A young mother of three children complains of increased anxiety during her annual
physical exam. Which information should the nurse obtain first?
A) Sexual activity patterns.
B) Nutritional history.
C) Leisure activities.
D) Financial stressors.
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B) Nutritional History
Rationale
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a
nutritional history should be obtained first so that health teaching can be
initiated if indicated.
,The nurse looks up the chart of a cousin who is not under the care of the nurse. What
is the manager's next action?
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Contact HR department
There is a breach of confidentiality in this case
An older client who is a resident in a long-term care facility has been bedridden for a
week. Which finding should the nurse identify as a client risk factor for pressure
ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower extremities.
C) Red flush over the entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions.
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D.
Rationale
Immobility, constant contact with bed clothing, and excessive heat and
moisture in areas where airflow is limited contribute to bacterial and fungal
growth, which increases the risk for rashes, skin breakdown, and the
development of pressure ulcers.
A resident in a skilled nursing facility for short-term rehabilitation after a hip
replacement tells the nurse, "I don't want any more blood taken for those useless
tests." Which narrative documentation should the nurse enter into the client's medical
record?
,A) Healthcare provider was notified of the failure to collect specimens for prescribed
blood studies.
B) Blood specimens were not collected because the client no longer wants blood
tests performed.
C) The healthcare provider was notified of the client's refusal to have blood
specimens collected for testing.
D) The client is irritable, uncooperative, and refuses to have blood collected. The
healthcare provider was notified.
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C. The healthcare provider was notified of the client's refusal to have blood
specimens collected for testing.
Rationale
When a client refuses treatment, the exact words of the client regarding the
client's refusal of care should be documented in a narrative format. The
nurse should not editorialize, make judgments, or document assumptions
about the client's wishes.
sleep patterns for adults
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An adult has four to six sleep cycles, each with non-rapid eye movement
(NREM) sleep and rapid eye movement (REM) sleep, during a normal
night's sleep.
1 cup
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, 8 ounces or 240 mL
Three days following surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the nurse that it is much bigger than he expected.
Which is the best response by the nurse?
A) Reassure the client that he will become accustomed to the stoma appearance in
time.
B) Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C) Offer to contact a member of the local ostomy support group to help him with his
concerns.
D) Encourage the client to handle the stoma equipment to gain confidence with the
procedure.
Give this one a try later!
B.
Rationale
Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when the swelling is
diminished. This will help reduce the client's anxiety and promote
acceptance of the colostomy.
A client who is a Jehovah's Witness is admitted to the nursing unit. What should the
nurse be aware of when planning care in terms of the client's beliefs?
A) Autopsy of the body is prohibited.
B) Blood transfusions are forbidden.
C) Alcohol use in any form is not allowed.
D) A vegetarian diet must be followed.
Give this one a try later!
physical exam. Which information should the nurse obtain first?
A) Sexual activity patterns.
B) Nutritional history.
C) Leisure activities.
D) Financial stressors.
Give this one a try later!
B) Nutritional History
Rationale
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a
nutritional history should be obtained first so that health teaching can be
initiated if indicated.
,The nurse looks up the chart of a cousin who is not under the care of the nurse. What
is the manager's next action?
Give this one a try later!
Contact HR department
There is a breach of confidentiality in this case
An older client who is a resident in a long-term care facility has been bedridden for a
week. Which finding should the nurse identify as a client risk factor for pressure
ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower extremities.
C) Red flush over the entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions.
Give this one a try later!
D.
Rationale
Immobility, constant contact with bed clothing, and excessive heat and
moisture in areas where airflow is limited contribute to bacterial and fungal
growth, which increases the risk for rashes, skin breakdown, and the
development of pressure ulcers.
A resident in a skilled nursing facility for short-term rehabilitation after a hip
replacement tells the nurse, "I don't want any more blood taken for those useless
tests." Which narrative documentation should the nurse enter into the client's medical
record?
,A) Healthcare provider was notified of the failure to collect specimens for prescribed
blood studies.
B) Blood specimens were not collected because the client no longer wants blood
tests performed.
C) The healthcare provider was notified of the client's refusal to have blood
specimens collected for testing.
D) The client is irritable, uncooperative, and refuses to have blood collected. The
healthcare provider was notified.
Give this one a try later!
C. The healthcare provider was notified of the client's refusal to have blood
specimens collected for testing.
Rationale
When a client refuses treatment, the exact words of the client regarding the
client's refusal of care should be documented in a narrative format. The
nurse should not editorialize, make judgments, or document assumptions
about the client's wishes.
sleep patterns for adults
Give this one a try later!
An adult has four to six sleep cycles, each with non-rapid eye movement
(NREM) sleep and rapid eye movement (REM) sleep, during a normal
night's sleep.
1 cup
Give this one a try later!
, 8 ounces or 240 mL
Three days following surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the nurse that it is much bigger than he expected.
Which is the best response by the nurse?
A) Reassure the client that he will become accustomed to the stoma appearance in
time.
B) Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C) Offer to contact a member of the local ostomy support group to help him with his
concerns.
D) Encourage the client to handle the stoma equipment to gain confidence with the
procedure.
Give this one a try later!
B.
Rationale
Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when the swelling is
diminished. This will help reduce the client's anxiety and promote
acceptance of the colostomy.
A client who is a Jehovah's Witness is admitted to the nursing unit. What should the
nurse be aware of when planning care in terms of the client's beliefs?
A) Autopsy of the body is prohibited.
B) Blood transfusions are forbidden.
C) Alcohol use in any form is not allowed.
D) A vegetarian diet must be followed.
Give this one a try later!
