The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy ANSWER Correct Answer: 1 Rationale 1: This is an incontinent urinary diversion (ileal conduit). Rationale 2: This is […]
The nurse has determined the following outcome for a client with a skin impairment: “Erythema will be reduced in 3 days.” Evaluation will specifically focus on: 1. Selection of appropriate wound care 2. Notation of the odor and color of drainage 3. Inspection of the color and condition of the area 4. Measurement of the […]
Clients experiencing post-traumatic stress disorder (PTSD) following the World Trade Tower bombing work with nurses in the medical center. An approach that is appropriate and should be incorporated into the plan of care is: 1. Suppression of anxiety-producing memories 2. Reinforcement that the PTSD is short term 3. Promotion of relaxation strategies 4. Focus on […]
The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. 5. Allay fears and anxiety. ANSWER Correct […]
A client recently lost a child in a severe case of poisoning. The client tells the nurse, “I don’t want to make any new friends right now.” This is an example of which of the following indica-tors of stress? 1. Spiritual indicator 2. Emotional indicator 3. Intellectual indicator 4. Sociocultural indicator ANSWER ANS: 4 […]
Individuals at the young adult point in their life are generally expected to, according to devel-opmental patterns: 1. Continue physical growth 2. Experience severe illnesses 3. Ignore physical symptoms 4. Seek frequent medical care ANSWER ANS: 3 Young adults generally are quite active, experience severe illnesses less commonly than older age-groups, tend to ignore […]
The client is to receive a Kayexalate enema. The nurse recognizes that this is used to: 1. Prevent further constipation 2. Remove excess potassium from the system 3. Reduce bacteria in the colon before diagnostic testing 4. Provide direct antidiarrheal medication to the intestine ANSWER ANS: 2 Kayexalate is a type of medicated enema […]
When assessing a client’s peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress ANSWER Correct Answer: 2 Rationale 1: Depth is a term used when assessing edema. Rationale 2: When assessing peripheral pulses, one of the characteristics being assessed is rhythm, along […]
Home care nursing is a fast-growing sector of the healthcare system. Which of the following factors have contributed to the growth of home health care? 1. The need for custodial care. 2. Third-party payers who support cost-control measures. 3. The increase in the older adult population. 4. The decreasing need for acute care. 5. A […]
The nurse is assessing a client’s blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: 1. Reflect a normal variation 2. Should be reported to the client’s health care provider 3. Dictate that […]
