A client with a suspected narcotic (heroin) overdose is brought to the emergency department by the police. The nurse anticipates that assessment findings will reveal: 1. Agitation 2. Hyperpnea 3. Restlessness 4. Decreased level of consciousness ANSWER ANS: 4 With a narcotic overdose, the respiratory center is depressed, reducing the rate and depth of […]
A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The electrocardiogram (ECG) reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and rate of 108 beats per minute. The nurse should recognize this cardiac dysrhythmia as: 1. Sinus dysrhythmia 2. Sinus tachycardia 3. […]
An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2. BP = 104/52 mm Hg, […]
Standard classification of terms used in health care—particularly nursing data—along with definitions would greatly benefit computer-based patient records. Which of the following are among those systems used in the United States? 1. ANA. 2. HIPAA. 3. NANDA. 4. The Omaha system. 5. HHCC. 6. NOC. ANSWER Correct Answer: 3,4,5,6 Rationale 1: The ANA has […]
The nurse recognizes that facilitating correct body alignment for a dependent client may well re-sult in which of the following positive client outcomes? (Select all that apply.) 1. A comfortable night’s sleep 2. Minimized activity intolerance 3. Muscle tone that promotes ambulation 4. Reduction of falls caused by general weakness 5. Minimal strain placed on […]
A client tells the nurse that fresh fruit should be eaten only on an empty stomach, as it will cause other foods to ferment in the stomach. The nurse realizes this client’s nutritional status is influenced by 1. lifestyle. 2. culture. 3. beliefs about food. 4. religious practices. ANSWER Correct Answer: 3 Rationale 1: […]
Which of the following goals is most appropriate for a preoperative client with a nursing diagno-sis of deficient knowledge regarding preoperative requirements related to lack of exposure to in-formation? 1. Client will understand the need for scheduled surgery before leaving the provid-er’s office. 2. Client will understand the preoperative routines of surgical care before leaving […]
The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child. The nurse should have the child: 1. Use the standard Snellen chart 2. Read a few lines from a children’s book 3. Follow the peripheral movement of an object 4. Identify crayon colors ANSWER ANS: 4 To assess […]
Which of the following would be a correctly formulated diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood. that is being placed in a long-term, structured institutional environment? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. […]
The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally ANSWER Correct Answer: 3 Rationale 1: Bilateral equal pulses is a normal assessment finding. Rationale 2: […]
