold feet at night. Which should the nurse teach the client to do? A. Wear socks B. Keep them elevated C. Apply a heating pad D. Use a hot water bottle

Wear socks