A female client presents in the emergency department and tells the nurse that she was raped last night.
Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department?
A. Has she taken a bath since the rape occurred?
We have an expert-written solution to this problem!
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing
increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
B. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated
serum amylase. Which additional information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
A. Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which
information is most important for the nurse to provide the parents prior to discharge?
,A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
A. Instructions about how much fluid the child should drink daily
We have an expert-written solution to this problem!
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the
location on the image with a red dot).
I placed the red dot on the base of the neck on the right side
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing abdominal distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel
sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after vaping at a party. The client
is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base
imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
D. Respiratory alkalosis
,A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival,
the nurse should ensure that the client's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
Fowlers
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
information in the client's admission assessment is relevant to the nurse's plan for taking the blood
pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
A. Frequent syncope
C. Flat affect
D. Blurred vision
We have an expert-written solution to this problem!
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound.
Before reporting this finding to the healthcare provider, the nurse should review which of the client's
laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
, B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-
drowning incident. While providing care to the child, the nurse begins talking with his preadolescent
brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices
the older boy becomes withdrawn when asked about what happened. Which action should the nurse
take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
B. Ask the older brother how he felt during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in
hot baths at night with no relief of his discomfort. Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved
A. Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart
failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare
provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse
expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department?
A. Has she taken a bath since the rape occurred?
We have an expert-written solution to this problem!
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing
increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
B. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated
serum amylase. Which additional information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
A. Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which
information is most important for the nurse to provide the parents prior to discharge?
,A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
A. Instructions about how much fluid the child should drink daily
We have an expert-written solution to this problem!
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the
location on the image with a red dot).
I placed the red dot on the base of the neck on the right side
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing abdominal distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel
sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after vaping at a party. The client
is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base
imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
D. Respiratory alkalosis
,A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival,
the nurse should ensure that the client's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
Fowlers
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
information in the client's admission assessment is relevant to the nurse's plan for taking the blood
pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
A. Frequent syncope
C. Flat affect
D. Blurred vision
We have an expert-written solution to this problem!
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound.
Before reporting this finding to the healthcare provider, the nurse should review which of the client's
laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
, B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-
drowning incident. While providing care to the child, the nurse begins talking with his preadolescent
brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices
the older boy becomes withdrawn when asked about what happened. Which action should the nurse
take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
B. Ask the older brother how he felt during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in
hot baths at night with no relief of his discomfort. Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved
A. Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart
failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare
provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse
expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
