Answers6
The nurse is talking with a client who had a colostomy created 2 days ago. Which of the
following statements by the client would indicate ineffective coping? Select all that apply.
A. "I am not touching that disgusting bag."
B. "I am glad I can still go to the gym just as I used to."
C. "I really like raw vegetables, and it will be hard for me to limit them."
D. "I understand the need for the colostomy, but I am afraid that the bag will leak."
E. "I do not understand why I cannot have a nurse perform the colostomy bag changes for me."
- ANSWERS-A. "I am not touching that disgusting bag." (key)
E. "I do not understand why I cannot have a nurse perform the colostomy bag changes for me."
(key)
The nurse is teaching a client who had a subtotal gastrectomy about ways to prevent dumping
syndrome. Which of the following foods would be appropriate for the nurse to recommend to
eliminate from the client's diet?
1. cheese
2. red meat
3. ice cream
4. yellow vegetables - ANSWERS-3. ice cream (key)
The nurse is caring for a client who has a prescription for lactated Ringer's solution 1,000 mL, IV,
to be infused over 24 hours. The nurse has tubing with a drop factor of 12 gtt/mL available. How
many gtt/min should the nurse administer to the client? Record your answer using a whole
number. - ANSWERS-Answer: 8 gtt/min
, The nurse is caring for a client who is scheduled for a lumbar puncture. It would be most
important for the nurse to assess the client for:
A. bowel and bladder function.
B. presence of Trousseau's sign.
C. signs of increased intracranial pressure (ICP).
D. circulation, movement and sensation of the legs. - ANSWERS-C. signs of increased intracranial
pressure (ICP). (key)
The nurse is assessing a client with viral meningitis. Which of the following findings would the
nurse expect to observe? Select all that apply.
A. nausea
B. vomiting
C. piloerection
D. bradycardia
E. photophobia - ANSWERS-A. nausea (key)
B. vomiting (key)
E. photophobia (key)
The nurse has been made aware of the following client situations. The nurse should first assess
the client:
A) with diverticulitis who is reporting left lower quadrant (LLQ) pain
B) with chronic obstructive pulmonary disease (COPD) who is reporting hemoptysis
C) who had an evacuation of a subdural hematoma 8 hours ago and has become agitated
D) who had a total knee replacement 8 hours ago and whose affected extremity is internally
rotated - ANSWERS-C) who had an evacuation of a subdural hematoma 8 hours ago and has
become agitated (key)