Which of the following is an example of a problem statement used in the Prob-lem-Intervention-Evaluation documentation method? 1. Risk for injury related to falling due to dizziness 2. Client fell while walking to bathroom unassisted 3. Client continues to report periods of dizziness upon sitting up 4. Educated to the purpose of dangling on the […]
A client can be aroused only with extreme or repeated stimuli. How should the nurse document this client’s behavior? 1. Somnolent 2. Disoriented 3. Comatose 4. Semicomatose ANSWER Correct Answer: 4 Rationale 1: The somnolent client is very drowsy, but will respond to stimuli. Rationale 2: A disoriented client is alert, but not oriented […]
The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit’s cli-ents. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1. “I’ll ask the clients what their blood pressure usually runs.” 2. “I’ll give you a list of […]
A newly diagnosed client with type 2 diabetes expresses concern that he will not be able to maintain his active lifestyle, which includes bicycling. The nurse instructs the client about risks and precautions regarding exercise including which of the following? 1. To avoid leisurely bicycling day trips 2. To avoid strenuous bicycling for long periods […]
Which of the following nursing actions best shows an understanding of the guiding principles regarding the inspection method of physical assessment? (Select all that apply.) 1. Positioning the client so as to expose body parts adequately but with attention to modesty 2. Providing a general survey of the client’s body, area by area and extremity […]
A connection on a client’s intravenous solution was dislodged and solution saturated the client’s gown and bed linens. The nurse will provide which type of hygienic care to the client? 1. Hour-of-sleep care 2. As-needed care 3. Early morning care 4. Morning care ANSWER Correct Answer: 2 Rationale 1: Hour-of-sleep care includes providing for […]
In selecting an appropriate alternative therapy, the nurse knows that the client who may benefit the most from the passive type of relaxation is one who is experiencing: 1. Hypertension 2. Terminal cancer 3. Work-related stress 4. Dysfunctional grieving ANSWER ANS: 2 Passive relaxation is useful for persons for whom the effort and energy […]
The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective? 1. The client continues to ask for his pain medication. 2. The client decreases his fluid consumption. 3. The client refuses to eat the bran flakes on his tray. 4. The client walks around the unit […]
Which of the following statements made by the nurse shows the best understanding of the ther-apeutic value of a support system for a client experiencing stress? 1. “They will be there when you need them and make sure you will have your needs met.” 2. “They will provide you with someone to talk with about […]
A nurse shows an understanding of the reasons critical thinking is so vital to today’s nursing profession when stating: 1. “Patient acuity is so much greater than it was even 10 years ago.” 2. “Care delivery systems are only as good as the nurses delivering care.” 3. “Nurses have always relied on common sense thinking […]
