ANSWERS 100% ACCURATE!
,A school nurse is assessing a child who has been stung by a bee. The child's hand is
swelling and the nurse notes that the child is allergic to insect stings. Which of the
following findings should the nurse expect if the child develops anaphylaxis? (SATA)
A) Bradycardia
B) Nausea
C) Hypertension
D) Urticaria
E) Stridor - ANSWER B) Nausea
D) Urticaria
E) Stridor
A nurse is caring for a client who is unconscious. Which of the following actions should
the nurse take when providing oral care for the client?
A) Test for the presence of the clients gag reflex
B) Place the client in the supine position
C) Use a firm toothbrush for tooth and gum care
D) Use 2 gauze-wrapped fingers to hold the mouth open - ANSWER A) Test for the
presence of the clients gag reflex
A nurse is planning care for a client who has acute myelogenous leukemia and a
platelet count of 48,000/mm^3. Which of the follow interventions should the nurse
include?
A) Avoid IM injections
B) Assess the client for ecchymosis once per shift
C) Do not allow the client to have visitors
D) Encourage daily flossing between teeth - ANSWER A) Avoid IM injection
A nurse is preparing to assess the function of the clients trigeminal nerve (cranial nerve
V). Which of the following items should the nurse gather for the test?
A) Sugar
B) Coffee
C) Cotton wisps
D) Snellen chart - ANSWER C) Cotton wisps
, A nurse is caring for a middle-aged adult client. The nurse should identify which of the
following statements as an indication that the client has completed Eriksons
developmental task for her age group?
A) "I am comfortable with my decision to choose a lifelong partner."
B) "I think I have done a good job with my children since they are all independent now."
C) "As I look back over my life, I can see that I have achieved most of the goals I set for
myself."
D) I love my work so much that it's difficult to think about retirement." - ANSWER B) "I
think I have done a good job with my children since they are all independent now."
A nurse is conducting an admission interview with a client. Which of the following pieces
of assessment information should the nurse collect during the introductory phase of the
interview?"
A) Clients level of comfort and ability to participate in the interview
B) Previous illnesses and surgeries
C) Events surrounding the clients recent illness
D) Sociocultural history - ANSWER A) Clients level of comfort and ability to participate
in the interview
A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use
first?
A) inspection
B) Auscultation
C) Percussion
D)Palpation - ANSWER A) Inspection
A nurse is performing a comprehensive physical assessment of a client. The nurse
should use inspection to assess which of the following?
A) Liver size
B) Pedal edema
C) Skin texture
D) Gait - ANSWER D) Gait
A nurse is caring for a client who is immobile. The nurse should recognize that
immobility places the client at risk of which of the following health alterations?