While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the client’s health status has occurred. 2. […]
The nurse expects which of the following healthy clients to present with the best view of self-esteem? 1. 8-year-old boy 2. 18-year-old male adolescent 3. 38-year-old woman 4. 58-year-old woman ANSWER ANS: 1 Self-esteem is usually highest in childhood, drops during adolescence, rises gradually throughout adulthood, and declines again in old age. Although variability […]
The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) 1. “Slowly deflate the pressure from the cuff.” 2. “Wrap the cuff snuggly around the […]
Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data? 1. “Client was angry because breakfast was not to her liking.” 2. “Client is depressed; was observed crying while alone in room.” 3. “Client expressed pain as an 8 out of 10, was […]
A client is told by his nurse that he has to take the medications, including an injection. The client refuses the medications, but continues to have them administered by the nurse. This action is an example of the intentional tort of: 1. Assault 2. Battery 3. Malpractice 4. Invasion of privacy ANSWER ANS: 2 […]
When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is: 1. “Our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use.” 2. “Without skin we would not be able to enjoy the sense of touch that […]
A student nurse who claims to be very uncreative doesn’t understand why it is necessary to learn and develop new ideas in the clinical area. The best response by the nurse educator is: 1. “Creativity allows unique solutions to unique problems.” 2. “Not all your answers are going to be from your textbook.” 3. “Creativity […]
The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and: 1. Decrease metabolic rate 2. Catabolic tissue breakdown 3. Inactivity-induced depression 4. Anorexia caused by decreased peristalsis ANSWER ANS: 2 Weight loss, decreased muscle mass, and weakness result from […]
The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower. ANSWER Correct Answer: 1 Rationale 1: When transferring […]
The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which ac-tion is consistent with sterile asepsis? 1. Clean forceps may be used to move items on the sterile field. 2. Sterile fields may be prepared well in advance of the procedures. 3. The first small amount of sterile solution should be poured […]
