A spouse of a client appears to be in spiritual distress over the anticipated death of
the client and is crying "Why is this happening to me?" What is the nurse's most
therapeutic response?
1- Remain with the spouse and listen empathetically.
2- Explain to the spouse the steps of the grieving process.
3- Gently ask the spouse why this is happening.
4- Redirect the spouse's thoughts to think about the good times.
Give this one a try later!
, 1- Remain with the spouse and listen empathetically.
Rationale:
A client experiencing spiritual distress does not require answers but
requires someone who will actively listen and respond with empathy.
A client with extracellular fluid volume deficit has received 500ml bolus of normal
saline intravenously. Which finding from the nurse's assessment indicates that the fluid
deficit is improving?
1- Heart rate is100 beats/minute.
2- Capillary refill less than 2 seconds.
3- Skin tenting is present on the dorsum of the hand.
4- Urine specific gravity of 1.030.
Give this one a try later!
2- Capillary refill less than 2 seconds.
Rationale:
Capillary refill will appear sluggish (greater than 2 seconds) when fluid
volume deficit is present.
Which data would be considered objective from the nurse's documentation of the
client's assessment?
1- The client indicated discomfort by pointing to 9 on a 10-point pain scale.
2- The client winced and moaned when the nurse palpated the abdomen.
3- The client reported feeling nauseated and having abdominal cramping.
4- The client had labored breathing with intercostal retractions on inspiration.
, 5- The client vomited 100 ml of bile and was diaphoretic.
Give this one a try later!
2- The client winced and moaned when the nurse palpated the abdomen.
4- The client had labored breathing with intercostal retractions on
inspiration.
5- The client vomited 100 ml of bile and was diaphoretic.
Rationale:
Objective data are signs; observable information that the nurse gathers,
witnesses, measures and tests during the physical assessment such as the
client wincing and moaning and demonstrating rebound tenderness during
palpation of the abdomen and witnessing the client's vomitus and labored
breathing. Information the client shares is typically subjective data.
Which factor is most likely to contribute to the development of osteoarthritis?
1- Atrophy of skeletal muscles.
2- Calcium deficiency.
3- High body mass index.
4- Sedentary lifestyle.
Give this one a try later!
3- High body mass index.
Rationale:
Increased weight causes joint changes. For each pound of weight (0.45KG)
there is four pounds (1.8KG) of pressure on the body's weight bearing
joints.
the client and is crying "Why is this happening to me?" What is the nurse's most
therapeutic response?
1- Remain with the spouse and listen empathetically.
2- Explain to the spouse the steps of the grieving process.
3- Gently ask the spouse why this is happening.
4- Redirect the spouse's thoughts to think about the good times.
Give this one a try later!
, 1- Remain with the spouse and listen empathetically.
Rationale:
A client experiencing spiritual distress does not require answers but
requires someone who will actively listen and respond with empathy.
A client with extracellular fluid volume deficit has received 500ml bolus of normal
saline intravenously. Which finding from the nurse's assessment indicates that the fluid
deficit is improving?
1- Heart rate is100 beats/minute.
2- Capillary refill less than 2 seconds.
3- Skin tenting is present on the dorsum of the hand.
4- Urine specific gravity of 1.030.
Give this one a try later!
2- Capillary refill less than 2 seconds.
Rationale:
Capillary refill will appear sluggish (greater than 2 seconds) when fluid
volume deficit is present.
Which data would be considered objective from the nurse's documentation of the
client's assessment?
1- The client indicated discomfort by pointing to 9 on a 10-point pain scale.
2- The client winced and moaned when the nurse palpated the abdomen.
3- The client reported feeling nauseated and having abdominal cramping.
4- The client had labored breathing with intercostal retractions on inspiration.
, 5- The client vomited 100 ml of bile and was diaphoretic.
Give this one a try later!
2- The client winced and moaned when the nurse palpated the abdomen.
4- The client had labored breathing with intercostal retractions on
inspiration.
5- The client vomited 100 ml of bile and was diaphoretic.
Rationale:
Objective data are signs; observable information that the nurse gathers,
witnesses, measures and tests during the physical assessment such as the
client wincing and moaning and demonstrating rebound tenderness during
palpation of the abdomen and witnessing the client's vomitus and labored
breathing. Information the client shares is typically subjective data.
Which factor is most likely to contribute to the development of osteoarthritis?
1- Atrophy of skeletal muscles.
2- Calcium deficiency.
3- High body mass index.
4- Sedentary lifestyle.
Give this one a try later!
3- High body mass index.
Rationale:
Increased weight causes joint changes. For each pound of weight (0.45KG)
there is four pounds (1.8KG) of pressure on the body's weight bearing
joints.
