A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?
A. Compulsive attention to details
B. Avoid
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A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations ......ANSWER......C. Uses others for personal gain
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a Harrington rod ......ANSWER......A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
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A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit ......ANSWER......A. Generalized edema
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug ......ANSWER......This technique decreases the risk of subcutaneous infiltration
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes ......ANSWER......C. Monitor the client for 1 hr after meals
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A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs ......ANSWER......B. Maintain the head at a midline position
10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia ......ANSWER......A. Hallucinations
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses ......ANSWER......D. Bounding pulses
A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
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A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain ......ANSWER......B. Hyperemesis
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketones ......ANSWER......B. HbA1c
A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?
A. Wear an N95 respirator
B. Insert an indwelling urinary catheter to monitor urinary output
C. Monitor the client's vital signs every 8 hr
D. Use a dedicated stethoscope ......ANSWER......D. Use a dedicated stethoscope
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
B. Tell the client to avoid drinking fluids 1 hr before bedtime
C. Schedule routine care tasks during hours when the client is awake
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D. Advise the client to leave the television in the room on when trying to fall asleep ......ANSWER......C. Schedule routine care tasks during hours when the client is awake
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
A. Clothe the newborn in light cotton
B. Check the newborn's temperature every 8 hrs. (every 4)
C. Administer 120 mL of water between feedings
D. Place the newborn 45 cm (18 in) from the light source ......ANSWER......D. Place the newborn 45 cm (18 in) from the light source
A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make?
A. Art therapist
B. Speech-language pathologist
C. Social worker
D. Recreational therapist ......ANSWER......A. Art therapist
A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?
A. Decreased reflexes
B. Weight gain of 1.4 kg
C. Increased urinary output
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D. Jugular vein distention ......ANSWER......A. Decreased reflexes
Loop diuretics cause excessive urination leading to hypotension and finally resulting in decreased reflexes.
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
A. Constipation
B. Indigestion
C. Swollen ankles
D. Urinary frequency ......ANSWER......B. Indigestion
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene?
A. Encourages the client to use the incentive spirometer
B. Elevates the head of the client's bed
C. Offers oral fluids to the client
D. Checks the client's pulse oximetry ......ANSWER......C. Offers oral fluids to the client
A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first?
A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10
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B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101F)
C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89%
D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void ......ANSWER......A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex?
A. Peanuts
B. Shellfish
C. Avocados
D. Eggs ......ANSWER......C. Avocados
A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?
A. I wonder if the metal in my knee will show up in airport screenings
B. The physical therapy has not been working, so I will need to have the surgery
C. I look forward to being able to bend my knee again when I sit in a chair
D. I am thankful there are no serious complications from this type of surgery ......ANSWER......D. I am thankful there are no serious complications from this type of surgery
