QUESTIONS AND WELL VERIFIED
ANSWERS GRADED A+[ACTUAL
EXAM 100%]
A nurse is caring for a client who was admitted for acute alcohol
delirium withdrawal 2 days ago. Which of the following findings is
associated with this diagnosis?
A. Increased appetite
B. Elevated Temperature
C. Bradycardia
D. Drowsiness - ANS✔✔---Elevated Temperature
,Rationale: The content of this question emphasizes the concept of
client-centered care through identifying findings associated with a
client's diagnosis. Client-centered care focuses on the client and
emphasizes the client's cultural, ethnic, and social values. The
identification of expected and unexpected findings associated with
a client's diagnosis assists the nurse to distinguish possible
unrelated complications the client might be experiencing, which
indicates the need for further investigation. The specific focus on
the client enhances the provision of safe, quality nursing care. An
elevated temperature is a finding associated with acute alcohol
delirium.
A nurse working in a hospice facility is talking to a client's son
who is distressed because his mother cries frequently and says
she wants to die. Which of the following responses by the nurse is
appropriate?
A. "I know this must be difficult, but your mother will calm
down soon."
B. "Lets discuss some strategies you can use when this
happens again."
C. Individuals near death are ready to let go toward the end."
D. "Have you determined why she is crying and saying she is
ready to die?" - ANS✔✔---" Let's discuss some strategies
you can use when this happens again."
,Rationale: This response by the nurse offers to provide
information, which can reduce anxiety and enhance decision
making. This response creates a safe environment, fosters trust
and respect, and is appropriate.
A nurse is caring for a client who had cerebrovascular accident 2
days ago. Which of the following is the first sign of increased
intracranial pressure (ICP)?
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia - ANS✔✔---Lethargy
rationale: Lethargy occurs when pressure is placed on the
reticular activating system within the brainstem. Along with other
indicators of a change in level of consciousness, such as
restlessness, irritability, and disorientation. Lethargy is the first
sign of increased ICP.
A nurse working in a provider's office is reinforcing teaching with a
client who is 14 weeks of gestation. The nurse should instruct the
client to immediately notify the provider if she experiences which
of the following?
A. facial edema
, b. urinary frequency
c. acid indigestion
d. breast leakage - ANS✔✔---Facial edema
rationale: facial edema is an indication of pregnancy-induced
hypertension and should be reported immediately to the provider.
A nurse is caring for a client who is receiving parenteral nutrition
through a nontunneled central venous catheter and reports
hearing a gurgling sound on the side of the catheter. The nurse
suspects the catheter has migrated to the jugular vein. Which of
the following actions should the nurse take first?
A. Notify the provider
B. Obtain a chest x-ray
C. Flush the catheter.
D. Stop the infusion. - ANS✔✔---Stop the infusion
Rationale: This prevents further damage to vessel and minimizes
any additional harm to the client
A nurse is reinforcing teaching with a caregiver who has
aphasia. The nurse should include which of the following
communication strategies in the teaching?
A. Cue the client by providing picture cards that portray
common needs.