AND ANSWERS || VERIFIED ||GRADED
A+|| 100% Pass
\.A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a
coma. What is the priority nursing care for this client?
1 Monitor vital signs.
2 Maintain an open airway.
3 Maintain fluid and electrolytes.
4 Monitor pupil response and equality. - Answer- 2
\.A nurse is creating a therapy group for low-functioning clients. Which client is the most
appropriate member?
1 A 77-year-old man with anxiety and mild dementia
2 A 52-year-old woman with alcoholism and an antisocial personality
3 A 38-year-old woman whose depression is responding to medication
4 A 28-year-old man with bipolar disorder who is in a hypermanic state - Answer- 1
\.A client who was in a motor bike accident has a severe neck injury. Which priority nursing care
is most needed?
1 Assessing for crepitus
2 Assessing for bleeding
3 Maintaining a patent airway
4 Performing neurologic assessment - Answer- 3
,\.A nurse is making a home visit to a young client manifesting chronic symptoms of acquired
immune deficiency syndrome (AIDS). The nurse assesses the client for what signs of altered
mental health function associated with AIDS? Select all that apply.
1 Delusions
2 Memory loss
3 Hopelessness
4 Hyperactivity
5 Paranoid thinking - Answer- 1,2,3,5
\.The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What
nursing intervention is the priority?
1 Weigh the client daily.
2 Restrict the client's oral fluid intake.
3 Measure the client's urine specific gravity.
4 Observe the client for increasing confusion. - Answer- 4
\.What developmental skills does a preschooler exhibit? Select all that apply.
1 Personal identity
2 Specific reasoning
3 Increased curiosity
4 Magical thinking
5 Understanding of others - Answer- 2,3,4
\.During a nursing assessment, a nurse notes that a client has begun to create new words. What
term does the nurse use to document this finding?
1 Neologism
2 Perseveration
,3 Pressured speech
4 Tangential speech - Answer- 1
\.What should the nurse assess first when evaluating memory impairment in a client with
dementia?
1 Disorientation of self
2 Recollection of past events
3 Remembrance of recent events
4 Impaired ability to name objects - Answer- 3
\.A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress
syndrome. When assessing the client, what does the nurse expect to identify?
1 Hypertension
2 Tenacious sputum
3 Altered mental status
4 Slow rate of breathing - Answer- 3
\.A client with schizophrenia reports having ongoing auditory hallucinations and describes them
as "voices telling me that I'm a bad person" to the nurse. What is the best response by the
nurse?
1 "Try to ignore the voices."
2 "What are the voices saying to you?"
3 "Do you believe what the voices are saying?"
4 "They're only voices, so just try not to be afraid." - Answer- 1
\.An older adult is being admitted to a nursing home with the diagnosis of dementia. The
history reveals confusion, difficulty recognizing family members, and nighttime wandering.
What should the nurse include in the client's plan of care?
, 1 Ordering a vest restraint for the client to be applied at night
2 Obtaining a prescription for a sedative so the client will sleep better at night
3 Requesting that the family provide a companion to stay with the client at night
4 Assigning the client to a room near the nurses' station for closer supervision at night - Answer-
4
\.After assessing a client, the nurse suspects that the client has shift-work sleep disorder
(SWSD). Which medication would be prescribed to the client?
1 Caffeine
2 Modafinil
3 Atomoxetine
4 Methylphenidate - Answer- 2
\.What should a nurse include in the plan of care for a client with vascular dementia?
1 Reeducation program
2 Supportive care interventions
3 Introduction of new leisure-time activities
4 Involvement in group therapy sessions - Answer- 2
\.The student nurse is performing a rapid baseline assessment using a disability mnemonic
(AVPU) in a client with drug abuse. Which parameters should the student nurse consider for
proper assessment? Select all that apply.
1 Level of anxiety
2 Reaction to pain
3 Response to voice
4 Body temperature
5 Evidence of assault - Answer- 2,3