Mental Health Updated Version A & B with
Verified Answers and Rationale Grade A+
2025 Brand New
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During the postpartum period a client tells the nurse that she was very uncomfortable during her
pregnancy because of varicose veins. In light of this information, what should the nurse's assessment
include?
Assessing for signs of thrombophlebitis
A 6-year-old boy is hospitalized with an exacerbation of nephrotic syndrome. The mother asks the
nurse what she should bring for her son to play with during the hospitalization. What should the nurse
suggest?
Checkers, simple card games, and crayons,
A neonate at 34 weeks' gestation is admitted to the neonatal intensive care unit. The nurse reviews
the medical record and obtains the neonate's vital signs. What objective should the nurse designate
as the priority?
Oxygenation will remain adequate
A child with Wilms tumor is undergoing chemotherapy in a protocol that includes vincristine
(Oncovin) and doxorubicin hydrochloride (Adriamycin). Which common side effect unique to
doxorubicin should the nurse expect to observe in the child?
Red urine
A nurse is teaching a pregnant client with type 1 diabetes at her first visit to the clinic how to minimize
fetal/neonatal complications. What is the most important action for the client to take?
Adhere to the management plan
A nurse is assessing a newborn. Which sign should the nurse report?
Breathing pattern with recurrent sternal retractions
What is the safest position for a woman in labor when the nurse notes a prolapsed cord?
Trendelenburg
,A nurse is caring for a high-risk pregnant client who has had a positive contraction stress test (CST).
The nurse interprets the result to mean that
Late decelerations of the fetal heart rate are occurring with each contraction.
When planning nursing care for a 5-year-old child with acute post streptococcal glomerulonephritis,
what should the nurse emphasize that the child and family must maintain?
Isolation from children with infections
A nurse is teaching a class for staff members working in a group home about the cognitive
development of children with cognitive impairments. What concept can these children probably learn
the fastest?
Large versus small
A child is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. The nurse
concludes that isolation:
Will be necessary for 24 to 72 hours after the initiation of antibiotic therapy,,
An 8-year-old child with cerebral palsy is admitted to the hospital for a tendon-lengthening
procedure. After the surgery the parents ask a nurse why their child must wear braces and shoes for
at least 12 hours a day, even while in bed. What is the best response by the nurse?
They maintain body alignment and help prevent foot drop."
The nurse assesses a newborn, using the Apgar scale. One minute after birth the newborn has a heart
rate of 120 beats/min, slow and irregular respirations, a weak cry, some flexion of extremities, and a
pink body with blue extremities. What does the nurse record as the 1-minute Apgar score?
6
A nurse is assessing several postpartum clients. Which problem does the nurse identify that will most
likely predispose a client to postpartum hemorrhage?
Multifetal pregnancy,,
what medication does a nurse expect to administer to control bleeding in a child with hemophilia A?
Factor VIII concentrate
How can a school nurse help determine a young child's readiness to learn?
By assessing the child's vision and hearing
What is the initial nursing objective for a grand multipara who has had a cesarean birth?
,Prevention of hemorrhage
A nurse is caring for several preterm infants. What precautions should the nurse take to limit the risk
for retinopathy of prematurity (retrolental fibroplasia)?
Keeping oxygen at the lowest concentration necessary and discontinuing it as soon as it is feasible,,
A postpartum client is changing her female newborn's diaper, sees what appears to be red-tinged
mucus on the diaper, and calls the nursing station for assistance. What nursing intervention is
necessary?
Explaining that this is a normal reaction to the mother's hormones
A school nurse is teaching a class of school-age children about bicycle safety. The nurse determines
that a child needs further teaching when the child states:
"I will always wear a helmet and ride with traffic facing me."
A second-grade teacher discusses the behavior of one of the students with the school nurse. The
school nurse suspects that the child has attention deficit-hyperactivity disorder (ADHD). Which finding
often is associated with ADHD?
Impulsivity
A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To
ensure client and visitor safety during transport, the nurse should take which precaution?
Place a surgical mask on the client.
A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment
device has been prescribed to hasten wound healing. Which nursing action is most appropriate when
caring for this client?
Replace the wound sponge every 48 hours
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly
instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene
because these behaviors eventually will cause the other clients to feel:
Angry
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks
about the best way to prevent infection and keep the catheter clean. Which would be appropriate for
the nurse to include in the client teaching?
Replace the drainage bag with a new bag once a week.
, What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs
because of cerebral palsy?
Test the temperature of the water before a bath.
To ensure accuracy when assessing a client's blood pressure, how does the nurse avoid a parallax
error?
Read the manometer at eye level.
A child with β-thalassemia (Cooley anemia) is admitted to the ambulatory care unit for a transfusion.
What instruction should the nurse include in the plan of care?
Protect from infections.
Haloperidol (Haldol) 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered
and agitated after a street brawl. The nurse reviews the prescription and concludes that:
The dose is more than recommended
The nurse determines that a client with a spinal cord injury is developing autonomic hyperreflexia
(autonomic dysreflexia) when the client exhibits:
Paroxysmal hypertension and bradycardia,,
A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to
demonstrate?
Fluctuating weakness of muscles innervated by the cranial nerves
A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical
manifestation of meningeal irritation for which the nurse assesses the client is:
Help maintain the strength of the unaffected limb
A married couple in their 80s is living independently. They have three adult children. The husband,
who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has
diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing,
dressing, and meal preparation. The nurse suggests that the plan that would be the most suitable for
this couple is to
Keep them in their home with a home health aide
A client with a sucking chest wound has a large tight dressing over the site. The nurse understands
that the purpose of this dressing is to
Maintain the appropriate pressure within the chest cavity
Verified Answers and Rationale Grade A+
2025 Brand New
------------------------------------------------------------------------------------------------------------------------------------------
During the postpartum period a client tells the nurse that she was very uncomfortable during her
pregnancy because of varicose veins. In light of this information, what should the nurse's assessment
include?
Assessing for signs of thrombophlebitis
A 6-year-old boy is hospitalized with an exacerbation of nephrotic syndrome. The mother asks the
nurse what she should bring for her son to play with during the hospitalization. What should the nurse
suggest?
Checkers, simple card games, and crayons,
A neonate at 34 weeks' gestation is admitted to the neonatal intensive care unit. The nurse reviews
the medical record and obtains the neonate's vital signs. What objective should the nurse designate
as the priority?
Oxygenation will remain adequate
A child with Wilms tumor is undergoing chemotherapy in a protocol that includes vincristine
(Oncovin) and doxorubicin hydrochloride (Adriamycin). Which common side effect unique to
doxorubicin should the nurse expect to observe in the child?
Red urine
A nurse is teaching a pregnant client with type 1 diabetes at her first visit to the clinic how to minimize
fetal/neonatal complications. What is the most important action for the client to take?
Adhere to the management plan
A nurse is assessing a newborn. Which sign should the nurse report?
Breathing pattern with recurrent sternal retractions
What is the safest position for a woman in labor when the nurse notes a prolapsed cord?
Trendelenburg
,A nurse is caring for a high-risk pregnant client who has had a positive contraction stress test (CST).
The nurse interprets the result to mean that
Late decelerations of the fetal heart rate are occurring with each contraction.
When planning nursing care for a 5-year-old child with acute post streptococcal glomerulonephritis,
what should the nurse emphasize that the child and family must maintain?
Isolation from children with infections
A nurse is teaching a class for staff members working in a group home about the cognitive
development of children with cognitive impairments. What concept can these children probably learn
the fastest?
Large versus small
A child is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. The nurse
concludes that isolation:
Will be necessary for 24 to 72 hours after the initiation of antibiotic therapy,,
An 8-year-old child with cerebral palsy is admitted to the hospital for a tendon-lengthening
procedure. After the surgery the parents ask a nurse why their child must wear braces and shoes for
at least 12 hours a day, even while in bed. What is the best response by the nurse?
They maintain body alignment and help prevent foot drop."
The nurse assesses a newborn, using the Apgar scale. One minute after birth the newborn has a heart
rate of 120 beats/min, slow and irregular respirations, a weak cry, some flexion of extremities, and a
pink body with blue extremities. What does the nurse record as the 1-minute Apgar score?
6
A nurse is assessing several postpartum clients. Which problem does the nurse identify that will most
likely predispose a client to postpartum hemorrhage?
Multifetal pregnancy,,
what medication does a nurse expect to administer to control bleeding in a child with hemophilia A?
Factor VIII concentrate
How can a school nurse help determine a young child's readiness to learn?
By assessing the child's vision and hearing
What is the initial nursing objective for a grand multipara who has had a cesarean birth?
,Prevention of hemorrhage
A nurse is caring for several preterm infants. What precautions should the nurse take to limit the risk
for retinopathy of prematurity (retrolental fibroplasia)?
Keeping oxygen at the lowest concentration necessary and discontinuing it as soon as it is feasible,,
A postpartum client is changing her female newborn's diaper, sees what appears to be red-tinged
mucus on the diaper, and calls the nursing station for assistance. What nursing intervention is
necessary?
Explaining that this is a normal reaction to the mother's hormones
A school nurse is teaching a class of school-age children about bicycle safety. The nurse determines
that a child needs further teaching when the child states:
"I will always wear a helmet and ride with traffic facing me."
A second-grade teacher discusses the behavior of one of the students with the school nurse. The
school nurse suspects that the child has attention deficit-hyperactivity disorder (ADHD). Which finding
often is associated with ADHD?
Impulsivity
A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To
ensure client and visitor safety during transport, the nurse should take which precaution?
Place a surgical mask on the client.
A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment
device has been prescribed to hasten wound healing. Which nursing action is most appropriate when
caring for this client?
Replace the wound sponge every 48 hours
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly
instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene
because these behaviors eventually will cause the other clients to feel:
Angry
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks
about the best way to prevent infection and keep the catheter clean. Which would be appropriate for
the nurse to include in the client teaching?
Replace the drainage bag with a new bag once a week.
, What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs
because of cerebral palsy?
Test the temperature of the water before a bath.
To ensure accuracy when assessing a client's blood pressure, how does the nurse avoid a parallax
error?
Read the manometer at eye level.
A child with β-thalassemia (Cooley anemia) is admitted to the ambulatory care unit for a transfusion.
What instruction should the nurse include in the plan of care?
Protect from infections.
Haloperidol (Haldol) 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered
and agitated after a street brawl. The nurse reviews the prescription and concludes that:
The dose is more than recommended
The nurse determines that a client with a spinal cord injury is developing autonomic hyperreflexia
(autonomic dysreflexia) when the client exhibits:
Paroxysmal hypertension and bradycardia,,
A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to
demonstrate?
Fluctuating weakness of muscles innervated by the cranial nerves
A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical
manifestation of meningeal irritation for which the nurse assesses the client is:
Help maintain the strength of the unaffected limb
A married couple in their 80s is living independently. They have three adult children. The husband,
who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has
diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing,
dressing, and meal preparation. The nurse suggests that the plan that would be the most suitable for
this couple is to
Keep them in their home with a home health aide
A client with a sucking chest wound has a large tight dressing over the site. The nurse understands
that the purpose of this dressing is to
Maintain the appropriate pressure within the chest cavity
