A nurse is caring for a client who was just informed of a new diagnosis of breast cancer.
The nurse evaluates the client's response. Which of the following statements by the
client represents the SDOH of health and health care? -ANSWER-"I wish we lived closer
to the big medical centers in the city."
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and
reports difficulty following the diet and remembering to take the prescribed medication.
Which of the following actions should the nurse take to promote client adherence?
Select all that apply -ANSWER-1. Ask the dietitian to assist with meal planning
2. Provide educational materials for home use
3. Contact the clients support system
4. Encourage the use of daily medication dispenser
A nurse in the ED is preparing to care for a group of clients. Which of the following
clients should the nurse classify as urgent when using the three-level system of triage?
Select all that apply -ANSWER-1. Client who has a pressure injury and a blood glucose
of 200 mg/dL
2. Client who reports urinary frequency and fever
A nurse encounters an unresponsive client during a walk. The client's partner states,
"He was pulling weeds in the yard and slumped to the ground." Which of the following
techniques should the nurse use to open the client's airway? -ANSWER-Head-tilt, chin-
lift
A nurse in the ED is caring for a client who has been exposed to freezing temperatures
for several hours and is alert and talking. Which of the following actions should the
nurse take? Select all that apply -ANSWER-1. Remove wet clothing
2. Apply warm blankets
3. Infuse warm IV fluids
A nurse in the ED is caring for a client who is suspected of having opioid poisoning.
During the interview, the nurse notes that the client suddenly becomes unresponsive,
,respirations and pulse are absent. Which of the following actions should the nurse take?
Select all that apply -ANSWER-1. Administer naloxone
2. Obtain AED
3. Begin performing CPR
A nurse in the ED is caring for a client who suddenly becomes unresponsive and notes
ventricular asystole on their monitor. Place the actions the nurse should take in their
correct order -ANSWER-1. perform initial round of CPR
2. administer epinephrine
3. analyze heart rhythm with AED
4. identify cause
A nurse is teaching a client who is scheduled for a cerebral angiography. Which of the
following statements by the client indicates understanding? -ANSWER-"I will feel warm
after that dye is injected."
A nurse is caring for a client who is scheduled for a cerebral computed tomography
scan with contrast. Which of the following actions should the nurse take? -ANSWER-
Ensure the client is not wearing any metal objects prior to procedure.
A nurse is providing education to a client who is scheduled for an electroencephalogram
(EEG) the next day. Which of the following statements should the nurse make? -
ANSWER-"You should wash your hair prior to the procedure."
A nurse is caring for a client immediately following a lumbar puncture. Which of the
following actions should the nurse take?
Select all that apply. -ANSWER-1. administer analgesic for pain
2. encourage increased fluid intake
3. monitor puncture site for drainage
A nurse is caring for a client who came into the emergency department after an injury to
the right arm. The nurse is assessing the client's pain. Which question should the nurse
ask first? -ANSWER-Where is your pain?
A nurse is caring for a client who reports pain at 10 on a 0 to 10 scale. The nurse plans
to administer morphine. Which of the following adverse effects should the nurse monitor
for in the client?
Select all that apply. -ANSWER-1. confusion
2. constipation
3. bradypnea
A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse expect?
Select all the apply. -ANSWER-1. headache
2. nuchal rigidity
3. photophobia
4. seizures
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected
meningitis. Which of the following actions should the nurse take when performing this
technique?
Select all that apply. -ANSWER-1. place client in supine position
2. place hands behind the clients neck
3. bend clients head toward chest
, A nurse is caring for a newly admitted client. The client has been identified as having
bacterial meningitis. Which of the following is the priority action for the nurse to take? -
ANSWER-isolate the client (droplet precautions)
A nurse is caring for a client who has meningitis and is at risk for SIADH. Which of the
following findings should the nurse monitor for?
Select all that apply. -ANSWER-1. change in LOC
2. bounding pulse
A nurse is providing discharge instructions to a client who has a prescription for
phenytoin. Which of the following information should the nurse include? -ANSWER-Take
the medication at the same time every day.
A nurse is caring for a client who has Parkinson's disease. Which of the following
findings should the nurse anticipate the client to exhibit?
Select all that apply. -ANSWER-1. shuffling gait
2. lack of facial expression
3. pill-rolling tremor of the finger
4. drooling
A nurse is caring for a client who is taking benztropine and is reporting tremors and
rigidity in the left hand and arm. Which of the following findings should the nurse identify
as an adverse effect of benztropine? -ANSWER-dry mouth
A nurse is caring for a client who has stage IV Parkinson's disease and has lost 20 lbs
since their last checkup one month ago. The client presents with akinesia and rigidity. A
nurse is developing a plan of care for the nutritional needs. Which of the following
actions should the nurse include?
Select all that apply. -ANSWER-1. offer nutritional supplements between meals
2. record diet and fluid daily
3. offer cold fluids such as milk shakes
A nurse is caring for a client who has Alzheimer's disease. A family member of the client
asks the nurse about risk factors for the disease. Which of the following factors should
be included in the nurse's response?
Select all that apply. -ANSWER-1. Exposure to metal
2. History of herpes infection
3. Previous head injury
Lilly is planning care for Mrs. Roberts, who has mild Alzheimer's disease. Which of the
following interventions should be included in the plan of care? -ANSWER-Reorient the
client to self and current events.
Lilly is caring for Mrs. Roberts who has Alzheimer's disease and fell at home prior to
admission. Which of the following actions should the nurse take first to keep the client
safe? -ANSWER-Place the client in a room close to the nurses' station.
A nurse is providing teaching to the partner of a client who has Alzheimer's disease and
has a new prescription for donepezil. Which of the following statements by the partner
indicates the teaching is effective? -ANSWER-"This medication should help my spouse's
daily function."
A nurse is making a home visit to a client who has AD. The client's partner states that
the client is often disoriented to time and place, is unsteady, and has a history of
wandering. Which of the following safety measures should the nurse review with the
partner?
The nurse evaluates the client's response. Which of the following statements by the
client represents the SDOH of health and health care? -ANSWER-"I wish we lived closer
to the big medical centers in the city."
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and
reports difficulty following the diet and remembering to take the prescribed medication.
Which of the following actions should the nurse take to promote client adherence?
Select all that apply -ANSWER-1. Ask the dietitian to assist with meal planning
2. Provide educational materials for home use
3. Contact the clients support system
4. Encourage the use of daily medication dispenser
A nurse in the ED is preparing to care for a group of clients. Which of the following
clients should the nurse classify as urgent when using the three-level system of triage?
Select all that apply -ANSWER-1. Client who has a pressure injury and a blood glucose
of 200 mg/dL
2. Client who reports urinary frequency and fever
A nurse encounters an unresponsive client during a walk. The client's partner states,
"He was pulling weeds in the yard and slumped to the ground." Which of the following
techniques should the nurse use to open the client's airway? -ANSWER-Head-tilt, chin-
lift
A nurse in the ED is caring for a client who has been exposed to freezing temperatures
for several hours and is alert and talking. Which of the following actions should the
nurse take? Select all that apply -ANSWER-1. Remove wet clothing
2. Apply warm blankets
3. Infuse warm IV fluids
A nurse in the ED is caring for a client who is suspected of having opioid poisoning.
During the interview, the nurse notes that the client suddenly becomes unresponsive,
,respirations and pulse are absent. Which of the following actions should the nurse take?
Select all that apply -ANSWER-1. Administer naloxone
2. Obtain AED
3. Begin performing CPR
A nurse in the ED is caring for a client who suddenly becomes unresponsive and notes
ventricular asystole on their monitor. Place the actions the nurse should take in their
correct order -ANSWER-1. perform initial round of CPR
2. administer epinephrine
3. analyze heart rhythm with AED
4. identify cause
A nurse is teaching a client who is scheduled for a cerebral angiography. Which of the
following statements by the client indicates understanding? -ANSWER-"I will feel warm
after that dye is injected."
A nurse is caring for a client who is scheduled for a cerebral computed tomography
scan with contrast. Which of the following actions should the nurse take? -ANSWER-
Ensure the client is not wearing any metal objects prior to procedure.
A nurse is providing education to a client who is scheduled for an electroencephalogram
(EEG) the next day. Which of the following statements should the nurse make? -
ANSWER-"You should wash your hair prior to the procedure."
A nurse is caring for a client immediately following a lumbar puncture. Which of the
following actions should the nurse take?
Select all that apply. -ANSWER-1. administer analgesic for pain
2. encourage increased fluid intake
3. monitor puncture site for drainage
A nurse is caring for a client who came into the emergency department after an injury to
the right arm. The nurse is assessing the client's pain. Which question should the nurse
ask first? -ANSWER-Where is your pain?
A nurse is caring for a client who reports pain at 10 on a 0 to 10 scale. The nurse plans
to administer morphine. Which of the following adverse effects should the nurse monitor
for in the client?
Select all that apply. -ANSWER-1. confusion
2. constipation
3. bradypnea
A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse expect?
Select all the apply. -ANSWER-1. headache
2. nuchal rigidity
3. photophobia
4. seizures
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected
meningitis. Which of the following actions should the nurse take when performing this
technique?
Select all that apply. -ANSWER-1. place client in supine position
2. place hands behind the clients neck
3. bend clients head toward chest
, A nurse is caring for a newly admitted client. The client has been identified as having
bacterial meningitis. Which of the following is the priority action for the nurse to take? -
ANSWER-isolate the client (droplet precautions)
A nurse is caring for a client who has meningitis and is at risk for SIADH. Which of the
following findings should the nurse monitor for?
Select all that apply. -ANSWER-1. change in LOC
2. bounding pulse
A nurse is providing discharge instructions to a client who has a prescription for
phenytoin. Which of the following information should the nurse include? -ANSWER-Take
the medication at the same time every day.
A nurse is caring for a client who has Parkinson's disease. Which of the following
findings should the nurse anticipate the client to exhibit?
Select all that apply. -ANSWER-1. shuffling gait
2. lack of facial expression
3. pill-rolling tremor of the finger
4. drooling
A nurse is caring for a client who is taking benztropine and is reporting tremors and
rigidity in the left hand and arm. Which of the following findings should the nurse identify
as an adverse effect of benztropine? -ANSWER-dry mouth
A nurse is caring for a client who has stage IV Parkinson's disease and has lost 20 lbs
since their last checkup one month ago. The client presents with akinesia and rigidity. A
nurse is developing a plan of care for the nutritional needs. Which of the following
actions should the nurse include?
Select all that apply. -ANSWER-1. offer nutritional supplements between meals
2. record diet and fluid daily
3. offer cold fluids such as milk shakes
A nurse is caring for a client who has Alzheimer's disease. A family member of the client
asks the nurse about risk factors for the disease. Which of the following factors should
be included in the nurse's response?
Select all that apply. -ANSWER-1. Exposure to metal
2. History of herpes infection
3. Previous head injury
Lilly is planning care for Mrs. Roberts, who has mild Alzheimer's disease. Which of the
following interventions should be included in the plan of care? -ANSWER-Reorient the
client to self and current events.
Lilly is caring for Mrs. Roberts who has Alzheimer's disease and fell at home prior to
admission. Which of the following actions should the nurse take first to keep the client
safe? -ANSWER-Place the client in a room close to the nurses' station.
A nurse is providing teaching to the partner of a client who has Alzheimer's disease and
has a new prescription for donepezil. Which of the following statements by the partner
indicates the teaching is effective? -ANSWER-"This medication should help my spouse's
daily function."
A nurse is making a home visit to a client who has AD. The client's partner states that
the client is often disoriented to time and place, is unsteady, and has a history of
wandering. Which of the following safety measures should the nurse review with the
partner?
