The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia […]
Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1. “Altered speech” 2. “As evidenced by” 3. “Recent neurological disturbances” 4. “Inability to speak in complete sentences” ANSWER ANS: 4 Defining characteristics are assessment findings that support the […]
The nurse is working in the labor and delivery area with parents who are members of the Shinto and Buddhist religions. The nurse expects that after the birth of the child: 1. Baptism will be performed immediately 2. Special prayers will be said over the child 3. Special preparations will be made for the umbilical […]
A client with a history of a gastrointestinal disorder eats a well-balanced diet that keeps his GI symptoms suppressed. Which level of prevention corresponds to his dietary management? 1. Health promotion 2. Primary prevention 3. Tertiary prevention 4. Secondary prevention ANSWER ANS: 3 The goal of tertiary prevention is to preclude further deterioration of […]
An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from: 1. Metabolic acidosis 2. Respiratory acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis ANSWER ANS: […]
The physician has ordered 6 mg of morphine sulfate every 3 to 4 hours prn for a client’s postop-erative pain. The unit dose in the medication dispenser has 15 mg in 1 mL. How much solution should the nurse give? 1. 1/5 mL 2. 1/3 mL 3. 2/5 mL 4. 1/4 mL ANSWER ANS: […]
A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive. ANSWER Correct Answer: 3 Rationale 1: A diagnostic surgery is done to confirm or establish a diagnosis. Rationale 2: Palliative surgery is done to relieve or reduce pain or […]
A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced: 1. Decreased muscle tone 2. Hypertension 3. Diarrhea 4. Fever ANSWER ANS: 3 A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may […]
A client’s results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10–15, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection ANSWER Correct Answer: 4 Rationale 1: An elevated specific gravity is seen in […]
The wife of a client recently diagnosed with end-stage renal failure shares with the nurse that, “He just accepts this; I want a second opinion.” The nurse recognizes that while the client has reached the acceptance stage of grieving, his wife is experiencing the: 1. Anger stage 2. Denial stage 3. Depression stage 4. Bargaining […]
