Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
1. Click to highlight the aspects of the assessment that require urgent attention:
The client's pain is 2/10. The client requests sleeping medication for the night. She states she
has horrible thoughts and memories about the house collapsing all the time, and that it is
keeping her from falling asleep. She states "I used to be so happy before all of this hap-
pened. Now I can;t seem to get out of this funk I am in." The client would also prefer to be in
a quieter area of the unit as she is currently by the nurses station and hears talking and
alarms constantly. - ANSWER -She states she has horrible thoughts and memories about
the house collapsing all the time.
- it is keeping her from falling asleep.
-prefers to be in a quieter area of the unit.
The nurse is planning discharge instructions for a client with type 2 diabetes who will be
starting Exenatide. Which information should be included in the discharge instructions?
A. Exenatide acts in the same way as insulin in lowering blood glucose.
B. Inject exenatide within 30 minutes before or after a meal.
C. There are no precautions when taking Exenatide with other medications.
D. Notify your healthcare provider if you start having abdominal pain. - ANSWER D. Notify
your healthcare provider if you start having abdominal pain.
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
1
,2. Drag from the options to complete the sentence:
After listening to the clients symptoms, the nurse realizes that she likely has______________
related to _______________ - ANSWER Acute Stress Disorder, Traumatic Stress exposure
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
3. Click to specify which client statement of behaviors is most likely associated with each of
the listed defense mechanism. Some statements or behaviors may be consistent with more
than one mechanism. Each column must have at least one but may have more than one an-
swer selected. - ANSWER
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
4. What nursing reviews the physicians orders for Clonazepam and gives the medication as
ordered. (SATA)
a. monitor calcium levels
b. assist the client to the bathroom
c. screen for orthostatic hypotension
d. assess mental status regularly
e. provide oral care at least twice a day
f. have an opioid agonist at the bedside - ANSWER b. assist the client to the bathroom
d. assess mental status regularly
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
2
,5. What other treatment might be helpful for this client? SATA
a. animal therapy
b. administration of lithium
c. consciousness-raising
d. phototherapy
e. electroconvulsive therapy
f. cognitive behavioral therapy - ANSWER a. animal therapy
c. consciousness-raising
f. cognitive behavioral therapy
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
6. For each client statement, click to highlight the statement(s) below that require follow up
teaching by the nurse.
a. "this diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
c. "I can use holistic approaches like medication to help my symptoms"
d. "Many people have the same response to a stressful situation as I am having right"
e. "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"
f. " I will probably need to be on medication for the rest of my life" - ANSWER a. "this di-
agnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
f. " I will probably need to be on medication for the rest of my life"
3
, A client with foul-smelling drainage from an incision on the upper left arm is admitted with a
suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing interventions
should the nurse include in the plan of care? Select all that apply
a. Explain the purpose of a low-bacteria diet
b. Send wound drainage for culture and sensitivity
c. Institute contact precautions for staff and visitors
d. Use standard precautions and wear a mask
e. Monitor the clients white blood cell count - ANSWER b. Send wound drainage for cul-
ture and sensitivity
c. Institute contact precautions for staff and visitors
e. Monitor the clients white blood cell count
An older adult client who has difficulty hearing is being discharged form surgery following
cataract extraction and lens implantation. Which intervention is most important for the
nurse to implement to ensure the clients compliance with self-care.
a. Provide written instructions for eye drop administration
b. Speak clearly and face the client for lip reading
c. Have the client vocalize the instructions provided
d. Ensure that someone will stay with the client for 24 hours - ANSWER a. Provide written
instructions for eye drop administration
When assessing a client with an ionized calcium level of 15 mg/dL (4.25 mmol/L), which in-
tervention is most important for the nurse to implement Reference Range Ionized calcium [
adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)
a. Compare muscle strength bilaterally b. Assess strength of deep tendon reflexes
c. Determine apical pulse rate and rhythm
4
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
1. Click to highlight the aspects of the assessment that require urgent attention:
The client's pain is 2/10. The client requests sleeping medication for the night. She states she
has horrible thoughts and memories about the house collapsing all the time, and that it is
keeping her from falling asleep. She states "I used to be so happy before all of this hap-
pened. Now I can;t seem to get out of this funk I am in." The client would also prefer to be in
a quieter area of the unit as she is currently by the nurses station and hears talking and
alarms constantly. - ANSWER -She states she has horrible thoughts and memories about
the house collapsing all the time.
- it is keeping her from falling asleep.
-prefers to be in a quieter area of the unit.
The nurse is planning discharge instructions for a client with type 2 diabetes who will be
starting Exenatide. Which information should be included in the discharge instructions?
A. Exenatide acts in the same way as insulin in lowering blood glucose.
B. Inject exenatide within 30 minutes before or after a meal.
C. There are no precautions when taking Exenatide with other medications.
D. Notify your healthcare provider if you start having abdominal pain. - ANSWER D. Notify
your healthcare provider if you start having abdominal pain.
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
1
,2. Drag from the options to complete the sentence:
After listening to the clients symptoms, the nurse realizes that she likely has______________
related to _______________ - ANSWER Acute Stress Disorder, Traumatic Stress exposure
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
3. Click to specify which client statement of behaviors is most likely associated with each of
the listed defense mechanism. Some statements or behaviors may be consistent with more
than one mechanism. Each column must have at least one but may have more than one an-
swer selected. - ANSWER
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
4. What nursing reviews the physicians orders for Clonazepam and gives the medication as
ordered. (SATA)
a. monitor calcium levels
b. assist the client to the bathroom
c. screen for orthostatic hypotension
d. assess mental status regularly
e. provide oral care at least twice a day
f. have an opioid agonist at the bedside - ANSWER b. assist the client to the bathroom
d. assess mental status regularly
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
2
,5. What other treatment might be helpful for this client? SATA
a. animal therapy
b. administration of lithium
c. consciousness-raising
d. phototherapy
e. electroconvulsive therapy
f. cognitive behavioral therapy - ANSWER a. animal therapy
c. consciousness-raising
f. cognitive behavioral therapy
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
6. For each client statement, click to highlight the statement(s) below that require follow up
teaching by the nurse.
a. "this diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
c. "I can use holistic approaches like medication to help my symptoms"
d. "Many people have the same response to a stressful situation as I am having right"
e. "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"
f. " I will probably need to be on medication for the rest of my life" - ANSWER a. "this di-
agnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
f. " I will probably need to be on medication for the rest of my life"
3
, A client with foul-smelling drainage from an incision on the upper left arm is admitted with a
suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing interventions
should the nurse include in the plan of care? Select all that apply
a. Explain the purpose of a low-bacteria diet
b. Send wound drainage for culture and sensitivity
c. Institute contact precautions for staff and visitors
d. Use standard precautions and wear a mask
e. Monitor the clients white blood cell count - ANSWER b. Send wound drainage for cul-
ture and sensitivity
c. Institute contact precautions for staff and visitors
e. Monitor the clients white blood cell count
An older adult client who has difficulty hearing is being discharged form surgery following
cataract extraction and lens implantation. Which intervention is most important for the
nurse to implement to ensure the clients compliance with self-care.
a. Provide written instructions for eye drop administration
b. Speak clearly and face the client for lip reading
c. Have the client vocalize the instructions provided
d. Ensure that someone will stay with the client for 24 hours - ANSWER a. Provide written
instructions for eye drop administration
When assessing a client with an ionized calcium level of 15 mg/dL (4.25 mmol/L), which in-
tervention is most important for the nurse to implement Reference Range Ionized calcium [
adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)
a. Compare muscle strength bilaterally b. Assess strength of deep tendon reflexes
c. Determine apical pulse rate and rhythm
4
