NR 464-SAUNDERS EXAM QUESTIONS
WITH 100% VERIFIED ANSWERS!!
The nurse has made a judgment that a client who had a craniotomy is experiencing a
problem with body image. The nurse develops goals for the client but determines that the
client has not met the outcome criteria by discharge if the client performs which action?
1. Wears a turban to cover the incision
2. Indicates that facial puffiness will be a permanent problem
3. Verbalizes that periorbital bruising will disappear over time
4. States an intention to purchase a hairpiece until hair has grown back
2. Indicates that facial puffiness will be a permanent problem
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and
ineffective cough and is using accessory neck muscles in breathing. The nurse carefully
monitors the client and suspects the presence of which problem?
1. Altered breathing pattern
2. Increased likelihood of injury
3. Ineffective oxygen consumption
4. Increased susceptibility to aspiration
1. Altered breathing pattern
A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries
to administer care. The nurse should perform which action?
,1. Ask the family to deliver the care.
2. Leave the client alone until ready to participate.
3. Advise the client that rehabilitation progresses more quickly with cooperation.
4. Acknowledge the client's anger and continue to encourage participation in care.
4. Acknowledge the client's anger and continue to encourage participation in care.
A client with a neurological impairment experiences urinary incontinence. Which nursing
action would be most helpful in assisting the client to adapt to this alteration?
1. Using adult diapers
2. Inserting a Foley catheter
3. Establishing a toileting schedule
4. Padding the bed with an absorbent cotton pad
3. Establishing a toileting schedule
A client with a neurological problem is experiencing hyperthermia. Which measures would
be appropriate for the nurse to use in trying to lower the client's body temperature? Select
all that apply.
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
3. Covering the client with blankets
4. Administering acetaminophen per protocol
, 5. Placing ice packs over the client's abdomen and in the axilla and groin
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
4. Administering acetaminophen per protocol
The nurse is administering mouth care to an unconscious client. The nurse should perform
which actions in the care of this person? Select all that apply.
1. Use products that contain alcohol.
2. Position the client on his or her side.
3. Brush the teeth with a small, soft toothbrush.
4. Cleanse the mucous membranes with soft sponges.
5. Use lemon glycerin swabs when performing mouth care.
2. Position the client on his or her side.
3. Brush the teeth with a small, soft toothbrush.
4. Cleanse the mucous membranes with soft sponges.
The nurse assigned to the care of an unconscious client is making initial daily rounds. On
entering the client's room, the nurse observes that the client is lying supine in bed, with the
head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running
at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious
breath sounds. Which judgment should the nurse formulate for the client?
WITH 100% VERIFIED ANSWERS!!
The nurse has made a judgment that a client who had a craniotomy is experiencing a
problem with body image. The nurse develops goals for the client but determines that the
client has not met the outcome criteria by discharge if the client performs which action?
1. Wears a turban to cover the incision
2. Indicates that facial puffiness will be a permanent problem
3. Verbalizes that periorbital bruising will disappear over time
4. States an intention to purchase a hairpiece until hair has grown back
2. Indicates that facial puffiness will be a permanent problem
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and
ineffective cough and is using accessory neck muscles in breathing. The nurse carefully
monitors the client and suspects the presence of which problem?
1. Altered breathing pattern
2. Increased likelihood of injury
3. Ineffective oxygen consumption
4. Increased susceptibility to aspiration
1. Altered breathing pattern
A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries
to administer care. The nurse should perform which action?
,1. Ask the family to deliver the care.
2. Leave the client alone until ready to participate.
3. Advise the client that rehabilitation progresses more quickly with cooperation.
4. Acknowledge the client's anger and continue to encourage participation in care.
4. Acknowledge the client's anger and continue to encourage participation in care.
A client with a neurological impairment experiences urinary incontinence. Which nursing
action would be most helpful in assisting the client to adapt to this alteration?
1. Using adult diapers
2. Inserting a Foley catheter
3. Establishing a toileting schedule
4. Padding the bed with an absorbent cotton pad
3. Establishing a toileting schedule
A client with a neurological problem is experiencing hyperthermia. Which measures would
be appropriate for the nurse to use in trying to lower the client's body temperature? Select
all that apply.
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
3. Covering the client with blankets
4. Administering acetaminophen per protocol
, 5. Placing ice packs over the client's abdomen and in the axilla and groin
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
4. Administering acetaminophen per protocol
The nurse is administering mouth care to an unconscious client. The nurse should perform
which actions in the care of this person? Select all that apply.
1. Use products that contain alcohol.
2. Position the client on his or her side.
3. Brush the teeth with a small, soft toothbrush.
4. Cleanse the mucous membranes with soft sponges.
5. Use lemon glycerin swabs when performing mouth care.
2. Position the client on his or her side.
3. Brush the teeth with a small, soft toothbrush.
4. Cleanse the mucous membranes with soft sponges.
The nurse assigned to the care of an unconscious client is making initial daily rounds. On
entering the client's room, the nurse observes that the client is lying supine in bed, with the
head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running
at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious
breath sounds. Which judgment should the nurse formulate for the client?
