A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in 1. Ventilation. 2. Alveolar gas exchange. 3. Transportation of oxygen and carbon dioxide. 4. Systemic diffusion. ANSWER Correct Answer: 1 Rationale 1: Atelectasis affects lung compliance, which is a condition that needs to be present for adequate ventilation. […]
There are a variety of teaching methodologies that may be utilized to meet the client’s needs. Which teaching method is best applied to a cognitive learning need? 1. Modeling of behavior 2. Discussion of feelings 3. Computer-assisted instruction 4. Demonstration of a procedure ANSWER ANS: 3 An independent project such as computer-assisted instruction is […]
Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client? 1. “2-cm area of scaly, dry skin located on the client’s right heel.” 2. “2-cm area of nonblanching erythema located on the client’s right heel.” 3. “2-cm area purplish blue in color surrounded […]
The nurse is preparing to assess a client’s reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight ANSWER Correct Answer: 3 Rationale 1: Sterile gloves are not needed to test reflexes. Rationale 2: Clean gloves are not needed to test reflexes. […]
The nurse is engaging in an activity to develop spiritual self-awareness. What activities can aid the nurse in achieving this goal? 1. Write a will. 2. Complete an advance directives form. 3. Explore personal end-of-life issues. 4. Create a personal loss history. 5. List significant values. ANSWER Correct Answer: 3, 4, 5 Rationale 1: […]
Which of the following assessment questions is most likely to determine the reason an older adult client refuses to remove and brush his dentures? 1. “Why are you being difficult about cleaning your dentures?” 2. “Will you allow me to clean your denture if you don’t want too?” 3. “Are you concerned about damaging your […]
Clients undergoing stress may have periods of regression. The nurse assesses this regressive be-havior in the situation where: 1. An adult client exercises to the point of fatigue 2. An 8-year-old child sucks his thumb and wets the bed 3. An adult client avoids speaking about health concerns 4. An 11-year-old child experiences stomach cramps […]
Traditional Western medicine, in contrast to alternative therapy, uses: 1. Acupuncture 2. Herbal therapy 3. Spiritual advising 4. Medication administration ANSWER ANS: 4 Traditional Western medicine uses medication administration as a method of treatment. Acupuncture is an alternative therapy often used in non-Western cultures such as the Chinese and Southeast Asians. Herbal therapy is […]
The nurse has an order for 325 mg acetaminophen p.r. q4h prn for pain for a 7-year-old client who has had surgery. In preparing the client for insertion of the suppository, the client states that she feels the need to have a bowel movement. The nurse’s best response is to: 1. Insert the suppository, knowing […]
During assessment, the client tells the nurse, “I don’t believe that the existence of God has been proven. I don’t see the scientific evidence I need to be certain.” How should the nurse document this finding? 1. The client demonstrates polytheism. 2. The client is an atheist. 3. The client has beliefs that support monotheism. […]
