A nurse is caring for a client in the emergency department who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the client’s back and arms. When questioned, the client is distracted and ambiguous with her answers. The […]
A nursing student would like to explore the meaning of spirituality among clients and their response to spiritually centered interventions in nursing practice. The work of which theorist would be most beneficial for this student? 1. Roy 2. Neuman 3. Nightingale 4. Peplau ANSWER Correct Answer: 1 Rationale 1: Sr. Callista Roy’s work focuses […]
An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client ANSWER Correct Answer: 4 Rationale 1: Active bowel sounds would indicate […]
From culture to culture time often takes on different meanings. In exploring the relationship of time to nursing interventions, the nurse should: 1. Avoid using set times to do procedures, if possible 2. Maintain the set times for treatments and inform the client of the schedule 3. Maintain a flexible attitude when the client requests […]
A client receives several tube feedings each day. After documenting the client’s tolerance of the feedings and assessments in the medical record, the nurse should also document the amount of feeding provided on the 1. graphic sheet. 2. dietary consultation notes. 3. vital signs record. 4. intake and output record. ANSWER Correct Answer: 4 […]
The school-aged child is taken to the school nurse after experiencing a nosebleed during a soft-ball game. The appropriate intervention is for the nurse to: 1. Have the child lean backward 2. Apply pressure to the anterior nose 3. Apply a warm cloth to the area 4. Have the child close his mouth and blow […]
The nurse evaluates which of the following statements as an indication that the client is not ready to learn at this time? 1. “I need to understand more about the reason for the colostomy.” 2. “I will find out more about that when the support group meets.” 3. “There’s no sense in showing me that […]
The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse 1. should receive specific training. 2. must be certified. 3. is required to ask the client’s permission. 4. has to obtain special assessment equipment. ANSWER Correct […]
When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.) 1. Stress management 2. Enhanced cardiac output 3. Improved bone integrity 4. Facilitation of weight control 5. Increased cognitive function 6. Increased musculoskeletal flexibility […]
Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery? 1. The client will show no systemic or local signs of infection by time of discharge from hospital. 2. The client will demonstrate an understanding of the proper use of pa-tient-controlled analgesia (PCA). […]
