Management Quiz 6

The wife of a client diagnosed with a brain tumor tells the nurse, "I don't know how I will make it if something happens to my husband. I love him so much." Which statement is most appropriate for the nurse? 1. "I will call the chaplain to come and talk to you." 2. "Do you have any family support to be with you?" 3. "You don't know how you will make it if something happens." 4. "Do not worry, everything will be all right. You are a strong woman."

"I will call the chaplain to come and talk to you."

The clinic nurse is providing discharge instructions to an elderly client diagnosed with cataracts. Which intervention is most important for the nurse to implement? 1. Teach the client to increase the light in the home. 2. Encourage the client to wear dark glasses outside. 3. Discuss the need to have the cataracts removed. 4. Tell the family not to rearrange furniture in the home

- Teach the client to increase the light in the home.

Which task is most appropriate for the clinic nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to ride in the ambulance with a client. 2. Ask the UAP to escort the client in a wheelchair to the car. 3. Instruct the UAP to show the client how to use crutches. 4. Tell the UAP to call the pharmacy to refill a prescription.

Ask the UAP to escort the client in a wheelchair to the car.

The neurologist has explained to the family of a 22-year-old client with a traumatic brain injury placed on a ventilator after a motor vehicle accident that the client does not have any brain function. Which referral is appropriate at this time? 1. A local funeral director. 2. A hospice agency. 3. A home health nurse. 4. A tissue and organ bank.

- A tissue and organ bank.

The 24-year-old client diagnosed with a traumatic brain injury is being transferred to a rehabilitation unit. Which healthcare provider order should the nurse question? 1. Physical therapy to work on lower extremity strength daily. 2. Occupational therapy to work on cognitive functioning bid. 3. A soft diet with mechanical ground meats and thickening agent in fluids. 4. Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.

- Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.

The client with a C-6 spinal cord injury (SCI) comes to the emergency department complaining of a throbbing headache and has a B/P of 200/120. Which intervention should the nurse implement first? 1. Place the client on a telemetry unit. 2. Complete a neurological assessment. 3. Insert an indwelling urinary catheter. 4. Request a STAT CT scan on the head.

Insert an indwelling urinary catheter.

The nurse is at a park and observes a client fall and a stick become impaled into the right eye. Which intervention should the nurse implement first? 1. Tell someone to call 911 immediately. 2. Stabilize the stick in the client's eye. 3. Apply direct pressure to the right eye. 4. Use a non-toxic liquid and irrigate the eye.

Stabilize the stick in the client's eye

A client has been diagnosed with rule out bacterial meningitis, and a nurse is assisting the healthcare provider with a lumbar puncture. Which intervention should the nurse implement first? 1. Have the client lie in the lateral recumbent position. 2. Tell the client to empty the bladder. 3. Encourage the client to complete an advance directive. 4. Keep the client NPO prior to the procedure.

Tell the client to empty the bladder.

The home health (HH) nurse enters the home of an 80-year-old female client who had a cerebrovascular accident (CVA), or "brain attack," 2 months ago. The client is complaining of a severe headache. Which intervention should the nurse implement first? 1. Determine what medication the client has taken. 2. Assess the client's pain on a pain scale of 1 to 10. 3. Ask whether the client has any acetaminophen (Tylenol). 4. Tell the client to sit down, and take her blood pressure.

Tell the client to sit down, and take her blood pressure

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client's waist prior to ambulating. 2. The UAP places the client on the abdomen with the client's head to the side. 3. The UAP places her hand under the client's right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently.

The UAP places her hand under the client's right axilla to help the client move up in bed.

The intensive care unit nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis secondary to a cerebrovascular accident. Which action by the UAP requires the nurse to intervene? 1. The UAP performs passive range-of-motion (ROM) exercises for the client. 2. The UAP places the client on the abdomen with the head to the side. 3. The UAP uses a lift sheet when moving the client up in bed. 4. The UAP praises the client for attempting to feed him- or herself.

The UAP places the client on the abdomen with the head to the side.

. The rehabilitation nurse tells the unlicensed assistive personnel (UAP) to assist the client recovering from Guillain-Barré syndrome with a.m. care. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain. 2. The UAP massages the client's back with lotion. 3. The UAP checks the temperature of the bathing water. 4. The UAP puts the side rails up when bathing the client.

The UAP puts the side rails up when bathing the client.

The nurse is caring for clients in a long-term care facility. Which client should the nurse assess first after receiving the morning report? 1. The client diagnosed with Parkinson's disease who began to hallucinate during the night. 2. The client diagnosed with congestive heart failure who has 3+ pitting edema of both feet. 3. The client diagnosed with Alzheimer's disease who was found wandering in the hall at 0200. 4. The client diagnosed with terminal cancer who has lost 8 pounds since the last weight taken 4 weeks ago.

The client diagnosed with Parkinson's disease who began to hallucinate during the night.

The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? 1. The client has purposeful movement when the nurse rubs the sternum. 2. The client extends the upper and lower extremities in response to painful stimuli. 3. The client is aimlessly thrashing in the bed when a noxious stimulus is applied. 4. The client is able to squeeze the nurse's hand on a verbal request.

The client extends the upper and lower extremities in response to painful stimuli.

The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation? 1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. 2. The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). 3. The client with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. 4. The client with a seizure disorder who has been experiencing status epilepticus for the past 24 hours.

The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside.

The nurse is triaging phone calls in a neurosensory clinic. Which client should the nurse contact first? 1. The client with Méniére's disease who is complaining of vertigo and tinnitus. 2. The client with otitis media with effusion complaining of feeling of fullness in the ear. 3. The client with external otitis who has serosanguineous drainage and otalgia. 4. The client with otoclersosis who has bilateral hearing loss.

The client with external otitis who has serosanguineous drainage and otalgia.

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

The elderly client who is experiencing a stroke in evolution.

The nurse is administering medications on a neurological unit. Which medication should the nurse administer first? 1. The osmotic diuretic to the client with a closed head injury. 2. The morning medications to the client scheduled for physical therapy. 3. The narcotic pain medication to a client with increased intracranial pressure. 4. The anticonvulsant gabapentin (Neurontin) to the client with restless legs syndrome.

- The osmotic diuretic to the client with a closed head injury.

The nurse is the first person on the scene of a motor vehicle accident. The driver is in the driver's seat unconscious. Which action should the nurse implement first? 1. Stabilize the driver's cervical spine. 2. Do not move the client from the accident. 3. Ensure the driver has a patent airway. 4. Control any external bleeding

Ensure the driver has a patent airway.

The client is postoperative a right eye enucleation. Which statement indicates the client needs more discharge teaching? 1. "It will be approximately 2 weeks before I can get a prosthetic eye." 2. "I can show you how to insert the conformer in the socket in case it falls out." 3. "I should insert the eye drops into the lower conjunctiva of my eye." 4. "If I develop an increased temperature I should call my healthcare provider."

"It will be approximately 2 weeks before I can get a prosthetic eye."

The nurse and LPN have been assigned to care for clients on a neurology unit. Which nursing task is most appropriate to assign to the LPN? 1. Administer the adrenocorticotropic hormone to the client with multiple sclerosis. 2. Take the vital signs for the client who is experiencing status epilepticus. 3. Assist the client with Parkinson's disease to ambulate to the bathroom. 4. Assess the client newly admitted who has pneumonia and restless legs syndrome.

Administer the adrenocorticotropic hormone to the client with multiple sclerosis.

. The nurse is teaching the client with tension-type headaches. Which statement indicates the client needs more teaching? 1. "I will do some type of exercise every day." 2. "I am going to do yoga techniques when I get a headache." 3. "Cold packs to the back of my neck will help my headache." 4. "Foods containing amines like cheese and chocolate can cause headaches."

"Cold packs to the back of my neck will help my headache."

The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN? 1. Feed the client who is being allowed to eat for the first time. 2. Administer the client's anticoagulant subcutaneously. 3. Check the client's neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow.

Administer the client's anticoagulant subcutaneously.

The terminally ill client diagnosed with ALS (Lou Gehrig's disease) has a DNR order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? 1. Administer the narcotic pain medication IVP. 2. Turn and reposition the client for comfort. 3. Refuse to administer pain medication. 4. Notify the HCP of the client's vital signs.

Administer the narcotic pain medication IVP.

The home health (HH) nurse is caring for a 22-year-old female client who sustained an L-5 spinal cord injury 2 months ago. The client says, "I will never be happy again. I can't walk, I can't drive, and I had to quit college." Which intervention should the nurse implement first? 1. Allow the client to ventilate her feelings of powerlessness. 2. Refer the client to the home healthcare agency social worker. 3. Recommend contacting the American Spinal Cord Association. 4. Ask the client whether she has any friends who come and visit.

Allow the client to ventilate her feelings of powerlessness.

The nurse is planning care for the client diagnosed with Parkinson's disease (PD). Which client problem is priority? 1. Altered nutrition. 2. Altered mobility. 3. Altered elimination. 4. Altered body image.

Altered mobility.

The home health (HH) nurse is admitting a female client diagnosed with myasthenia gravis. The client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement? 1. Talk to the client's husband about helping around the house more. 2. Contact the HH occupational therapist to discuss the client's concern. 3. Allow the client to verbalize her feelings of being exhausted. 4. Recommend the client make an appointment with her HCP.

Contact the HH occupational therapist to discuss the client's concern.

. The nurse on the surgical unit is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? 1. Change an abdominal dressing on a client who is 2 days postoperative. 2. Check the client's IV insertion site on the right arm. 3. Monitor vital signs on a client who has just returned from surgery. 4. Escort a client who has been discharged to the client's vehicle.

Escort a client who has been discharged to the client's vehicle.

The client in a multiple car crash dies in the emergency department. Which priority intervention should the emergency department nurse implement when addressing the needs of the client's family? 1. Ask if the client wanted to be a tissue donor. 2. Give the family the client's personal belongings. 3. Escort the family to a private room to grieve. 4. Determine which funeral home should be contacted.

Escort the family to a private room to grieve.

The clinic nurse is making assignments for the large family practice clinic. Which task should be assigned to the staff nurse who is 4 months pregnant? 1. Have the staff nurse answer the telephone calls from clients. 2. Instruct the staff nurse to work in the radiology department. 3. Tell the staff nurse to work in the front desk triage area. 4. Assign the staff nurse to work in the oncology clinic.

Have the staff nurse answer the telephone calls from clients.

The nurse in a long-term care facility is developing the plan of care for a client diagnosed with end-stage Alzheimer's disease. Which client problem is priority for this client? 1. Inability to do activities of daily living. 2. Increased risk for injury. 3. Potential for constipation. 4. Ineffective family coping.

Increased risk for injury.

The employee health nurse is caring for a male employee who reports tripping and is complaining of right knee pain. There is no visible injury, and the client has a normal neurovascular assessment. Which intervention should the nurse implement? 1. Request the employee to return to work. 2. Obtain a urine specimen for a drug screen. 3. Send the client to the emergency department. 4. Place a sequential compression device on the leg

Obtain a urine specimen for a drug screen.

. The multidisciplinary team is meeting to discuss a client with right-sided weakness who has developed a Stage 2 pressure ulcer over the sacral area that is not healing. Which priority intervention should the client's home health (HH) nurse recommend? 1. Recommend the client get a hospital bed with a trapeze bar. 2. Recommend a home health aide provide care 7 days a week for the client. 3. Recommend the client be transferred to a skilled nursing unit. 4. Recommend a referral to the home healthcare agency wound care nurse.

Recommend a referral to the home healthcare agency wound care nurse.

The employee health nurse is caring for an employee who fell off a ladder and is complaining of low back pain radiating down both legs. Which intervention should the nurse implement first? 1. Refer the client to an HCP for further evaluation. 2. Complete the workers' compensation documentation. 3. Investigate the cause of the fall off the ladder. 4. Notify the employee's supervisor of the incident.

Refer the client to an HCP for further evaluation.

The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. 3. The client with Parkinson's disease who is experiencing "pill rolling." 4. The client with Huntington's disease who has writhing, twisting movements of the face.

The client with a C-6 spinal cord injury who has autonomic dysreflexia.

The nurse is caring for a client newly diagnosed with multiple sclerosis. Which referral is appropriate at this time? 1. To a social worker to apply for disability. 2. To a dietician for a nutritional consult. 3. To a psychological counselor for therapy. 4. To a chaplain to discuss spiritual issues.

To a psychological counselor for therapy.

The charge nurse observes the client's nurse telling the unlicensed assistive personnel (UAP) to feed an elderly client diagnosed with a cerebrovascular accident (CVA). Which question should the charge nurse ask the client's nurse? 1. "How does the client swallow the medications?" 2. "Did you complete your head to toe assessment?" 3. "Does the client have some Thick-It in the room?" 4. "Why would you delegate feeding to a UAP?"

"How does the client swallow the medications?"

The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should not be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Check the client's skin under the restraints. 2. Administer the client's antipsychotic medication. 3. Perform the client's morning hygiene care. 4. Ambulate the client to the bathroom. 5. Obtain the client's routine vital signs.

- Check the client's skin under the restraints. - Administer the client's antipsychotic medication.

The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? 1. Encourage the client to move the buttocks every 2 hours. 2. Order a high-protein diet to prevent skin breakdown. 3. Get a pressure-relieving cushion to place in the wheelchair. 4. Refer the client to physical therapy for transfer teaching.

- Get a pressure-relieving cushion to place in the wheelchair.

The 19-year-old client is in the rehabilitation unit following a traumatic brain injury. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Make safety rounds hourly. 2. Refer the client to a college and career counselor. 3. Assist the client with meals. 4. Clamp and unclamp the indwelling catheter every 2 hours. 5. Discuss discharge placement with the parents.

- Make safety rounds hourly. - Assist the client with meals. - Clamp and unclamp the indwelling catheter every 2 hours.

The nurse and unlicensed assistive personnel (UAP) are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. Which action is priority when moving the client in the bed? 1. Obtain a lifting device made for lifting heavy clients. 2. Do not attempt to move the client because of the weight. 3. Get another UAP to help move the client in the bed. 4. Tell the family that the client must assist in moving in the bed.

- Obtain a lifting device made for lifting heavy clients.

The client diagnosed with a right-sided cerebral vascular accident (CVA), or brain attack, is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Refer the client to occupational therapy daily. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises five times a day. 5. Instruct the client to hold the fingers in a fist.

- Position the client to prevent shoulder adduction. - Refer the client to occupational therapy daily. - Encourage the client to move the affected side. - Perform quadriceps exercises five times a day.

The nurse is caring for clients in the emergency department. Which client should the nurse assess first? 1. The client with an epidural hematoma. 2. The client who had a seizure who is in the postictal state. 3. The client diagnosed with R/O encephalitis who has a headache. 4. The client with multiple sclerosis who has scanning speech.

- The client with an epidural hematoma.

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a stroke who has a platelet level of 250,000 µ/L. 2. The client with a seizure disorder who has a divalproex (Depakote) level of 75 µg/mL. 3. The client with multiple sclerosis on prednisone who has a glucose level of 208 mg/dL. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL.

The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL.

The community health nurse is triaging victims at the site of a disaster. Which client should the nurse categorize as black, priority 4? 1. The client who is alert and has a sucking chest wound. 2. The client who cannot stop crying and can't answer questions. 3. The client whose abdomen is hard and tender to the touch. 4. The client who has full thickness burns over 60% of the body.

The client who has full thickness burns over 60% of the body.

The clinic nurse is triaging client's telephone calls. Which client should the nurse call first? 1. The client diagnosed with AIDS who has developed Kaposi's sarcoma. 2. The client diagnosed with dementia who is having difficulty dressing himself. 3. The client with trigeminal neuralgia who is having lightening-like shock to the cheeks. 4. The client whose friend has botulism who has vomiting and abdominal cramping pain.

The client whose friend has botulism who has vomiting and abdominal cramping pain.

The home health (HH) nurse is scheduling visits for the day. Which client should the nurse visit first? 1. The client with an L-4 SCI who is complaining of a severe, pounding headache. 2. The client with amyotrophic lateral sclerosis (ALS) who is depressed and wants to die. 3. The client with Parkinson's disease who is walking with a short, shuffling gait. 4. The client with a C-5 SCI who reports redness and drainage at the Halo vest sites.

The client with a C-5 SCI who reports redness and drainage at the Halo vest sites.

Which client should the charge nurse assess first after receiving the change-of-shift report? 1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. 2. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. 3. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. 4. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%.

The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute.

. A client comes to the emergency department after having bleach splash in the eyes. Which intervention should the nurse implement first? 1. Cover both the eyes with sterile patches. 2. Assess the client's visual acuity. 3. Irrigate the eyes with sterile solution. 4. Elevate head of bed 45 degrees.

Irrigate the eyes with sterile solution.

A client sustained a severe head injury, and his wife is concerned about what to do if he has a seizure when they go home. Which statement indicates the wife understands the most important action to take if her husband has a seizure? 1. "I should check to see if my husband urinates on himself." 2. "I will move all the furniture out of his way." 3. "I will call 911 as soon as the seizure begins." 4. "I will make sure he rests after the seizure is over."

"I will move all the furniture out of his way."

The nurse in the neurological clinic is triaging phone calls. Which client should the nurse contact first? 1. The client with a tension headache who is reporting nausea and vomiting. 2. The client with a migraine headache who is reporting bilateral throbbing pain. 3. The client with a cluster headache who is reporting a sharp and stabbing pain. 4. The client with hypertension who is reporting pressure type pain in the back of head.

- The client with a tension headache who is reporting nausea and vomiting.

The nurse is caring for clients in an ophthalmology clinic. Which client warrants intervention by the nurse? 1. The client with cataracts who reports decreased vision and abnormal color perception. 2. The client with a retinal detachment who reports a painless loss of peripheral vision. 3. The client with an external hordeolum who reports reddened tender area under eye. 4. The client with primary open angle glaucoma who reports excruciating eye pain.

- The client with primary open angle glaucoma who reports excruciating eye pain.

The charge nurse observes the new graduate nurse delegating tasks to the unlicensed assistive personnel (UAP) and the UAP appears to be ignoring the graduate nurse. Which action should the charge nurse implement first? 1. Wait and observe how the graduate nurse handles the situation. 2. Tell the UAP to get busy and complete the assigned tasks. 3. Discuss learning to assert authority with the new graduate. 4. Informally counsel the UAP about the response to the nurse.

- Wait and observe how the graduate nurse handles the situation.

The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? 1. A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale. 2. A steroid to the client experiencing an acute exacerbation of multiple sclerosis. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

An anticholinesterase medication to a client diagnosed with myasthenia gravis.

The home health (HH) aide tells the nurse the client diagnosed with multiple sclerosis is having problems getting out of the bed to the chair, and is now having problems getting into the shower. Which intervention should the nurse implement? 1. Ask the HH aide whether the bathroom has grab bars. 2. Assess the client's ability to transfer in the home. 3. Instruct the HH aide to give the client a bed bath. 4. Contact the agency physical therapist about the situation.

Contact the agency physical therapist about the situation.

The charge nurse is making rounds and notices that the sharps container in the client's room is above the fill line. Which action should the charge nurse implement? 1. Complete an adverse occurrence report. 2. Discuss the situation with the primary nurse. 3. Instruct the UAP to change the sharps container. 4. Notify the infection control nurse immediately.

Instruct the UAP to change the sharps container.

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome who is admitted to the critical care unit? 1. Decreased cardiac output. 2. Fear and anxiety. 3. Complications of immobility. 4. Ineffective breathing pattern.

Ineffective breathing pattern.

The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center.

Inpatient rehabilitation unit.

The nurse in a long-term care facility is administering medications to a group of clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid (aspirin) to a client diagnosed with cerebrovascular disease. 2. Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis. 3. Cephalexin (Keflex) to a client diagnosed with an acute urinary tract infection. 4. Acyclovir (Zovirax) to a client diagnosed with Bell's palsy.

Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis.

The nurse enters the room, and the client is beginning to have a tonic-clonic seizure. Which action should the nurse implement first? 1. Identify the first area that began seizing. 2. Note the time the client's seizure began. 3. Pad the siding of the client's bed rails. 4. Provide the client with privacy during the seizure.

Note the time the client's seizure began.

The nurse caring for a client is accidentally stuck with the stylet used to start an IV infusion. The nurse flushes the skin with water and tries to get the area to bleed. Which action should the nurse implement next? 1. Have the laboratory draw the client's blood. 2. Notify the charge nurse and complete the incident report. 3. Contact the employee health nurse to start prophylactic medication. 4. Follow up with the employee health nurse to have lab work drawn.

Notify the charge nurse and complete the incident report.

4. A wife tells the clinic nurse her husband had been fine and is now confused, doesn't know where he is, and is not acting like his usual self. Which intervention should the nurse implement first? 1. Perform a neurological assessment. 2. Notify the client's healthcare provider. 3. Ask the wife to explain more about the behavior. 4. Determine when the client last had something to eat.

Perform a neurological assessment.

The rehabilitation nurse is planning the discharge of a 68-year-old client whose status post-subarachnoid hemorrhage includes residual speech and balance deficits. Which referral should the nurse initiate at this time? 1. Referral to a hospice organization. 2. Referral to the speech therapist. 3. Referral to the physical therapist. 4. Referral to a home health agency.

Referral to a home health agency.

The client being admitted with transient ischemic attack is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse question? 1. Schedule for CT scan with contrast in a.m. 2. Administer acetaminophen 2 PO for headache. 3. Take client's vital signs per protocol. 4. Provide the client with a low-fat, low-cholesterol diet.

Schedule for CT scan with contrast in a.m.

To which collaborative healthcare team member should the critical care nurse refer the client in the late stages of myasthenia gravis (MG)? 1. Occupational therapist. 2. Physical therapist. 3. Social worker. 4. Speech therapist.

Speech therapist.

The nurse in a rehabilitation facility is evaluating the progress of a female client who sustained a C-6-C-7 spinal cord injury. Which outcome indicates the client is improving? 1. The client can maneuver the automatic wheelchair into the hallway. 2. The client states she will be able to return to work in a few weeks. 3. The client uses eye blinks to communicate yes and no responses. 4. The client's husband built a wheelchair ramp onto their house.

The client can maneuver the automatic wheelchair into the hallway.