Questions and Answers
Updated Latest (Verified Answers)
1. A nurse is collecting data from a client who has an elevated temperature with
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no sweating. Which of the following findings is an indication of hyperna- tremia?
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Thirst
Muscle twitching g g
Headache
Abdominal cramps g
Answer Thirst. g
Rationale
Thirst, combined with an elevated temperature and a lack of sweating, can be an indicati
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n of hypernatremia.
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2. A nurse is caring for a client who reports difficulty sleeping due to the noise on th
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e nursing unit. Which of the following actions should the nurse take to reduce env
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ironmental noise? g
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,Close the door to the client's room.
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Turn off the alarms and beeps on monitoring equipment. Co
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nduct change-of-shift report outside the client's door.
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Keep the television on low in the client's room.
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Answer Close the door to the client's room.
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Rationale
The nurse should close the door to the client's room whenever possible to reduce enviro
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mental noise. g
3. A nurse is reinforcing teaching about health promotion with a client. Which of t
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he following actions should the nurse take first to promote effective learn- ing?
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Identify areas of concern. Prioritize
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g learning objectives. Demonstrate p g g g
sychomotor skills. g
Observe nonverbal communication. g g
Answer Identify areas of concern.
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Rationale
The first action the nurse should take when using the nursing process is to collect data fr
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m the client. Identifying and understanding the client's concerns prior to reinforcing tea
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,hing promotes effective learning.
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, 4. A home health nurse is assisting with the plan of care for a client. Which of the f
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ollowing should the nurse include during the orientation phase of the helping rel
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ationship?
Review current client data.
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Assist to meet client goals.
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Review shared memories of interactions with client.
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Clarify the role of this individual nurse.
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Answer Clarify the role of this individual nurse.
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Rationale
The nurse should plan to establish a warm, caring relationship while clarifying the
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role of each participant, which occurs during the orientation phase of the relations
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hip.
5. A nurse is preparing to assist with the admission of a client who has pneu-
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g monia. Which of the following observations about the client's room requires im
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mediate attention? g
The wall BP gauge is missing.
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The room has no IV infusion pump.
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