NCLEX Q&A TEST # 4

930. A client who is experiencing suicidal thoughts shares with the nurse that, “I was awake most of the night. It just doesn’t seem worth it anymore. Why not just end it all?” Which response should the nurse make to best further assess the client?. 1. “Did you sleep at all last night?”. 2. “Tell me what you mean by that.”. 3. “I know you have had a stressful night.”. 4. “I’m sure that your family is worried about you.”.

931. A mother states to the nurse, “I am afraid that my child might have another febrile seizure.” Which therapeutic statement is best for the nurse to make to the mother?. 1. “Tell me what frightens you the most about seizures.”. 2. “Tylenol can prevent another seizure from occurring.”. 3. “Most children will never experience a second seizure.”. 4. “Why worry about something that you cannot control?”.

932. A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?. 1. Guilt. 2. Grief. 3. Anger. 4. Depression.

933. An infant has been diagnosed with acute chalasia. During the nursing history, the mother tells the nurse, “I am concerned that I am somehow causing my infant to vomit after feeding her.” Considering this statement, which concern should the nurse identify for the mother?. 1. An unrealistic expectation of herself. 2. Denial that chalasia is a physiological defect. 3. Lack of understanding about feeding an infant with chalasia. 4. Anxiety about the need for hospitalization of the infant for chalasia.

934. A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, “If my doctor tells me to do it, I will. Otherwise, I won’t.” Which behavior should the nurse determine that the client is displaying?. 1. Anger. 2. Denial. 3. Depression. 4. Dependency.

935. The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, “I’m scared to death that it’ll come back.” Based on these statements, which concern should the nurse identify for this client at this time?. 1. Fear of dying. 2. Lack of understanding about the disease proces. 3. Anxiety about the anticipation of recurrent severe pain. 4. Retention of urine from the obstruction of the urinary tract by calculi.

936. The nurse is observing the parents at the bedside of their small-for gestational-age (SGA) infant, who was born at 27 weeks’ gestation. The infant’s mother states, “She is so tiny and fragile. I’ll never be able to hold her with all those tubes.” Considering this statement, which concern should the nurse identify for the mother?. 1. Impaired adjustment. 2. Trouble with family coping. 3. Potential for compromised parenting. 4. Difficulty understanding health concerns.

937. A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant’s facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client’s concerns?. 1. “I can show you how to gently stroke the face and not cause pain.”. 2. “It is a normal finding in large babies and nothing to be concerned about.”. 3. “The bruising is caused by polycythemia, which usually leads to jaundice.”. 4. “Because the bruising is painful, it is advisable that you not touch the baby’s face.”.

938. A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care?. 1. Attend a support group. 2. Cease dwelling on the negative. 3. Reach out for help to face this fear. 4. Share her feelings with her partner.

939. A 9-year-old child is hospitalized in traction for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development?. 1. Providing a music player. 2. Tutoring to keep the child up with schoolwork. 3. Providing a phone for calling family and friends. 4. Placing computer games, a television, and videos at the bedside.

940. A client who is in halo traction states to the visiting nurse, “I can’t get used to this contraption. I can’t see properly on the side, and I keep misjudging where everything is.” Which therapeutic response should the nurse make to the client?. 1. “If I were you, I would have had the surgery rather than suffer like this.”. 2. “No one ever gets used to that thing! It’s horrible. Many of our sports people who are in it complain vigorously.”. 3. “Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around.”. 4. “Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don’t you think?”.

941. An older client has been admitted to the hospital diagnosed with a hip fracture. The nurse prepares a plan of care for the client and identifies desired outcomes related to surgery and impaired physical mobility. Which statement by the client supports a positive adjustment to the surgery and impairment in mobility?. 1. “Hurry up and go away. I want to be alone.”. 2. “What took you so long? I called for you 30 minutes ago.”. 3. “I wish you nurses would leave me alone! You are all telling me what to do!”. 4. “I find it a little difficult to concentrate since the surgeon talked with me about the surgery tomorrow.”.

942. A client who is quadriplegic frequently makes lewd sexual suggestions and uses profanity. The nurse concludes that the client is inappropriately using displacement. Which concern should the nurse identify as being appropriate for this client?. 1. Disuse syndrome. 2. Lack of coping skills. 3. Negative body image. 4. Lack of awareness of surroundings.

943. The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can implement to assist the parents with developing attachment behaviors?. 1. Support visits by family and friends. 2. Encourage the parents to touch and speak to their infant. 3. Report only positive qualities and progress to the parents. 4. Provide information regarding infant development and stimulation.

944. A 16-year-old client diagnosed with diabetes is admitted for hyperglycemia. The client states, “I’m fed up with having my life ruled by diets, doctors’ prescriptions, and machines!” Based on this assessment data, which is the priority client concern?. 1. A chronic illness. 2. A personal crisis. 3. Feelings of loss of control. 4. Lack of understanding about nutrition.

945. The client angrily tells the nurse that the primary health care provider (HCP) purposefully provided incorrect information. Which responses by the nurse to the client support therapeutic communication? Select all that apply. 1. “I’m certain that the HCP would not lie to you.”. 2. “I’m not sure what you mean by that statement.”. 3. “Can you describe the information that you are referring to?”. 4. “Do you think it would be helpful to talk to your doctor about this?”. 5. “You can check the information on lots of websites on the Internet.”.

946. A client with a diagnosis of depression states to the nurse, “I should have died. I’ve always been a failure.” Which therapeutic response should the nurse make to the client?. 1. “You don’t see anything positive?”. 2. “You still have a great deal to live for.”. 3. “Feeling like a failure is part of your illness.”. 4. “You’ve been feeling like a failure for some time now?”.

947. Two months after a right mastectomy for breast cancer, a client comes to the office for a follow-up appointment. After being diagnosed with cancer in the right breast, the client was told that the risk for cancer in the left breast existed. When asked about her breast self-examination (BSE) practices since the surgery, the client replied, “I don’t need to do that anymore.” The nurse interprets this response to be using which coping mechanism?. 1. Denial. 2. Grief and mourning. 3. Change in body image. 4. Change in role pattern.

948. When planning for the care of the client who is dying of diagnosed cancer, one of the goals is that the client verbalizes her or his acceptance of impending death. Which client statement indicates to the nurse that this goal has been reached?. 1. “I just want to live until my 100th birthday.”. 2. “I would like to have my family here when I die.”. 3. “I’ll be ready to die when my children finish school.”. 4. “I want to go to my daughter’s wedding. Then I’ll be ready to die.”.

949. The nurse is caring for a client diagnosed with colon cancer who is receiving an antimetabolite for chemotherapy. Which actions should the nurse plan to discuss with the client? Select all that apply. 1. The significance of wearing cotton gloves. 2. The importance of rinsing the mouth after eating. 3. The use of cosmetics to hide drug-induced rashes. 4. The use of wigs, which are often covered by insurance. 5. Proper dental hygiene with the use of a foam toothbrush.

950. A client diagnosed with hyperaldosteronism has developed kidney failure and states to the nurse, “This means that I will die very soon.” Which is the most appropriate therapeutic response for the nurse to make to the client?. 1. “You will do just fine.”. 2. “What are you thinking about?”. 3. “You sound discouraged today.”. 4. “I read that death is a beautiful experience.”.

951. A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which should be the initial action by the home care nurse?. 1. Attempt to identify the cause of the frustration. 2. Call the primary health care provider to discuss the client’s problem. 3. Offer to administer the insulin on a daily basis until the client is ready to learn. 4. Continue with teaching, knowing that the client will overcome any frustrations.

952. A client diagnosed with cancer is placed on permanent total parenteral nutrition as a means of providing nutrition. Which is the rationale for the nurse to include psychosocial support when planning care for this client?. 1. Death is imminent. 2. The client will need to adjust to the idea of living without eating by the usual route. 3. Total parenteral nutrition requires disfiguring surgery for permanent port implantation. 4. Nausea and vomiting occur regularly with this type of treatment and will prevent the client from participating in social activity.

953. A client who is to be discharged to home with a temporary colostomy states to the nurse, “I know I’ve changed this thing once, but I just don’t know how I’ll do it by myself when I’m home alone. Can’t I stay here until the surgeon puts it back?” Which therapeutic response should the nurse make to best deal with the client’s concerns?. 1. “This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery.”. 2. “So you’re saying that, although you’ve practiced changing your colostomy bag once, you don’t feel comfortable on your own yet?”. 3. “Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you’ll have to fight it out with them.”. 4. “Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you’re feeling more comfortable.”.

954. The parents of a newborn infant diagnosed with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which concern for the parents?. 1. Inability to cope with change. 2. Anger about lost opportunities. 3. Trouble adjusting to a child born with medical issues. 4. Depression associated with the birth of a child with defects.

955. The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known pathological dysfunction. Based on this information, the nurse determines that the client is experiencing which type of dysfunctional communication?. 1. Mutism. 2. Verbigeration. 3. Pressured speech. 4. Poverty of speech.

956. A client with schizophrenia states to the nurse, “I am a spy for the FBI. I am an eye, an eye in the sky.” Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?. 1. Echolalia. 2. Word salad. 3. Clang associations. 4. Loosened associations.

957. The nurse is planning the hospital discharge of a young client who has been newly diagnosed with type 1 diabetes mellitus. The client expresses concern about self-administering insulin while in school with other students around. Which statement by the nurse best supports the client’s need for support at this time?. 1. “Oh, don’t worry about that! You’ll do fine!”. 2. “You could leave school early and take your insulin at home.”. 3. “You shouldn’t be embarrassed by your diabetes. Lots of people have this disease.”. 4. “Ask the school nurse about identifying a private area for you to use for injections.”.

958. The nurse is preparing a client for a parathyroidectomy when the client states, “I guess I’ll have to wear a scarf after this surgery.” Considering this statement, which concern should the nurse address?. 1. Denial that the surgery is necessary. 2. Trouble coping with the need for surgery. 3. Issues with potential changes to body image. 4. Anxiety about postsurgical altered function.

959. The significant other of a client diagnosed with Graves’ disease expresses concern regarding the client’s bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client. 1. Grief. 2. Socialization issues. 3. Issues related to sensory perception. 4. Trouble with coping with a disease process.

960. A client who was admitted for the treatment of thyroid storm (hyperthyroidism) is preparing for discharge. The client is anxious about the illness and is, at times, emotionally labile. Which intervention is most appropriate for the nurse to implement at this time?. 1. Assist the client with identifying coping skills, support systems, and potential stressors. 2. Avoid teaching the client anything about the disease until he or she is emotionally stable. 3. Reassure the client that everything will usually be fine after returning to one’s home and family. 4. Explain that being able to control of one’s behavior must be achieved being discharge to home can occur.

961. The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?. 1. Poor self-care. 2. Body image insecurity. 3. Neck range of motion restrictions. 4. Uncontrolled pain related to the CVC.

962. A 12-year-old client is seen in the health care clinic. During the assessment, which finding would suggest to the nurse that the client is experiencing a disruption in the development of self-concept?. 1. The child has many friends. 2. The child has a part-time babysitting job. 3. The child has an intimate relationship with a significant other. 4. The child enjoys playing chess and mastering new skills with this game.

963. A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client?. 1. Noting whether the client has visitors. 2. Instructing all staff members to not touch the client. 3. Giving the client a roommate with TB who persistently tries to talk. 4. Removing the calendar and clock in the room so that the client will not obsess about time.

964. The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse’s observations, which is the appropriate client concern?. 1. Lack of knowledge about COPD. 2. Difficulty coping related with a situational crisis. 3. Negative self-image because of neurological deficit. 4. Restricted verbal communication because of a physical barrier.

965. While intoxicated, a client received a severe full-thickness burn to his left leg. After an unsuccessful response to treatment, an amputation is required. After signing the informed consent form, the nurse observes that the client appears withdrawn. Which action should the nurse implement at this time?. 1. Let the client have some time alone to grieve about the future loss of the limb. 2. Teach the client that the injury was a result of alcohol abuse, and suggest counseling. 3. Communicate with the client in a manner that reflects back to the client that he appears to be upset. 4. Inform the primary health care provider of the client’s behavior, and request medication to assist with coping.

966. The nurse is caring for a client diagnosed with left-sided Bell’s palsy. Which statement by the client shows a need for further teaching by the nurse?. 1. “My left eye is tearing a lot.”. 2. “I have trouble closing my left eyelid.”. 3. “I don’t know how I’ll live with this stroke.”. 4. “I can’t feel anything on the left side of my face.”.

967. A client has a scheduled office visit due to a new diagnosis of diabetes mellitus. The client tells the nurse that he has trouble maintaining proper health due to anxiety regarding the self-administration of insulin. Which teaching/learning strategy should the nurse initially plan to implement?. 1. Teach a family member to give the client the insulin. 2. Leave a list of instructions at the bedside for practicing the insulin injections. 3. Insert the needle, and have the client push in the plunger and remove the needle. 4. Give the injection until the client feels sufficiently confident to preform it alone.

968. A client who is in labor has human immunodeficiency virus (HIV) and states to the nurse, “I know I will have a sick-looking baby.” Which appropriate therapeutic response should the nurse make?. 1. “You are very sick, but your baby may not be.”. 2. “All babies are beautiful. I am sure your baby will be too.”. 3. “You have concerns about how HIV will affect your baby?”. 4. “There is no reason to worry. Our neonatal unit offers the latest treatments available.”.

969. A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, “The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?” Which is the most appropriate therapeutic response the nurse should make to the client?. 1. “Any invasive procedure brings risk with it. You need to report any shoulder pain immediately.”. 2. “You seem to understand the preparation very well. Are you having any concerns about the procedure?”. 3. “Trouble? There is never any trouble with this procedure. That’s why the surgeon will use local anesthesia.”. 4. “There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported immediately.”.

970. The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?. 1. Support in maintaining a sense of control. 2. Less pain and anxiety than with a normal labor. 3. A sense of satisfaction regarding her quick labor. 4. Fewer fears regarding the effect of labor on the newborn infant.

971. The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a “tearing” sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the client should the nurse make?. 1. “Try not to worry, you and your baby are in good hands.”. 2. “I understand your concerns. I’ll let your health care provider know you need to talk.”. 3. “I don’t have time to answer questions now but I’ll plan for us to have time to talk later.”. 4. “I can understand that you are fearful. We are doing everything possible for your baby.”.

972. A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?. 1. Atrophy. 2. Infertility. 3. Malignancy. 4. Feminization.

973. The mother of a newborn diagnosed with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse, “I’m not sure if I can care for my baby at home.” Which therapeutic response should the nurse make to the mother?. 1. “All babies have individual needs.”. 2. “Mothers instinctively know what is best for their babies.”. 3. “You have concerns about your baby’s condition and care?”. 4. “There is no reason to worry. You have a good pediatrician.”.

974. A preschooler has just been diagnosed with impetigo. The child’s mother tells the nurse, “But my children take baths every day.” Which therapeutic response should the nurse make to the mother?. 1. “You are concerned about how your child got impetigo?”. 2. “There is no need to worry. We will not tell your day care provider why your child is absent.”. 3. “Not only do you have to do a better job of keeping your children clean, you must also wash your hands more frequently.”. 4. “You should have seen the doctor before the wound became infected, and then you would not have had to worry about the child having impetigo.”.

975. The nurse is preparing to care for a child with anemia from a culture that is different from the nurse’s. Which is the best way to address the cultural needs of the child and family when the child is admitted to the health care facility?. 1. Address only those issues that directly affect the nurse’s care of the child. 2. Ask questions, and explain to the family why the questions are being asked. 3. Explain that cultural practices need to be discontinued during hospitalization. 4. Ignore cultural needs because they are not important to health care professionals.

976. A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, “I’m no good to anyone. I might as well be dead.” Which most therapeutic response should the nurse make to the client?. 1. “You’re not a useless person at all.”. 2. “I’ll ask the psychologist to see you about this.”. 3. “You appear to be feeling pretty bad about things.”. 4. “It makes me uncomfortable when you talk this way.”.

977. The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client’s distress, how should the nurse best respond?. 1. “Do you want me to call your daughter?”. 2. “Can you tell me a little about what has you so upset?”. 3. “Try not to be so upset. Psychological stress is bad for your heart.”. 4. “I understand how you feel. I’d cry, too, if I had a major heart attack.”.

978. A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?. 1. The client is projecting by insisting that walking is the rehabilitation goal. 2. To speed acceptance, the client needs reinforcement that he will not walk again. 3. Denial can be protective while the client deals with the anxiety created by the new disability. 4. The client needs to move through the grieving process rapidly to benefit from rehabilitation.

979. The nurse is developing a plan of care for a client scheduled for an above the-knee leg amputation. Which action should the nurse include in the plan of care when addressing the psychosocial needs of the client?. 1. Explain to the client that open grieving is abnormal. 2. Encourage the client to express feelings about body changes. 3. Advise the client to seek psychological treatment after surgery. 4. Discourage sharing with others who have had similar experiences.

980. A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?. 1. Ask a family member to stay with the client during the procedure. 2. Give the client the call bell, and encourage its use if the client feels worse. 3. Leave the client alone only to gather the required equipment and medications. 4. Stay with the client, and ask another nurse to gather needed equipment and supplies.

981. The family of a client diagnosed with a myocardial infarction complicated by cardiogenic shock is visibly anxious and upset about the client’s condition. Which should the nurse plan to implement to provide support to the family?. 1. Offer them coffee and other beverages on a regular basis. 2. Insist that they go home to sleep at night to keep up their own strength. 3. Ask the hospital chaplain to sit with them until the client’s condition stabilizes. 4. Provide flexible visiting times according to the client’s condition and family needs.

982. A client having premature ventricular contractions states to the nurse, “I’m so afraid that something bad will happen.” Which action by the nurse provides the most immediate help to the client?. 1. Telephoning the client’s family. 2. Using a television to distract the client. 3. Having a staff member stay with the client. 4. Giving reassurance that nothing will happen to the client.

983. A client diagnosed with Raynaud’s disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change should the nurse teach the client to consider to help alleviate his stress?. 1. Change to a less stressful job. 2. Seek help from a psychologist. 3. Consider a stress management program. 4. Use earplugs to minimize environmental noise.

984. A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, “I’m not sure about this. What if it doesn’t work and I’m just as bad off as before?” Which concern for the client should the nurse identify at this time?. 1. Anxiety and depression. 2. Inability to handle the treatment regimen. 3. Lack of knowledge about the surgical procedure. 4. Fear about the potential risks and outcomes of surgery.

985. A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client’s anxiety, should now be limited?. 1. Radio. 2. Television. 3. Family visitors. 4. Antianxiety medications.

986. A client scheduled for pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. Which therapeutic response should the nurse make to the client to provide reassurance?. 1. “The procedure is somewhat painful, but there is minimal exposure to radiation.”. 2. “Discomfort may occur with needle insertion, and there is minimal exposure to radiation.”. 3. “There is very mild pain throughout the procedure, and the exposure to radiation is negligible.”. 4. “There is usually no pain, although a moderate amount of radiation must be used to get accurate results.”.

987. The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client’s anxiety?. 1. Staying with the client. 2. Distracting the client with television. 3. Interpreting the arterial blood gas report. 4. Encouraging the client to cough and breathe deeply.

988. A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares with the nurse feelings of social isolation. Which strategy should the nurse suggest as the most useful way to decrease the client’s stated loneliness?. 1. Reinstituting contact with the client’s family, who live in a distant city. 2. Contacting a support group for clients with AIDS that is available in the local region. 3. Using the Internet or the computer to facilitate communication while maintaining isolation. 4. Using the television and newspapers to maintain a feeling of being “in touch” with the world.

989. A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, “Maybe I shouldn’t bother going. I wonder if I should just take more medication instead.” Which therapeutic response should the nurse make to the client?. 1. “Can you tell me more about how you’re feeling?”. 2. “Don’t you really want to control your heart disease?”. 3. “Most people tolerate the procedure well without any complications.”. 4. “Don’t worry. Emergency equipment is available if it should be needed.”.

990. The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, “What’s the use? I’ll never remember all of this, and I’ll probably die anyway!” The nurse determines that the client’s statement is most likely due to which psychosocial concern?. 1. Anger about the new medical regimen. 2. The teaching strategies used by the nurse. 3. Insufficient financial resources to pay for the medications. 4. Anxiety about the ability to manage the disease process at home.

991. Before inserting a peripheral intravenous (IV) catheter into a preoperative client, the nurse notes that the client’s muscles are tense and the client is fidgeting with the bed sheet, stating that she does not understand why she has to have the IV. Which statement should the nurse first verbalize to the client?. 1. “This will be finished before you know it.”. 2. “Inserting the IV does not hurt very much.”. 3. “The IV adds needed fluid into your bloodstream.”. 4. “The IV catheter is an 18-gauge angiocatheter, which is small.”.

992. A client who received an implanted port for intermittent chemotherapy says, “I’m not sure if I can handle having a tube coming out of me. What will my friends think?” Which action should the nurse implement first?. 1. Show the client various central line catheters. 2. Assure the client that his friends will understand. 3. Explain that implanted ports are subcutaneous and not visible. 4. Notify the primary health care provider of the client’s concerns.

993. A postoperative client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued as a result of an infiltration. Which appropriate statement should the nurse make to the client?. 1. “This is usually a painless experience. It is nothing to worry about.”. 2. “I’m sure it will be a real relief for you just as soon as I discontinue this IV for good.”. 3. “Just relax and take a deep breath. This procedure will not take long, and it will be over soon.”. 4. “I can see that you’re anxious. Removal of the IV shouldn’t be painful, but the IV will need to be restarted in another location.”.

994. A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. Which knowledge should the nurse use to provide support to the client?. 1. The client is HIV positive, but the client’s CD4 cell count is high. 2. The client is HIV positive, but the disease has been detected early. 3. There are occasional false-positive readings with this test; results can be verified by repeating it one more time. 4. False-positive results can occur, and more testing is needed before diagnosing the client as being HIV positive.

995. When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?. 1. “Do you have a death wish?”. 2. “Do you wish your life was over?”. 3. “Do you ever think about ending it all?”. 4. “Do you have any thoughts of killing yourself?”.

996. A client diagnosed with cancer of the bladder is fearful of the potential outcomes of an upcoming cystectomy and urinary diversion. Which statement made to the nurse indicates the client’s fear?. 1. “I wish I’d never gone to the doctor at all.”. 2. “I’m so afraid that I won’t live through all this.”. 3. “I’ll never feel like myself if I can’t go to the bathroom normally.”. 4. “What if I have no help at home after going through this awful surgery?””.

997. A client diagnosed with nephrotic syndrome asks the nurse, “Why should I even bother trying to control my diet and the edema? It doesn’t really matter what I do if I can never get rid of this kidney problem, anyway!” Which should the nurse identify as the most appropriate concern for this client?. 1. Anxiety. 2. Powerlessness. 3. Difficulty coping. 4. Negative self-image.

998. A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information should the nurse initially provide to the client?. 1. It is very likely that the client will need dialysis within 5 to 10 years. 2. One kidney is adequate to meet the needs of the body, as long as it has normal function. 3. There is absolutely no chance of the client needing dialysis because of the nature of the surgery. 4. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.

999. A charge nurse is supervising a new nurse who is providing care to a client diagnosed with end-stage heart failure. The client is withdrawn and reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement, if made by the new nurse to the client, indicates that the new nurse has a need for further teaching regarding the use of therapeutic communication techniques?. 1. “What are your feelings right now?”. 2. “Why don’t you feel like getting up for your bath?”. 3. “These dreams you mentioned, what are they like?”. 4. “Many clients with end-stage heart failure fear death.”.

1000. The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy should the nurse plan to incorporate into the care of the client?. 1. Reducing anxiety. 2. Increasing fluid volume. 3. Decreasing cardiac output. 4. Promoting a positive body image.

1001. A client diagnosed with acute kidney injury is having trouble remembering information and instructions as a result of altered laboratory values. Which actions should the nurse take when communicating with this client? Select all that apply. 1. Give simple, clear directions. 2. Include the family in discussions related to care. 3. Explain treatments using understandable language. 4. Explain the possibility of hemodialysis in simple terms. 5. Give thorough and complete explanations of treatment options.

1002. The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation session. Which would be the most appropriate therapeutic statement for the nurse to make to identify the feelings of the client?. 1. “You seem upset.”. 2. “Oh, don’t let this get you down.”. 3. “It will seem better tomorrow. Now smile.”. 4. “You shouldn’t get upset. It’ll affect your heart.”.

1003. The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which should the nurse assess to yield the best information about this area of functioning?. 1. Judgment. 2. Emotions. 3. Consciousness. 4. Eye movements.

1004. A client is admitted to the mental health unit with a diagnosis of panic disorder. The nurse should check the primary health care provider’s prescription sheet anticipating that which medication, a benzodiazepine, will be prescribed?. 1. Doxepin. 2. Alprazolam. 3. Imipramine. 4. Bupropion.

1005. A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure should the nurse offer emotional support to the client?. 1. This problem may decrease the client’s life expectancy. 2. The client is likely to be in excruciating pain after surgery. 3. The client will probably have chronic dyspnea after the surgery. 4. Chest tubes will be in place after surgery, and the healing process is slow.

1006. A client who has never been hospitalized before and is in a hospital room with a roommate is anxious and having trouble initiating a stream of urine. Knowing that there is no pathological reason for this difficulty, which nursing interventions should be included when assisting the client? Select all that apply. 1. Catheterizing the client. 2. Running tap water in the sink. 3. Assisting the client to a commode behind a closed curtain. 4. Instructing the client to pour warm water over the perineum. 5. Closing the bathroom door and instructing the client to pull the call bell when done.

1007. The client states to the nurse, “I’m scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I’m afraid. What happens if something goes wrong after I go home?” Which statement by the nurse is the most therapeutic?. 1. “Don’t worry about the details. This procedure is done all the time and generally without any problems. You’ll be fine!”. 2. “They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I’ll come.”. 3. “Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can’t be too careful.”. 4. “You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?”.

1008. During the nursing assessment, the client states, “My surgeon just told me that my cancer has spread, and I have less than 6 months to live.” Which nursing response would be the most therapeutic?. 1. “I am sorry. Would you like to discuss this with me some more?”. 2. “I am sorry. There are no easy answers in times like this, are there?”. 3. “I hope you’ll focus on the fact that your doctor says you have 6 months to live and that you’ll think of how you’d like to live.”. 4. “I know it seems desperate, but there have been a lot of breakthroughs. Something might come along in a month or so to change your status drastically.”.

1009. A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication should the nurse determine may be the best for the client?. 1. Use a picture or word board. 2. Have the family interpret needs. 3. Devise a system of hand signals. 4. Use a pad of paper and a pencil.

1010. The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, “I really miss eating dinner with my family.” Which statement from the nurse is the most therapeutic?. 1. “What you are feeling is very common.”. 2. “Tell me more about your family dinners.”. 3. “In a few weeks, you may be allowed to eat.”. 4. “You can sit down to dinner even if you do not eat.”.

1011. A client has been prescribed imipramine. The nurse notifies the primary health care provider if which adverse effect to the medication is noted?. 1. Increased appetite. 2. Increased drowsiness. 3. Reported decrease in anxiety. 4. Increased sense of well-being.

1012. A client who is to undergo thoracentesis is afraid of not being able to tolerate the procedure. The nurse interprets that the client needs honest support and reassurance, best accomplished with which information?. 1. “I’ll be right by your side, but the procedure will be totally painless as long as you don’t move.”. 2. “The procedure only takes 1 to 2 minutes, so you might try to get through it by mentally counting up to 120.”. 3. “The needle hurts when it goes in, and you must remain still. I’ll stay with you throughout the entire procedure and help you hold your position.”. 4. “The needle is a little bit uncomfortable going in, but this is controlled by rhythmically breathing in and out. I’ll be with you to coach your breathing.”.

1013. A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea–anxiety–dyspnea cycle?. 1. Guided imagery and limiting fluids. 2. Relaxation and breathing techniques. 3. Biofeedback and coughing techniques. 4. Distraction and increased dietary carbohydrates.

A client who has end-stage cancer is admitted to a hospice care facility from her home. Which intervention should the nurse implement to address the client’s psychosocial needs?. 1. Administer total care for the client. 2. Engage the client in social activities. 3. Allow the client to verbalize feelings. 4. Provide pain medication every 4 hours.

Communication A client with myasthenia gravis is having difficulty with the motor aspects of speech. The client has difficulty forming words, and the voice has a nasal tone. The nurse should plan to use which communication technique when working with this client?. 1. Encourage the client to speak quickly. 2. Nod continuously while the client is speaking. 3. Repeat what the client has said to verify the message. 4. Engage the client in lengthy discussions to strengthen the voice.

Documentation The nurse finds a client lying on the floor. The nurse performs an assessment,assists the client back to bed, and completes an incident report. Which should the nurse document on the incident report?. 1. The client fell onto the floor. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The nurse was the only responder to the event.

Culture and Spirituality The nurse notes that a female Muslim client shows discomfort with many of the male health care providers. Based on this observation, which action should the nurse take?. 1. Inform all health care providers to ensure privacy because of modesty issues in this culture. 2. Assign older male health care providers to the client if a female health care provider is not available. 3. Assign female health care providers to the client and try to assign the same female health care provider every day. 4. Let the client know that you understand that modesty is very important in the Muslim culture and ask the client if there is some way to make the client more comfortable.

The nurse is performing an educational session on incorporating spiritual assessment in client care. Which statement, if made by one of the participants, indicates a need for further education regarding spirituality in health care?. 1. “Spirituality has different meanings for different people.”. 2. “Spirituality can positively influence health and quality of life.”. 3. “Nurses need to be aware of their own spirituality to address this topic with others.”. 4. “Spirituality can be a comforting influence; however, there is no scientific evidence of the benefits.”.

Nursing Process: Assessment The clinic nurse in a well-baby clinic is collecting data regarding the motor development of a 15-month-old child. Which is the highest level of development that the nurse would expect to observe in this child?. 1. The child turns a doorknob. 2. The child unzips a large zipper. 3. The child builds a tower of two blocks. 4. The child puts on simple clothes independently.

Nursing Process: Analysis A client is admitted to the cardiac unit and placed on telemetry. The nurse reviews the client’s laboratory results and notes that the potassium level is 6.3 mEq/L (6.3 mmol/L). When analyzing the cardiac rhythm, the nurse would expect to note which electrocardiogram (ECG) finding?. 1. A sinus tachycardia with an extra U wave. 2. A sinus rhythm with a tall, peaked T wave. 3. A sinus rhythm with a depressed ST segment. 4. A sinus tachycardia with a prolonged QT interval.

Nursing Process: Planning The nurse is planning care for a child admitted to the hospital with an infectious and communicable disease. The nurse should identify which as the primary goal?. 1. The public health department will be notified. 2. The child will not spread the infection to others. 3. The child will experience only minor complications. 4. The nursing supervisor will be notified about the child’s diagnosis.

Nursing Process: Implementation The nurse in the postpartum unit checks the temperature of a client who delivered a healthy newborn 4 hours ago. The mother’s temperature is 100.8° F (38.2° C). The nurse provides oral hydration to the mother and encourages fluid intake. Four hours later, the nurse rechecks the temperature and notes that it is still 100.8° F. Which appropriate action should the nurse take at this time?. 1. Document the temperature. 2. Increase the intravenous fluids. 3. Notify the primary health care provider (PHCP). 4. Continue hydration and recheck the temperature in 4 hours.

Nursing Process: Evaluation A client has been given a prescription for a course of azithromycin. The nurse determines that the medication is having the intended effect if which is noted?. 1. The pain is relieved. 2. The blood pressure is lowered. 3. The joint discomfort is reduced. 4. The signs and symptoms of infection are relieved.

Teaching and Learning The nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin. Which instruction should the nurse include in the plan?. 1. Monitor the child’s intake and output daily. 2. Provide oral hygiene, especially care of the gums. 3. Administer the medication 1 hour before food intake. 4. Check the child’s blood pressure before the administration of the medication.

Caring 1014. A client diagnosed with diabetes mellitus requires the immediate amputation of a leg. The client is very upset and states, “This is the doctor’s fault! I did everything that I was told to do!” When considering the grieving process, how should the nurse respond to the client’s statement?. 1. Notify the agency’s risk management department. 2. Help the client consider alternatives to treatment. 3. Allow the client to use anger as a coping mechanism. 4. Ask the client to list all previous health care providers.

1015. The nurse has an established relationship with the family of a client whose death is imminent. Which intervention should the nurse focus on in order to help the family most effectively cope with this experience?. 1. Limiting time in the client’s room to promote privacy. 2. Providing education regarding coping mechanisms to use. 3. Identifying spiritual measures that work best for dying clients. 4. Answering questions clearly and providing resources as requested.

1016. A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?. 1. Remaining with the client. 2. Placing the client in a quiet room. 3. Teaching the client deep-breathing exercises. 4. Encouraging the expression of feelings and concerns.

1017. When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?. 1. “Autopsies are mandatory for clients who are DOA.”. 2. “Federal law requires autopsies for clients who are DOA.”. 3. “The medical examiner makes the decision about autopsies.”. 4. “I will make sure the medical examiner is aware of your request.”.

1018. The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach should the nurse use to help the family cope with their concerns?. 1. Explain equipment and procedures on an ongoing basis. 2. Discuss displaying their grief only when not in the room with the client. 3. Discourage them from touching the client in order to minimize stimulation. 4. Explain that they need their rest so they should adhere to regular visiting hours.

1019. The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman’s daughter states, “If this is a stroke, it’s the kiss of death.” What initial response should the nurse make?. 1. “Why would you think like that?”. 2. “You feel your mother is dying?”. 3. “These symptoms are reversible.”. 4. “A stroke is not the kiss of death.”.

1020. A client and her infant have been diagnosed as being positive for human immunodeficiency virus (HIV). When the mother is observed crying, the nurse determines that which intervention will meet the client’s initial needs?. 1. Discussing how the mother was exposed to HIV. 2. Sitting quietly with the mother as she talks and cries. 3. Describing the progressive stages and treatments of HIV. 4. Calling an HIV counselor to make an appointment for the mother and infant.

1021. The nurse cared for a client who died a few minutes ago. Which event supports the nurse’s belief that the client died with dignity?. 1. The family thanks the nurse for facilitating such a peaceful death. 2. The nurse states that it is difficult to give that kind of care to a dying client. 3. The primary health care provider acknowledges that all of the prescriptions were carried out. 4. The nurse kept the client’s last hours comfortable with increasing doses of pain medication.

1022. A client diagnosed with Parkinson’s disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client’s activities of daily living. Which statement indicates that the teaching has been effective?. 1. “We should plan for only a few activities during the day.”. 2. “We should assist with activities of daily living as much as possible.”. 3. “We should cluster activities at the end of the day, to help conserve energy.”. 4. “We should encourage and praise efforts to exercise and perform activities of daily living.”.

1023. A community health nurse is caring for a group of homeless people. What is the most immediate concern when planning for the potential needs of this group?. 1. Finding affordable housing for the group. 2. Setting up a 24-hour crisis center and hotline. 3. Providing peer support through structured support groups. 4. Ensuring that adequate food, shelter, and clothing are available.

1024. A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective?. 1. “How can I assist you with ways to remember your baby?”. 2. “You seem upset. Do you think a tranquilizer would help?”. 3. “I feel so bad. I don’t understand why this happened either.”. 4. “I can allow another 15 minutes together for you to grieve.”.

1025. The nurse is caring for a depressed, withdrawn client who was responsible for an automobile accident that recently resulted in the death of a child. What is the nurse’s initial action?. 1. Allow the client to have some time alone to grieve over the loss. 2. Reinforce to the client that the child’s death was a result of an accident. 3. Communicate in a manner that acknowledges and respects the client’s depressed state. 4. Inform the primary health care provider of the client’s possible need for medication to cope.

1026. The nurse is bathing a client when the client begins to cry. Which action by the nurse is therapeutic at this time?. 1. Continue bathing the client and say nothing. 2. Stop the bath, cover the client, and sit with the client. 3. Stop the bath, cover the client, and allow the client private time. 4. Call the primary health care provider to report the signs of depression.

1027. An older couple was emotionally despondent when their home was severely damaged by flooding. When planning for the couple’s initial needs, what intervention should the community health nurse implement?. 1. Contacting their families. 2. Attending to their emotional needs. 3. Arranging for the repair of their home. 4. Attending to their basic physiological needs.

1028. The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?. 1. Placing the client in a private room to ensure privacy and confidentiality. 2. Interacting with the client demonstrating examples of unconditional positive regard. 3. Maintaining a distance of 10 inches in order to ensure the client that personal control will be provided. 4. Placing the client in charge of a meaningful unit activity, such as the morning chess tournament.

1029. Shortly after a client dies, the nurse asks the family about funeral arrangements. When the family refuses to discuss the issue, which intervention by the nurse is appropriate for their stage of grief?. 1. Displaying acceptance of the family’s issues. 2. Providing information about funerals in general. 3. Probing for information about funeral arrangements. 4. Asking the family if they would like time alone with the client.

1030. A client diagnosed with incurable cancer has a life expectancy of a few weeks. Which response indicates that the client’s partner is reacting with an expected coping response?. 1. Refusing to visit the client. 2. Expresses anger with his God. 3. Not allowing the death to occur at home. 4. Sending the children to live with relatives.

Communication and Documentation 1031. The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse–client relationship. Which intervention is representative of this phase of the relationship?. 1. The nurse and client determine the contract for time. 2. The client is encouraged to make use of all services depending on need. 3. The client begins to identify with the nurse, and trust and rapport are maintained. 4. The nurse focuses on facilitating the therapeutic expression of the client’s feelings.

1032. The partner of a client who has an esophageal tube introduced for a second time tells the nurse, “I thought having this tube down the nose the first time would convince anyone to quit drinking.” Which response to the statement should the nurse make?. 1. “I think you are a good person to stay with her.”. 2. “Alcoholism is a disease that affects the whole family.”. 3. “Have you discussed this subject at the Al-Anon meetings?”. 4. “You sound frustrated dealing with such a drinking problem.”.

1033. The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?. 1. “Do you have concerns about managing your condition?”. 2. “Do you think you might need to go to the nursing home?”. 3. “If you take the correct medications, I doubt this will happen again.”. 4. “Don’t worry. I’m sure your family will provide all the help you need.”.

1034. The nurse assesses the client’s peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?. 1. Phlebitis. 2. Infection. 3. Infiltration. 4. Thrombosis.

1035. The nurse is providing education to the unlicensed assistive personnel (UAP) in preparation for communicating with a hearing-impaired client? Which statements by the UAP indicates that teaching has been effective? Select all that apply. 1. “Speak using a normal tone of voice.”. 2. “Speak clearly when communicating with the client.”. 3. “Speak slowly and directly into the client’s impaired ear.”. 4. “Face the client directly when carrying on a conversation.”. 5. “Be aware of signs that the client does not understand the conversation.”.

1036. The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?. 1. Directing the discussions so that teaching needs are met. 2. Focusing directly on the client’s message regarding needs. 3. Reflecting only facts related to the client’s expressed concerns. 4. Reacting to the client’s responses in a matter-of-fact, professional manner.

1036. The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?. 1. Directing the discussions so that teaching needs are met. 2. Focusing directly on the client’s message regarding needs. 3. Reflecting only facts related to the client’s expressed concerns. 4. Reacting to the client’s responses in a matter-of-fact, professional manner.

1037. The nursing student is listening to a lecture on correcting errors in a written narrative on a medical record. Which statement by the nursing student indicates that the teaching has been effective?. 1. “The correct procedure is to document the correction as a late entry.”. 2. “The correct procedure is to draw a line through the error to identify it.”. 3. “The correct procedure is to remove the error in a manner approved by the facility.”. 4. “The correct procedure is to cover the error completely using a permanent marker.”.

1038. When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?. 1. The client fell out of bed and was found on the floor. 2. The client fell while climbing over the bed’s side rails. 3. The client was found lying on the floor beside the bed. 4. The client was restless and fell while getting out of bed.

1039. A client diagnosed with angina pectoris appears to be very anxious and states, “So, I had a heart attack, right?” Which response should the nurse make to the client?. 1. “No. That is not why you are hospitalized.”. 2. “No, but there could be some minimal damage to your heart.”. 3. “No, not this time and we will do our best to prevent a future heart attack.”. 4. “No, but it’s necessary to monitor you and control or eliminate your pain.”.

1040. A client diagnosed with delirium anxiously states, “Look at the spiders on the wall.” Which response by the nurse addresses the client’s concerns therapeutically?. 1. “Would you like me to kill the spiders for you?”. 2. “While there may be spiders on the wall, they are not going to hurt you.”. 3. “I know that you are frightened, but I do not see any spiders on the wall.”. 4. “You are having a hallucination; I’m sure there are no spiders in this room.”.

1041. While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client’s degree of adjustment to the new diagnosis?. 1. “Is there anyone to help with housework and shopping?”. 2. “How do you feel about making changes to your lifestyle?”. 3. “Do you understand the schedule for your new medications?”. 4. “Did you make a follow-up appointment with your provider?”.

1042. A client has been using crutches to ambulate for 1 week and now reports pain, fatigue, and frustration with crutch walking. How should the nurse respond when the client states, “I feel like I will always be crippled”?. 1. “Tell me what makes this so bothersome for you.”. 2. “I know how you feel. I had to use crutches before too.”. 3. “Why don’t you take a couple of days off of work and rest?”. 4. “Just remember, you’ll be done with the crutches in another month.”.

1043. A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse’s ability to use therapeutic communication techniques to effectively assess the teenager’s feelings about using a cane?. 1. “How do you feel about needing a cane to walk?”. 2. “Do you have questions about ambulating with a cane?”. 3. “Are you worried about what your friends will think about your cane?”. 4. “What types of problems do you think you’ll have ambulating with a cane?”.

1044. After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client’s need to ambulate?. 1. “What is it about getting out of bed that concerns you?”. 2. “If you are afraid of the pain, I can give you medication to help.”. 3. “If you don’t get up and start walking, your recovery will take much longer.”. 4. “Being dependent on others must be a depressing for an active person like yourself.”.

1045. The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?. 1. “Elevating the affected leg is indicated.”. 2. “Keeping the affected leg flat encourages healing.”. 3. “Engaging in activity as tolerated should be encouraged.”. 4. “Maintaining bathroom privileges is the most important action.”.

1046. A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?. 1. Open-ended questions and silence. 2. Offering personal opinions about the need to eat. 3. Verbalizing reasons why the client may choose not to eat. 4. Focusing on self-disclosure of the nurse’s own food preferences.

1047. The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, “I don’t think that this ECT will be helpful, especially since it makes people’s memory worse.” What form of communication should the nurse implement to address the family member’s concern?. 1. Ask other family members and the client if they think that ECT makes people worse. 2. Immediately reassure the client and family that ECT will help and that the memory loss is only temporary. 3. Involve the family member in a dialog to ascertain how the family member arrived at this conclusion. 4. Reinforce with the client and the family member that depression causes more memory impairment than ECT.

Culture and Spirituality 1048. The nurse is caring for a postoperative client with spiritual and culturally based eating and food requirements. Which interventions demonstrate the nurse’s spiritual and cultural consideration of the client? Select all that apply. 1. Encouraging the client to try new foods only until healing is complete. 2. Suggesting the substitution of similar foods for the culturally appropriate ones. 3. Asking the client to explain the factors that are important to his eating practices. 4. Including the family in discussions regarding the preparation of accepted foods. 5. Discussing the nutritional requirements the client currently has postoperatively.

1049. The nurse is caring for an older adult client of an unfamiliar ethnic culture. The nurse shows an understanding of the general principles of culturally sensitive interaction when implementing which interventions? Select all that apply. 1. Addressing the client by his full surname in order to display respect. 2. Maintaining eye contact with the client so as to show respect for the client’s age. 3. Utilizing the position of authority nurses hold to provide explanation of facility rules. 4. Touching the client only when necessary and only after explaining the need to do so. 5. Avoiding any frequent engagement with the client in conversation of a personal nature.

1050. The nurse is participating in end-of-life care for a client who has recently immigrated from Vietnam. Which interventions should the nurse consider in the plan of care for this client? Select all that apply. 1. Respect family wishes for use of herbal medicines. 2. Recognize that the use of healers is a common practice. 3. Have direct conversations with the matriarch of the family. 4. Acknowledge that lack of eye contact does not mean disinterest. 5. Allow someone from the family to stay with the body after death until burial.

1051. The nurse is caring for a client who primarily speaks Spanish. An interpreter is currently unavailable. The nurse must perform a dressing change. What should the nurse do in order to enhance communication with this client prior to changing the dressing?. 1. Use relatives to interpret because an interpreter is unavailable. 2. Speak slowly and allow the client time to interpret what is being said. 3. Use many nonverbal cues and repetition to reinforce what is being said. 4. Use common words in the nurse’s language, because the client is likely to be familiar with them.

1051. The nurse is caring for a client who primarily speaks Spanish. An interpreter is currently unavailable. The nurse must perform a dressing change. What should the nurse do in order to enhance communication with this client prior to changing the dressing?. 1. Use relatives to interpret because an interpreter is unavailable. 2. Speak slowly and allow the client time to interpret what is being said. 3. Use many nonverbal cues and repetition to reinforce what is being said. 4. Use common words in the nurse’s language, because the client is likely to be familiar with them.

1052. The nurse is conducting a cultural and spiritual assessment on a newly admitted client. Which factors specifically related to culture and spirituality should the nurse address? Select all that apply. 1. Nutrition. 2. Communication. 3. Insurance coverage. 4. High-risk behaviors. 5. Health care practices. 6. Family roles and organization.

1053. The nurse is caring for an older Orthodox Jewish client of the opposite sex whose condition is terminal. The nurse is implementing a plan of care and wishes to communicate this plan with the client and family. The nurse should be aware of what end-of-life spiritual and religious practices when planning and communicating with the client and family? Select all that apply. 1. The client may demonstrate a high level of anxiety. 2. Religious laws are suspended during times of severe illness. 3. During the process of dying, visitors and conversation should be kept to a minimum. 4. Family members may not shake hands or make direct eye contact with members of the opposite sex. 5. Clients that are of the Orthodox Jewish faith are usually very quiet and do not express what they are thinking or feeling.

1054. The nurse is caring for a Hispanic client who reports that she is a practicing Roman Catholic. Which actions by the nurse most demonstrate spiritual and cultural sensitivity? Select all that apply. 1. Turn the client’s bed toward the east, toward Mecca. 2. Ensure that meals while hospitalized include Halal foods. 3. Allow the client to observe communion daily if requested. 4. Facilitate anointing of the client by the priest if requested. 5. Advocate for the client in her choice to refuse blood products.

1055. The nurse is caring for a Jewish client who follows a kosher diet. Which foods should the nurse use in meal planning for the client? Select all that apply. 1. Pork. 2. Tuna. 3. Apples. 4. Chicken. 5. Potatoes.

1056. The nurse is caring for an older Hispanic client who is a migrant farm worker and has been admitted for asthma. The nurse is unfamiliar with the cultural and spiritual practices and beliefs of the client’s homeland. Which questions are most appropriate for the nurse to ask during the admission process? Select all that apply. 1. What do you believe is causing your illness?. 2. Why don’t you take some asthma medication?. 3. Why do you wear that amulet around your neck?. 4. Are there any remedies you have used in the past?. 5. Who do you usually see for help when you are sick?.

1057. The nurse is assessing a Southeast Asian woman who presented to the emergency department with complaints of a headache and nausea. The client is accompanied by her adult son. Upon assessment, the nurse notes long, pale red welts on both arms. Which actions should the nurse take next? Select all that apply. 1. Ask if she has used any home remedies. 2. Assess cultural health beliefs and practices. 3. Report the use of coin rubbing to social services. 4. Remove the adult son from the room immediately. 5. Recognize the redness as a result of a traditional form of healing.

1058. The hospice nurse is caring for five clients from various religious backgrounds. Which observations should the nurse expect for the clients of the various religious backgrounds? Select all that apply. 1. A client of the Muslim faith having his bed positioned toward Mecca. 2. A priest hearing the confession of the client who is of the Methodist faith. 3. An Asian client’s family desiring the client to be moved to a room number of 4. 4. Meals on Friday do not include warm-blooded meats for the client of the Baptist faith. 5. A Hindu believing that the family arranges to have the client’s body cremated within 24 hours of death.

1059. An Arab Muslim female client has been stabilized following an assault in the parking lot of a local restaurant. The nurse manager is making assignments for the oncoming shift. Which action by the nurse manager is the most appropriate to ensure the client’s comfort?. 1. Assign the best male nurse to the client. 2. Assign the client a female nurse for every shift. 3. Allow the client to pick which nurses she would like to care for her. 4. Remove all of the client’s clothing each shift to perform a skin assessment.

1060. The unit manager working on a medical-surgical unit is conducting an in service session on the provision of spirituality and culturally competent care and factors that contribute to health disparities. Which factors does the manager incorporate into this teaching session? Select all that apply. 1. Age. 2. Genetics. 3. Ethnicity. 4. Education. 5. Past medical history. 6. Health care provider attitudes.

1061. The nurse is caring for a client who is of Asian descent and is assessing for client perceptions regarding nutrition. Which, in addition to the impact of food on disease and illness, should the nurse consider in order to provide culturally competent care?. 1. Educational background and employment history. 2. Familial support systems and financial well-being. 3. Client perception of body weight and size relative to culture. 4. Ability to purchase foods necessary for disease management.

1062. The nurse is caring for a new immigrant from the Philippines. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing; her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to call the health care provider for an epidural prescription. The mother declines. The nurse should hypothesize that the client declined the epidural for which reason? Select all that apply. 1. Filipino mothers fear drug addiction. 2. Filipino mothers decrease their pain through a verbal release. 3. Filipino mothers prefer to accept treatments for pain from their parteras. 4. Filipino mothers are often stoic and view childbirth pain as a normal part of life. 5. Filipino mothers believe that pain is a form of spiritual atonement for one’s past deeds.

Teaching and Learning 1063. The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply. 1. “All used dishes should be sterilized.”. 2. “My close contacts should be tested for TB.”. 3. “Soiled tissues should be disposed of properly.”. 4. “House isolation is required for at least 8 months.”. 5. “The mouth should always be covered when coughing.”.

1064. A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client’s education?. 1. Protect the IV site continually. 2. Keep the IV site clean and dry. 3. Report local pain, drainage, or edema. 4. Apply pressure to the IV site if it dislodges.

1065. The home care nurse provides instructions about the management of pruritus to a client diagnosed with jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching?. 1. “I need to wear loose cotton clothing.”. 2. “A tepid water bath should help stop the itching.”. 3. “Keeping the house warmer is likely to lessen the itching”. 4. “I need to take the prescribed antihistamines as I’m supposed to.”.

1066. The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?. 1. “Prune juice needs to be included in my diet.”. 2. “I need to avoid strenuous activity for 4 to 6 weeks.”. 3. “My intake of water needs to be at least 6 to 8 glasses daily.”. 4. “I can’t lift or push objects that weigh more than 30 pounds.”.

1067. A client is being treated for an atrial dysrhythmia with quinidine gluconate. Which statement by the client indicates to the nurse that the medication instructions about what to do if a dose is missed have been understood?. 1. “I should call my primary health care provider.”. 2. “I should take the next prescribed dose as usual.”. 3. “I should take the dose as soon as I realize I’ve missed it.”. 4. “I take two doses of the medication at the next scheduled time.”.

1068. The nurse is educating the client on how to save lives and prevent burn injuries, in the event of a fire in the home. Which statement by the client indicates that the teaching has been effective?. 1. “I should lace escape ladders in the bedrooms.”. 2. “I should install a whole-house sprinkler system.”. 3. “I should keep fresh batteries in smoke detectors.”. 4. “I should mount fire extinguishers in several areas.”.

1069. A client has had same-day surgery to insert a ventilating tube into the tympanic membrane. Which statement assures the nurse that the client understands the discharge instructions?. 1. “I will use a shower cap when taking a shower.”. 2. “I was told to try and avoid taking medications for pain.”. 3. “I need to wash my hair quickly; taking 2 minutes or less.”. 4. “Swimming is allowed only if I keep my head above water.”.

1070. The nurse has completed diet teaching for a client on a low-sodium diet for the treatment of hypertension. Which statement by the client should indicate to the nurse that there is a need for further teaching?. 1. “Frozen foods are usually lowest in sodium.”. 2. “This diet will help lower my blood pressure.”. 3. “This diet is not a replacement for my antihypertensive medications.”. 4. “The reason I need to lower my salt intake is to reduce fluid retention.”.

1071. The nurse is giving dietary instructions to a client who has been prescribed cyclosporine. Which statement by the client indicates the need for further teaching?. 1. “Red meats are alright to eat.”. 2. “Orange juice is a great choice for breakfast.”. 3. “Grapefruit juice will not interfere with the medication.”. 4. “Green leafy vegetables should be eaten as often as possible.”.

1072. The nurse performs an initial assessment on a pregnant client and determines that the client is at risk for toxoplasmosis. The nurse provides education to the client on how to prevent the disease. Which statement by the client indicates that teaching has been effective?. 1. “It’s alright to eat raw meats.”. 2. “I should wash hands only before meals.”. 3. “I should avoid exposure to litter boxes used by my cat.”. 4. “I should use topical corticosteroid treatments prophylactically.”.

1073. A home care nurse is instructing a mother of a child diagnosed with cystic fibrosis (CF) about the appropriate dietary measures. Which diet should the nurse tell the mother that the child needs to consume?. 1. Low-calorie, low-fat diet. 2. High-calorie, restricted fat. 3. Low-calorie, low-protein diet. 4. High-calorie, high-protein diet.

1074. The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?. 1. “Crutch walking instructions should be scheduled before surgery.”. 2. “Crutch walking instructions should be given on the first postoperative day.”. 3. “Crutch walking instructions should be scheduled on the second postoperative day.”. 4. “Crutch walking instructions should be scheduled at the time of discharge after surgery.”.

1075. A client with a short leg plaster cast reports intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which statement by the client indicates an understanding of the measures used to relieve the itching?. 1. “I can use the blunt part of a ruler to scratch the area.”. 2. “I can trickle small amounts of water down inside the cast.”. 3. “I need to obtain assistance when placing an object into the cast for the itching.”. 4. “I can use a hair dryer on the low setting and allow the air to blow into the cast.”.

1076. Disulfiram has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?. 1. “I must be careful taking cold medicines.”. 2. “I will have to check my aftershave lotion.”. 3. “I’ll be fine as long as I don’t drink alcohol.”. 4. “I need to be careful with ingredients when I cook.”.

1077. The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?. 1. “I need to eat a high-protein diet.”. 2. “I need to avoid exposure to sunlight.”. 3. “I need to wash my skin with a mild soap and pat it dry.”. 4. “I need to apply pressure on the irritated area to prevent bleeding.”.

1078. During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client needs further teaching regarding TSE?. 1. “I know to report any small lumps.”. 2. “I should examine myself every 2 months.”. 3. “I should examine myself after I take a warm shower. 4. “I know it’s normal to feel something that is cord-like in the back.”.

1079. A client diagnosed with acquired immunodeficiency syndrome (AIDS) is reporting fatigue. The nurse educates the client on ways to conserve energy. Which statement indicates that the teaching was effective?. 1. “Bathe before eating breakfast.”. 2. “Sit for as many activities as possible.”. 3. “Stand in the shower instead of taking a bath.”. 4. “Group all tasks to be performed early in the morning.”.

1080. A 10-year-old child has been diagnosed with type 1 diabetes mellitus. What instruction should the nurse provide concerning the monitoring of the child’s insulin needs?. 1. The child should be taught to self-monitor insulin needs. 2. The parents will need to be available to monitor the child’s insulin needs. 3. The child’s school teacher will assume responsibility of insulin need monitoring. 4. Friends and family will need to be involved with monitoring the child’s insulin needs.

1081. The nurse instructs a client diagnosed with oral candidiasis (thrush) about caring for the disorder. Which statement by the client indicates a need for additional teaching?. 1. “I can eat foods that are liquid or pureed.”. 2. “I should eliminate spicy foods from my diet.”. 3. “It’s best if I don’t drink citrus juices or hot liquids.”. 4. “I need to rinse my mouth four times daily with commercial mouthwash.”.

1082. The nurse has given instructions about site care to a hemodialysis client who had an implantation of an arteriovenous (AV) fistula in the right arm. Which statement by the client indicates a need for further teaching?. 1. “I will need to sleep on my right side.”. 2. “It’s important that I don’t carry heavy objects with the right arm.”. 3. “I will perform range-of-motion exercises routinely on my right arm.”. 4. “It’s important that I report any right arm redness or drainage at the site.”.

1083. The nurse provides instructions to a client about applying a nitroglycerin patch. What statement indicates that the client is using correct technique?. 1. “A second patch will be applied if chest pain occurs.”. 2. “I will apply the patch to a nonhairy area of the body.”. 3. “I will remove the patch when bathing and reapply it after the bath.”. 4. “I will remove the patch after gently rubbing the area to activate the medication.”.

1084. The nurse is giving medication instructions to a client who is receiving furosemide. Which client statement indicates a need for further teaching?. 1. “I need to change positions slowly.”. 2. “I need to be careful to not get overheated in warm weather.”. 3. “I need to talk to my primary health care provider about the use of alcohol.”. 4. “I need to avoid the use of salt substitutes because they contain potassium.”.

1085. A client has been prescribed a clonidine patch, and the nurse has instructed the client regarding the use of the patch. Which client statement indicates a need for further teaching?. 1. “I intend to change the patch every 7 days.”. 2. “I need to trim the patch if an edge becomes loose.”. 3. “It’s important to put the patch on a hairless site on my torso.”. 4. “It’s alright to leave the patch in place during bathing or showering.”.

1086. Cholestyramine is prescribed, and the nurse provides instructions to the client about the medication. Which client statement indicates a need for further teaching?. 1. “I should take this medication with meals.”. 2. “I need to mix the medication with juice or applesauce.”. 3. “I should increase my fluid intake while taking this medication.”. 4. “I should call my primary health care provider immediately if it causes constipation.”.

1087. The nurse is reviewing written medication instructions with a client who is prescribed colestipol hydrochloride. Which statement by the client indicates that the teaching has been effective?. 1. “Vitamin C will help control unintended side effects.”. 2. “Vitamin B12 will help control unintended side effects.”. 3. “B-complex vitamins will help control unintended side effects.”. 4. “Fat-soluble vitamins will help control unintended side effects.”.

Nursing Process 1088. Which data should the nurse expect to obtain during the admission assessment of a child to support the diagnosis of irritable bowel syndrome?. 1. Frequent incidents of frothy diarrhea. 2. Frequent foul-smelling ribbon stools. 3. Profuse, watery diarrhea and vomiting daily. 4. Diffuse abdominal pain unrelated to meals or activity.

1089. The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik’s spots. On the basis of this documentation, which observation is expected?. 1. Pinpoint petechiae noted on both legs. 2. Whitish vesicles located across the chest. 3. Petechiae spots that are reddish and pinpoint on the soft palate. 4. Small, blue-white spots with a red base found on the buccal mucosa.

1090. Which assessment finding should the nurse expect to note in the child hospitalized with a diagnosis of nephrotic syndrome?. 1. Weight loss. 2. Constipation. 3. Hypotension. 4. Abdominal pain.

1091. A child is admitted to the hospital with a suspected diagnosis of von Willebrand’s disease. On assessment of the child, which symptom would most likely be noted?. 1. Hematuria. 2. Presence of hematomas. 3. Presence of hemarthrosis. 4. Bleeding from the mucous membranes.

1092. A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?. 1. “I’ll take the medication with a bedtime snack.”. 2. “I’ll take the medication upon awaking in the morning.”. 3. “I’ll take the medication two hours before going to bed.”. 4. “I’ll take the medication at least 6 hours before bedtime.”.

1093. The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?. 1. The child is unable to think clearly and rapidly. 2. The child is unable to recognize place or person. 3. The child always requires considerable stimulation for arousal. 4. The child has limited interaction with the environment unless aroused.

1094. The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?. 1. Nausea and vomiting. 2. Fever and exertional dyspnea. 3. An arterial blood gas pH of 7.40. 4. A respiratory rate of 20 breaths per minute.

1095. An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first?. 1. “Do you have a history of a recent brain abscess?”. 2. “Do you have a chronic hearing problem in the left ear?”. 3. “Do you successfully obtain pain relief with acetaminophen?”. 4. “Do you have a history of a recent upper respiratory infection (URI)?”.

1096. The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a dehydrated client. Which priority assessment should the nurse obtain before initiating the IV infusion?. 1. Daily body weight. 2. Serum electrolytes. 3. Intake and output records. 4. Identifying the client’s dominant side.

1097. A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client’s safety?. 1. Vital signs. 2. Intake and output. 3. Height and weight. 4. Allergy to iodine or shellfish.

1098. The nurse is performing a cardiovascular assessment on a client. Which item should the nurse assess to obtain the best information about the client’s left-sided heart function?. 1. The status of breath sounds. 2. The presence of peripheral edema. 3. The presence of hepatojugular reflux. 4. The presence of jugular vein distention.

1099. The nurse is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. What are the most likely signs/symptoms the client experienced before the stroke occurred? Select all that apply. 1. Temporary aphasia. 2. Throbbing headaches. 3. Transient hemiplegia. 4. Paresthesias of the hands and feet. 5. Unexplained loss of consciousness.

1100. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper and lower GI series and endoscopies. Upon return to the long-term care facility, which priority assessment should the nurse focus on?. 1. The comfort level. 2. Activity tolerance. 3. The level of consciousness. 4. The hydration and nutrition status.

1101. Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply. 1. Weight. 2. Appetite. 3. Sleep patterns. 4. Suicidal ideations. 5. Psychomotor activity. 6. Rational decision making.

1102. A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?. 1. Dry skin. 2. Excitability. 3. Constipation. 4. Hyperkalemia.

1103. The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?. 1. Fetal heart rate. 2. Maternal heart rate. 3. Fetal scalp sampling. 4. Maternal blood pressure.

1104. The nurse is monitoring a client who is receiving an oxytocin infusion for the induction of labor. The nurse should suspect water intoxication if which sign or symptom is noted?. 1. Fatigue. 2. Lethargy. 3. Sleepiness. 4. Tachycardia.

1105. The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client should the nurse expect to observe?. 1. A rash. 2. Dermatitis. 3. Reddened skin. 4. Weeping of the skin.

1106. The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in?. 1. Vulva. 2. Around the eyes. 3. Fingers of the hands. 4. Around the abdomen.

1107. A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance?. 1. Decreased pulse. 2. Bibasilar crackles. 3. Increased blood pressure. 4. Increased urinary specific gravity.

1108. A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?. 1. Miscarriage. 2. Preterm labor. 3. Intrauterine fetal demise. 4. Premature rupture of the membranes.

1109. On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note?. 1. Palpitations. 2. A cardiac dysrhythmia. 3. A generalized skin rash. 4. Enlarged and inflamed joints.

1110. A child experienced a basilar skull fracture that resulted in the presence of Battle’s sign. Which should the nurse expect to observe in the child?. 1. Bruising behind the ear. 2. The presence of epistaxis. 3. A bruised periorbital area. 4. An edematous periorbital area.

1111. When assessing a child which finding would indicate the presence of Kernig’s sign?. 1. Calf pain when the foot is dorsiflexed. 2. Pain when the chin is pulled down to the chest. 3. The inability of the child to extend the legs fully when lying supine. 4. The flexion of the hips when the neck is flexed from a lying position.

1112. A home care nurse assesses an older client’s functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse’s assessment?. 1. Everyday routines. 2. Self-care activities. 3. Household management. 4. Endurance and flexibility.

1113. The nurse is assessing a client diagnosed with Addison’s disease for signs of hyperkalemia. Which sign/symptom should the nurse observe with this electrolyte imbalance?. 1. Polyuria. 2. Cardiac dysrhythmias. 3. Dry mucous membranes. 4. Prolonged bleeding time.

1114. The nurse performs an Allen’s test before blood is drawn from the radial artery for an arterial blood gas (ABG) assessment. This intervention is done to determine the collateral circulatory adequacy of which arterial vessel?. 1. Ulnar. 2. Carotid. 3. Brachial. 4. Femoral.

1115. A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?. 1. Urine for specific gravity. 2. For the presence of edema. 3. Urine for glucose and ketones. 4. Blood pressure, pulse, and respirations.

1116. A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing?. 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Respiratory acidosis. 4. Respiratory alkalosis.

1117. The nurse caring for a child diagnosed with kidney disease is analyzing the child’s laboratory results and notes a sodium level of 148 mEq/L (148 mmol/L). On the basis of this finding, which clinical manifestation should the nurse expect to note in the child?. 1. Lethargy. 2. Diaphoresis. 3. Cold, wet skin. 4. Dry, sticky mucous membranes.

1118. The nurse is caring for an infant admitted to the hospital with a diagnosis of hemolytic disease. Which finding should the nurse expect to note in this infant when reviewing the laboratory results?. 1. Decreased bilirubin count. 2. Elevated blood glucose level. 3. Decreased red blood cell count. 4. Decreased white blood cell count.

1119. Intravenous immune globulin (IVIG) therapy is prescribed for a child diagnosed with idiopathic thrombocytopenic purpura (ITP). What are the expected results of this medication?. 1. Urine positive for glucose and negative for protein. 2. Urine specific gravity of 1.020 and negative for red blood cells. 3. White blood cell count 18,000 mm3 (18×109/L) and platelets 355,000 mm3 (355×109/L). 4. Blood urea nitrogen (BUN) 22 mg/dL (7.92 mmol/L) and creatinine levels of 2.1 mg/dL (185 mcmol/L).

1120. A child was diagnosed with acute poststreptococcal glomerulonephritis and renal insufficiency. Which laboratory result should the nurse expect to note in the child?. 1. Urine positive for glucose and negative for protein. 2. Urine specific gravity of 1.020 and negative for red blood cells. 3. White blood cell count 18,000 mm3 (18×109/L) and platelets 355,000 mm3 (355×109/L). 4. Blood urea nitrogen (BUN) 22 mg/dL (7.92 mmol/L) and creatinine levels of 2.1 mg/dL (185 mcmol/L).

1121. A child is admitted to the hospital with a suspected diagnosis of bacterial endocarditis. The child has been experiencing fever, malaise, anorexia, and a headache. Which diagnostic study will confirm the diagnosis?. 1. A blood culture. 2. A sedimentation rate. 3. A white blood cell count. 4. An electrocardiogram (ECG).

1122. The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?. 1. Mild drowsiness. 2. Unilateral ptosis. 3. Diminished mental acuity. 4. Less frequent spontaneous speech.

1123. A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating?. 1. That the client is not adapting well to the disability. 2. That the problem is likely to get worse before it gets better. 3. That the client is experiencing the usual sequelae of a stroke. 4. That the client is experiencing the side effects of prescribed anticoagulants.

1124. The nurse is developing a plan of care for a client in Buck’s (extension) traction. The nurse should determine that which is a priority client problem?. 1. Immobility. 2. Risk of infection. 3. Altered independence. 4. Insufficient sensory stimulation.

1125. A pregnant client diagnosed with mitral valve prolapse is prescribed anticoagulant therapy during pregnancy. The nurse reviews the client’s medical record, expecting to note that which medication therapy is prescribed daily?. 1. Oral warfarin. 2. Intravenous infusion of heparin sodium. 3. Subcutaneous administration of terbutaline. 4. Subcutaneous administration of heparin sodium.

1126. At the last vaginal exam, the client who is in the late first stage of labor was fully effaced, 8 cm dilated, vertex presentation, and station −1. Which observation would indicate that the fetus was in fetal distress?. 1. The fetal heart rate slowly drops to 110 beats/min during strong contractions, recovering to 138 beats/min immediately afterward. 2. Fresh meconium is found on the examiner’s gloved fingers after a vaginal exam, and the fetal monitor pattern remains essentially unchanged. 3. Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable descending baseline. 4. The vaginal exam continues to reveal some old meconium staining, and the fetal monitor demonstrates a U-shaped pattern of deceleration during contractions, recovering to a baseline of 140 beats/min.

1127. A child diagnosed with seizures is being treated with carbamazepine. The nurse reviews the laboratory report for the results of the drug plasma level and determines that the plasma level is in a therapeutic range if which is noted?. 1. 1 mcg/mL (4.2 mcmol/L). 2. 10 mcg/mL (42.3 mcmol/L). 3. 18 mcg/mL (76.1 mcmol/L). 4. 20 mcg/mL (84.6 mcmol/L).

1128. The nurse performs an assessment on a client with a history of heart failure who has been taking diuretics on a long-term basis. The nurse reviews the medication record, knowing that which medication, if prescribed for this client, would place the client at risk for hypokalemia?. 1. Bumetanide. 2. Triamterene. 3. Spironolactone. 4. Hydrochlorothiazide.

1129. The home care nurse is preparing to visit a client diagnosed with Ménière’s disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?. 1. A low-fiber diet with decreased fluids. 2. A low-sodium diet and fluid restriction. 3. A low-fat diet with a restriction of citrus fruits. 4. A low-carbohydrate diet and the elimination of red meats.

1130. The nurse is caring for a client who has been diagnosed with tuberculosis. The client is receiving 600 mg of oral rifampin daily. Which laboratory finding would indicate to the nurse that the client is experiencing an adverse effect?. 1. A sedimentation rate of 15 mm/hour. 2. A white blood cell count of 6000 mm3 (6×109/L). 3. A total bilirubin level of 0.3 mg/dL (5.1 mcmol/L). 4. Alanine aminotransferase (ALT) of 80 U/L (80 U/L).

1131. A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance?. 1. “If I feel dizzy, I’ll skip my dose for a few days.”. 2. “I can’t see the numbers on the label to know how much salt is in the food.”. 3. “I understand why I have to keep taking the pills even when my blood pressure is normal.”. 4. “If I have a cold, I shouldn’t take any over-the-counter remedies without consulting my doctor.”.

1132. A client manages peptic ulcer disease (PUD) with excessive amounts of oral antacids. Signs/symptoms of which acid–base imbalance should the nurse assess for?. 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Respiratory acidosis. 4. Respiratory alkalosis.

1133. The nurse is assessing a 39-year-old Caucasian client with a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol level of 180 mg/dL (4.5 mmol/L), and a fasting blood glucose level of 90 mg/dL (5.14 mmol/L). On which risk factor for coronary artery disease should the nurse place priority?. 1. Age. 2. Hypertension. 3. Hyperlipidemia. 4. Glucose intolerance.

1134. What is the nurse’s priority for the postprocedure care of a client who has just returned to the unit after a scheduled intravenous pyelogram (IVP)?. 1. Maintaining the client on bed rest. 2. Ambulating the client in the hallway. 3. Encouraging the increased intake of oral fluids. 4. Encouraging the client to try to void frequently.

1135. A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support?. 1. Myasthenic crisis. 2. Cholinergic crisis. 3. Systemic infection. 4. Reaction to plasmapheresis.

1136. The nurse is assigned to care for a child diagnosed with juvenile idiopathic arthritis (JIA). What is the child’s priority problem?. 1. Acute pain. 2. Potential difficulty with everyday tasks. 3. Impaired mobility causing potential injury. 4. Negative view of body because of activity intolerance.

1137. A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP) and diagnostic studies are performed. Which diagnostic result is indicative of this disorder?. 1. An elevated platelet count. 2. Elevated hemoglobin and hematocrit levels. 3. Bone marrow exam showing increased megakaryocytes. 4. Bone marrow exam indicating increased immature white blood cells.

1138. The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant’s abdomen. On the basis of these findings, which condition should the nurse suspect?. 1. Colic. 2. Intussusception. 3. Congenital megacolon. 4. Hypertrophic pyloric stenosis.

1139. The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis?. 1. Clear CSF with low protein and low glucose. 2. Cloudy CSF with low protein and low glucose. 3. Cloudy CSF with high protein and low glucose. 4. Decreased pressure and cloudy CSF with high protein.

1140. A child is admitted to the pediatric unit with a diagnosis of acute gastroenteritis. The nurse monitors the child for signs of hypovolemic shock as a result of fluid and electrolyte losses that have occurred in the child. Which finding would indicate the presence of compensated shock?. 1. Bradycardia. 2. Hypotension. 3. Profuse diarrhea. 4. Capillary refill time greater than 2 seconds.

1141. The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse should suspect that the child has which problem?. 1. School phobia. 2. Absence seizures. 3. Behavioral problem. 4. Attention-deficit/hyperactivity syndrome.

1142. A 3-week-old infant is brought to the well-baby clinic for a phenylketonuria (PKU) screening test. The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL (60 mmol/L). What is the nurse’s priority action?. 1. Report the test as inconclusive. 2. Tell the mother that the test is normal. 3. Prepare to perform another test on the client. 4. Notify the pediatrician that the test is moderately elevated.

Planning 1143. The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?. 1. Track the client’s oral temperature. 2. Administer antibiotics intravenously. 3. Evaluate the differential of the leukocytes. 4. Use sterile technique for dressing changes.

1144. The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?. 1. Use a bedside commode. 2. Ambulate to the bathroom. 3. Administer an enema daily. 4. Use a low-profile (fracture) bedpan.

1145. The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?. 1. Enforce bed rest. 2. Monitor the vital signs frequently. 3. Assess the breath sounds frequently. 4. Administer prescribed anticoagulant therapy.

1146. The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?. 1. “10% dextrose in water is a hypotonic solution.”. 2. “3% sodium chloride solution is a hypotonic solution.”. 3. “5% dextrose in water is considered an isotonic solution.”. 4. “0.45% sodium chloride solution is a hypertonic solution.”.

1147. The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client’s plan of care?. 1. Prevent social isolation. 2. Consider occupational therapy. 3. Discuss changes in body image. 4. Avoid stress-producing situations.

1148. A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about?. 1. A low-calorie diet to prevent weight gain. 2. A diet low in fluids and fiber to decrease blood volume. 3. A diet adequate in fluids and fiber to decrease constipation. 4. Unlimited sodium intake to increase circulating blood volume.

1149. The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?. 1. Maintain the client in a supine position. 2. Provide a daily fluid intake of 1000 mL. 3. Limit the intake of milk and milk products. 4. Monitor for signs of a low serum calcium level.

1150. The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)?. 1. Chest x-ray. 2. Sputum culture. 3. Complete blood cell count. 4. Computed tomography scan of the chest.

1151. The home care nurse is preparing a plan of care for a client diagnosed with Ménière’s syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?. 1. Instruct the client to cut down on cigarette smoking. 2. Encourage the client to increase the daily fluid intake. 3. Encourage the client to avoid sudden head movements. 4. Instruct the client to increase the amount of sodium in the diet.

1152. A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?. 1. Providing a supportive environment. 2. Examining intrapsychic conflicts and past issues. 3. Emphasizing social interaction with clients who are withdrawn. 4. Helping the client identify and examine dysfunctional thoughts and beliefs.

1153. The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?. 1. Scheduling weekly follow-up appointments. 2. Establishing contracts with available crisis resources. 3. Encouraging family and friends to be with the client at all times. 4. Providing phone numbers for the hospital and primary health care provider.

1154. The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information should the nurse plan to include in the parents education?. 1. The regimen of manipulation and casting is effective in all cases of bilateral club feet. 2. Genetic testing is wise for future pregnancies because other children born to this couple may also be affected. 3. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated. 4. Surgery performed immediately after birth has been found to be the most effective for achieving a complete recovery.

1155. Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?. 1. A syringe that contains a preservative. 2. A heparinized syringe and a bag of ice. 3. A heparinized syringe and a preservative. 4. A syringe that contains a preservative and a bag of ice.

1156. A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?. 1. Fluid restriction. 2. Administering diuretics. 3. Increased sodium intake. 4. Intravenous (IV) replacement of fluid losses.

1157. The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?. 1. Client will be free of hallucinations. 2. Client will feed self with cueing within 24 hours. 3. Client will be able to prepare simple foods by discharge. 4. Client will identify favorite foods by the time of discharge.

1158. The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?. 1. Infection. 2. Fluid overload. 3. Impaired sleep patterns. 4. Inability to expectorate secretions.

1159. The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant’s preoperative needs. 1. Administer enemas until returns are clear. 2. Provide the mother privacy to breast-feed every 2 hours. 3. Monitor the intravenous (IV) infusion, intake, output, and weight. 4. Provide small, frequent feedings of glucose, water, and electrolytes.

1160. A client who was a victim of a gunshot incident states, “I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.” Which strategy should the nurse include when initially formulating a therapeutic relationship?. 1. Teaching the client a variety of relaxation techniques. 2. Asking the psychiatrist to prescribe appropriate medication. 3. Encouraging the client to talk about the incident and feelings related to it. 4. Encouraging the client to think about just how lucky he or she is to still be alive.

1161. The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base a response?. 1. Involuntary movements affecting the legs, arms, and face. 2. Inflammation of all parts of the heart, primarily the mitral valve. 3. Tender, painful joints, especially in the elbows, knees, ankles, and wrists. 4. Red skin lesions that start as flat or slightly raised macules, usually over the trunk, and that spread peripherally.

1162. The nurse preparing to admit a 7-month-old infant with febrile seizures should anticipate the need for which equipment when planning care for this infant?. 1. Restraints at the bedside. 2. A code cart at the bedside. 3. Suction equipment and an airway at the bedside. 4. A padded tongue blade taped to the head of the bed.

1163. A 10-month-old infant is hospitalized for respiratory syncytial virus (RSV). On the basis of the developmental stage of the infant, what intervention should the nurse include in the plan of care?. 1. Restrain the infant with a total body restraint to prevent any tubes from being dislodged. 2. Follow the home feeding schedule, and allow the infant to be held only when the parents visit. 3. Wash hands, wear a mask when caring for the infant, and keep the infant as quiet as possible. 4. Provide a consistent routine, and touch, rock, and cuddle the infant throughout the hospitalization.

1164. A child with a diagnosis of Reye’s syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?. 1. Monitoring for hearing loss. 2. Monitoring intake and output (I&O). 3. Repositioning the child every 2 hours. 4. Providing a quiet environment with dimmed lighting.

1165. A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?. 1. Cerebral palsy is an infectious disease of the central nervous system. 2. Cerebral palsy is an inflammation of the brain as a result of a viral illness. 3. Cerebral palsy is a chronic disability characterized by difficulty with muscle control. 4. Cerebral palsy is a congenital condition that results in moderate to severe retardation.

1166. A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?. 1. Normal social play that ceases by age 5. 2. Lack of social interaction and awareness. 3. The consistent imitation of others’ action. 4. Normal verbal but abnormal nonverbal communication.

1167. Which interventions are appropriate to include in the plan of care for a child after a tonsillectomy? Select all that apply. 1. Offer clear, cool liquids when awake. 2. Administer pain medication as prescribed. 3. Monitor for bleeding from the surgical site. 4. Suction every 15 minutes and PRN as necessary. 5. Initially eliminate milk or milk products from the diet.

1168. The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?. 1. Lie flat and lift the legs straight up. 2. Lie on the right side and then roll to the left side while the arms are held overhead. 3. Walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides. 4. Stand with weight equally on both feet with the legs straight, and the arms hanging loosely at both sides.

1169. The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?. 1. Monitor rectal temperatures every 4 hours. 2. Monitor the mouth and anus each shift for signs of breakdown. 3. Encourage the child to consume fresh fruits and vegetables to maintain nutritional status. 4. Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a toothbrush.

1170. The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?. 1. Flashlight and pulse oximeter. 2. Cardiac monitor and suction equipment. 3. Padded bed rails and suction equipment. 4. Blood pressure cuff and cardiac monitor.

1171. The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client’s chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use?. 1. Nebulizer and pulse oximeter. 2. Blood pressure cuff and flashlight. 3. Flashlight and incentive spirometer. 4. Cardiac monitor and intubation tray.

1172. The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant’s arrival, which action should the nurse take?. 1. Obtain the newborn infant’s blood type and direct Coombs’ results from the laboratory. 2. Obtain the necessary equipment from the blood bank needed for an exchange transfusion. 3. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery. 4. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.

1173. The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?. 1. Supine. 2. Semi-Fowler’s. 3. Trendelenburg’s. 4. Dorsal recumbent.

1174. The nurse plans care for a client with alcohol abuse disorder based on which support system?. 1. Fresh Start, is an option for families of addicts. 2. Families Anonymous, an option for those addicted to nicotine. 3. Al- Anon, an option for parents of children who abuse substances. 4. Alcoholics Anonymous, a major self-help organization for the treatment of alcohol abuse.

1175. A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client’s right side. Which intervention should the home care nurse’s plan include when planning for the client’s care?. 1. Implements ROM exercises to the point of pain for the client. 2. Considers the use of active, passive, or active-assisted exercises in the home. 3. Encourages dependence on the home care nurse to complete the exercise program. 4. Develops a schedule involving ROM exercises every 3 hours during daylight hours.

Implementation 1176. A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?. 1. Administer the medications. 2. Contact the primary health care provider. 3. Check the morning serum digoxin level. 4. Check the morning serum potassium level.

1177. The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?. 1. Encourage the mother to ambulate. 2. Notify the primary health care provider. 3. Massage the fundus gently until it is firm. 4. Document fundal position, consistency, and height.

1178. A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?. 1. Document the finding. 2. Tell the client that the FHR is fast. 3. Consult with the primary health care provider. 4. Recheck the FHR with the client in the standing position.

1179. A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin?. 1. Myoflex. 2. Aspercreme. 3. Topical emollient. 4. Acetic acid solution.

1180. A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit?. 1. Pears. 2. Apples. 3. Bananas. 4. Cranberries.

1181. A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse’s initial intervention?. 1. Take the client’s vital signs. 2. Perform a Leopold’s maneuver. 3. Perform a manual sterile vaginal exam. 4. Test the vaginal fluid with a Nitrazine strip.

1182. The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?. 1. Determining tube placement. 2. Auscultating the bowel sounds. 3. Measuring the intake and outpu. 4. Establishing the client’s baseline weight.

1183. The nurse is asked to assist another health care team member with providing care for a client. On entering the client’s room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?. 1. Shock. 2. A head injury. 3. Respiratory insufficiency. 4. Increased intracranial pressure.

1184. The nurse needs to administer 7.5 mg of a medication intramuscularly. The medication label reads “10 mg/mL.” How much medication should the nurse prepare to administer? Fill in the blank.

1185. A client diagnosed with obsessive-compulsive rituals often misses the unit’s morning activities because of a bed-making ritual. What nursing action would be therapeutic?. 1. Verbalize tactful, mild disapproval of the behavior. 2. Discuss the social implications of the behavior with the client. 3. Help the client to make the bed so that the task can be finished quicker. 4. Offer reflective feedback, such as, “I see that you have made your bed several times.”.

1186. A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem?. 1. Trapeze. 2. Bed cradle. 3. Draw sheet. 4. Alternating pressure mattress.

1187. The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?. 1. Flat on the operative side. 2. Flat on the unoperative side. 3. Prone with the head of the bed elevated. 4. Supine with the head of the bed elevated.

1188. A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?. 1. To continue to monitor the child. 2. That lethargy and vomiting are normal manifestations of mumps. 3. To bring the child to the clinic to be seen by the primary health care provider. 4. That, as long as there is no fever, there is nothing to be concerned about.

1189. The nurse is reviewing the primary health care provider’s prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?. 1. Bed rest. 2. Intravenous fluids. 3. Supplemental oxygen. 4. Meperidine hydrochloride.

1190. The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?. 1. Prone. 2. Supine. 3. Supine with the neck flexed. 4. Prone with the neck hyperextended.

1191. The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?. 1. Monitoring the temperature. 2. Monitoring the blood pressure. 3. Inspecting the anterior fontanel for bulging. 4. Monitoring the specific gravity of the urine.

1192. During the assessment, the nurse notes that the child’s genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?. 1. Document the child’s physical findings. 2. Report the case because abuse is suspected. 3. Refer the family to appropriate support groups. 4. Assist the family with identifying resources and support systems.

1193. The nurse is planning care for an infant with a diagnosis of an encephalocele located in the occipital area. Which item should the nurse use to assist with positioning the child to avoid pressure on the encephalocele?. 1. Sandbags. 2. Sheepskin. 3. Feather pillows. 4. Foam half donut.

1194. The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?. 1. Document that the original positioning is unchanged. 2. Attempt to assess the flexibility of the child’s lower extremities. 3. Plan to continue to monitor the child for posturing every 2 hours. 4. Notify the primary health care provider of the change in posturing.

1195. The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?. 1. “It sounds as if the hepatitis may be worsening.”. 2. “It is necessary to isolate the child from others in the home.”. 3. “The jaundice may appear to get worse before it begins to resolve.”. 4. “You need to bring the child to the health care clinic to see the primary health care provider.”.

1196. The nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and should turn the suction to which setting?. 1. 60 mm Hg. 2. 90 mm Hg. 3. 110 mm Hg. 4. 120 mm Hg.

1197. A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?. 1. Raise the head of the bed. 2. Loosen restrictive clothing. 3. Remove the pillow and raise the padded side rails. 4. Position the client on the side with the head flexed forward.

1198. A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101° F (38.3° C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take?. 1. Notify the primary health care provider. 2. Administer an acetaminophen suppository. 3. Encourage the client to cough and deep breathe. 4. Administer a bronchodilator prescribed on an as-needed basis.

1199. Which action should the nurse implement as part of care for a client after a bone biopsy?. 1. Monitoring the vital signs once per day. 2. Keeping the area in a dependent position. 3. Administering intramuscular opioid analgesics. 4. Monitoring the site for swelling, bleeding, or hematoma formation.

1200. The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?. 1. Determining the presence of client allergies. 2. Asking if the client has any last-minute questions. 3. Telling the client to try to void before leaving the unit. 4. Emphasizing to the client the importance of remaining still during the procedure.

1201. The nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client’s arm may be broken. Which immediate action should the nurse take?. 1. Immobilize the arm. 2. Take a set of vital signs. 3. Call the radiology department. 4. Ask the client to describe what happened.

1202. The nurse is caring for a hospitalized 14-year-old child who is placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child’s needs?. 1. Allow the child to play loud music in the hospital room. 2. Let the child wear his or her own clothing when friends visit. 3. Allow the child to have his or her hair dyed if the parent agrees. 4. Allow the child to keep the shades closed and the room darkened.

1203. The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?. 1. A foot board. 2. Extra pillows. 3. A bed trapeze. 4. An electric bed.

1204. A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care? Select all that apply. 1. Assist the client in identifying supportive strategies. 2. Initiate the possibility of placing the baby up for adoption. 3. Stress the need for Alcoholics Anonymous (AA) meetings. 4. Encourage the client to continue counseling after the birth. 5. Encourage the client to participate in her rehabilitation care. 6. Minimize communication with codependent family members.

1205. A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?. 1. Document the findings as normal. 2. Notify the primary health care provider of the finding. 3. Inform the mother that the assessment is normal and everything is fine. 4. Instruct the mother to return to the clinic in 8 hours for reevaluation of the FHR.

1206. A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period?. 1. Place the client on bed rest. 2. Allow the client to ambulate only in the room. 3. Obtain a bedside commode for the client’s use. 4. Encourage the client to be up at least twice per day.

1207. Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?. 1. White blood cell count. 2. Serum electrolyte levels. 3. Arterial blood gas levels. 4. Hemoglobin and hematocrit levels.

Evaluation 1208. The nurse is evaluating the effects of care for the client with nephrotic syndrome. Which diagnostic result demonstrates the least amount of improvement over 2 days of care?. 1. Initial weight 208 pounds, down to 203 pounds. 2. Blood pressure 160/90 mm Hg, down to 130/78 mm Hg. 3. Serum albumin 1.9 g/dL (19 g/L), up to 2.0 g/dL (20 g/L). 4. Daily intake and output record of 2100 mL intake and 1900 mL output and 2000 mL intake and 2900 mL output.

1209. A client is being discharged after the application of a plaster leg cast. The nurse determines that the client understands the proper care of the cast when the client states the need to engage in which action?. 1. Avoid getting the cast wet. 2. Cover the casted leg with warm blankets. 3. Use the fingertips to lift and move the leg. 4. Use a padded coat hanger end to scratch under the cast.

1210. The client recovering from an acute kidney injury demonstrates an understanding of the therapeutic dietary regimen when indicating a need to limit which dietary factor?. 1. Fats. 2. Vitamins. 3. Potassium. 4. Carbohydrates.

1211. The nurse teaches the client with a history of anxiety and command hallucinations to harm self or others appropriate management techniques. Which client statement indicates that the client understands these techniques?. 1. “I can go to group and talk about my feelings to hurt myself or others.”. 2. “If I take my prescribed medication as I’m supposed too, I won’t be as anxious.”. 3. “I can call my counselor so that I can talk about my feelings and not hurt anyone.”. 4. “If I get enough sleep and eat well, I won’t be as likely to get anxious and hear things.”.

1212. A perinatal client has been instructed about the prevention of genital tract infections. Which statement by the client indicates an understanding of these preventive measures?. 1. “I can douche anytime I want.”. 2. “I can wear my tight-fitting jeans.”. 3. “I should avoid the use of condoms.”. 4. “I should wear underwear with a cotton panel liner.”.

1213. The nurse has given the client information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?. 1. “I will keep the nitroglycerin in a shirt pocket close to my body.”. 2. “I won't take the medication until the chest pain actually begins and intensifies.”. 3. “If I get a headache when I first start taking the nitroglycerin, then I will take an aspirin”. 4. “I will discard unused nitroglycerin tablets 3 to 6 months after the bottle is opened, and obtain a new prescription.”.

1214. A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking?. 1. Bland. 2. Full liquids. 3. Clear liquids. 4. Semisolid foods.

1215. An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?. 1. “I will be more careful to make sure that my father’s needs are 100% met.”. 2. “I am so sorry and embarrassed that the abusive event occurred. It won’t happen again.”. 3. “I feel better equipped to care for my father now that I know where to turn if I need assistance.”. 4. “Now that my father is going to move into my home with me, I will have to stop drinking alcohol.”.

1216. A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?. 1. Weight loss of 4 ounces and dry, peeling skin. 2. Blood glucose level of 40 mg/dL (2.28 mmol/L) before the last feeding. 3. Breast-feeding for 20 minutes or more, with strong sucking. 4. High-pitched cry, drinking 10 to 15 mL of formula per feeding.

1217. A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?. 1. The child is free of diarrhea. 2. The child is free of bloody stools. 3. The child tolerates dietary wheat and rye. 4. A balanced fluid and electrolyte status is noted on the laboratory results.

1218. A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?. 1. One contraction per minute, with resultant cervical dilation. 2. Four contractions every 5 minutes, with resultant cervical dilation. 3. One contraction every 10 minutes, without resultant cervical dilation. 4. Three to 5 contractions in a 10-minute period, with resultant cervical dilation.

1219. A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest?. 1. The child insists that his mother stay in the room. 2. The child is coloring and drawing pictures in a notebook. 3. The mother keeps providing new activities for the child to do. 4. The child sucks his thumb whenever he does not get what he asked for.

1220. A client has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, is it appropriate for the nurse to determine that the medication has been effective?. 1. Nausea. 2. Heartburn. 3. Constipation. 4. Abdominal pain.

1221. The nurse is providing instructions to the mother of a child with a diagnosis of strabismus of the left eye. Which statement by the mother indicates that the mother understands the procedure for patching?. 1. “I will place the patch on both eyes.”. 2. “I will place the patch on the left eye.”. 3. “I will place the patch on the right eye.”. 4. “I will alternate the patch from the right eye to the left eye every hour.”.

1222. The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?. 1. Urinary output is increased. 2. Presence of trace urinary protein. 3. Client complaints of blurred vision. 4. Blood pressure reading at prenatal baseline.

1223. A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted?. 1. Edema present at 3+. 2. Weight loss of 5 pounds within 2 days. 3. Pulse rate increased from 58 to 74 beats/min. 4. Blood pressure decreased from 142/94 mm Hg to 128/82 mm Hg.

1224. The nurse has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?. 1. Cola. 2. Coffee. 3. Chocolate milk. 4. Cranberry juice.

1225. A client is prescribed glipizide once daily. What intended effect of this medication should the nurse observe for?. 1. Weight loss. 2. Resolution of infection. 3. Decreased blood glucose. 4. Decreased blood pressure.

1226. A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse should monitor the client for the relief of which sign/symptom?. 1. Diarrhea. 2. Bleeding. 3. Infection. 4. Epigastric pain.