A nurse is caring for a client who is scheduled to undergo ECT. The provider has explained
the procedure to the client. Which of the following statements made by the client indicates
a need for further teaching? - ANSWER This procedure can increase my risk for develop-
ing Parkinson's
There has been a massive community disaster and stable clients must be discharged from
the hospital to prepare for the influx of new casualties. Which of the following clients is safe
to discharge? - ANSWER A client with multiple sclerosis who reports ataxia
A nurse is providing discharge teaching to a client and family members following an admis-
sion for a seizure disorder. Which of the following actions should the nurse instruct the fam-
ily members to take if the client experiences a seizure? - ANSWER Loosen constricting
clothing
A nurse is caring for a client who reports pain. When documenting the quality of the client's
pain on an initial pain assessment, the nurse should record which of the following client
statements? - ANSWER The pain is like a dull ache in my stomach.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the fol-
lowing should the nurse document as therapeutic outcome? - ANSWER Decrease in
flexor and extensor spasticity
A client recently diagnosed with bipolar disorder is placed in a room with a client who has
severe depression. The client who has depression reports to the nurse, "That man in my
room never sleeps and he keeps me up, too." Which of the following is an appropriate inter-
vention for the nurse to take? - ANSWER Move the client who has bipolar disorder to a
private room.
1
, The nurse is assisting a group of clients to identify skin cancer-related risk factors that can be
reduced. Which of the following is an appropriate health behavior change? - ANSWER
Wearing a wide-brim hat while gardening.
An older adult client is to receive an annual influenza vaccine. While preparing the client for
this immunization, the nurse should ask the client if he has a hypersensitivity to which of the
following? - ANSWER Eggs
Which of the following nursing interventions is helpful in establishing trust in the initial
phase of a nurse-client relationship? - ANSWER Discussing the boundaries of the relation-
ship with the client.
A nurse is assessing a client who is diagnosed with rheumatoid arthritis. Which of the follow-
ing nonpharmacologic interventions should the nurse suggest to a client to reduce pain? -
ANSWER Alternate application of heat and cold
A nurse is watching an assistive personnel empty a postsurgical client's Jackson-Pratt drain.
Which of the following indicates that the AP needs further instruction on this procedure? -
ANSWER The AP puts on sterile gloves beore performing the procedure.
A nurse is caring for a child who has experienced a generalized seizure. During the postictal
period, which of the following actions should the nurse take? - ANSWER Document the
time until the child is fully awake
A client who has systemic lupus erythematosus presents to the clinic. Which of the following
findings should be reported to the primary care provider? - ANSWER Increase in heart
rate 25/min above baseline.
A nurse is educating a client who is at 30 weeks of gestation regarding a 3-hr oral glucose tol-
erance test. Which of the following should the nurse include in her teaching? - ANSWER
Consume 150 g of carbs for 3 days prior
2
the procedure to the client. Which of the following statements made by the client indicates
a need for further teaching? - ANSWER This procedure can increase my risk for develop-
ing Parkinson's
There has been a massive community disaster and stable clients must be discharged from
the hospital to prepare for the influx of new casualties. Which of the following clients is safe
to discharge? - ANSWER A client with multiple sclerosis who reports ataxia
A nurse is providing discharge teaching to a client and family members following an admis-
sion for a seizure disorder. Which of the following actions should the nurse instruct the fam-
ily members to take if the client experiences a seizure? - ANSWER Loosen constricting
clothing
A nurse is caring for a client who reports pain. When documenting the quality of the client's
pain on an initial pain assessment, the nurse should record which of the following client
statements? - ANSWER The pain is like a dull ache in my stomach.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the fol-
lowing should the nurse document as therapeutic outcome? - ANSWER Decrease in
flexor and extensor spasticity
A client recently diagnosed with bipolar disorder is placed in a room with a client who has
severe depression. The client who has depression reports to the nurse, "That man in my
room never sleeps and he keeps me up, too." Which of the following is an appropriate inter-
vention for the nurse to take? - ANSWER Move the client who has bipolar disorder to a
private room.
1
, The nurse is assisting a group of clients to identify skin cancer-related risk factors that can be
reduced. Which of the following is an appropriate health behavior change? - ANSWER
Wearing a wide-brim hat while gardening.
An older adult client is to receive an annual influenza vaccine. While preparing the client for
this immunization, the nurse should ask the client if he has a hypersensitivity to which of the
following? - ANSWER Eggs
Which of the following nursing interventions is helpful in establishing trust in the initial
phase of a nurse-client relationship? - ANSWER Discussing the boundaries of the relation-
ship with the client.
A nurse is assessing a client who is diagnosed with rheumatoid arthritis. Which of the follow-
ing nonpharmacologic interventions should the nurse suggest to a client to reduce pain? -
ANSWER Alternate application of heat and cold
A nurse is watching an assistive personnel empty a postsurgical client's Jackson-Pratt drain.
Which of the following indicates that the AP needs further instruction on this procedure? -
ANSWER The AP puts on sterile gloves beore performing the procedure.
A nurse is caring for a child who has experienced a generalized seizure. During the postictal
period, which of the following actions should the nurse take? - ANSWER Document the
time until the child is fully awake
A client who has systemic lupus erythematosus presents to the clinic. Which of the following
findings should be reported to the primary care provider? - ANSWER Increase in heart
rate 25/min above baseline.
A nurse is educating a client who is at 30 weeks of gestation regarding a 3-hr oral glucose tol-
erance test. Which of the following should the nurse include in her teaching? - ANSWER
Consume 150 g of carbs for 3 days prior
2
