A mother and her child sit in a playroom on the pediatric unit. The boy wants to play with a toy that another child has but the mother says no. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as: 1. Displacement 2. Compensation […]
Which of the following statements by a client reporting constipation reflects the most informed understanding of interventions that will aid in assuming proper bowel mobility? 1. “Could it be that I need to get more exercise, even here in the hospital?” 2. “Is it true that drinking coffee often helps stimulate the bowels to work?” […]
A nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the increased risk poor physical environment creates for this client, the nurse will focus on which of the following during the intake phase of the interview? 1. Lack of social support 2. Recent history of chills and body aches […]
An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client? 1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 20–35 grams a day. 3. Engage in enjoyable exercise. 4. […]
Which of the following client responses shows the best understanding regarding the management of risk factors for acquiring a sexually transmitted disease (STD) among young adults? 1. “I may want to have children someday, so I need to be careful.” 2. “Even though there are treatments for STDs, I don’t take chances.” 3. “There is […]
Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month well-baby visit? 1. Moro 2. Startle 3. Babinski 4. Extrusion ANSWER ANS: 3 The Babinski reflex is a normal reflex found in a 6-month-old infant. The Moro reflex is seen in the newborn. The startle reflex is […]
A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instruc-tional? 1. “After defining the client’s symptomatology, eliminate those nursing diagnoses that are not supported by the database.” 2. “Assess your client and then select the nursing diagnosis […]
A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and “feels uncomfortable.” The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client’s four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress ANSWER ANS: 3 Wrapping the client’s […]
Older adults are at an increased risk for dehydration from a variety of risk factors that include a decreased thirst drive. Which of the following should a nurse include in a discussion with members of a senior center regarding the signs of dehydration? (Select all that apply.) 1. Dry, hot skin 2. Memory lapses 3. […]
A 45-year-old female client has been hospitalized for severe abdominal pain. The health care pro-vider has ordered a PCA pump for the client to help control the pain. It has been determined that the pain is due to cholelithiasis and the client is scheduled for a cholecystectomy later that day. The client returns to the […]