RN Adult Medical Surgical Exam
Test Bank RN Adult Medical Surgical Exam 2
QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% Verified Solutions | Updated
Per Latest Guidelines | Graded A+
61. The community mental health nurse is planning to visit four clients with schizophrenia
today.
Which client should the nurse see first?
a. The mother who took her children from school because aliens were after them.
b. The young man who has a history of substance abuse and has no telephone.
c. The newly diagnosed client who needs to be evaluated for
medication compliance.
A+ TEST BANK 1
, RN Adult Medical Surgical Exam
d. The young woman who believes she is to blame for her recent miscarriage –
Correct Answer :ANS: A
The client who is exhibiting paranoid behavior (A) has a high risk of harming herself or her
children, so the nurse should plan to visit this client first. (B) is not in immediate danger. (C)
is not a high priority. Although (D) may be experiencing depression, she does not have the
priority of a client with paranoid ideation who is having hallucinations about her children's
safety
62. The nurse is caring for a client whose urine drug screen is positive for cocaine. What
behavior
is this client likely to exhibit during cocaine withdrawal?
a. Intense cravings.
b. Increased energy.
c. Talkativeness.
d. Euphoria –
Correct Answer :ANS: A
During cocaine withdrawal, the nurse should expect the client to experience cravings (A) and
a pattern of withdrawal symptoms similar to amphetamine use. (B, C, and D) are signs and
symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal
A+ TEST BANK 2
, RN Adult Medical Surgical Exam
63. The nurse enters the room of a client with a history of seizure activity and observes that
the
unlicensed assistive personnel (UAP) is securing several pillows against the side rails to
protect the client. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead
of pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side-lying position. –
Correct Answer :ANS: B
The nurse should instruct the UAP to pad the side rails with soft blankets (B) because the use
of pillows (A) could result in suffocation. The nurse can delegate padding the side rails to the
UAP (C). A side-lying position (D) may help prevent aspiration during a seizure, but turning
the client is not the priority when implementing seizure precautions.
64. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle
cell crisis. Which intervention should the nurse implement first?
a. Initiate normal saline IV at 50 ml/hr.
b. Administer a loading dose of penicillin IM.
c. Obtain a culture of any sputum or wound drainage.
d. Administer the initial dose of folic acid PO –
A+ TEST BANK 3
, RN Adult Medical Surgical Exam
Correct Answer :ANS: A
The most important intervention is the initiation of IV fluids (A) because hydration promotes
hemodilution and RBC circulation. (B, C, and D) are also important interventions that should
be implemented by the nurse, but after initiating administration of the IV fluids
65. A client with a compound fracture of the left ankle is being discharged with a below-the-
knee
cast. Before being discharged, the nurse should provide the client with what instruction?
a. Keep the left leg in a dependent position.
b. Apply heat to the left leg cast.
c. Do not attempt to scratch the skin under the cast.
d. Apply a cold pack to any "hot spots" on the cast –
Correct Answer :ANS: C
Trying to scratch the skin under the cast (C) may cause a break in the skin and result in the
formation of a skin ulcer. Cool air from a hair dryer may alleviate an itch. The affected leg
should be elevated to help decrease edema (A). Ice bags or cold application devices should
be
placed on each side of the cast to help decrease edema and pain (B). "Hot spots" (D), or
warm
spots on the cast, may indicate infection and should be reported to the healthcare provider
immediately.
A+ TEST BANK 4
Test Bank RN Adult Medical Surgical Exam 2
QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% Verified Solutions | Updated
Per Latest Guidelines | Graded A+
61. The community mental health nurse is planning to visit four clients with schizophrenia
today.
Which client should the nurse see first?
a. The mother who took her children from school because aliens were after them.
b. The young man who has a history of substance abuse and has no telephone.
c. The newly diagnosed client who needs to be evaluated for
medication compliance.
A+ TEST BANK 1
, RN Adult Medical Surgical Exam
d. The young woman who believes she is to blame for her recent miscarriage –
Correct Answer :ANS: A
The client who is exhibiting paranoid behavior (A) has a high risk of harming herself or her
children, so the nurse should plan to visit this client first. (B) is not in immediate danger. (C)
is not a high priority. Although (D) may be experiencing depression, she does not have the
priority of a client with paranoid ideation who is having hallucinations about her children's
safety
62. The nurse is caring for a client whose urine drug screen is positive for cocaine. What
behavior
is this client likely to exhibit during cocaine withdrawal?
a. Intense cravings.
b. Increased energy.
c. Talkativeness.
d. Euphoria –
Correct Answer :ANS: A
During cocaine withdrawal, the nurse should expect the client to experience cravings (A) and
a pattern of withdrawal symptoms similar to amphetamine use. (B, C, and D) are signs and
symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal
A+ TEST BANK 2
, RN Adult Medical Surgical Exam
63. The nurse enters the room of a client with a history of seizure activity and observes that
the
unlicensed assistive personnel (UAP) is securing several pillows against the side rails to
protect the client. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead
of pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side-lying position. –
Correct Answer :ANS: B
The nurse should instruct the UAP to pad the side rails with soft blankets (B) because the use
of pillows (A) could result in suffocation. The nurse can delegate padding the side rails to the
UAP (C). A side-lying position (D) may help prevent aspiration during a seizure, but turning
the client is not the priority when implementing seizure precautions.
64. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle
cell crisis. Which intervention should the nurse implement first?
a. Initiate normal saline IV at 50 ml/hr.
b. Administer a loading dose of penicillin IM.
c. Obtain a culture of any sputum or wound drainage.
d. Administer the initial dose of folic acid PO –
A+ TEST BANK 3
, RN Adult Medical Surgical Exam
Correct Answer :ANS: A
The most important intervention is the initiation of IV fluids (A) because hydration promotes
hemodilution and RBC circulation. (B, C, and D) are also important interventions that should
be implemented by the nurse, but after initiating administration of the IV fluids
65. A client with a compound fracture of the left ankle is being discharged with a below-the-
knee
cast. Before being discharged, the nurse should provide the client with what instruction?
a. Keep the left leg in a dependent position.
b. Apply heat to the left leg cast.
c. Do not attempt to scratch the skin under the cast.
d. Apply a cold pack to any "hot spots" on the cast –
Correct Answer :ANS: C
Trying to scratch the skin under the cast (C) may cause a break in the skin and result in the
formation of a skin ulcer. Cool air from a hair dryer may alleviate an itch. The affected leg
should be elevated to help decrease edema (A). Ice bags or cold application devices should
be
placed on each side of the cast to help decrease edema and pain (B). "Hot spots" (D), or
warm
spots on the cast, may indicate infection and should be reported to the healthcare provider
immediately.
A+ TEST BANK 4
