and Answers | A+ Score Assured
Physical examination of a 6-year-old boy reveals several bite marks in various
locations on his body. X-ray examination reveals healed fractures of the ribs. The
mother tells the nurse that her child is always having accidents. Which initial
response by the nurse would be most appropriate?
A. "I need to tell the health care provider about your child's tendency to be
accident-prone."
B. "Tell me more about these accidents that your child has been having."
C."I need to report these injuries to the authorities because they do not seem
accidental."
D. Boys this age always seem to require more supervision and can be quite
accident-prone." - 🧠ANSWER ✔✔B B. "Tell me more about these accidents that
your child has been having."
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,On admission, a depressed client tells the nurse, "I can't eat because my tongue is
rubber." Which is the best action for the nurse to take?
A.Provide packaged foods for the client to eat.
B.Begin the client on total parenteral nutritional (TPN) therapy.
C.Provide a well-balanced liquid diet for the client.
D.No action is necessary because the client will eat when hungry. - 🧠ANSWER
✔✔c
On admission, a highly anxious client is described as delusional. Delusions are
most likely to occur with which disorders?
A.Dissociative disorders
B.Personality disorders
C.Anxiety disorders
D.Psychotic disorders - 🧠ANSWER ✔✔D
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,The nurse develops a plan of care for a client with symptoms of paranoia and
psychosis. The priority nursing diagnosis is impaired social interactions related to
inability to trust. Which action is most important for the nurse to take first?
A.Greet the client by first name during each social interaction.
B.Determine if the client is experiencing auditory hallucinations.
C.Introduce the client to peers on the unit as soon as possible.
D.Assign the client to a group about developing social skills. - 🧠ANSWER
✔✔Greet the client by first name during each social interaction.
An individual with a known history of alcohol abuse is admitted for emergency
surgery following a motor vehicle collision. The nurse includes in the client's plan
of care, "Observe for signs of delirium tremens." Which early signs indicate that
the client is beginning to have delirium tremens?
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, A.Abdominal cramping and watery eyes
B.Depression and fatigue
C.Restlessness and confusion
D.Hostility and anger - 🧠ANSWER ✔✔c
The clinic nurse notes in a new client a spontaneous onset of hyperventilation,
tremulousness, and an inability to concentrate. What is the nurse's priority action?
A.Stay with the new client.
B.Request the healthcare provider order a sedative.
C.Have a coworker call 911.
D.Assess for nausea and dizziness. - 🧠ANSWER ✔✔A
At the first meeting of a group at a daycare center for older adults, the nurse asks
one of the members what kinds of things the client would like to do with the group.
The older adult shrugs and says, "You tell me. You're the leader." What would be
the best response for the nurse to make?
A."Yes, I am the leader today. Would you like to be the leader tomorrow?"
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