The nurse is caring for a client who has right-sided paralysis following a stroke. Which of the following factors would be most likely to result in decubitus ulcer formation for this client? 1. Poor nutrition 2. Immobility 3. Reduced hydration 4. Skin secretions ANSWER ANS: 2 The client, who has right-sided paralysis, is at […]
A nurse is caring for a client of a different culture. The nurse is not familiar with the customs of this particular client and becomes disturbed when the client’s spouse makes all the decisions about care and treatments. The nurse’s reaction is an example of which of the following? 1. Inference 2. Judgment 3. Opinion […]
An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. […]
A client diagnosed with an autoimmune disorder uses guided imagery to help control anxiety. Which of the following assessment data supports the effectiveness of the intervention on the ac-tual management of the disease? 1. A noticeable increase in the client’s appetite 2. A decrease in the client’s HDL cholesterol level 3. A white blood cell […]
A nurse is having difficulty with the decision for aggressive cancer therapy in an elderly client, wondering if the therapy will actually be more harmful than the disease and knowing that the client will be subjected to harmful chemicals. This nurse is struggling with which of the following principles? 1. Autonomy 2. Justice 3. Beneficence […]
Which of the following statements made by a new nursing graduate best reflects an understand-ing of expected outcomes? 1. “It gives the client something positive to strive towards.” 2. “They are statements of how the client’s behavior should change.” 3. “They are measurable criteria by which I can evaluation whether a goal has been achieved.” […]
A rehab client has orders for active range of motion exercises to her shoulder following a stroke. The client doesn’t like to do these because they are uncomfortable and she can’t understand “what good they will do anyway.” Which of the following statements by the nurse demonstrates the critical-thinking component of creativity? 1. “You’ll only […]
The nurse in a pediatrician’s office teaches the mother of a preteen client who was treated for strep throat to do which of the following to help prevent a reoccurrence? 1. Isolate the child from the their siblings until the child has been on antibiotics for at least 24 hours. 2. Disinfect all the child’s […]
Routine hygiene care can provide an opportunity for the nurse to assess the client’s level of activ-ity intolerance. Which of the following assessment questions is most likely to provide information that supports this nursing diagnosis? 1. “Will you need my help to take a bath?” 2. “Does taking a bath or shower cause you any […]
To maintain the client’s sense of self-worth during the end of life while working with a client in an inpatient hospice unit, the nurse should: 1. Leave the client alone to deal with final affairs 2. Call upon the client’s spiritual advisor to manage care 3. Include regular visits throughout the day into the client’s […]
