A 5 year old is admitted to the unit following a
tonsillectomy. Which of the following would indicate a
complication of the surgery?
A. Decreased appetite
B. A low-grade fever
C. Chest congestion
D. Constant swallowing
A 6-month-old client is admitted with possible C." Describe his usual diet."
intussuception. Which question during the nursing
history is least helpful in obtaining information why?
regarding this diagnosis?
The least-helpful questions are those describing his usual diet. A, B, and D
A. "tell me about the pain" are useful in determining the extent of disease process and thus, are
B."what does his vomit look like?" incorrect
C." Describe his usual diet."
D. " have you noticed changes in his adominal size?"
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A 6 year old with cerebral palsy functions at the level
of an 18 month old. Which finding would support that
assessment?
A. She dresses herself
B. She pulls a toy behind her
C. She can build a tower of eight blocks
D. She can copy a horizontal or vertical line.
A 24 year-old female client is scheduled for surgery in A. taking the vital signs
the morning. Which of the following is the primary
responsibility of the nurse? why?
the primary responisblity of the nurse is to take the vital signs before any
A. taking the vital signs surgery.
B. obtaining the permit
C. explaining the procedure answers B,C and D are the responsibility of the doctor.
D. Checking the lab work
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A 25 year old male is brought to the ER with a piece C. Cover both eyes with paper cups
of metal in his eye. Which action by the nurse is
correct? why?
A. Use a magnet to remove the object Covering both eyes prevents consensual movement of the affected eye.
B. Rinse the eye thoroughly with saline
C. Cover both eyes with paper cups
D. Patch the affected eye only
A 70 year old man who is recovering from a stroke A. The client is observed by shaving only one side of his face
exhibits signs of unilateral neglect. Which behavior is
suggested of unilateral neglect? why?
A. The client is observed by shaving only one side of The client with unilateral neglect will neglect one side of the body
his face
B. The client is unable to distinguish between two
tactile stimuli presented simultaneously
C. The client is unable to complete a range a vision
without turning his head side to side
D. The client is unable to carry out cognitive and
motor activity at the same time
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The child with seizure disorder is being treated with
Dilantin (phenytoin). Which of the following
statements by the patient's mother indicates to the
nurse that the patient is experiencing a side effect of
Dilantin therapy?
A. "She is very irritable lately."
B. "She sleeps quite a bit of the time."
C. "Her gums look too big for her teeth."
D. "She has gained about 10 pounds in the last 6
months."
A client arrives in the emergency room with a C. Bucks traction
possible fractured femur. The nurse should anticipate
an order for: why?
A. Trendelenburg position The client with a fractured femur will be placed in Bucks traction to realign
B. Ice to the entire extremity the leg and decrease spasms and pain.
C. Bucks traction
D. An abduction pillow
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