The nurse is taking information for the client’s database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just “leave me alone.” Which of the following is an example of subjective data regarding this client? 1. Restlessness 2. “Leave me alone” 3. Not talkative 4. […]
A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and […]
A 2-year-old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in bed holding a stuffed animal and will not interact with the parents. What should the nurse identify as causing this client’s behavior? 1. The parents may have been abusing this child. 2. The child is probably developmentally […]
When the nurse gathers all the equipment needed for a particular procedure and arranges the cli-ent’s room for proficient implementation of the procedure, the nurse is displaying: 1. Multitasking 2. Organization 3. Effectiveness 4. Professionalism ANSWER ANS: 2 The well-organized nurse approaches any planned procedures by having all of the necessary equipment available and […]
The nurse caring for members of the Hispanic community recognizes which of the following sit-uations as the best reflection of the culture’s view of family caring? 1. A husband calling each evening to tell his wife goodnight 2. Family members taking turns staying with the client at night 3. The daughter bringing her father’s favorite […]
Which of the following statements made by a nurse most reflects a poor understanding of trust-worthiness regarding nurse-client communication in response to a client’s report that, “I don’t like the night shift nurse”? 1. “How can I meet your needs and expectations on dayshift?” 2. “Tell me more about why you dislike the night shift […]
The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response ANSWER Correct Answer: 1, 2, 3 Rationale: The Glasgow Coma Scale tests in three major areas: eye response, […]
The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the […]
After visiting with the client, the nurse documents the assessment data. Both objective and sub-jective information have been obtained during the assessment. Which of the following is classi-fied as subjective data? 1. “Client appears sleepy” 2. “No physical distress noted” 3. “Abdomen soft and non-tender” 4. “States feels anxious and tense” ANSWER ANS: 4 […]
During a hospital stay, the client has taken control of her recovery and rehabilitation and is utilizing available resources for her needs. This describes which level of Peplau’s model? 1. Orientation 2. Identification 3. Exploitation 4. Resolution ANSWER Correct Answer: 3 Rationale 1: Orientation is the first phase, when the client seeks help and […]
