Answers
Which clinical findings would support the primary health care provider's conclusion of
actinic keratosis?
1. Erythematous, barely elevated plaques
2. Elevated, dry, hyperkeratotic scaly papule
3. Variegated colors of tan, brown, and black within a single mole
4. Thin, scaly, erythematosus plaque without invasion into the dermis - Answer-2
Which activity places a client at risk for hyperthermia?
1. Snowmobiling
2. Skiing in the winter
3. Hiking Alaskan mountains
4. Performing strenuous activity in high humidity - Answer-4
The community nurse is assessing an older adult client who lives alone at home. The
nurse finds that the client refrains from physical activity for fear of falling when walking.
Which intervention(s) by the nurse are beneficial to promote a healthy lifestyle? Select
all that apply. One, some, or all responses may be correct.
1. Instruct the client to apply bedside rails
2. Encourage the client to wear nonskid shoes.
3. Suggest that the client use an assistive device
4. Ask the client to install handrails in the bathroom.
5. Help the client rearrange furniture in the house. - Answer-2, 3, 5
The nurse places a client in restraints due to violent combative behavior. Which
intervention would the nurse perform next?
1. Offer food and drink.
2. Document the behavior.
3. Obtain a written or verbal prescription.
4. Provide a 1:1 attendant in the room. - Answer-3
An older adult client states, "I walk 2 miles [3.2 km] a day for exercise, but now that the
weather is hot, I am worried about becoming dehydrated." Which statement would the
nurse use to respond to this client?
1. "Drink fruit juices if you start to feel dehydrated."
2. "Thirst is a good guide to use to determine fluid intake."
3. "Fluids should be increased if the urine becomes darker."
, 4. "Water should be consumed when the skin becomes dry." - Answer-3
Which finding would lead the nurse to contact the state bureau of motor vehicles to
obtain a driving evaluation for an older adult?
1. Cancer
2. Arthritis
3. Dementia
4. Depression - Answer-3
Which statements made by the nursing student demonstrate adequate knowledge about
the etiology of hypothermia and administration of different treatments? Select all that
apply. One, some, or all responses may be correct.
1. "Blood infusion causes hypothermia."
2. "Amphetamines cause hypothermia."
3. "β-Adrenergic blockers cause hypothermia."
4. "Tricyclic antidepressants causes hypothermia."
5. "Neuromuscular blocking agents causes hypothermia." - Answer-1, 5
While hospitalized, a client with diabetes is observed picking at calluses on the feet.
Which intervention would the nurse implement immediately?
1. Warn the client of the danger of infection.
2. Suggest that the client wear white cotton socks.3
3. Teach the client the importance of effective foot care.
4. Check the client's shoes for their fit in the area of the calluses. - Answer-3
When a client is using a hypothermia blanket to reduce fever, which finding indicates a
need for a change in the treatment?
1. Shivering
2. Vomiting
3. Dehydration
4. Hypotension - Answer-1
When assisting a client with Parkinson disease to ambulate, which instruction would the
nurse provide the client?
1. Avoid leaning forward.
2. Hesitate between steps.
3. Rest when tremors are experienced.
4. Keep arms close to the center of gravity. - Answer-1
Which nursing interventions would the nurse provide to an older client with
hypertension? Select all that apply. One, some, or all responses may be correct.
1. Provide skin care.
2. Advise the client to limit salt intake.
3. Teach stress management.
4. Instruct the client to quit smoking.
5. Advise the client to eat finger foods. - Answer-2, 3, 4