The nurse noticed that an 8-month-old ...

While a client with hypertension is being assessed, he says to the nurse, "I really don’t know why I’m here. I feel fine and haven’t had any symptoms. " Which of the following would be the nurse’s best response()

A. "Symptoms of hypertension are often not present. "
B. "Symptoms of hypertension signify a high risk of stroke. "
C. "Symptoms of hypertension occur only with malignant hypertension. "
D. "Symptoms of hypertension appear after irreversible kidney damage has occurred. \

单项选择题

Mrs. Cray, an African American, is admitted to the hospital after sustaining a hip fracture. She is 5 ft. , 4 inches tall and weighs 96 lbs. She has five children and has used estrogen replacement therapies for 10 years. She told the nurse that she "just stepped forward and fell. " The results of her bone density tests indicate she has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman()

A. Her long-term use of estrogen.
B. Her weight.
C. Her family.
D. Her race.

单项选择题

The client exhibits signs of sleep disturbance. Which intervention should the nurse try first()

A. Administer sleeping medication before bedtime.
B. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
C. Ask the client each morning to describe the quality of sleep during the previous night.
D. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.

单项选择题

A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement()

A. Provide an unstructured environment for the client.
B. Rotate the nurses who are assigned to the client.
C. Ignore the client’s behaviors.
D. Bend unit rules to meet the client’s needs.

单项选择题

The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients()

A. By their teeth.
B. By body size and weight.
C. By looking for Mallory-Weiss tears.
D. The clients are indistinguishable upon physical examination.

单项选择题

The nurse is instructing an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions()

A. "I will empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag. "
B. "I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container. "
C. "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container. "
D. "I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container. \

单项选择题

The nurse plans to teach a client who is receiving radiation therapy how to care for his skin at home. Which of the following should be included in the nurse’s instructions

A. "Apply a heating pad to the area to relieve pain. "
B. "Keep the area covered when you go outdoors. "
C. "You may use deodorant soap if you wish to cleanse the area. "
D. "Put baby oil on the area after each treatment to keep it from getting dry. \

单项选择题

Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt()

A. Monitoring intake and output.
B. Allowing the infant to rest undisturbed.
C. Providing age-appropriate diversionary activities.
D. Initiating oral feedings.

单项选择题

A client with diabetes is explaining to the nurse how he cares for his feet at home. The nurse could judge from which of the following statements that the client needs further instruction on how to care for his feet properly()

A. "I inspect my feet once a week for cuts and redness. "
B. "I am not allowed to use a heating pad on my feet. "
C. "It is important to dry my feet carefully after my bath. "
D. "I should not go barefoot, even in my home. \

单项选择题

The nurse noticed that an 8-month-old child’s posterior fontanel is slightly open. Which of the following should the nurse do next()

A. Check the child’s head circumference.
B. Question the mother about the child’s delivery.
C. Schedule an X-ray of the child’s head.
D. Document this as a normal finding.

单项选择题

Mrs. Wilson, a primigravida, was admitted to the hospital at 12 weeks’ gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse determines that the client is most likely experiencing which of the following types of abortion()

A. Complete.
B. Threatened.
C. Inevitable.
D. Missed.

单项选择题

When developing a teaching plan for the mother of a child diagnosed with spastic cerebral palsy, which of the following descriptions would the nurse include()

A. Wide-based gait and poor muscle coordination.
B. Tremors and lack of active movement.
C. Increased muscle tone and stretch reflexes.
D. Slow, wormlike writhing movements.

单项选择题

Which of the following findings is suggestive of myocardial infarction (MI)()

A. Below-normal erythrocyte sedimentation rate.
B. Elevated white blood cell count.
C. Elevated serum cholesterol value.
D. Elevated creatine phosphokinase (CPK) value.

单项选择题

A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following should the nurse include in the teaching plan()

A. It will be necessary for the client to take potassium supplements to prevent hypokalemia.
B. The client should use a soft toothbrush and floss teeth daily.
C. The use of phenytoin can lead to the development of diabetes.
D. It is appropriate to substitute various brands of phenytoin as long as the dosage is the same.

单项选择题

A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer which of the following medication()

A. Ritodrine (Yutopar).
B. Bromocriptine (Parlodel).
C. Betamethasone (Celestone).
D. Magnesium sulfate.

单项选择题

While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid()

A. Paralytic ileus.
B. Gastric distention.
C. Hiatal hernia.
D. Gastrointestinal ulceration.

单项选择题

The client experiences a wound evisceration on day 2 after the abdominal hysterectomy. What should the nurse immediately do()

A. Approximate the wound edges by applying strips of adhesive over the wound.
B. Cover the exposed tissues with sterile dressings moistened with normal saline solution.
C. Replace the abdominal contents into the wound carefully while wearing gloves.
D. Apply a loose-fitting sterile abdominal binder over the wound.

单项选择题

Which of the following serum electrolyte levels would the nurse expect to find in an infant with persistent vomiting()

A. K⁺, 3.2 mEq/L; Cl^-, 92 mEq/L; Na⁺, 120 mEq/L.
B. K⁺, 3.4 mEq/L; Cl^-, 120 mEq/L; Na⁺, 140 mEq/L.
C. K⁺, 3.5 mEq/L; Cl^-, 90 mEq/L; Na⁺, 145 mEq/L.
D. K⁺, 5.5 mEq/L; Cl^-, 110 mEq/L; Na⁺, 130 mEq/L.

单项选择题

An agitated client demands to see his chart so that he can read what has been written about him. Which of the following statements is the nurse’s best response in this situation()

A. "I’m sorry the chart is the property of the facility. We don’t permit clients to read them. "
B. "You have the right to see your chart. Please discuss this with your primary care provider. "
C. "You may see your chart after you’re discharged. "
D. "Please discuss this matter with your attorney. \

单项选择题

A client is prescribed 1000 mL of an antibiotic solution to be given over 6 hours. What would be the flow rate The infusion set administers 15 gtts/mL.()

A. 28 gtts/min.
B. 35 gtts/min.
C. 42 gtts/min.
D. 45 gtts/min.

单项选择题

A priority nursing diagnosis during the first 24 hours following an MI is()

A. Ineffective cardiac tissue perfusion.
B. Risk for infection.
C. Deficient fluid volume.
D. Constipation.

单项选择题

The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of the following()

A. The client is responding to the antipsychotic.
B. The client may be experiencing increased energy and is at an increased risk for suicide.
C. The client is ready to be discharged from treatment.
D. The client is experiencing a split personality.

单项选择题

The physician prescribes clomiphene citrate (Clomid) for a woman who has been having difficulty getting pregnant. When preparing the teaching plan for the client about this drug’s potential side effects, which of the following would the nurse include in the teaching plan()

A. Increase in fibrocystic breast disease.
B. Increase in congenital anomalies.
C. Multiple pregnancies.
D. Increase in spontaneous abortions.

单项选择题

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his action()

A. Somatic delusions.
B. Waxy flexibility.
C. Neologisms.
D. Nihilistic delusions.

单项选择题

A client is taking chlorpropamide (Diabenese). Which of the following side effects should be nurse expect from the medication()

A. Hypoglycemia.
B. Oral candidiasis.
C. Dumping syndrome.
D. Extrapyramidal symptoms.

单项选择题

The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings()

A. Presence of menses.
B. Uterine enlargement.
C. Breast sensitivity.
D. Fetal heart tones.

单项选择题

Which of the following signs or symptoms would the nurse expect to see in a client with pancreatitis()

A. Bradycardia.
B. Hypertension.
C. Decreased white blood cell count.
D. Left upper quadrant abdominal pain.

单项选择题

The nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client()

A. The client has regular obsessions.
B. Relaxation techniques and psychotherapy are necessary for cure.
C. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder.
D. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months.

单项选择题

The nurse is assessing a client with an ileal conduit. She notes that the client’s urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data()

A. These findings are normal for the client.
B. There is irritation of the stoma.
C. The client is developing an infection of the urinary tract.
D. The mucus is caused by elevated levels of glucose in the urine.

单项选择题

When caring for an adolescent client diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include which of the following()

A. Helplessness, hopelessness, hypersomnolence, and anorexia.
B. Truancy, a change of friends, social withdrawal, and oppositional behavior.
C. Curfew breaking, stealing from family members, truancy, and oppositional behavior.
D. Hypersomnolence, obsession with body image, and valuing of peers’ opinions.

The nurse noticed that an 8-month-old child’s posterior fontanel is slightly open. Which of the following should the nurse do next()

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While a client with hypertension is being assessed, he says to the nurse, "I really don’t know why I’m here. I feel fine and haven’t had any symptoms. " Which of the following would be the nurse’s best response()

The client exhibits signs of sleep disturbance. Which intervention should the nurse try first()

The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients()

The nurse is instructing an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions()

The nurse plans to teach a client who is receiving radiation therapy how to care for his skin at home. Which of the following should be included in the nurse’s instructions

Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt()

A client with diabetes is explaining to the nurse how he cares for his feet at home. The nurse could judge from which of the following statements that the client needs further instruction on how to care for his feet properly()

The nurse noticed that an 8-month-old child’s posterior fontanel is slightly open. Which of the following should the nurse do next()

Mrs. Wilson, a primigravida, was admitted to the hospital at 12 weeks’ gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse determines that the client is most likely experiencing which of the following types of abortion()

When developing a teaching plan for the mother of a child diagnosed with spastic cerebral palsy, which of the following descriptions would the nurse include()

Which of the following findings is suggestive of myocardial infarction (MI)()

A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following should the nurse include in the teaching plan()

A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer which of the following medication()

While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid()

The client experiences a wound evisceration on day 2 after the abdominal hysterectomy. What should the nurse immediately do()

Which of the following serum electrolyte levels would the nurse expect to find in an infant with persistent vomiting()

An agitated client demands to see his chart so that he can read what has been written about him. Which of the following statements is the nurse’s best response in this situation()

A client is prescribed 1000 mL of an antibiotic solution to be given over 6 hours. What would be the flow rate The infusion set administers 15 gtts/mL.()

A priority nursing diagnosis during the first 24 hours following an MI is()

The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of the following()

The physician prescribes clomiphene citrate (Clomid) for a woman who has been having difficulty getting pregnant. When preparing the teaching plan for the client about this drug’s potential side effects, which of the following would the nurse include in the teaching plan()

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his action()

A client is taking chlorpropamide (Diabenese). Which of the following side effects should be nurse expect from the medication()

The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings()

Which of the following signs or symptoms would the nurse expect to see in a client with pancreatitis()

The nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client()

The nurse is assessing a client with an ileal conduit. She notes that the client’s urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data()

When caring for an adolescent client diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include which of the following()