cat 3 (haitian)
10. A client who is 81 years old and in the hospital has numerous complaints and uses her
call button frequently to summon staff to assist her with activities capable of performing for
herself. Which plan might be most beneficial in
dealing with this client? - ANS-Check on the client at designated time intervals and let the
client
understand the nurse's return date. 106. A 17-year-old male who was arrested last month
for gang-related activities
has a court order to attend weekly group therapy sessions at the mental
health clinic. Today his mother calls the clinic nurse to report that her son
became angry last night and put his fist through a window. Which
intervention is most import for the nurse to implement? - ANS-Advise the mother to call the
police if violent behavior occurs again.
107. Her mother brings an 8-year-old girl to the clinic and reports that For the past three
days, her daughter has had a severe throat infection, and suddenly began drooling. The
child's tympanic temperature is 103 F and
she is struggling to breathe. What initial action should the nurse take? - ANS-Notify the
healthcare provider immediately.
11. When treating a fever in a 3-year-old child with a cooling bath, which action should the
nurse include? - ANS-Pour tepid water over the child's back and chest.
113. The nurse is monitoring a 6-month-old infant with a closed head injury.
Which assessment result best identifies the earliest neurological deterioration? -
ANS-Irritable and unable to rest.
116. While the nurse is bathing a bedfast client with generalized weakness, the
The patient exhibits labored breathing as well as audible pharyngeal rattles. The
nurse auscultates coarse rattles in the upper lung fields. What action should
the nurse implement first? - ANS-a. performing suctioning of the oropharynx. 125. At 40
weeks of pregnancy, a 27-year-old gravida 2 is experiencing firm contractions occurring 4 to
5 minutes apart. Three hours after initiation of
labor, she begins moaning and crying, is restless, belches, and states that
she needs to have a bowel movement. Which intervention should the nurse
implement? - ANS-Assess the client's cervical dilation.
137. a client who has been treated for metastasized breasts, aged 48 cancer for the past
year is told by her healthcare provider that
chemotherapy is not producing the desired remission. The next morning
client is crying and asks the nurse, "Who will care for my children?" Which
Which response should the nurse give? ANS: "What would you like to see happen with your
children?" 147. A male client receiving fentanyl (Duragesic) via transdermal patch reports
to the nurse that he is experiencing abdominal discomfort. The nurse's
assessment indicates abdominal distention with decreased bowel sounds.
Which intervention should the nurse initiate? - ANS-Administer a prescribed PRN laxative.
148. The father of an 11-year-old boy tells the nurse that he feels unsure about
discussing nocturnal emissions with his son. How should the nurse address
, this issue with this parent? - ANS-Inform the father that it is most important to let the son
know that
Normal emissions occur at night. 151. The pediatric unit is extremely busy when the
admission office notifies the
inform the nurse that a child suffering from acute lymphocytic leukemia (ALL) requires to be
admitted to the unit. The parents brought prescriptions from the
healthcare provider for their child to have a chest x-ray and blood work
drawn on admission. What action should the charge nurse take? - ANS-Tell the admission
clerk to bring the child immediately to the unit and
places the child in a private room.
153. Following a traumatic delivery, an infant receives an initial Apgar score of 3.
What intervention is most important for the nurse to implement? - ANS-Continue
resuscitative efforts.
154. A 10-year-old boy is being cared for by the nurse, who has been diagnosed with acute
glomerulonephritis. Which outcome is the priority for this child? - ANS-Fluid balance
maintained as evidenced by a urine output of 1 to 2
ml/kg/hr.
18. Which statement by a 16-year-old male client with acute osteomyelitis in
his leg indicates the best understanding of the appropriate activity level for
ANS: "During this illness, I need to keep my leg as immobile as possible." What is his
disorder? 20. A 25-year-old female client is diagnosed with endometriosis by her
healthcare provider. Which nursing diagnosis has the highest priority? - ANS-Pain related
to extrauterine tissue inflammation.
28. A 22-year-old female client calls the public health clinic because her breasts
are tender and she felt several small lumps during a breast self-examination
(SBE). What information should the nurse elicit from the client first? - ANS-Date of last
menstrual period.
29. An adolescent female who has been a lacto-ovo-vegetarian for six months
tells the nurse she is experience increased fatigue. What dietary
recommendation should the nurse provide? - ANS-Eat spinach three times a weeks.
39. A 60-year-old male client is admitted to the hospital with the complaint of
right knee pain for the past week. His right knee and calf are warm and
edematous. He has a history of diabetes and arthritis. Which neurological
assessment action should the nurse perform for this client? - ANS-Pulses, paresthesia,
paralysis distal to the right knee.
40. The parents of a 4-week-old infant phone the pediatric clinic to report that
their infant eats well but vomits after each feeding. To differentiate
between normal regurgitation and pyloric stenosis, which information is
most important for the nurse to obtain? - ANS-Degree of forcefulness of vomiting episodes.
43. A 9-year-old girl is diagnosed with nontropical sprue (celiac diasease), and
the nurse is evaluating teaching about a gluten-free diet. What action
indicates that the teaching is successful? - ANS-The girl chooses a rice cake instead of a
whole-wheat toast for
breakfast.
54. A 59-year-old female client who has diabetes is receiving 25 units of NPH-
100 insulin each morning. What assessment finding indicates that the
amount of insulin is inadequate to meet this client's current needs? - ANS-The client's
serum glucose reading has been over 260 mg/dl for the
10. A client who is 81 years old and in the hospital has numerous complaints and uses her
call button frequently to summon staff to assist her with activities capable of performing for
herself. Which plan might be most beneficial in
dealing with this client? - ANS-Check on the client at designated time intervals and let the
client
understand the nurse's return date. 106. A 17-year-old male who was arrested last month
for gang-related activities
has a court order to attend weekly group therapy sessions at the mental
health clinic. Today his mother calls the clinic nurse to report that her son
became angry last night and put his fist through a window. Which
intervention is most import for the nurse to implement? - ANS-Advise the mother to call the
police if violent behavior occurs again.
107. Her mother brings an 8-year-old girl to the clinic and reports that For the past three
days, her daughter has had a severe throat infection, and suddenly began drooling. The
child's tympanic temperature is 103 F and
she is struggling to breathe. What initial action should the nurse take? - ANS-Notify the
healthcare provider immediately.
11. When treating a fever in a 3-year-old child with a cooling bath, which action should the
nurse include? - ANS-Pour tepid water over the child's back and chest.
113. The nurse is monitoring a 6-month-old infant with a closed head injury.
Which assessment result best identifies the earliest neurological deterioration? -
ANS-Irritable and unable to rest.
116. While the nurse is bathing a bedfast client with generalized weakness, the
The patient exhibits labored breathing as well as audible pharyngeal rattles. The
nurse auscultates coarse rattles in the upper lung fields. What action should
the nurse implement first? - ANS-a. performing suctioning of the oropharynx. 125. At 40
weeks of pregnancy, a 27-year-old gravida 2 is experiencing firm contractions occurring 4 to
5 minutes apart. Three hours after initiation of
labor, she begins moaning and crying, is restless, belches, and states that
she needs to have a bowel movement. Which intervention should the nurse
implement? - ANS-Assess the client's cervical dilation.
137. a client who has been treated for metastasized breasts, aged 48 cancer for the past
year is told by her healthcare provider that
chemotherapy is not producing the desired remission. The next morning
client is crying and asks the nurse, "Who will care for my children?" Which
Which response should the nurse give? ANS: "What would you like to see happen with your
children?" 147. A male client receiving fentanyl (Duragesic) via transdermal patch reports
to the nurse that he is experiencing abdominal discomfort. The nurse's
assessment indicates abdominal distention with decreased bowel sounds.
Which intervention should the nurse initiate? - ANS-Administer a prescribed PRN laxative.
148. The father of an 11-year-old boy tells the nurse that he feels unsure about
discussing nocturnal emissions with his son. How should the nurse address
, this issue with this parent? - ANS-Inform the father that it is most important to let the son
know that
Normal emissions occur at night. 151. The pediatric unit is extremely busy when the
admission office notifies the
inform the nurse that a child suffering from acute lymphocytic leukemia (ALL) requires to be
admitted to the unit. The parents brought prescriptions from the
healthcare provider for their child to have a chest x-ray and blood work
drawn on admission. What action should the charge nurse take? - ANS-Tell the admission
clerk to bring the child immediately to the unit and
places the child in a private room.
153. Following a traumatic delivery, an infant receives an initial Apgar score of 3.
What intervention is most important for the nurse to implement? - ANS-Continue
resuscitative efforts.
154. A 10-year-old boy is being cared for by the nurse, who has been diagnosed with acute
glomerulonephritis. Which outcome is the priority for this child? - ANS-Fluid balance
maintained as evidenced by a urine output of 1 to 2
ml/kg/hr.
18. Which statement by a 16-year-old male client with acute osteomyelitis in
his leg indicates the best understanding of the appropriate activity level for
ANS: "During this illness, I need to keep my leg as immobile as possible." What is his
disorder? 20. A 25-year-old female client is diagnosed with endometriosis by her
healthcare provider. Which nursing diagnosis has the highest priority? - ANS-Pain related
to extrauterine tissue inflammation.
28. A 22-year-old female client calls the public health clinic because her breasts
are tender and she felt several small lumps during a breast self-examination
(SBE). What information should the nurse elicit from the client first? - ANS-Date of last
menstrual period.
29. An adolescent female who has been a lacto-ovo-vegetarian for six months
tells the nurse she is experience increased fatigue. What dietary
recommendation should the nurse provide? - ANS-Eat spinach three times a weeks.
39. A 60-year-old male client is admitted to the hospital with the complaint of
right knee pain for the past week. His right knee and calf are warm and
edematous. He has a history of diabetes and arthritis. Which neurological
assessment action should the nurse perform for this client? - ANS-Pulses, paresthesia,
paralysis distal to the right knee.
40. The parents of a 4-week-old infant phone the pediatric clinic to report that
their infant eats well but vomits after each feeding. To differentiate
between normal regurgitation and pyloric stenosis, which information is
most important for the nurse to obtain? - ANS-Degree of forcefulness of vomiting episodes.
43. A 9-year-old girl is diagnosed with nontropical sprue (celiac diasease), and
the nurse is evaluating teaching about a gluten-free diet. What action
indicates that the teaching is successful? - ANS-The girl chooses a rice cake instead of a
whole-wheat toast for
breakfast.
54. A 59-year-old female client who has diabetes is receiving 25 units of NPH-
100 insulin each morning. What assessment finding indicates that the
amount of insulin is inadequate to meet this client's current needs? - ANS-The client's
serum glucose reading has been over 260 mg/dl for the
