FULLY SOLVED GRADED A+
◍ The nurse has an order to insert an indwelling urinary catheter for a
male client. What is the best reason for lubricating the tip of the
catheter prior to insertion?
A. Reduce the friction within the urethra
B. Diminish the leakage of urine around the catheter
C. Minimize risk for infection
D. Prevent bladder distention Answer: A
Due to the somewhat long length of the male urethra, lubrication
reduces potential discomfort and localized tissue irritation as the
catheter is passed.
◍ A client asks the nurse about including her 2 year-old and 12 year-
old sons in the care of their newborn sister. Which response is an
appropriate initial statement by the nurse?
A. "Focus on your sons' needs during the first days at home."
B. "Suggest that your partner spend more time with the boys."
C. "Tell each child what he can do to help with the baby."
D. "Ask the children what they would like to do for the newborn."
Answer: A
,In an expanded family, it is important for parents to reassure older
children that they are loved and as important as the newborn.
◍ The nurse is caring for a client who is exhibiting a panic attack.
What should the nurse do for this client?
A. Assist the client to describe the experience in detail
B. Develop a trusting relationship
C. Maintain safety for the client
D. Teach the client to control behaviors Answer: C
Clients who display signs of severe anxiety in the form of a panic
attack need to be supervised closely until the anxiety is lessened. They
may harm themselves or others because during panic attacks
perception is narrowed and thinking is flawed.
◍ The nurse is to review the topic of caring for clients with Guillain-
Barré syndrome with other staff members at a monthly meeting.
Which of these findings should the nurse include in the discussion?
(Select all that apply.)
A. Weakness, tingling or loss of sensation in legs and feet occur first
B. Rapidly progressive ascending paralysis of the legs, arms,
respiratory muscles and face
C. Difficulty with bladder control or intestinal functions
D. Hypertension
,E. Difficulty with eye movement, facial movement, speaking,
chewing or swallowing
F. Numbness, tingling, prickling sensation or moderate pain
throughout the body Answer: A,B,C,E,F
Guillian-Barré is an autoimmune disease. The symptoms of weakness
or tingling sensation begins in the legs and progresses to the arms and
upper body, resulting in almost complete paralysis. The client is often
put on a ventilator during the worst part of the disease to assist
breathing. The client may have low blood pressure or poor blood
pressure control.
◍ A 1 year-old child is receiving temporary total parental nutrition
(TPN) through a central venous line. This is the first day of TPN
therapy. Although all of the following nursing actions must be
included in the plan of care of this child, which one would be a
priority at this time?
A. Use aseptic technique during dressing changes
B. Check results of liver enzyme tests
C. Maintain central line catheter integrity
D. Monitor serum glucose levels Answer: D
Hyperglycemia may occur during the first day or two as the child
adapts to the high-glucose load of the TPN solution. Thus, a priority
nursing responsibility is blood glucose testing.
◍ The nurse is teaching diet restrictions to a client diagnosed with
Addison's disease. The client indicates an understanding of the dietary
restrictions when making which of these statements?
, A. "I will increase fluids and restrict sodium and potassium."
B. "I will increase sodium and fluids and restrict potassium."
C. "I will increase sodium, potassium and fluids."
D. "I will increase potassium and sodium and restrict fluids." Answer:
B
The manifestations of Addison's disease (also called adrenal
insufficiency or hypocortisolism) are due to mineralocorticoid
deficiency that results in renal sodium wasting and potassium
retention. Other findings are dehydration, hypotension, hyponatremia,
hyperkalemia and metabolic acidosis.
◍ A nurse is working in an inpatient psychiatric setting. The nurse
understands what reason touching clients should be limited to a quick
handshake?
A. A handshake allows the use of therapeutic touch while maintaining
boundaries.
B. Touching a client, other than a handshake, can set off a violent
episode.
C. Refraining from touching signals the termination of the nurse-
client relationship.
D. A handshake will not be misinterpreted as an invitation to more
sexual behavior. Answer: A
The therapeutic use of touch is a basic part of the nurse-client
relationship. However, in a psychiatric setting, the extent of physical
contact should be limited to handshakes. Some facilities may even