& Solutions
A nurse is assisting with the care of a client who was admitted to the
emergency department (ED). Correct Ans - Schizophrenia
- Pressured speech
- Social impairment
- Grandiose delusions
Bipolar 1 Disorder
- Pressured speech
- Social impairment
- Grandiose delusions
A nurse is caring for a client who is 12 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse take?
Correct Ans - Place an abduction wedge between the client's legs when in
bed.
A nurse is evaluating the safe use of electrical equipment by a newly hired
assistive personnel (AP). Which of the following actions by the AP
demonstrates an understanding of the proper use of electrical equipment?
Correct Ans - Grasps the plug of a device in the client's room to pull it
straight out from the wall
A nurse is assisting with the care of an adolescent in the emergency
department (ED). Correct Ans - - skin findings
- temperature
- WBC count
- casual blood glucose
- potassium
- pain
A nurse is assisting with the care of a client admitted with profuse vomiting
and abdominal pain. Correct Ans - - peritonitis
- bowel obstruction
,A nurse on the medical-surgical unit is assisting with the care of a client who
was admitted from the emergency department (ED). Correct Ans - -
confusion
- sodium level
A nurse is assisting with care of a client who is on 24-hr observation.
Correct Ans - - hemorrhage
- thrombocytopenia
A nurse is caring for a client who is postoperative following a perineal
prostatectomy. For each potential postoperative complication below, click to
specify the nursing intervention that the nurse should implement. Correct
Ans - - offer the client a sitz bath to relieve pain and promote healing
- encourage the client to drink prune juice to relieve constipation
- instruct the client to perform calf pump and foot circle exercises to promote
venous return and reduce the risk of a deep vein thrombosis.
A nurse is collecting data on a newborn who is 3 days old. Correct Ans -
- temperature of 36.4° C (97.5° F)
- Weight 2,545 g (5 lb 9 oz) 12% weight loss
- Breastfeeding every 3 to 5 hr for 5 to 10 min.
- Birth parent reports nipple discomfort throughout the feeding
- Mild tremors noted when awake
A nurse on a mental health unit is caring for a client. For each nursing action,
click to specify if the nursing action is anticipated or contraindicated for the
client. Correct Ans - ANTICIPATED:
- Offer high calorie snacks frequently.
- Initiate suicide precautions.
- Encourage the client to attend group therapy.
CONTRAINDICATED:
- Allow the client to sleep with their hands beneath the blanket.
A nurse is assisting in the care of a client who is postoperative following
administration of general anesthesia. Correct Ans - ACTIONS:
- administer dantrolene
, - administer oxygen
CONDITION:
-malignant hyperthermia
PARAMETERS:
- monitor for hypercapnia
- monitor for muscle tension
A nurse is assisting with the care of a client who has a new diagnosis of
anorexia nervosa. Complete the following sentence by using the lists of
options. Correct Ans - - electrolyte imbalance
- fear of weight gain
A nurse is assisting with the care of a client who has bulimia nervosa. Drag
words from the choices below to fill in each blank in the following sentence.
Correct Ans - - cardiovascular abnormalities
- electrolyte imbalance
A nurse is assisting with the development of an in-service for newly licensed
nurses about seclusion. In which of the following situations should the nurse
identify the need to request a prescription for seclusion? Correct Ans -
A client attempts to hit another client during group therapy.
A nurse is caring for a client who has an indwelling urinary catheter. Which of
the following actions should the nurse take? Correct Ans - Wipe the
drainage port with an antiseptic wipe after emptying urine from the bag.
A nurse is reinforcing teaching with a client who has acute diverticulitis.
Which of the following statements by the client indicates an understanding of
the instructions? Correct Ans - "I will receive the nutrients I need
through my IV fluid."
A nurse is reinforcing teaching with a client about the client's recent diagnosis
of multiple sclerosis. The client states, "I am very upset and I want to be alone
for a little while." Which of the following responses should the nurse make?
Correct Ans - "I see that you are feeling overwhelmed. I will come back
when you are ready."