NMNC 3130 Nursing Process Quiz 3
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene to prevent these behaviors from causing the other clients to feel what?
Angry
The registered nurse is caring for a client with peptic ulcers and dysphagia. Which task does the RN exclude while delegating the care of a client with peptic ulcers and dysphagia to an unlicensed assistive personnel (UAP)?
Assisting the client in administering the medications: Administering the medications is not within the scope of UAP. Therefore, this task is excluded while delegating the care of a client with peptic ulcers and dysphagia to a UAP. The UAP can perform all the hygiene related tasks while caring for a client with peptic ulcer and dysphagia. Therefore, the RN delegates the tasks such as assistance with feeding, bathing, and oral hygiene to a UAP.
What in students is being assessed when a school nurse conducts audiometric screenings?
Hearing acuity
At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing?
Hypoglycemia
Which nursing process includes tasks that can be delegated?
Implementation
According to Erikson, a young adult must accomplish the tasks associated with which stage?
Intimacy versus isolation
A married couple in their 80s is living independently. They have three adult children. The husband, who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing, dressing, and meal preparation. What does the nurse suggest as the most suitable plan for this couple?
Keep them in their home with a home health aide.
A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, which action should the nurse take?
Place a support under the scrotum.
An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. What does the nurse identify as the cause of these problems?
Receptive aphasia
The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. What teaching will be included?
The client will need to stay In the supine position with the affected leg extended for several hours after the procedure
While caring for survivors of a massive tsunami, the nurse makes an initial assessment of a client's condition and assigns a yellow tag. What is the likely role of the nurse?
Triage officer
The mother of an infant with meningitis is concerned that if she stays with her infant at the hospital her toddler at home will feel neglected. How should the nurse respond?
"Can you arrange with someone to stay here when you are at home?"
A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse?
"I don't hear anyone else talking, but I can see that you're upset."
The nurse is teaching an 18-year-old athlete about measures to reverse amenorrhea. Which statements made by the adolescent indicates effective learning? Select all that apply.
"I will increase my food intake." "I will perform weight training exercises."
During an interview for a nurse manager position, the panel asks the nurse about the primary role of a leader. Which answer provided by the nurse would be most appropriate?
"To inspire followers"
In an effort to foster a healthy grief response to the birth of a stillborn child, how should the nurse respond to the mother's questions about the cause?
"You may be wondering whether something you did caused this."
Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.
1.Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist 2.Apply either a surgical mask or a respirator around the mouth and nose 3.Apply eyewear or goggles snugly around the face and eyes 4.Apply clean gloves within the gown 5.Bring the glove cuffs over the edge of the gown sleeves
To which client should the nurse provide education regarding the pubertal growth spurt?
A 12-year-old school-age female client.
What does an Apgar score recorded 5 minutes after birth assist the nurse in evaluating when caring for the newborn?
Adequacy of the transition to extrauterine life
While assessing the vital signs of an elderly alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. What other findings does the nurse expect to observe? Select all that apply.
Body temperature of 84.2 °F Blood pressure of 100/62 mmHg Respiratory rate of 12 breaths/minute
A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find?
Brown or black mole with red, white, or blue areas.
A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub? Choose the appropriate location marked on the image.
D: the lower-lateral chest, which is the area of greatest thoracic excursion.
A woman visits the clinic because she has dysmenorrhea. Which goal is most realistic for this client to achieve?
Easing the pain of the client's menstruation.
An adolescent reports pain in the scrotum and is having dysuria and pyuria. The nurse observes redness and swelling in the scrotal part. What penile abnormality does the nurse infer from these findings?
Epididymitis: an inflammatory reaction of the epididymis characterized by scrotal pain, redness, swelling along with urethral discharge, dysuria, and pyuria.
A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon?
Measure the blood glucose level between 2 AM and 4 AM.
A 13-year-old who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for further testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. Which is the best response by the nurse?
Refer the mother to the psychiatrist.
During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions.
1.Elevate the head of the bed to 45 degrees 2.Apply oxygen via nasal cannula 3.Reduce the flow rate of the transfusion 4.Administer furosemide (Lasix) per provider prescription 5.Document findings in the client record
A client who has passed the acute phase of rheumatoid arthritis is permitted to be out of bed as tolerated. After assisting the client out of bed, where should the nurse place the client?
A straight-back armchair: allows the hips and shoulders to be against the back of the chair while fully supporting the thighs
After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply.
Fat cells in the urine PaO 2 value of 58 mm Hg (7.73 kPa) Hematocrit value of 30% (0.30)
A client with class I heart disease has reached 34 weeks' gestation. Which problem should the nurse anticipate now that the client is in her third trimester?
Dyspnea at rest: associated with cardiopulmonary disorders and may be a sign of impending decompensation. Vasovagal syncope is an expected physiologic change. The client with heart disease is more likely to have exertional syncope. Dependent edema commonly occurs in women with uncomplicated pregnancies as they progress toward term. The client with heart disease is more likely to experience generalized edema. In the third trimester, clients with uncomplicated pregnancies complain of shortness of breath on exertion; this is caused by compression of the diaphragm by the enlarging uterus.