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A nurse documents the following in a client chart: "client demonstrates problems with
spatial orientation, memory 7. language, and changes in personality." What level of
consciousness/arousal is being described?
A) Delirium
B) Dementia
C) Confusion
D) Locked-in syndrome - Answer a
A client exhibits an acute onset of a set of global changes in attention, cognition, and
level of consciousness. What 18. would be the most appropriate nursing diagnosis?
A) Acute Confusion
B) Chronic Confusion
C) Poor Memory
D) Altered Senses - Response a
A nurse is caring for a client who experiences delusions. The nurse must do which of
the following when conversing with the client? A) Gently touch the client and speak
B) Refrain from debating false statements
C) Orient reality for the false statement
D) Maintain eye contact always - Response c
,The nurse is caring for a client who had a stroke three days ago and is evaluating the
client's state of arousal. The 32. nurse understands that the part of the body responsible
for a person being alert or aroused is which of the following?
A) Reticular activating system
B) Renin-angiotensin-aldosterone system
C) Cranial nerves
D) Adrenal glands -Answer a
The nurse is formulating a plan of care for a client admitted with pneumonia. The nurse
has determined that apriority
This client's nursing diagnosis is "Ineffective Airway Clearance related to copious and
tenacious secretions." Based 2. on this nursing diagnosis, which of the following is an
appropriate nursing intervention to include in this client's care plan?
A) Encouraging the client to drink two to three quarts of clear fluids daily
B) Creating an environment that is likely to decrease anxiety
C) Placing the client in a supine position
d) Instruct the client to decrease daily intake of cigarettes - Response a
To provide care for a client with a chest tube during morning hygiene, the client
suddenly turns onto his side and the 3. chest tube has become disconnected from the
drainage unit. What is the nurse's first response to this event?
A) Seal the end of the tube in sterile water.
B) Clamp the tube near the end and also near the insertion site.
C) Place the end of the tube on a sterile surface and call for help immediately.
D) Wipe the end of the tube with an alcohol swab and reattach it to the drainage unit. -
Answer a
A client has received a head injury affecting the brain stem. Which of the following are
located in the brain stem that may affect respiratory 4. function?
,A) Chemoreceptors
B) Stretch receptors
C) Respiratory center
D) Oxygen center - Answer c
The nurse caring for a client with emphysema has determined that a priority nursing
diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements
related to dyspnea while eating." Based on this 1. diagnosis which of the following is an
appropriate nursing intervention to include in the client's care plan? A) Offer six small
meals per day.
B) Offer three large meals per day.
C) Instruct the client to eat immediately prior to breathing treatments.
D) Instruct the client to alternate eating and nebulizer treatments during mealtimes. -
Answer a
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below
normal. What abnormal 6. respiratory process does this demonstrate?
A) changes in the alveolar-capillary membrane and diffusion
B) alterations in the structures of the ribs and diaphragm
C) rapid decreases in atmospheric and intrapulmonic pressures
D) lower-than-normal concentrations of environmental oxygen - Answer a
In what age group would a nurse expect to assess the most rapid respiratory rate?
A) Older adults
B) Middle adults
C) Adolescents
D) Infants - Answer d
, A father of a preschool-age child tells the nurse that his child "has had a constant cold
since going to daycare." How 8. would the nurse respond?
A) "Your child must have a health problem that needs medical care."
B) "Children in daycare have more exposure to colds."
C) "Are you washing your hands before you touch the child?
D) "Be sure and have your child wear a protective mask at school."-Answer b
A nurse is beginning an interview to collect data about a health history from a client
diagnosed with respiratory disease. He notices that the client is in 11. respiratory
distress. Which is the appropriate action by the nurse at this time? A) Continue the
health history but at a slower pace.
B) Obtain information from the family rather than the client.
C) Perform the interview later and allow the client to rest.
D) Begin interventions to alleviate the symptomatology. - Answer d
An emergency room nurse is auscultating the chest of a child who is experiencing an
asthmatic attack. Auscultation indicates the 12. presence of wheezes. During which
phase of respirations do wheezing sounds occur?
A) Inspiration and expiration
B) Only on inspiration
C) Only on expiration
D) When coughing - Answer a