Saunders Test Yourself 1 with Questions and correct Answers 2024/2025

Saunders Test Yourself 1 with Questions
and correct Answers 2024/2025
A client has come to the emergency department complaining of burning with urination.
What should the nurse consider a priority when providing care in order to maintain the
client's psychosocial integrity?

Use medical terminology when speaking to the client.
Provide the client with as much privacy as possible during the examination.
Explain to the client that all questions will be answered at the time of discharge.
Administer medications as soon as they are prescribed by the health care provider. -
correct answers--B

Rationale: Providing the client with as much privacy as possible during the examination
is the best way to maintain psychosocial integrity and should be considered a priority by
the nurse. Using medical terminology may be confusing to the client. The nurse should
explain all actions and procedures to the client before they occur. Administering
medications as soon as prescribed is important, but does not necessarily maintain the
client's psychosocial integrity in this situation

A client is being assessed for post-partum depression. Which actions by the client
would indicate a need for follow-up by the nurse? Select all that apply.

Not responding to the infant's cries.
Crying after talking with spouse on the phone.
Stating that family was not supportive of the pregnancy.
Making statements about being fat and unattractive now.
Stating that the infant latched on properly during a feeding. - correct answers--A, B, C,
D

Rationale: The weeks following the birth are a time of vulnerability to psychiatric
disorders, such as depression for many women, causing significant distress for the
mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional
and social development. It is important that the nurse frequently assess the client for
post-partum depression. Ignoring the infant's cries should alert the nurse that further
assessment is needed. Crying after talking with a spouse of the phone could indicate a
problem at home. Statements of non-supportive family members need to be addressed
by the nurse, for the safety and well-being of the client and infant. The nurse should
also address the client's statements about body image, educating the client about what
is normal and what is not normal in the post-partum period. Stating that the infant
latched on during a feeding is a positive action and would not indicate the need for
further assessment.

,A client is being discharged home after a routine hip replacement surgery. The nurse is
instructing the client on how to prevent postoperative complications. What statements
by the client would indicate the need for further teaching? Select all that apply.

"Limiting fiber is necessary to avoid diarrhea."
"I should empty my bladder when I feel the urge."
"Avoiding pain medication will prevent constipation."
"I should drink plenty of liquids like iced tea or coffee."
"I should continue with my physical therapy and walking." - correct answers--A, C, D

Rationale: Constipation is common after surgery due to pain medication, decreased
movement, and anesthesia. Fiber intake should be encouraged as it promotes the
prevention of stool retention. Although pain medication can cause constipation, it should
not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for
both bowel and bladder maintenance, but the client should choose non-caffeinated
options. Physical therapy, walking, and exercise will help prevent constipation.
Emptying the bladder when the urge is present can help prevent urinary tract infections.

A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT).
The client will be discharged home on oral anticoagulants. What information in the
client's medical record would warrant the need for teaching? Refer to chart.

Sodium result
D-Dimer result
Vitamin D 400 IU daily
10 pack year history of smoking - correct answers--D

Rationale: A deep vein thrombosis (DVT) is the most common type of venous
thromboembolism (VTE). DVTs occur most often in the legs, but can also occur in the
upper arms. Smoking increases the risk of DVT formation, and clients should educated
on the importance of quitting. The sodium result is within normal limits. The positive d-
dimer result is expected, as it is a marker for DVTs. Vitamin D supplementation does
not impact DVTs or anticoagulation therapy.

A client with anxiety has just been seen by the health care provider and has been
prescribed alprazolam. A week later, the client is brought to the emergency room, after
consuming a large number of tablets in an attempt to overdose. The client is
unresponsive and has gasping respirations. Which action should the nurse take first?

Administer the antidote naloxone
Administer the antidote flumazenil
Assist with intubation of the client
Assist with insertion of a central venous line - correct answers--C

Rationale: The client requires immediate intubation because of the gasping respirations
and unresponsiveness. Flumazenil is the antidote for an overdose of benzodiazepines;

, however, the priority is securing the airway. Naloxone is the antidote for an opiate
overdose. Assisting with insertion of a central venous line is not the priority and would
involve a great deal of time while the client is gasping to breathe.

A mother brings her 9-month-old child to see the pediatrician and has concerns that the
child may have a developmental delay because the child cannot roll over yet. for the
nurse should ask the mother about which risk factors associated with a developmental
delay? Select all that apply.

Age
Race
Income
Chronic illness
Low birth weight
Environmental exposure to toxins - correct answers--C,D, E, F

Rationale: Developmental delays can occur at any age; however, it is most commonly
seen in infancy through adolescence. Developmental delays can occur regardless of
race. Children living in poverty, those with chronic illnesses, low birth weight, or
exposure to environmental exposure to toxins are at a higher risk for developmental
delays.

A nurse employed at a long-term care facility is caring for a client who has recently been
transferred from the hospital. The client is confused and is acting out. The nurse
suspects the client is suffering from relocation stress. The nurse should include which
helpful actions in the plan of care? Select all that apply.

Encourage friends and family to visit frequently.
Establish a trusting relationship with the client as soon as possible.
Change rooms frequently to prevent the client from becoming bored.
Ensure the client is an active part of decision making regarding their care.
Allow the client to move around the halls as desired to decrease the confusion and
acting-out. - correct answers--A, B, D

Rationale: Relocation stress can occur when a client is removed from their usual
surrounding such as home. In order to provide safe and quality care, encourage friends
and family to visit the client often and establish a trusting relationship with the client as
soon as possible. It is important for the client to have an active role in decision-making.
In order to lessen confusion, the nurse should provide the client time to become familiar
with the immediate surroundings such as his or her room before allowing or
encouraging ambulation to new surroundings; allowing the client to move around the
halls as desired may increase confusion and acting-out behaviors. Likewise, changing
the client's room frequently may increase confusion.

The client has been diagnosed with valvular disease. Which interventions should the
nurse be prepared to discuss with the client? Select all that apply.