hesi-mid-curricular

-HESI MID-CURRICULAR -QUESTIONS & ANSWERS The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's blood pressure is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 gm/dL. Which of the following instructions by the nurse is MOST important? 1. The client should decrease caloric intake. 2. The client should eliminate all salt from her diet. 3. The client should ensure adequate protein. 4. The client should increase her intake of iron. The client should ensure adequate protein. A client comes to the prenatal clinic for her first visit. The nursing history reveals that the client's last menstrual period was five months ago, and the client is sure she is pregnant because she has been feeling the baby move. Which of the following responses byt he nurse is BEST? 1. "Since you have felt fetal movement, I am sure that you are pregnant." 2. "Lie down so that I can listen for fetal heart tones with the Doppler." 3. "We'll collect a urine specimen for testing to confirm that you are pregnant." 4. "Have you noticed feeling more fatigued lately?" "Lie down so that I can listen for fetal heart tones with the Doppler." The nurse notes that a two-day old infant shows a tendency to bleed. The nurse understands this is MOST likely caused by which of the following? 1. Hemophilia. 2. Absence of intestinal bacteria needed for the production of vitamin K. 3. Immature liver that is unable to synthesize clotting factors. 4. Excessive breakdown of red blood cells coupled with a delayed production of new ones. Absence of intestinal bacteria needed for the production of vitamin K. The nurse cares for a patient after a breast biopsy. After the procedure, it is MOST important for the nurse to take which of the following actions? 1. Apply ice to the area. 2. Reposition the patient for comfort 3. Carefully transport the specimen to the lab 4. Observe for bleeding. Observe for bleeding. The nurse admits a patient to the postpartum unit two hours after a vaginal delivery. Three hours after admission the nurse ambulates the patient to the bathroom, and the patient states there is a sudden gush of bleeding from her vagina. The nurse understands that the increase in amount of bleeding is due to which of the following? 1. The lochia pooled in the patient's vagina when she was lying in bed. 2. The patient has a tear in her cervix that needs to be repaired. 3. The patient's fundus is relaxed and requires massaging. 4. The patient's bladder is distended because she needs to void. The lochia pooled in the patient's vagina when she was lying in bed. A woman comes to the clinic pregnant with her second child. She questions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is the MOST important response by the nurse? 1. "You can continue your activities but rest when you get tired." 2. "You should take a brisk walk daily." 3. "You can exercise as much as you want but limit household activities." 4. "What is your usual type of exercise?" "What is your usual type of exercise?" The health care provider orders a colposcopy for the client. The nurse explains to the client that which is the purpose of this procedure? 1. Magnify the tissue for examination 2. Directly examine ovaries, fallopian tubes, uterus, and small intestine. 3. View structures in the pelvic cavity, 4. Visualize the bladder. Magnify the tissue for examination The nurse monitors a client at 30 weeks gestation, and the client states that she has periodic heartburn. It is MOST important for the nurse to make which of the following recommendations? 1. Lie down after eating a meal. 2. Eat frequent small meals. 3. Take Alka-Seltzer as needed. 4. Sip iced tap water. Eat frequent small meals. The nurse instructs the woman about how to prevent conception using the basal body temperature (BBT) method. The nurse explains that during ovulation the woman's basal body temperature will change in which direction? 1. Lowers significantly 2. Rises significantly 3. Is unchanged 4. Rises slightly Rises slightly A nurse accidentally bumps into a newborn's bassinet. The newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which of the following reflexes? 1. Tonic neck 2. Moro's 3. Babinski's 4. Rooting Moro's When administering phototherapy to a newborn with jaundice, it is MOST important for the nurse to take which of the following actions? 1. Expose only the infant's back to the light. 2. Remove the infant from the light for 15 minutes each hour. 3. Cover the infant's eyes with protective pads during therapy. 4. Check the infant's temp every hour. Cover the infant's eyes with protective pads during therapy. The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take FIRST? 1. Instruct the patient to take a deep breath and bear down. 2. Apply pressure to the patient's fundus. 3. Coach the patient in relaxation techniques. 4. Encourage the patient to pant with pursed lips. Encourage the patient to pant with pursed lips. A 25-year-0ld primigravida diagnosed with type 1 diabetes mellitus reviews insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following? 1. Insulin requirements will increase during pregnancy and decrease after delivery. 2. Insulin requirements will decrease during pregnancy and increase after delivery. 3. Insulin requirements will increase during pregnancy and remain increased after delivery. 4. Insulin requirements decrease during pregnancy and remain decreased after delivery. Insulin requirements will increase during pregnancy and decrease after delivery. By the fifth month of pregnancy, a 32 year old multipara of average prenatal height and weight has gained 14 pounds. Which of the following actions by the nurse is MOST important? 1. Advise the client she has gained too much weight and her diet should be reevaluated. 2. Advise the client she has not gained enough weight and her diet should be reevaluated. 3. Inform the client her weight gain is appropriate and she should continue on her present diet. 4. Inform the client she may have difficulties later in pregnancy and more frequent visits to the physician are indicated. Inform the client her weight gain is appropriate and she should continue on her present diet. The nurse instructs a patient who recently had a modified radical mastectomy. The nurse states that it is important that the patient exercise her arm postoperatively to 1. increase muscle strength and diameter. 2. maintain body balance. 3. limit full range of motion. 4. prevent lymphedema. prevent lymphedema. The nurse instructs a client in the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which of the following foods from a menu? 1. Two eggs and 8 oz of milk 2. A 2 oz steak and 10 oz of beer. 3. A lettuce and tomato salad and 12 oz of orange juice. 4. One bag of potato chips and 16 oz of cola. Two eggs and 8 oz of milk The nurse prepares the client for a total abdominal hysterectomy with bilateral salpingo-oophorectomy due to uterine cancer. The nurse observes that the client is talking continuously and has difficulty maintaining eye contact. Which response by the nurse is BEST? 1. "What are your concerns about the surgery?" 2. "Why isn't your husband here with you?" 3. "Are you afraid that you are going to die?" 4. "You seem to be coping with the surgery very well." "What are your concerns about the surgery?" A woman is in active labor when her membranes rupture. She expresses a concern to the nurse she is afraid of having a "dry labor." Which of the following responses by the nurse is MOST appropriate? 1. "Amniotic fluid does not function as lubrication for the labor process." 2. "The sac actually impedes the progress of labor and if it had not ruptured, the doctor would have to do it artificially." 3. "Labor is only slightly more difficult with early rupture of the amniotic sac." 4. "Now that there is limited amniotic fluid, you may have to have a cesarean section." "Amniotic fluid does not function as lubrication for the labor process." The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food? 1. Chicken livers 2. Pork 3. Hamburger 4. Tofu Chicken livers The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in a preterm infant? 1. Red, wrinkled skin, lanugo, and hypotonic muscles. 2. Vernix caseosa,silky hair, and facial edema. 3. Absent nose bridge, depressed fontanels, and absent lanugo. 4. Mottled skin, meconium stools, and hypertonic muscles. Red, wrinkled skin, lanugo, and hypotonic muscles. A woman is in active labor. As labor progresses, she becomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of these actions should the nurse take FIRST? 1. Contact the physician 2. Coach the patient in proper breathing and relaxation techniques. 3. Administer an analgesic. 4. Remove the fetal monitor to allow the client to move around. Coach the patient in proper breathing and relaxation techniques. A woman arrives at the hospital in labor. The midwife states that the client is 4 cm dilated and 60% effaced. The nurse explains to the client this means which of the following? 1. The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal 2. The cervix is 4 cm short in dilation and 60% thinner than normal. 3. The walls of the cervix are 4 cm thick and 60% shorter than normal 4. The cervix is 4 cm long and 60% wider than normal. The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal The nurse should place the HIGHEST priority on monitoring a woman after a cesarean section for which of the following? 1. Infection and pain. 2. Hemorrhage and shock. 3. Hemorrhage and pain management. 4. Dehydration and infection. Hemorrhage and shock. To assess an apical pulse on a 8 lb, 4 oz newborn infant, the nurse should take which of the following actions? 1. Place the diaphragm of the stethoscope between the nipple line and the sternal notch. 2. Place the diaphragm of the stethoscope between the second and third intercostal spaces, the midaxillary line. 3. Place the bell of the stethoscope between the fourth and fifth intercostal spaces, the midclavicular line. 4. Place the bell of the stethoscope between the second and third intercostal spaces, the midsternal line. Place the bell of the stethoscope between the fourth and fifth intercostal spaces, the midclavicular line. The nurse prepares a client for an abdominal hysterectomy. The client asks why she has to have a Foley catheter. Which statement by the nurse is MOST appropriate? 1. "This will help you since you will be temporarily incotinent." 2. "This will enable us to measure your output accurately." 3. "This will allow you to heal by keeping your bladder decompressed." 4. "This will allow your bladder to recover after the surgery." "This will allow you to heal by keeping your bladder decompressed." An infant is born by vaginal delivery. At birth, the infant is crying and respiration and pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. The nurse should record baby's one-minute and five-minute Apgar scores as which of the following? 1. 8 and 9, respectively 2. 8 and 10, respectively 3. 9 and 10, respectively 4. 9 and 7, respectively 9 and 10, respectively A woman complains to the nurse that during the client's menstrual period she gains weight and gets muscle cramps. The nurse should suggest which of the following measures to alleviate the client's symptoms? 1. Take over the counter analgesics, restrict caffeine, exercise moderately. 2. Avoid analgesics and exercise. 3. Restrict fluid intake, exercise moderately, increase caffeine intake. 4. Restrict sodium intake, restrict exercise, sedatives. Take over the counter analgesics, restrict caffeine, exercise moderately. The nurse cares for a woman in labor. Which method should the nurse use to measure the frequency of a uterine contraction? 1. Timing the contractions from the end of one contraction to the end of the next contraction. 2. Timing the contraction from the beginning of one contraction to the end of the same contraction. 3. Timing the contraction from the peak of one contraction to the beginning of the next contraction. 4. Timing the contraction from the beginning of one contract to the beginning of the next contraction. Timing the contraction from the beginning of one contract to the beginning of the next contraction. The nurse cares for the client immediately after a normal vaginal delivery. Which action should the nurse take FIRST? 1. Observe the lochial flow. 2. Palpate the fundus. 3. Obtain a warming blanket. 4. Obtain vital signs. Observe the local flow. An adult male client has a history of diabetes insipidus. The nurse identifies which imbalance is MOST likely to develop if this medical problem recurs? 1) Hypernatremia 2) Hyponatremia 3) Hyperkalemia 4) Hypokalemia Hypernatremia The nurse understands fatigue, weakness, and nausea and vomiting are signs of which? 1) Hypernatremia 2) Hyponatremia 3) Hyperkalemia 4) Hypokalemia Hypokalemia The emergency department nurse knows that which is the MOST frequent underlying cause of tetany? 1) Hypocalcemia 2) Puncture wound from dirty and rusty metal 3) Hypermagnesemia 4) Genetric cardiac defect Hypocalcemia The nurse monitors a patient receiving a blood transfusion. The nurse should intervene if which is observed? 1) The blood infuses in three hours. 2) The blood is started with normal saline 3) The blood is started 15 min after arriving from the blood bank 4) The blood infuses at 10 mL/min for the first 15 mins. The blood infuses at 10 mL/min for the first 15 mins. A central venous pressure line is inserted in a patient. Following the catheter insertion, the patient complains of dyspnea, shortness of breath, and chest pain. The nurse understands the MOST probable cause of these symptoms is which? 1) Fluid overload 2) Pneumothorax 3) Hypokalemia 4) Pneumonia Pneumothorax In order to administer 1,000 mL of D5W, 40 mEq of KCl at 100 mL/hour using an administer set that delivers 60 drops/mL, the nurse should adjust the flow rate to deliver how many drops/minute? 100 ggts/min The nurse identifies nasogastric drainage, vomiting, diarrhea, and the use of diuretics likely causes which electrolyte imbalance? 1) Hypernatremia 2) Hyperkalemia 3) Hyponatremia 4) Hypokalemia Hypokalemia The nurse performs an assessment on a patient sustaining burn injury in an apartment fire. The nurse is most concerned if which is observed? 1) The patient has signed nasal hair 2) The patient's blood pressure is 106/62 3) The patient has blisters on the hands 4) The patient's capillary refill time is less than 3 seconds. The patient has signed nasal hair When any type of transfusion reaction occurs, the nurse's FIRST action should be what? 1) Recheck the type and cross-match 2) Slow down the transfusion 3) Stop the transfusion 4) Notify the physician Stop the infusion The nurse cares for a patient during the shock phase after suffering a full thickness burn injury. The nurse understands which finding is expected during this phase? 1) Increased blood pressure 2) Decreased urine output 3) Hypokalemia 4) Decreased pulse Decreased urine output The nurse identifies which central venous pressure (CVP) reading indicates fluid overload? 1) 0 mm Hg 2) 3 mm Hg 3) 8 mm Hg 4) 15 mm Hg 15 mm Hg The nurse observes a student nurse begin an IV on an elderly patient. The nurse should intervene if which is observed? 1) The student nurse uses a 24 gauge catheter to start the IV 2) The student nurse marks the time on the IV bag with a permanent marker 3) The student nurse inserts the catheter at a 10 degree angle. 4) The student nurse sets the flow rate at 100 mL per hour. The student nurse marks the time on the IV bag with a permanent marker The nurse determines a patient has a deep partial thickness burn injury of the back. Which is the BEST initial nursing action? 1) Break the blisters with scalpel using sterile technique. 2) Gently clean and then leave the area alone. 3) Apply a thin layer of Vaseline to the area. 4) Wrap snugly with sterile gauze. Gently clean and then leave the area alone. The nurse evaluates a patient's fluid balance. Which finding MOST likely requires an intervention? 1) Output is 300 mL less than intake. 2) Output is 800 mL less than intake. 3) Intake is 1,800 mL in 24 hours. 4) Intake and output are equal. Output is 800 mL less than intake. The nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which menu? 1) Meat and orange juice 2) Whole grain bread and an apple 3) Green vegetables and milk 4) Peanut butter and a banana Meat and orange juice A patient receives magnesium sulfate IV for treatment of preeclampsia.The nurse knows that it is MOST important to have what at the bedside? 1) Oxygen and padded tongue blade. 2) Reflex hammer and calcium gluconate 3) Protamine sulfate and Vitamin K. 4) Particulate respirator and suction equipment Reflex hammer and calcium gluconate The nurse cares for an older man admitted to the hospital for persistent vomiting and abdominal pain. A nasogastric (NG) tube is inserted and connected to suction, and an intravenous infusion of 1,000 ml of D5W with 20 mEq/L of potassium chloride is started to infuse at 200 ml per hour. The nurse understands potassium chloride has been added to the infusion for which reason? 1) Replaces the potassium lost in the gastric fluid 2) Replace decreased dietary potassium due to NPO status 3) Prevent the loss of sodium in the urine 4) Prevent the loss of potassium in the urine. Replaces the potassium lost in the gastric fluid The nurse cares for a patient receiving a blood transfusion. The nurse observes which if fluid overload occurs during the transfusion? 1) Decreased pulse rate, increased BP, decreased respirations 2) Increased pulse rate, increased BP, increased respirations 3) Increased pulse rate, increased BP, decreased respirations 4) Decreased pulse rate, decreased BP, increased respirations Increased pulse rate, increased BP, increased respirations The nurse cares for a patient receiving a blood transfusion. The nurse is MOST concerned if which is observed? 1) Blood pressure is 130/80 2) The patient complains of shortness of breath 3) The patient complains of pruritus 4) Hematuria Hematuria Which laboratory finding should the nurse expect if a patient is diagnosed with fluid volume deficit? 1) Specific gravity 1.020 2) Specific gravity 1.034 3) Potassium 5.8 mEq/L 4) Potassium 4.8 mE2q/L Specific gravity 1.034 The nurse notices that an intravenous infusion is not running. Which action should the nurse take initially? 1) Reposition the patient's arm 2) Check the site 3) Raise the solution 4) Flush the tubing. Check the site The nurse knows which patient is MOST likely to manifest symptoms of fluid volume deficit? 1) A patient diagnosed with Addison's disease 2) A patient diagnosed with cirrhosis of the liver 3) A patient diagnosed with epilepsy 4) A patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) A patient diagnosed with Addison's disease In order to deliver 3,000 mL of D5W in 24 hours using an administration set that delivers 15 drops/mL, the nurse should regulate the flow rate to deliver how many drops/minute? 31 gtts/min The nurse cares for a patient diagnosed with a fractured right hip. The patient's lab values are: Hbg 15, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L and chloride 100 mEq/L. The nurse is MOST concerned if which is observed? 1) A weight gain of 4 lbs in 1 day 2) An increase in nausea 3) An increase in muscle irritability 4) An episode of ventricular fibrillation An episode of ventricular fibrillation The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction? 1) Hypotension,sudden fever, flushed skin. 2) Kidney pain, hematuria, cyanosis 3) Urticaria, wheezing, flushed skin. 4) Hives, itching, anaphylaxis Kidney pain, hematuria, cyanosis Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which action is MOST appropriate for the nurse to take initially? 1) Check the type and cross-match with another nurse. 2) Leave the blood at the patient's bedside until the doctor checks it 3) Flush tubing with normal saline and hang next unit 4) Run first 50 mL of blood rapidly to check for any reaction. Check the type and cross-match with another nurse. The nurse knows that medication is best absorbed by a patient with a major burn injury via which route? 1) Intramuscularly 2) Orally 3) Intravenously 4) Topically Intravenously When measuring the central venous pressure, it is MOST important for the nurse to take action? 1) Find out about the previous reading 2) Place the manometer at level of the right atrium 3) Position the patient in an upright position 4) Instruct the patient hold his breath during the reading Place the manometer at level of the right atrium A nurse assesses a patient who has sustained a burn injury. The burn area is blistered and painful. Which classification best describes the burned area? 1) Third degree 2) Full thickness 3) Deep partial thickness 4) Superficial partial thickness. Deep partial thickness The nurse identifies which sign or symptom as an early indication of fluid volume excess? 1) Cyanosis 2) Diarrhea 3) Edema 4) Shock Edema On the first postoperative day, a patient develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands which of the following complications of the surgery is probably developing? a) heart failure b) thrombophebitis c) pulmonary embolism d) atelectatis d atelectasis The nurse identifies which finding is characteristic of chronic pain? a) weight loss or gain, fatigue b) obesity, restlessness, and thirst c) anxiety, insomnia, and memory loss d) quick response to anaglesics weight loss or gain, fatigue The nurse prepares four patients for surgery, The nurse is most concerned about the psychological adjustment of which of the following patients? a) a 13 y/o girl scheduled to have a wart removed from her nose b) a 26 y/o man scheduled for the Whipple procedure due to cancer of the pancreas c) a 42 y/o woman scheduled to have a benign cyst removed from the left breast d) an 80 y/o scheduled for colostomy due to severe diverticular disease b) a 26 y/o man scheduled for the Whipple procedure due to cancer of the pancreas Which of the following actions is essential for the nurse to take after administration of a preoperative medication to the patient? a) ensure the operative permit is signed b) discuss the patient's feelings about the surgery c) raise the side rails of the bed d) tell the patient what to expect in the operating room c) raise the side rails of the bed A client returns from abdominal surgery with an order for morphine sulfate IV q 3 hours prn for pain. During the first 24 hours of surgery, which action by the nurse is BEST? a) offer pain medication every 4 hours b) administer pain medication every 3 hours c) offer pain medication every 3 hours d) administer pain medication every 4 hours b) administer pain medication every 3 hours The nurse identifies which of the lab findings reflects the signs and symptoms of infection? a) serum creatine level of 2.4 mg/dL b) AST (SGOT) 15 u/L c) white blood cell count of 16,000/mm^3 d) white blood cell count of 4,000/mm^3 c) white blood cell count of 16,000/mm^3 A client is admitted to the hospital with a temperature of 101° F (38.3°C) and a WBC count of 3000/mm^3. The nurse should insitute which of the following precautions? a) contact precautions b) airborne precautions c) droplet precautions d) neutropenic precautions d) neutropenic precautions To promote evening rest and sleep for patients who are immobilized and in bed, it is MOST important for the nurse to provide which of the following? a) privacy b) back rubs c) daily baths d) daytime activities d) daytime activities The nurse knows that aspirin, if given in high, prolonged dosages, may precipitate which of the following physiological changes? a) urinary frequency b) hypoventilation c) GI bleeding d) hemoconcentration c) GI bleeding The nurse cares for a postoperative client with a nasogastric tube. Which observation by the nurse is the MOST reliable indication the nasogastric tube is correctly positioned? a) absence of respiratory distress b) pH of aspirate is 3 c) the marking of the tube designating the correct length remains visible just outside the nares d) the tube is securely taped b) pH of aspirate is 3 The home care nurse cares of a client diagnosed with a fractured humerus due to a fall in the home. Which of the following observations, if made by the nurse, requires an immediate intervention. a) The bathroom is equipped with grab bars b) Throw rugs have been removed c) The client ambulates wearing socks d) The stairs are well lighted c) The client ambulates wearing socks The nurse understands the purpose of a drain in a wound is to a) keep the tissues close together so that the healing can occur b) prevent infection by providing a means for bacteria to escape c) evaluate the effectiveness of hemostasis d) create a space that will facilitate reconstructive surgery at a later date a) keep the tissues close together so that the healing can occur A client comes in to the emergency room after puncturing a foot with a dirty, rusty nail. The client states the last Td immunization was 6 years ago. Which of the following actions should the nurse take FIRST? a) administer tetanus toxoid b) determine how many Td immunizations the client has received c) administer tetanus immune globulin d) monitor for lock jaw b) determine how many Td immunizations the client has received The home care nurse visits an elderly client living alone on a limited income. The client's diet consists primarily of carbohydrates. Based on an understanding of nutritional needs of the elderly, which of these interpretations of the client's diet by the nurse is most justified? a) The patient should increase the intake of protein b) The patient should reduce the intake of fat c) The patient should increase the caloric intake d) The patient should decrease the fluid intake a) The patient should increase the intake of protein The nurse helps a patient to cough and deep breath after surgery. It is desirable for the patient to assume which of the following positions? a) side-lying b) prone c) supine with pillow d) high fowler's d) high fowler's The nurse notes that an elderly patient has a reddened area on the coccyx. Which of the following actions should the nurse take FIRST? a) continue the assessment of the area b) reposition the patient every 2 hours c) massage the reddened are four times per day d) place the patient in the semireclining position b) reposition the patient every 1-2 hours The nurse explain to the client the most vitamin C can be found in which juice? a) canned apple juice b) canned tomato juice c) frozen grapefruit juice d) fresh orange juice d) fresh orange juice The nurse instructs a patient about how to successfully establish a regular exercise program. The nurse determines further teaching is needed if the patient makes which of the following statements? a) "I should choose an exercise that suits my lifestyle" b) " I should incorporate exercise into my daily routine" c) " I should make a commitment to exercise regularly" d) "I should start by running 5 miles everyday" d) "I should start by running 5 miles everyday" Several days postoperatively, a client reports pain, tenderness, and redness of the right calf. Which signs and symptoms are critical for the nurse to assess next? a) Nausea and abdominal distention b) Back pain and hematuria c) Chest pain and shortness of breath d) Similar findings in the right arm c) Chest pain and shortness of breath The nurse observes a staff member prepare to leave the room of a patient on droplet precautions. The nurse should intervene if which of the following is observed? a) The staff member removes the gloves by pulling off inside out b) the staff member holds onto the surface of the face mask while pulling mask away from face c) The staff member unties the gown and removes it without touching the outside of the gown d) The nurse performs hand hygiene b) the staff member holds onto the surface of the face mask while pulling mask away from face The nurse identifies which diet BEST meets the needs of a person with multiple wounds? a) high protein, low fat, high iron diet b) high vitamin C, high protein, high carbohydrate diet c) high vitamin A, high calcium, high fat diet d) high vitamin B, high protein, low carbohydrate diet b) high vitamin C, high protein, high carbohydrate diet The nurse cares for a client with body mass index of 38 kg/m^2. What is the best description of the client's body weight? a) underweight b) normal weight c) overweight d) obese d) obese The nurse observes a staff member enter the patient's room wearing a protective respiratory device. The nurse determines care is appropriate if the staff member is caring for which of the following patients? a) patient diagnosed with varicella b) patient diagnosed with mumps c) patient diagnosed with vancomycin- resistant d) patient diagnosed with pneumonia a) patient diagnosed with varicella The nurse counsels a patient about how to maintain an adequate intake of protein. The nurse determines that further teaching is required? a) Peanut butter on whole wheat bread b) rice and red beans c) orange juice and white toast d) spaghetti and meat sauce c) orange juice and white toast In which situation should the nurse consider witholding morphine until further assessment is completed? a) patient complains of acute pain from deep partial thickness burn affecting the lower extremities b) patient's blood pressure is 140/90, and respirations are 28 c) patient's level of consciousness fluctuates from alert to lethargic d) patient exhibits restlessness, anxiety, and cold, clammy skin c) patient's level of consciousness fluctuates from alert to lethargic The nurse knows which statement is an important fact about warfarin a) It has prolonged action b) It is never given for prolonged periods of time c) It must be given several times of day to be effective d) It can only be given parenterally a) It has prolonged action A patient requires a dressing change. The LPN/LVN nurse assigned to care for the patient reports to the registered nurse that she/he once observed a similar dressing change while in nursing school, but has never performed the procedure. The registered nurse should take which action? a) Ask the LPN/LVN to review the hospital's procedure manual regarding dressing changes b) review the steps of the dressing change with LPN/LVN c) complete the dressing change while the LPN/LVN observes d) assign a more experienced LPN/LVN to the patient c) complete the dressing change while the LPN/LVN observes A patient with acute pain has a physician's order for morphine 8mg IV every 3-4 hours prn for pain. The patient asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should take which of the following actions? a) assume the pain is psychological b) check to see if the patient has a history of addiction c) try several other pain relief measures d) asses location, character, and intensity of pain d) asses location, character, and intensity of pain The nurse performs discharge teaching for a client receiving warfarin. The nurse determines further teaching is required if the client makes which statement? a) "I should look for yellow-tinged complexion" b) " I will wear a medic-alert bracelet" c) " I should tell the health care provider if I have black stools" d) " I should consult the health care provider before taking any medications" a) "I should look for yellow-tinged complexion" The nurse understands which of the following behaviors is helpful to facilitate a patient to have bowel elimination? a) engage in sedentary activity b) increase in dietary bulk c) decrease fluid intake d) use oral laxatives b) increase in dietary bulk The nurse is caring for an elderly patient diagnosed with a fractured femur. The nurse recognizes that which of the following is an early sign of fat embolism? 1) chest pain and dyspnea 2) Increased respirations, pulse, and temperature 3) Altered mental status 4) Petechiae 3) Altered mental status A patient asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which of the the following responses by the nurse is BEST? a. "Rheumatoid arthritis is a systemic disease and osteoarthritis is not." b. "There is very little clinical difference between rheumatoid arthritis and osteoarthritis." c. "Rheumatoid arthritis is often treated surgically and osteoarthritis is not." d. "Rheumatoid arthritis is progressive and osteoarthritis is not." a. "Rheumatoid arthritis is a systemic disease and osteoarthritis is not." The nurse assesses a patient with a diagnosis of osteoarthritis. The nurse expects to observe which of the following signs/symptoms a. Pain on abduction on the hips, waddling gait. b. Fever, rash, and nodules over bony promineces. c. Swollen, reddened, painful joint with limitation of motion d. Stiffness of the hips, knees, vertebrate, and fingers d. Stiffness of the hips, knees, vertebrate, and fingers The home care nurse makes a home visit for a patient diagnosed with osteoarthritis.The nurse asks the client's spouse if the client is having any problems. The nurse should further assess if the spouse makes which statement? a. "I can tell that my husband has been worrying because he is wringing his hands." b. "Last night, my husband carried a big bowl of vegetables to the table using both hands." c. "My husband bends from the knees when he picks the papers up from the floor." d. "My husband only uses a small pillow under his head when he sleeps at night." a. "I can tell that my husband has been worrying because he is wringing his hands." In teaching a patient with a below-the-knee amputation to care for the residual limb at home, the nurse should advise the patient do to which of the following? a. apply cream daily to the residual limb b. cover the residual limb with a nylon sock c. keep the residual limb elevated d. expose the residual limb to air. d. expose the residual limb to air. An elderly female patient undergoes an open reduction and internal fixation of the left femoral head after a fracture. Which action by the nurse is BEST? a. Offer the patient a low-residue diet. b. Turn the patient to the unoperated side. c. Instruct the patient to exercise the arms. d. Encourage the patient to cough and deep breath every 2 hours d. Encourage the patient to cough and deep breath every 2 hours The nurse cares for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions? 1. Assess drainage from Penrose drains. 2. Observe dressings for signs of excessive bleeding. 3. Elevate the stump for no less than 40 hours. 4. Provide cast care on the affected extremity. 4. Provide cast care on the affected extremity. During an acute bout of gouty arthritis, the nurse should expect the patient's affected foot to appear 1) pale. 2) red. 3) mottled 4) cyanotic 2) red. The nurse cares for a patient in Buck's traction. It is MOST important for the nurse to take which of the following actions? a. encourage the patient to limit body movements. b. allow weights to hang freely at all times. c. remove weights immediately when patient complains of discomfort. d. give pain medication regularly b. allow weights to hang freely at all times. A patient diagnosed with type 1 diabetes is scheduled for a right below-the-knee amputation due to a gangrenous toe. The patient asks the nurse why the amputation is so extensive. The nurse's response should be based on which of the following? a. A below-the-knee amputation ensures enough skin to form a flap over the stump. b. A below-the-knee amputation results in better circulation and healing. c. A below-the-knee amputation facilitates earliest prosthesis training. d. A below-the-knee amputation significantly reduces edema of the residual limb. b. A below-the-knee amputation results in better circulation and healing. The nurse is caring for a patient with degenerative joint disease (osteoarthritis). The physician orders celecoxib (Celebrex). The nurse is MOST concerned if the patient makes which of the following statements? a. "I am allergic to aspirin" b. "I should take this medication with food" c. "This medication will reduce joint discomfort" d. "I will contact the physician if I have any weight gain" a. "I am allergic to aspirin" The nurse prepares a patient for a total hip replacement. Which of the following observations by the nurse necessitates contacting the physician? a. The patient's Hgb is 15 g/dL b. The patient complains of burning on urination c. The patient complains of periodic heartburn d. The patient's platelet count is 250,000/mm3 b. The patient complains of burning on urination Three hours after arriving at the orthopedic unit, a patient complains about a hot feeling under the cast. Which action should the nurse take FIRST? a. Instruct the patient to lie still since the cast is newly applied b. Check the circulation in the casted extremity and change the patient's position c. Take the patient's temperature and observe for other signs of infection d. Medicate the patient for pain and notify the doctor of the complaint b. Check the circulation in the casted extremity and change the patient's position The nurse cares for a patient after a right below-the-knee amputation. The nurse is MOST concerned if which of the following observed? a. The patient periodically naps. b. The patient complains of a throbbing headache. c. The patient complains of persistent pain at the operative site. d. The nurse palpates a pulse above the operative site. c. The patient complains of persistent pain at the operative site. Total hip arthroplasty is scheduled for a patient with a degenerative joint disease of the left femoral head. It is MOST important for the nurse to place the patient's left leg in which of the following positions? a. abducted with toes pointing upward b. elevated on 2 pillows with knees flexed c. elevated on several pillows with the ankle abducted d. adducted with ankle joint hyperextended a. abducted with toes pointing upward Which of the following nursing interventions is MOST appropriate for a patient diagnosed with rheumatoid arthritis? a. provide support of flexed joints with pillows and pads b. position the patient on the abdomen several times a day c. massage the inflamed joints alternately with oil and alcohol d. assist the patient with heat application and ROM exercises d. assist the patient with heat application and ROM exercises The nurse performs discharge teaching for a patient diagnosed with a fractured left femur that is in a cast. The patient asks how to keep the muscles of the legs strong during the time the cast is on the left leg. Which response by the nurse is BEST? a. "It's important to perform active ROM everyday with you left leg." b. "I'll teach your mother to perform active assistive ROM exercises." c. "Perform left leg lifts with a 2lb weight attached to your ankle." d. "I'll teach you how to do isometric exercises." d. "I'll teach you how to do isometric exercises." A client is evaluated in the clinic for rheumatoid arthritis. Which of the following findings should assume the highest priority for the nurse when assessing and planning the client's care? a. Subcutaneous nodules on the client's right and left forearms. b. Slight contracture of the right wrist. c. Mild erythema of finger joints d. Bruised area about 3mm in diameter of right forearm. b. Slight contracture of the right wrist. The nurse performs a home care visit on a client with a fractured right femur. The nurse assesses the client's safety when using crutches. The nurse should intervene if which of the following is observed? a. When standing, the crutch tips are placed 6in in front and 6in to the side of each foot. b. The client ambulates using 3 point gait c. When going down steps, the client stands on the unaffected leg and places the crutches on next steps. d. Before sitting in a chair, client stands on the unaffected leg and transfers both crutches in the hand opposite the unaffected leg. d. Before sitting in a chair, client stands on the unaffected leg and transfers both crutches in the hand opposite the unaffected leg. The nurse in the outpatient clinic is measuring the height of an older woman. The client expresses surprise that she is 1 inch shorter than she used to be. Which of the following statements by the nurse is BEST? a. "You have degenerative joint disease of the knees and that will cause your height to decrease." b. "You have lost height because you have bursitis of the left shoulder." c. "You are shorter as a result of Paget's disease." d. "Maybe it is because you were diagnosed with juvenile rheumatoid arthritis." c. "You are shorter as a result of Paget's disease." The nurse evaluates care given to a patient after a left below the knee amputation. The nurse should intervene if which of the following is observed? a. A tourniquet is placed in the patient's bedside table. b. The patient lies on his stomach several times per day. c. The nurse uses a transfer belt when patient transfers from bed to chair. d. The patient sits in a chair frequently for short periods of time. a. A tourniquet is placed in the patient's bedside table. Prednisone 2mg qd is prescribed for a patient with rheumatoid arthritis. What important points should the nurse include when teaching the patient about this drug? a. The health care provider will increase the dose until there is complete relief ofsymptoms b. The dosage of prednisone must be increased and decreased gradually. c. Some people experience incontinence as a side effect of this medication. d. Prednisone is a dangerous medication and must be carefully monitored. b. The dosage of prednisone must be increased and decreased gradually. The nurse cares for a client with a newly applied plaster cast to the lower extremity. The nurse should take which action? a. set up a fan to blow on the cast and turn the patient frequently b. Rest the casted leg on the mattress and avoid handling it until it has dried. c. Elevate the leg on pillows and leave the cast open to air. d. Cover the cast lightly with a sheet and remove it frequently c. Elevate the leg on pillows and leave the cast open to air. The nurse cares for a patient in balanced suspension traction. The patient complains of pain in the affected extremity, and the nurse administers the prescribed medication. One hour later the patient states, "I don't know why, but the pain isn't getting any better." Which of the following actions should the nurse take FIRST? a. contact the physician b. offer the patient a back rub c. assess the level of patient's pain d. perform neuro assessment d. perform neuro assessment The nurse in the outpatient clinic is instructing a client receiving probenecid (Benemid). It is MOST important to make which of the following statements? a. "I drink 6-8 glasses of water each day" b. "Take the medication on an empty stomach" c. "You may take aspirin for minor pain" d. "You are permitted to drink wine with dinner" a. "I drink 6-8 glasses of water each day" The clinic nurse counsels a client complaining of low back pain. Which of the following statements, if made by the client to the nurse, requires a follow up by the nurse? a. "I work full-time as a checker at the local grocery store" b. "I sleep on a firm mattress" c. "I walk for 30 minutes each day" d. "I sleep on my side with my knees and hips flexed" a. "I work full-time as a checker at the local grocery store" A nurse returns to the car after grocery shopping and witnesses a car hit a pedestrian in the parking lot. As the nurse approaches the pedestrian, the pedestrian cries out, "I think my leg is broken!" Which of the following actions should the nurse take FIRST? a. Ask the client to move the ankle and foot on the affected side b. inspect the client for evidence of bleeding c. cut away the client's pant leg on the affected side d. immobilize the affected leg c. cut away the client's pant leg on the affected side The nurse cares for an elderly patient eight days after an open reduction and internal fixation of the right hip. The nurse should intervene if which is observed? a. The patient ate half of the food on the breakfast tray. b. The patient is not wearing elastic stockings. c. The patient transfers from the bed to bedside commode with assistance. d. The patient requires pain medication three times per day. b. The patient is not wearing elastic stockings. Aspirin is prescribed for a client. The nurse should administer this medication with which liquid? a. A glass of milk b. A glass of OJ c. A glass of diet soda d. A small amount of water a. A glass of milk The nurse cares for a patient after a total hip replacement due to degenerate joint disease. The nurse should intervene if which of the following is observed? a. the patient uses an incentive spirometer q2h b. the patient is positioned with a pillow between the legs c. the patient's heels are lying on the bed with toes pointed upward d. the patient moves slowly when getting out of bed c. the patient's heels are lying on the bed with toes pointed upward The nurse manager wants to implement a three-day workweek on the nursing schedule. The nurse manager states, "Anyone who doesn't go along with the change will not receive vacation time this year." The staff identifies that the nurse manager is demonstrating which type of power. a. coercive power b. reward power. c. expert power. d. referent power. a. coercive power The charge nurse supervises care of patients on the medical/surgical unit. The charge nurse determines care is appropriate if which of the following tasks is delegated to a nursing assistant? a. A patient diagnosed with an ulcer requires the morning dose of famotidine (Pepcid) b. A patient diagnosed with COPD needs VS taken c. A patient requires discharge instructions d. A patient requires a sterile dressing change b. A patient diagnosed with COPD needs VS taken The nurse receives a call from the emergency management team that a bomb exploded on a train and that 30 victims will be transported to the hospital in 10 minutes. Which of the following actions should the nurse take FIRST? a. inform the emergency mgmt team that 10 patients will be accepted to the unit b. no action is required c. contact the nursing supervisor d. tell the nurses on the shift that they will have to work overtime c. contact the nursing supervisor An RN has received the assignment for the night shift. Which of the following tasks is appropriate for the nurse to delegate to a nursing assistant with 20 years of experience? a. assess the breathing pattern of an asthmatic client b. monitor a client who is expectorating rust-colored sputum c. administer codeine to a post-op client d. bathe a client prior to the scheduled 0600 surgery d. bathe a client prior to the scheduled 0600 surgery An RN assesses clients for the day shift. The nursing team includes one RN, two LPN/LVNs, and four nursing assistants. The nurse determines that assignments are appropriate if which of the following patients is assigned to a nursing assistant? a. a patient diagnosed with Crohn's disease requiring a sterile dressing change b. a patient diagnosed with chronic renal failure requiring I&O c. a patient diagnosed with full thickness burns requiring IV morphine prior to a dressing change d. a patient diagnosed with cancer of the lung complaining of a headache b. a patient diagnosed with chronic renal failure requiring I&O A nurse employment in a hospital using the SOAP system of documentation. The nurse understands that SOAP is an acronym for which information? a. strategic, operational, accountability, protocol b. status, orders, actions, precautions c. secure, orderly, appropriate, precise d. subjective, objective, assessment, plan d. subjective, objective, assessment, plan Four injured firefighters are transferred to the hospital. The nurse performs triage in the emergency department. Which of the following patients should the nurse see FIRST? a. a firefighter diagnosed with carbon monoxide poisoning b. a firefighter diagnosed with a superficial partial thickness burn to the hands c. a firefighter diagnosed with anxiety and having palpitations d. a firefighter diagnosed with lacerations to the right side of the face and ear a. a firefighter diagnosed with carbon monoxide poisoning A client diagnosed with inoperable cancer has difficulty walking after chemotherapy. When the nurse comes to assist the client to the bathroom the client says, "Leave me alone. You treat me like a child." Which of these interpretations of the client's behavior by the nurse is MOST justifiable? 1. The client is frightened about falling 2. The client is entering a regressive phase 3. The client wants to maintain his independence 4. The client is angry at the nurse's interference 3. The client wants to maintain his independence The nurse instructs a client about phenelzine sulfate. Which client statement indicates to the nurse that further teaching is necessary? 1. "I can't wait to eat a hot dog with sauerkraut" 2. "I'm going to have to get some polycarbophil when I get home" 3. "I will be playing doubles tennis with my neighbors" 4. "When I get home, I am going to take my car out for a road trip" 1. "I can't wait to eat a hot dog with sauerkraut" monoamine oxidase inhibitor; client should avoid foods such as aged cheese, beer, red wine, dry sausage, sauerkraut, liver because they are high in tyramine; may precipitate hypertensive crisis The nurse cares for patients in an inpatient psychiatric unit and leads an adolescent social/support group to discuss the difficulties of growing up in today's society. The nurse understands that therapeutic benefit of this group is based on which concepts? 1. The group's ability to evaluate their behavior 2. The phase of the group's interaction 3. The leader's skill in promoting progress 4. The group members' sense of belonging 4. The group members' sense of belonging The nurse overhears a patient diagnosed with dementia tell a story about something the nurse knows is not true. Which of the following actions by the nurse is BEST? 1. Correct the information as presented 2. Allow the patient to continue the story 3. Refer the patient for reminiscence therapy 4. Orient the patient to person, place, and time 2. Allow the patient to continue the story The nurse understands which statement is true regarding anorexia nervosa? 1. Adolescent males are most affected 2. 5-20% of clients diagnosed with anorexia nervosa will die 3. Clients diagnosed with anorexia nervosa see themselves as emaciated 4. Clients diagnosed with anorexia nervosa are self-indulgent 2. 5-20% of clients diagnosed with anorexia nervosa will die Nursing care for a patient diagnosed with substance abuse is based on which of the following principles? 1. The patient has difficulty making decisions 2. The patient expects too much of himself 3. The patient attempts to appease others at all costs 4. The patient has limited ability to tolerate anxiety 4. The patient has limited ability to tolerate anxiety A client diagnosed with a phobic disorder joins a group meeting with a psychiatric nurse-leader. During the first meeting, the client makes the following statements; "I know my feelings of being terrified of closed up spaces is dumb. It doesn't make any sense. I just can't seem to do anything about it. Right now I get nervous and scared just thinking about it. Which of these responses by the nurse is BEST? 1. "Having a nurse stay with you in a closed space could help you overcome your fear" 2. "Knowing that your fears don't make sense doesn't always help you feel better" 3. "Participating in several of our ward activities may make you feel better" 4. "Being frightened as a child by some particular incident probably caused these fears" 2. "Knowing that your fears don't make sense doesn't always help you feel better" The nurse anticipates which group of symptoms when caring for a patient with disorientation due to dementia? 1. Judgement alteration, memory deficit, and irritability 2. Anorexia and weight loss, fatigue, and hopelessness 3. Confusion , delirium, and hallucinations 4. Impaired motor skills, lack of coordination, and mood changes 1. Judgement alteration, memory deficit, and irritability The nurse cares for clients in the pediatric clinic. The nurse understands according to Erikson's stages of psychosocial development, trust, and significant early attachments develop during which year of life? 1. Birth-18 months 2. 18 months-3 years 3. 3-6 years 4. 6-12 years 1. Birth-18 months The nurse cares for patients in the pediatric clinic. The mother of a younger child asks why her child is involved in play therapy. Which statement by the nurse is BEST? 1. "Young children have difficulty verbalizing emotions." 2. "Children hesitate to confide in anyone but their parents" 3. "Play is an enjoyable form of therapy for children" 4. "Play therapy is helpful in preventing regression" 1. "Young children have difficulty verbalizing emotions." A mother of two school-aged children tells the nurse that her husband has recently become unemployed and the patient complains of feeling depressed. The nurse understands which of the following to be true? 1. The husband's unemployment is a significant potential stressor 2. The husband's unemployment is irrelevant 3. Unemployment is mainly a factor in development crises 4. The patient is using her husband's unemployment to avoid her own problems 1. The husband's unemployment is a significant potential stressor In the day unit of outpatient mental health program, the nurse finds a client diagnosed with undifferentiated schizophrenia dancing alone next to the radio. Suddenly, the client stops dancing and stares at the nurse in a menacing manner. which of the following actions by the nurse is BEST? 1. Leave for a short time promising to return soon 2. Remain silent and stand still until the client speaks 3. Start talking to the client about a neutral topic 4. Point out that the client that has stopped dancing and seems upset 4. Point out that the client that has stopped dancing and seems upset A client is brought to the emergency room by family members after taking an overdose of diazepam (Valium). The family reports the client has becoming increasingly depressed and withdrawn during the previous month. Which of the following questions is MOST important for the nurse to ask during the initial interview? 1. "Why did you do this to yourself?" 2. "Can you elaborate on what is bothering you?" 3. "Exactly what, how much, and when did you take the medication?" 4. "Did you seriously think of killing yourself?" 3. "Exactly what, how much, and when did you take the medication?" During the second session of individual therapy, a patient sits quietly with arms folded and eyes cast down. Which of the following approaches by the nurse is BEST? 1. Use small talk to keep the conversation going 2. Ask the patient why he is having difficulty talking 3. Ask concrete, direct questions that require simple answers 4. Use broad openings and leads to encourage discussion 4. Use broad openings and leads to encourage discussion A middle-aged client is admitted to the hospital with a diagnosis of terminal lunch cancer. The client's spouse reports to the nurse that the client did not want to come to the hospital and "refuses to slow down." The nurse should give priority to which of the following measures? 1. Promote rest and relaxation 2. Encourage the client to participate in planning care 3. Encourage the client to accept help from others 4. Set limits on excessive activities 2. Encourage the client to participate in planning care The nurse cares for patients on the medical/surgical unit. The nurse admits a patient for possible appendicitis. During the admission interview, the patient states, "most days I drink about a pint of vodka." The nurse understands that the MOST likely time for the patient to develop alcohol withdrawal delirium is 1. 6-12 hours after cessation of drinking 2. 12-18 hours after cessation of drinking 3. 48-72 hours after cessation of drinking 4. 4 days after cessation of drinking 3. 48-72 hours after cessation of drinking The nurse volunteers in a homeless shelter. The nurse notices that another volunteer develops an overly close relationship with the older women in the shelter. During conversation, the volunteer relates to the nurse that several years before her mother died, she refused to let her mother come live with her. The nurse understands that the volunteer is using which of the following defense mechanisms? 1. Substitution 2. Undoing 3. Compensation 4. Denial 2. Undoing A client is admitted to the hospital with a diagnosis of paranoid schizophrenia. the spouse states the client has not slept in three nights. Which of the following nursing goals takes priority? 1. Increase a sense of responsibility 2. Increase independence 3. Promote trust 4. Promote rest 3. Promote trust The nurse orients a patient to the unit. The nurse observes the patient is pacing, talking rapidly, and has elevated respirations. Which of the following actions by the nurse is BEST? 1. Provide an informational booklet 2. Keep the explanation simple 3. Delay the orientation until the anxiety has eased 4. Stress the positive aspects of the unit 2. Keep the explanation simple A mother of two delivers a newborn with a cleft palate. The parents visit the baby in the newborn nursery. Which of the following statements by the nurse to the parents is BEST? 1. "Sit in that rocking chair so that you can hold your baby" 2. "We feed the infant every four hours" 3. "I'll hold your baby while you look at him" 4. "You can watch the nurse give your baby a bath" 1. "Sit in that rocking chair so that you can hold your baby" During the period of elation for a patient diagnosed with bipolar disorder, which of these approaches should the nurse plan to use frequently? 1. Point out the effect a patient's behavior has on others 2. Attempt to distract and redirect the patient 3. Encourage the patient to express themselves 4. Provide opportunities for the patient to socialize 2. Attempt to distract and redirect the patient A patient with diagnosis of antisocial personality disorder fails to arrive on time for a scheduled appointment with a nurse. The contact the patient to remind him of the appointment, and the patient states, "I would rather meet between 12 and 1." Which responses by the nurse is BEST? 1. "Perhaps we can make that change next time" 2. "Is there something you are having trouble discussing?" 3. "I would have to discuss any changes with the team first" 4. "Are you having some difficulty with the time you agreed to? 4. "Are you having some difficulty with the time you agreed to? A man is brought to the hospital by his wife. He is boisterous, quarrelsome, and unusually energetic. His wife reports that this past week he has not slept more than three hours a night, and that he has been buying extravagant items that they cannot afford. Which of these understandings is basic to the care of a patient with episodes of elation and depression? 1. The patient has nonspecific fears 2. The patient is easily stimulated by his surroundings 3. The patient has recurrent unwanted thoughts 4. The patient has a well-organized delusional system 2. The patient is easily stimulated by hissurroundings The nurse finds a patient diagnosed with schizophrenia standing in the dayroom of the psychiatric inpatient unit completely undressed. Which of the following measures by the nurse is BEST? 1. Cover the patient with a towel or sheet and sent the patient to get dressed 2. Lead the patient back to his room and help the patient get dressed 3. Ask the patient why he seems to need extra attention this morning 4. Take the patient back to his room and privately reprimand him 2. Lead the patient back to his room and help the patient get dressed