HESI Exit (366 V2) Questions and Verified Answer Elaborations (Latest Update).

HESI Exit (366 V2) Questions and Verified Answer Elaborations (Latest Update). Question: The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." Question: Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? Give information about advance directives Question: A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to Administer epinephrine 1:1000 as ordered Question: Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A toddler with severe deep abrasions over 98% of the body Question: When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to Notify the admissions office and wait to apply the bracelet Question: The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? Call the provider for clarification Question: An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: open the client's airway Question: A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? Auscultate the lungs Question: Following change-of-shift report on an orthopedic unit, which client should the nurse see first? 72 year-old recovering from surgery after a hip replacement 2 hours ago Question: A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? That was done correctly. Did you have any problems with the insertion? Question: A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? contact precautions Question: The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? clean the meatus, begin voiding, then catch urine stream Question: The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? watermelon Question: A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? Immediately wash the hands with vigor Question: As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? Walk up and whisper in the student's ear "Stop. Aspirate. Then inject." Question: A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? Glascow Coma Scale 8, respirations regular Question: A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client? A notarized original of advance directives brought in by the partner Question: The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? An admission at the change of shifts with atrial fibrillation and heart failure - PN Question: A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? Restlessness and increased mucus production Question: As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? "Clothes are becoming tighter across her abdomen." Question: A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? Proceed with the triage process in the same manner as any adult client Question: A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? Report hourly outputs of less than 30 ml/hr Question: The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? Strep throat went through all the children at the day care last month. Question: A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to Discuss the feeling of reluctance with an objective peer or supervisor Question: A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action May result in charges of unlawful seclusion and restraint Question: A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? Pain related to ischemia Question: The provisions of the law for the Americans with Disabilities Act require nurse managers to Provide reasonable accommodations for disabled individuals Question: A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? "I have diminished sexual function." Question: A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? "I think I remember that standing cannot be done until after 72 hours." Question: Which statement best describes time management strategies applied to the role of a nurse manager? Set daily goals with a prioritization of the work Question: The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? Abdominal mass and weakness Question: A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? "I will only have to wear this for 6 months." Question: The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will Improve team morale Question: A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? Diffuse expiratory wheezing Question: The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to Request an immediate private meeting with the health care provider and staff nurse Question: A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states "I demand to be released now!" Let's discuss your decision to leave and then we can prepare you for discharge. Question: A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? Heart murmur Question: A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to Maintain alveolar surface tension Question: An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be Respiratory function Question: He nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? Hourly urine output Question: The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? Assume a decision-making role Question: The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? Metabolic alkalosis Question: Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? Check the blood pressure of a 2 hours post operative client Question: A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is Assess the child and the extent of the injury Question: When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? Household pets Question: An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? Slurred speech Question: A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? Pinworms Question: A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? Assessing the client's ability to participate in self care and/or the reliability of a caregiver Question: The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? "Folic acid should be taken before and after conception." Question: A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? Moist sterile non adherent dressing Question: A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? Let tap water run for 2 minutes before adding to concentrate Question: A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is Position client in upright position while eating Question: The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from... my thigh. Question: The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? Ineffective airway clearance Question: A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to Improve venous return Question: During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? Suggest communication strategies Question: The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to Keep a regular schedule of meals and snacks Question: The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated to the findings in the infant? DTaP Question: The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? Unprotected sex Question: The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with an order of enemas until clear prior to colonoscopy Question: A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: "My child seems to have problems in learning to count and recognizing basic colors." Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? Fetal alcohol syndrome Question: The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? Expiratory wheezes that are suddenly absent in 1 lobe Question: The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? Ground beef patty, lima beans, wheat roll, raisins, milk Question: A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to Plan nursing care around lengthy rest periods Question: The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? Client controlled analgesia Question: As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? The measles, mumps and rubella vaccine should be delayed Question: The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken With each meal or snack Question: The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? Irritability Question: The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? Use minimal physical contact Question: A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? The appearance of eyeballs that appear to "pop" out of the client's eye sockets Question: Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? HCT of 60 Question: The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? The affected child's age and weight Question: A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? Continue with the regular diet and include oral rehydration fluids Question: The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? Adding a spacer device to the MDI canister Question: Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? Whitish oval specks sticking to the hair Question: When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? Water Question: A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? Allergic to shellfish Question: The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? Solid foods are introduced 1 at a time beginning with cereal Question: The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? Limit the infusion time of each of the unit to a maximum of 4 hours Question: A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? Administer oxygen Question: A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from C I had a blood transfusion 15 years ago Question: A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? Tetany and paresthesia Question: A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? Particulate respirator mask Question: A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? The client's urine output was 1500 cc in 5 hours Question: The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied When it is 1/3 to 1/2 full Question: Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A decrease in lethargy Question: The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? Whole milk is difficult for a young infant to digest Question: The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the postoperative period? Estrogen replacement therapy Question: The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? Place nightlight in the bedroom Question: An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? Balloons Question: The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? Continue to monitor the client to see if the bubbling increases Question: The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? Begin treatment with acyclovir at the onset of symptoms of recurrence Question: An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? Chicken strips, corn on the cob, milk Question: The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? Empty the child's mouth in any case of possible poisoning Question: Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? Rash, blood dyscrasias, severe depression Question: The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? Assess movement and sensation of extremities Question: A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? Potato chips Question: A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Postoperatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? Administer the PRN dose of Albuterol Question: What finding signifies that children have attained the stage of concrete operations (Piaget)? Makes the moral judgement that "stealing is wrong" Question: The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? Liver enzymes (AST and ALT) Question: The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include Formula or breast milk Question: The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? Stimulates hydrochloric acid production Question: The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to Assess for abdominal distention Question: The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? "Keep in mind that for the age this is a normal response to being in the hospital." Question: When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? Prothrombin time Question: The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? Increased restlessness Question: The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? "In some instances the result is a retarded bone growth." Question: A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? Tardive dyskinesia Question: During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? "Telangiectatic nevi are normal and will disappear as the baby grows." Question: A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? Monitor vital signs Question: A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? Frequent neurovascular assessments of the affected leg Question: The nurse is teaching a client newly diagnosed with asthma how to use the metered dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is Drop the canister in water to observe floating Question: While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? Maintain good oral hygiene and dental care Question: A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate Abdominal ultrasound Question: The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? Decreased potassium Question: An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? Potassium levels Question: The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? Ineffective breathing patterns related to central nervous system depression Question: The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to Reassess the child's temperature Question: The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to Measure forced expiratory volume Question: The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? Vastus lateralis Question: A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? To discuss feelings with each other and use support persons Question: The parents of a 4 year-old hospitalized child tell the nurse, "We are leaving now and will be back at 6 PM." A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse? "They will be back right after supper." Question: The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? Peak air flow volumes Question: Therapeutic nurse-client interaction occurs when the nurse Assists the client to clarify the meaning of what the client has said Question: A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? Epistaxis The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is Pulse oximetry correct answer is B: Pulse oximetry 127. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? Offer the client frequent opportunities to interact with 1 person The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? Applying a hydrocolloid or foam dressing A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements? "Are you worried that the surgery will change you?" When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue Giving away valued personal items The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours? Blood urea nitrogen The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? Daily needs and concerns The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? No special preparation is necessary While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to Ask the client what she is feeling Which statement made by a client indicates to the nurse that he may have a thought disorder? "I can't find my 'mesmer' shoes. Have you seen them?" The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis? Repeatedly checking that the door is locked A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? Listen quietly without comment A client is admitted to a psychiatric unit with delusions. What findings can the nurse expect? Suspiciousness and resistance to therapy A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client's attire? Directly assist client to her room for appropriate apparel Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that Some clients misconstrue hugs as an invitation to sexual advances A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." An appropriate response for the nurse is "You are angry right now." An important goal in the development of a therapeutic inpatient milieu is to Provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions The nurse's primary intervention for a client who is experiencing a panic attack is to Maintain safety for the client Which intervention best demonstrates the nurse's sensitivity to a 16 year old's appropriate need for autonomy? Provides opportunity to discuss concerns without presence of parents A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are Brittle hair, lanugo, amenorrhea A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best response to this statement? "Have you thought about hurting yourself?" A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond? "Identify your relapse triggers as part of getting better." A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects Dental erosion, parotid gland enlargement A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is "You seem upset; tell me what the pregnancy and birth were like for you." Which of the following times is a depressed client at highest risk for attempting suicide? 7 to 14 days after initiation of antidepressant medication and psychotherapy A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? What does the skin on the testicles look and feel like? A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of Digoxin to this client? Assess the apical pulse, counting for a full 60 seconds A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem? Inspiratory crackles A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? Increasing pulse rate Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? Chest physiotherapy twice a day A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? Acute compartment syndrome The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? When I put the baby in a back lying position that's how I find the baby. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? I have to go at intervals for epoetin (Procrit) injections at the health department. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action? Weakness in left arm A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The mother states: "My child has not had a wet diaper all day." The nurse finds the child is pale with a heart rate of 132. What assessment data should the nurse obtain next? Status of the eyes and the tongue