Nur2308 NCLEX Question Trainer #2
The nurse reviews procedures with the healthcare team. The nurse intervenes if the RN staff member makes which statement? 1. "It is my responsibility to ensure the consent form has been signed and is attached to the client's record." 2. "It is my responsibility to witness the signature of the client before surgery is performed." 3. "It is my responsibility to explain the surgery and ask the client to sign the consent form." 4. "It is my responsibility to answer questions the client may have before surgery."
"It is my responsibility to explain the surgery and ask the client to sign the consent form."
The nursing assistive personnel (NAP) reports to the RN that the client with anemia reports weakness. Which nursing response is BEST? 1. "Listen to the client's breath sounds and report back to me." 2. "Set up the client's lunch tray." 3. "Obtain a diet history from the client." 4. "Instruct the client to balance rest and activity."
"Set up the client's lunch tray."
The nurse cares for the client the first day postop after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is BEST? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."
"The CBI enables urine to keep flowing."
During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which response by the nurse is BEST? 1. "You are nauseated because of the fatigue you are feeling." 2. "The nausea is due to an increase in the basal metabolic rate." 3. "The nausea is caused by an elevation in the hormones." 4. "If you eat different kinds of foods, you won't be nauseated."
"The nausea is caused by an elevation in the hormones."
The client is diagnosed with a gastric ulcer. The nurse anticipates the client will experience pain at which time? 1. Two to three hours after a meal 2. During the night 3. Prior to the ingestion of food 4. One-half to 1 hour after a meal
One-half to 1 hour after a meal
The client is diagnosed with myasthenia gravis. It is MOST important for the nurse to consider which action? 1. Prevent accidents from falls as a result of vertigo 2. Maintain fluid and electrolyte balance 3. Control situations that could increase intracranial pressure and cerebral edema 4. Assess muscle groups toward the end of the day.
Assess muscle groups toward the end of the day
Which is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate and pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.
Auscultates the chest for change or clearing of adventitious breath sounds.
The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? 1. Blood dyscrasia and extrapyramidal symptoms 2. Hearing loss and unsteady gait 3. Nystagmus and vertical gaze palsy 4. Alteration in level of consciousness and increased confusion
Blood dyscrasia and extrapyramidal symptoms
The nurse plans care for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1. Cause the client to defend the idea 2. Help the client clarify thoughts 3. Facilitate better communication 4. Lead to a breakdown of the defense
Cause the client to defend the idea
The client reports a severe headache, nausea, and photophobia. The health care provider orders a complete blood count (CBC) and a lumbar puncture (LP). A diagnosis of bacterial meningitis is made. Which laboratory result does the nurse expect? 1. Cerebrospinal fluid (CSF) cloudy, hemoglobin (Hgb) 13 g/dL (130 g/L), hematocrit (HCT) 38%, white blood cell count (WBC) 18,000/mm3. 2. CSF with red blood cells (RBCs) present, Hgb 10 g/dL (100 g/L), HCT 37%, WBC 8,000/mm3. 3. CSF cloudy, Hgb 12 g/dL (120 g/L), HCT 37%, WBC 7,000/mm3. 4. CSF clear, Hgb 15 g/dL (150 g/L), HCT 40%, WBC 11,000/mm3.
Cerebrospinal fluid (CSF) cloudy, hemoglobin (Hgb) 13 g/dL (130 g/L), hematocrit (HCT) 38%, white blood cell count (WBC) 18,000/mm3.
The nurse observes the student nurse auscultate the right middle lobe (RML) lung of the client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? 1. Posterior and anterior base of right side 2. Right anterior chest between the 4th and 6th intercostal spaces 3. Left of the sternum, midclavicular, at right 5th intercostal space 4. Posterior chest wall, midaxillary, right side.
Right anterior chest between the 4th and 6th intercostal spaces
The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? 1. Sodium 2. Protein 3. Potassium 4. Iron
Sodium
The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1. Darker skin that is more pigmented. 2. Skin that is ruddy and oily 3. Skin that is puffy and scaly 4. Skin that is pale and dry
Darker skin that is more pigmented
The client is admitted to the ED in acute respiratory distress. The client is very anxious, edematous, and cyanotic. The client receives morphine sulfate. Which finding does the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure 2. Decrease in anxiety 3. Depression of the sympathetic nervous system 4. Enhanced ventilation and deceased cyanosis
Decrease in anxiety
The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea 2. Distended abdomen with ascites 3. Minimal bowel sounds in all four quadrants 4. Distended abdomen with reports of pain
Distended abdomen with reports of pain
The adult client is admitted to the hospital unit diagnosed with hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1. Contact precautions 2. Airborne precautions 3. Standard precautions 4. Droplet precautions
Standard precautions
The client is diagnosed with an adjustment disorder with depressed mood. The client has the GREATEST chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1. During the morning hours 2. During the middle of the day 3. During the afternoon hours 4. During the evening hours
During the morning hours
The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the emergency department. The nurse knows the most common reaction of the significant other to a rape victim is reflected in which behavior? 1. Supportive and helpful to the victim 2. Disconnected from and apathetic toward the victim 3. Frustrated and feeling vulnerable, but denying the need for help 4. Emotionally distressed and needing assistance
Emotionally distressed and needing assistance
The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? 1. Paranoia 2. Grandiose delusions 3. Somatic difficulties 4. Difficulty concentrating 5. Agitation 6. Distorted perceptions
Grandiose delusions, difficulty concentrating, & agitation
The nurse notes that an adolescent female attending camp consumes 3 meals a day, averaging 900 calories and 3mg of iron for each meal. The client menstruates monthly and is of appropriate weight for height. Which statement BEST describes the adolescent's intake? 1. Low in calories and high in iron 2. Low in calories and low in iron 3. High in calories and low in iron 4. High in calories and high in iron
High in calories and low in iron
The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings? 1. Hypotension 2. Low back pain 3. Wet breath sounds 4. Fever 5. Urticaria 6. Severe SOA
Hypotension, low back pain, & fever
The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is MOST appropriate? 1. Maintain and improve the quality of oxygenation 2. Improve the status of ventilation 3. Increase oxygenation of peripheral circulation 4. Correct the bicarbonate deficit
Improve the status of ventilation
The client develops a low investing obstruction. The nurse anticipates which findings? 1. Nausea 2. Vomiting 3. Explosive diarrhea 4. Tarry stool 5. Abdominal distention 6. Rectal bleeding
Nausea, vomiting, abdominal distention
The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the pattern of urinary elimination occurs NORMALLY with aging? 1. Decreased frequency 2. Nocturia 3. Incontinence 4. Hematuria
Nocturia
The client returns from surgery. There is a fine, reddened rash around the area where provide iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? 1. Time and circumstances under which the rash was noted. 2. Explanation given to the client and family of the reason for the rash. 3. Notation on an allergy list and notification of the healthcare provider. 4. The need for application of corticosteroid cream to decrease inflammation
Notation on an allergy list and notification of the healthcare provider.
The nursing team consists of one RN, two LPNs, and three nursing assertive personnel (NAP). The RN cares for which client? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with an irrigation. 3. The client with a right-sided stroke requiring assistance with bathing. 4. The client declining medication to treat cancer of the colon.
The client declining medication to treat cancer of the colon.
The nurse develops care plans for these four clients. The nurse plans to use a restraint for which client? 1. The infant with septicemia 2. The child after a tonsillectomy 3. The infant after a cleft lip repair 4. The child with meningitis
The infant after a cleft lip repair
The parents tells the nurse about having had difficulty forming relationships. The parent is worried the 7-year-old child will have the same problem. Which statement by the nurse is BEST? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."
"Children develop trust from birth to 18 months of age."
The nurse prepares the client for a MRI. Which client statement indicates the teaching is successful? 1. "The dye used in the test will turn my urine green for about 24 hours." 2. "I will be put to sleep for this procedure. I will return to my room in two hours." 3. "This procedure will take about 90 minutes to complete. There will be no discomfort." 4. "The wires that will be attached to my head and chest will not cause me any pain."
"This procedure will take about 90 minutes to complete. There will be no discomfort."
The client comes to the clinic to have a hemoglobin A1C performed. Which client statement indicates to the nurse an understanding of the procedure? 1. "This test is performed by using a first voided urine specimen." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 2-3 months." 4. "I must follow my diet carefully for several days before the test."
"This test indicates how well my blood sugar has been controlled the past 2-3 months."
The nurse prepares discharge teaching for the parents of the newborn. Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test? 1. The initial specimen should be collected as close to discharge as possible but not later than 7 days. 2. The infant can have water but should not have formula for 6 hours before the test. 3. The test will need to be repeated at 6 weeks and at the 3-month check-up. 4. Blood will be drawn at three 1-hour intervals; there is no specific preparation.
The initial specimen should be collected as close to discharge as possible but not later than 7 days
The healthcare provider orders chlorpromazine to control the alcoholic client's restlessness, agitation, and irritability following surgery. The nurse checks the order with the healthcare provider because of which rationale? 1. The nurse believes the client's symptoms reflect alcohol withdrawal. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows the client is not psychotic. 4. The nurse routinely checks on the healthcare provider's orders.
The nurse believes the client's symptoms reflect alcohol withdrawal.
The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1. Anal sphincter 2. Abdominal 3. Trapezius 4. Rectus femoris
Abdominal
The client receives parenteral nutrition (PN) for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit which signs and symptoms? 1. Tinnitus, vertigo, blurred vision 2. Fever, malaise, anorexia 3. Diaphoresis, confusion, tachycardia 4. Hyperpnea, flushed face, diarrhea
Diaphoresis, confusion, tachycardia
The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is MOST likely to reveal which finding? 1. Hyperactive deep tendon reflexes 2. Peripheral neuropathy affecting the hands 3. Disorientation to person, place, and time 4. Impaired concentration and memory loss
Disorientation to person, place, and time
The nurse cares for the client with a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. 2. Handle the radium carefully using forceps and rubber latex gloves. 3. Document the date and time of removal together with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.
Document the date and time of removal together with the total time of implant treatment.
The nurse cares for the client diagnosed with a recurrent UTI. The healthcare provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? 1. Milk 2. Cranberry juice 3. Water 4. Tea
Milk
The client has a nasogastric tube connected to intermittent low suction. At 07:00, the nurse documents 235 mL of greenish drainage in the suction container. At 15:00, there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the nasogastric tube for 07:00 to 15:00? 1. 150 mL 2. 210 mL 3. 295 mL 4. 385 mL
150 mL (445-235-60=150)
The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride 0.4 mg IV is ordered stat. It is important for the nurse to consider which action? 1. The BP and respirations will need to increase before a second dose of naloxone can be given 2. Naloxone should not be given to the client because of the DNR status 3. A dose of naloxone may need to be repeated in 2-3 minutes 4. Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives
A dose of naloxone may need to be repeated in 2-3 minutes
The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insidious, the nurse will observe which symptoms? 1. Glucosuria 2. Cracked lips 3. Weight gain of alb 4. BP 160/100, pulse 56 5. Urinary output of 4 L/24 hours 6. Urine specific gravity of 1.004
Cracked lips, urinary output of 4 L/24 hours, & urine specific gravity of 1.004
The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1. Tetralogy of Fallot 2. Talipes equinovarus 3. Hemolytic disease of the newborn 4. Cleft lip and palate
Hemolytic disease of the newborn
The healthcare provider prescribes estrogen 0.625mg daily for the 43-year-old woman. The nurse identifies which symptom as a common initial adverse effect of this medication? 1. Nausea 2. Visual disturbances 3. Tinnitus 4. Ataxia
Nausea
Promethazine hydrochloride 25mg IV push is ordered for the client. Prior to administrating this medication, the nurse makes which assessment? 1. The color of the medication solution 2. The client's pulse and temperature 3. The time of the last analgesic dose the client received 4. The patency of the client's vein
The patency of the client's vein
The client returns from surgery after a right mastectomy. There is an IV of 0.9% NaCl infusing at 100 mL/h into the left forearm. The IV infiltrates several hours later. The nurse supervises the student nurse preparing to insert a new peripheral intravenous catheter. The nurse intervenes in which situation? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to the wrist joint. 4. The student nurse holds the skin taut prior to insertion of the catheter.
The student nurse selects a site close to the wrist joint
The nurse obtains a specimen from the client for sputum culture and sensitivity (C and S). Which instruction is BEST? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.
Upon awakening, cough deeply and expectorate into a container.
The client with type 1 diabetes asks the nurse why the healthcare provider prescribed short-acting insulin instead of intermediate-acting insulin. Which response by the nurse is BEST? 1. "More injections are required with intermediate-acting insulin than with short-acting insulin." 2. "Hypoglycemia and hyperglycemia are more common with intermediate-acting insulin." 3. "Development of eye and kidney damage is less likely with short-acting insulin." 4. "Blood glucose levels can be controlled more accurately with short-acting insulin."
"Blood glucose levels can be controlled more accurately with short-acting insulin."
The home care nurse plans activities for the day. In which order does the nurse see the clients? 1. The elderly client who used all the diuretic medication and is expectorating pink-tinged mucus 2. The client who is breastfeeding a 2-day-old infant born 5 days before the due date 3. The client discharged yesterday after IV heparin therapy for a deep vein thrombosis 4. The elderly client diagnosed with pneumonia and discharged from the hospital 3 days ago
1, 3, 4, 2
Under the supervision of the RN, a student nurse changes the dressing of the client with a newly inserted peritoneal dialysis catheter. In which order does the RN expect the student to perform this procedure? 1. Remove old dressing using clean gloves 2. Clean the insertion site using a circular motion from the insertion site outward 3. Apply two sterile precut 4x4s to the catheter insertion site 4. Apply providone-iodine to sterile cotton swabs 5. Securely tape the edges of the sterile dressing with paper tape
1, 4, 2, 3, 5
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which is the BEST response by the nurse? 1. 11 months of age 2. 14 months of age 3. 17 months of age 4. 20 months of age
20 months of age
The nurse supervises care given to a group of clients on the unit. The nurse observes a staff member entering a client's room wearing gown and gloves. The nurse knows the staff member is caring for which client? 1. An 18-month-old with respiratory syncytial virus 2. A 4-year-old with Kawasaki disease 3. A 10-year-old with Lyme disease 4. A 16-year-old with infectious mononucleosis
An 18-month-old with respiratory syncytial virus
The client is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptom? 1. Heart palpitations 2. Dizziness when walking 3. Blurred vision 4. Digital sensitivity to cold
Digital sensitivity to cold
The adolescent is scheduled for a below-knee amputation following a motorcycle accident. The nurse indicates which information in the preoperative teaching session? 1. Explain that the client will walk with a prosthesis soon after surgery 2. Encourage the client to share feelings and fears about the surgery 3. Take the informed consent to the client and ask the client to sign it 4. Evaluate how the client plans to complete schoolwork during hospitalization
Encourage the client to share feelings and fears about the surgery
A client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2.5 x 103/mm3 (2.5 x 109/L), RBC 5.1 x 106/mm3 (5.1 x 1012/L), total serum calcium 9.3 mg/dL (2.3 mmol/L). On the basis of the lab values, the nurse determines which is the PRIORITY nursing diagnosis? 1. Activity intolerance 2. Infection 3. Anxiety 4. Dehydration
Infection
The nurse evaluates the desired client response to diuretic therapy. Which action is the MOST reliable client measure for the nurse to use? 1. Obtain daily weights 2. Obtain urinalysis 3. Monitor Na+ and K+ levels 4. Measure intake
Obtain daily weights
The nurse provides care for a client after a modified radical mastectomy and axillary dissection. The nurse identifies which nursing diagnosis as the PRIORITY immediately after the procedure? 1. Anxiety 2. Altered skin integrity 3. Pain 4. Difficulty with self-care
Pain
The nurse recognizes which symptoms as characteristic of a panic attack? 1. Decreased BP 2. Palpitations 3. Decreased perceptual field 4. Bradycardia 5. Diaphoresis 6. Fear of going crazy
Palpitations, decreased perceptual field, diaphoresis, & fear of going crazy
The nurse cares for the client diagnosed with hypoparathyroidism. Which nursing action has the HIGHEST priority for this client? 1. Develop a teaching plan 2. Plan measures to deal with cardiac dysrhythmias 3. Take measures to prevent a respiratory infection 4. Assess lab results
Plan measures to deal with cardiac dysrhythmias
Which assessment information indicates to the nurse the client has hypocalcemia? 1. Constipation 2. Depressed reflexes 3. Decreased muscle strength 4. Positive Trousseau's sign
Positive Trousseau's sign
The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which goal as the PRIMARY goal of this type of group activity? 1. Provides psychosocial educational opportunities for stress and coping. 2. Provides an avenue for physical exercise. 3. Provides an environment for social interaction and companionship. 4. Reorients and provides a reality test for confused clients.
Provides an environment for social interaction and companionship
A Miller-Abbott tube is ordered for the client. The nurse knows this tube is inserted for which main reason? 1. Provides an avenue for nutrients to flow past an obstructed area. 2. Prevents fluid and gas accumulation in the stomach. 3. Administers medications that can be absorbed directly from the intestinal mucosa. 4. Removes fluid and gas from the small intestine.
Removes fluid and gas from the small intestine.
The newborn is diagnosed with fetal alcohol syndrome. The nurse knows which action is an important consideration for this newborn? 1. Prevent iron deficiency anemia 2. Decrease touch to prevent over stimulation 3. Provide feedings via gavage to decrease energy expenditure 4. Replace vitamins depleted as a result of poor maternal diet
Replace vitamins depleted as a result of poor maternal diet
The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred to assertiveness skills classes. This is an appropriate intervention because the client may exhibit which problem? 1. Aggressive behaviors and angry feelings 2. Self-identity and self-esteem issues 3. An intense focus on reality 4. Family boundary intrusions
Self-identity and self-esteem issues
The adult client receives dexamethasone for chronic lymphocytic leukemia. It is MOST important for the nurse to report which finding to the healthcare provider? 1. Prothrombin time (PT) 12 seconds and hemoglobin (Hgb) 15 g/dL (150 g/L). 2. Blood urea nitrogen(BUN) 18 mg/dL (6.4 mmol/L) and creatinine 1.0 mg/dL (88 µmol/L). 3. Serum potassium (K) 3.4 mEq/L (3.4 mmol/L) and serum calcium (Ca) 7.8 mg/dL (2 mmol/L). 4. Aspartate aminotransferase (AST) 18 U/L and alanine aminotransferase (ALT) 12 U/L.
Serum potassium (K) 3.4 mEq/L (3.4 mmol/L) and serum calcium (Ca) 7.8 mg/dL (2 mmol/L)
The nurse assesses the client diagnosed with a spinal cord injury. Which findings suggest the complication of autonomic dysreflexia? 1. Urinary bladder spasm pain 2. Severe pounding headache 3. Profuse sweating 4. Tachycardia 5. Severe hypotension 6. Nasal congestion
Severe pounding headache, profuse sweating, & nasal congestion
The 4-year-old child is admitted with drooling and an inflamed epiglottis. The nurse identifies which symptom as indicative of an increase in respiratory distress? 1. Bradycardia 2. Tachypnea 3. General pallor 4. Irritability
Tachypnea
The client has a history of hypertension and angle-closure glaucoma. Which medication order does the nurse question? 1. Propranolol 80mg PO QID 2. Verapamil 40mg PO TID 3. Tetrahydrozoline 2 drops in each eye TID 4. Timolol 1 drop in each eye once daily
Tetrahydrozoline 2 drops in each eye TID
The nurse cares for the client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which BEST describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips 2. The client does not have to turn the head to see the nurse 3. The nurse will have the client's undivided attention 4. There is a decrease in client's peripheral visual field
The client does not have to turn the head to see the nurse
The nurse cares for the homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which observation by the nurse confirms this suspicion? 1. The nurse notes that the bladder is distended 2. The client reports a constant urge to void 3. The nurse notes that the urine is concentrated 4. The client reports a burning sensation
The nurse notes that the bladder is distended
The nurse assesses orientation to person, place, and time for elderly hospitalized client. Which principle does the nurse understand? 1. Short-term memory is more efficient than long-term memory 2. The stress of an unfamiliar environment may cause confusion 3. A decline in mental status is a normal part of aging 4. Learning ability is reduced during hospitalization of the elderly client
The stress of an unfamiliar environment may cause confusion
The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1. Low BP and weight loss 2. Thin extremities with easy bruising 3. Decreased urinary output and decreased serum potassium 4. Tachycardia with reports of night sweats
Thin extremities with easy bruising
The healthcare provider diagnoses Graves' disease for the client. The nurse expects the client to exhibit which symptom? 1. Lethargy in the early morning. 2. Sensitivity to cold 3. Weight loss of 10lb in 3 weeks 4. Reduced deep tendon reflexes
Weight loss of 10lb in 3 weeks
The 7-year-old child is having some difficulty adjusting to the parents' impending divorce. The healthcare provider suggests play therapy. The nurse identifies which reason is effective for this age group? 1. Young children have difficulty verbalizing emotions 2. Children hesitate to confide in anyone but their parents 3. Play is an enjoyable form of therapy for children 4. Play therapy is helpful in preventing regression
Young children have difficulty verbalizing emotions
The nurse prepares the client for an IV pyelogram (IVP) scheduled in 2 hours. The nurse contacts the healthcare provider if the client makes which statement? 1. "I take metformin for type 2 diabetes." 2. "I completed the bowel prep last evening." 3. "I ate a light meal last evening." 4. "I had an IVP 3 years ago."
"I take metformin for type 2 diabetes."
The client was just placed in physical restraints. Which nursing intervention is MOST important for the client's care? 1. Prepare PRN dose of psychotropic medication 2. Check that the restraints have been applied correctly 3. Review hospital policy regarding duration of restraints 4. Monitor the client's needs for hydration and nutrition while restrained
Check that the restraints have been applied correctly
The nurse plans care for the 20-year-old client. Which psychosocial stage does the nurse identify as the PRIORITY to consider? 1. Identity vs. identity diffusion 2. Intimacy vs. isolation 3. Integrity vs. despair and disgust 4. Industry vs. inferiority
Intimacy vs. isolation