A client is reporting that the oral medication she was prescribed for her hypothyroidism does not seem to be helping. The client goes on to report that she has been experiencing tension-related headaches and constipation. She has been self-medicating with nonsteroidal antiinflammatory drugs (NSAIDs) and bulk laxa-tives. Which of the following assessment questions is most […]
In teaching a newly diagnosed 17-year-old client with type 1 diabetes, the nurse knows that the exercise is an important component in care. Which of the following activities would be most ap-propriate for the previously sedentary client? 1. Kick-boxing class 2. Football 3. Bicycling 4. Soccer ANSWER ANS: 3 Low to moderate intensity exercise […]
An adult client is prescribed the hepatitis B vaccination. The nurse will administer this medication through which site? 1. Dorsogluteal 2. Rectus femoris 3. Vastus lateralis 4. Deltoid ANSWER Correct Answer: 4 Rationale 1: Using the dorsogluteal site can lead to nerve damage, and is not recommended as a site for intramuscular injections. Rationale […]
During a routine physical assessment a 27-year-old client acknowledges the suspension of his driver’s license because of an arrest for driving under the influence of alcohol. This admission should prompt the nurse to discuss which of the following in detail with the cli-ent? 1. Use of illegal drugs 2. History of depression 3. Unprotected sexual […]
A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing 1. constipation. 2. diarrhea. 3. trapped flatus. 4. fecal impaction. ANSWER Correct Answer: 4 Rationale 1: Liquid stool is not an indication of constipation. Rationale 2: The liquid […]
A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? 1. Client’s tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received ANSWER Correct Answer: 1, 3, […]
It is suspected that the client’s oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the client’s decreased oxygenation is: 1. Poor skin turgor 2. Clubbing of the nails 3. Central cyanosis 4. Pursed-lip breathing ANSWER ANS: 3 Central cyanosis is the most […]
The nurse is collecting equipment to assess a client’s ankle/brachial index (ABI). What equipment should be taken to the client’s bedside? 1. Blood pressure cuff and a Doppler ultrasound device 2. None, as no special equipment is needed 3. Stethoscope and penlight 4. Reflex hammer and tuning fork ANSWER Correct Answer: 1 Rationale 1: […]
A client diagnosed with type 2 diabetes mellitus reports poor glucose control since starting her new stressful job. The nurse uses Neuman’s theory to focus on the: 1. Identification of new stressors and improve dietary choices 2. Acquisition of appropriate interpersonal communication skills 3. Learning of effective coping methods and relaxation techniques 4. Implementation of […]
A 78-year-old client with congestive heart failure (CHF) is reporting vascular pain in his lower legs and requests his oral narcotic analgesic. The nurse recognizes that the client’s pain relief will be negatively affected primarily because of: 1. The client’s age 2. The systemic effects of CHF 3. The route of administration 4. The status […]
