The nurse has been teaching adult clients about cardiac risks when they visit the hyperten-
sion clinic. Which form of evaluation would best measure learning? - ANSWER Reported
behavioral changes
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set
of dentures prior to leaving the unit for the operating room. What would be the most appro-
priate intervention by the nurse? - ANSWER Ask the client if the preference would be to
remove the dentures in the operating room receiving area
The nurse is planning care for an 18 month-old child. Which action should be included in the
child's care? - ANSWER Encourage the child to feed himself finger food
A partner is concerned because the client frequently daydreams about moving to Arizona to
get away from the pollution and crowding in southern California. The nurse explains that -
ANSWER Such fantasies can gratify unconscious wishes or prepare for anticipated future
events
An appropriate goal for a client with anxiety would be to - ANSWER Learn self-help tech-
niques
While the nurse is administering medications to a client, the client states "I do not want to
take that medicine today." Which of the following responses by the nurse would be best? -
ANSWER "Is there a reason why you don't want to take your medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area.
Which of the following assessments is appropriate for the nurse to perform? - ANSWER
Auscultate the mass
1
,The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main
source of fluids for an infant until about 12 months of age? - ANSWER Formula or breast
milk
A client is admitted to the hospital with a history of confusion. The client has difficulty re-
membering recent events and becomes disoriented when away from home. Which state-
ment would provide the best reality orientation for this client? - ANSWER "Good morn-
ing. You're in the hospital. I am your nurse Elaine Jones."
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be
affected by the injury. Which statement is true concerning long bone fractures in children? -
ANSWER Epiphyseal fractures often interrupt a child's normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 16, and she
has missed one period. She reports episodes of nausea and vomiting. Pregnancy is con-
firmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
- ANSWER December 23
When screening children for scoliosis, at what time of development would the nurse expect
early signs to appear? - ANSWER During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The nurse dis-
covers that the client has not been following the prescribed diet. What would be the most
appropriate nursing action? - ANSWER Discuss diet with the client to learn the reasons
for not following the diet
A client states, "People think I'm no good, you know what I mean?" Which of these re-
sponses would be most therapeutic? - ANSWER "I'm not sure what you mean. Tell me a
bit more about that."
A client being treated for hypertension returns to the community clinic for follow up. The cli-
ent says, "I know these pills are important, but I just can't take these water pills anymore. I
drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom."
2
, Which of these is the best nursing diagnosis? - ANSWER Noncompliance related to medi-
cation side effects
When teaching effective stress management techniques to a client 1 hour before surgery,
which of the following should the nurse recommend? - ANSWER Deep breathing
When observing 4 year-old children playing in the hospital playroom, what activity would
the nurse expect to see the children participating in? - ANSWER Playing cooperatively
with other preschoolers
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate
finding? - ANSWER Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form of expla-
nation meets the developmental needs of this age child? - ANSWER Explain the surgery
using a model of the heart
The parents of a child who has suddenly been hospitalized for an acute illness state that they
should have taken the child to the pediatrician earlier. Which approach by the nurse is best
when dealing with the parents' comments? - ANSWER Accept their feelings without judg-
ment
When caring for a client who is receiving a thrombolytic agent to open a clot occluded coro-
nary artery after a myocardial infarction, which finding would be of greatest concern to the
nurse? - ANSWER Hematemesis
A 52 year-old client is being transfused with one unit of packed cells. A half hour after the
transfusion was initiated, the client complains of chills and headache. Which action should
the nurse implement first? - ANSWER Stop the transfusion
When caring for a client with total parenteral nutrition (TPN), what is the most important ac-
tion on the part of the nurse? - ANSWER Sterile technique for dressing change at IV site
3
sion clinic. Which form of evaluation would best measure learning? - ANSWER Reported
behavioral changes
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set
of dentures prior to leaving the unit for the operating room. What would be the most appro-
priate intervention by the nurse? - ANSWER Ask the client if the preference would be to
remove the dentures in the operating room receiving area
The nurse is planning care for an 18 month-old child. Which action should be included in the
child's care? - ANSWER Encourage the child to feed himself finger food
A partner is concerned because the client frequently daydreams about moving to Arizona to
get away from the pollution and crowding in southern California. The nurse explains that -
ANSWER Such fantasies can gratify unconscious wishes or prepare for anticipated future
events
An appropriate goal for a client with anxiety would be to - ANSWER Learn self-help tech-
niques
While the nurse is administering medications to a client, the client states "I do not want to
take that medicine today." Which of the following responses by the nurse would be best? -
ANSWER "Is there a reason why you don't want to take your medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area.
Which of the following assessments is appropriate for the nurse to perform? - ANSWER
Auscultate the mass
1
,The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main
source of fluids for an infant until about 12 months of age? - ANSWER Formula or breast
milk
A client is admitted to the hospital with a history of confusion. The client has difficulty re-
membering recent events and becomes disoriented when away from home. Which state-
ment would provide the best reality orientation for this client? - ANSWER "Good morn-
ing. You're in the hospital. I am your nurse Elaine Jones."
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be
affected by the injury. Which statement is true concerning long bone fractures in children? -
ANSWER Epiphyseal fractures often interrupt a child's normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 16, and she
has missed one period. She reports episodes of nausea and vomiting. Pregnancy is con-
firmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
- ANSWER December 23
When screening children for scoliosis, at what time of development would the nurse expect
early signs to appear? - ANSWER During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The nurse dis-
covers that the client has not been following the prescribed diet. What would be the most
appropriate nursing action? - ANSWER Discuss diet with the client to learn the reasons
for not following the diet
A client states, "People think I'm no good, you know what I mean?" Which of these re-
sponses would be most therapeutic? - ANSWER "I'm not sure what you mean. Tell me a
bit more about that."
A client being treated for hypertension returns to the community clinic for follow up. The cli-
ent says, "I know these pills are important, but I just can't take these water pills anymore. I
drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom."
2
, Which of these is the best nursing diagnosis? - ANSWER Noncompliance related to medi-
cation side effects
When teaching effective stress management techniques to a client 1 hour before surgery,
which of the following should the nurse recommend? - ANSWER Deep breathing
When observing 4 year-old children playing in the hospital playroom, what activity would
the nurse expect to see the children participating in? - ANSWER Playing cooperatively
with other preschoolers
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate
finding? - ANSWER Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form of expla-
nation meets the developmental needs of this age child? - ANSWER Explain the surgery
using a model of the heart
The parents of a child who has suddenly been hospitalized for an acute illness state that they
should have taken the child to the pediatrician earlier. Which approach by the nurse is best
when dealing with the parents' comments? - ANSWER Accept their feelings without judg-
ment
When caring for a client who is receiving a thrombolytic agent to open a clot occluded coro-
nary artery after a myocardial infarction, which finding would be of greatest concern to the
nurse? - ANSWER Hematemesis
A 52 year-old client is being transfused with one unit of packed cells. A half hour after the
transfusion was initiated, the client complains of chills and headache. Which action should
the nurse implement first? - ANSWER Stop the transfusion
When caring for a client with total parenteral nutrition (TPN), what is the most important ac-
tion on the part of the nurse? - ANSWER Sterile technique for dressing change at IV site
3
