Complete 130+ Questions and Correct Detailed
Answers / Rationales.
Terms in this set (131)
Which assessment is most Respiratory effort.
important for the nurse to
perform on a client who is Guillain-Barre syndrome causes paralysis or weakness that
hospitalized for GuillainBarre typically starts at the feet and progresses upwards. As the
condition progresses, the nurse must ensure that the client
syndrome that is rapidly
is able to breathe effectively.
progressing?
Respiratory effort.
Unsteady gait.
Intensity of pain.
Ability to eat.
Collect a culture of the penile discharge.
A male client comes into the
clinic with a history of penile Penile discharge with painful urination is commonly
discharge with painful, associated with gonorrhea. The nurse should collect a
culture of the penile discharge to determine the cause of
burning urination. Which
these symptoms. The cause must be determined or
action should the nurse confirmed through culture to identify the organism and
implement? ensure effective treatment.
Collect a culture of the
penile discharge.
Palpate the inguinal lymph
nodes gently. Observe for
scrotal swelling and redness.
Express the discharge to
determine color.
,A client with history of atrial Check for a pulse deficit.
fibrillation is
admitted to the telemetry A client with a past history of atrial fibrillation may return to
unit with sudden onset of that rhythm. Any signs of atrial fibrillation, such as sudden
onset shortness of breath, requires further investigation.
shortness of breath. The
The nurse should assess this client for a pulse deficit
nurse observes a new because this condition occurs with atrial fibrillation.
irregular heart rhythm and
should perform which
assessment at this time?
Check for a pulse deficit.
Palpate the apical impulse.
Inspect jugular vein pulse.
Examine for a carotid bruit.
A 24-year-old with shoulder and lower abdominal quadrant pain.
Which client should be
A 24-year-old with sudden onset of lower abdominal
further assessed for an
quadrant pain should be assessed for an ectopic pregnancy.
ectopic pregnancy? The pain can also be referred to the shoulder and may be
associated with vaginal bleeding.
A 24-year-old with shoulder
and lower abdominal
quadrant pain. A 33-year-old
with intermittent lower
abdominal cramping. A 20-
year-old with fever and right
lower abdominal colic.
A 40-year-old with
jaundice and right lower
abdominal pain.
,Which dietary assessment Drinks a six pack of beer every day.
finding is most important for
the nurse to address when Drinking six beers every day is the dietary assessment
caring for a client with finding most important for the nurse to address when
caring for a client with diabetic nephropathy. The usual can
diabetic nephropathy?
of beer is 12 ounces (355 mL). Clients with diabetes are
recommended to drink no more than 12 ounces of beer per
Drinks a six pack of beer day because beer contains carbohydrates that can create
every day. unhealthy fluctuations in blood glucose and promote poor
glucose control. Nephropathy is exacerbated by poor blood
Enjoys a hamburger once a
glucose control.
month.
Eats fortified breakfast cereal
daily.
Consumes beans and rice
every day.
Which assessment finding is Cough brought on by swallowing.
of greatest concern to the
nurse who is caring for a A cough brought on by swallowing is a sign of dysphagia,
which is a finding of particular concern in a client with
client with stomatitis?
stomatitis. Dysphagia can cause numerous problems,
including airway obstruction, and should be reported to the
Cough brought on by healthcare provider immediately.
swallowing.
Sore throat caused by
speaking.
Painful and dry oral cavity.
Unintended weight loss.
, The nurse is teaching a client Altered sexual response.
diagnosed with peripheral
arterial disease. Which Peripheral arterial disease (PAD) is a cardiovascular
genitourinary system condition characterized by narrowing of the arteries and
reduced blood flow to the extremities. PAD is known to
complication should the
alter the blood flow to the male's penis and is associated
nurse include in the with erectile dysfunction in men.
teaching?
Altered sexual response.
Sterility.
Urinary incontinence.
Decreased pelvic muscle
tone.
A 40-year-old female client Oral contraceptives.
has a history of smoking.
Which finding should the Women older than 35 years old who smoke and take oral
nurse identify as a risk factor contraceptives have an increased risk of myocardial
infarction or stroke.
for myocardial infarction?
Oral contraceptives.
Senile osteopenia.
Levothyroxine therapy.
Pernicious anemia.
Decreased color perception.
A client has been told that
there is cataract formation
Decreased color perception occurs with cataract formation.
over both eyes. Which Cataract formation is also associated with blurred vision and
finding should the nurse a global loss of vision so gradual that the client may not be
expect when assessing the aware of it.
client?
Decreased color perception.
Presence of floaters.
Loss of central vision.
Reduced peripheral vision.