When asked about his or her religious affiliation, a client responds, “That’s personal; why do you want to know?” The most appropriate nursing response is: 1. “You need not answer my question if you prefer not to share that information.” 2. “All information you provide will be kept in strict confidence.” 3. “By knowing your […]
The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon […]
To assist older adults to meet their needs for sexuality, the nurse should recognize that the great-est impact on the sexuality of older adults is: 1. Therapeutic medications may alter sexual function 2. Sexual interest declines and then fades completely with age 3. Physiological changes do not adversely influence sexual activity 4. Prevention of sexually […]
The physiology of sleep is complex. Which of the following is the most appropriate statement in regard to this process? 1. Ultradian rhythms occur in a cycle longer than 24 hours. 2. Nonrapid eye movement (NREM) refers to the cycle that most clients experience when in a high-stimulus environment. 3. The reticular activating system is […]
The assistive nursing personnel reports that the heart rate of the sleeping 23-year-old athlete, who is hospitalized following complications of a tonsillectomy, is 56. The assistive nursing personnel states that this is 10 beats per minute slower than when she took it earlier in the evening. The nurse knows that this is considered: 1. Normal, […]
The nurse is instructing the client with peripheral vascular disease about daily foot care. The nurse’s instruction for the client includes: 1. Soaking the feet 5 to 10 minutes each day 2. Filing the nails into a curve shape 3. Using commercial corn removers if needed 4. Applying lamb’s wool between the toes ANSWER […]
Which of the following assessment data indicate the presence of a local inflammatory process? (Select all that apply.) 1. Client reports being cold 2. Left elbow warm to the touch 3. Elevated white blood cell (WBC) count 4. Pitting edema of +2 around the right ankle 5. Client reports knee pain of 5 on a […]
The mother of a 2-year-old child is frustrated because the child does not want to go to bed at the scheduled bedtime. The nurse should suggest that the parent: 1. Offer the child a bedtime snack 2. Eliminate one of the naps during the day 3. Allow the child to sleep longer in the mornings […]
The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: 1. Oral site 2. Rectal site 3. Axillary site 4. Tympanic site ANSWER ANS: 3 The axillary site can be used with newborns and uncooperative clients. The oral site […]
The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client. ANSWER Correct Answer: 2 Rationale 1: Assessing the data occurs in the pretest phase. Rationale 2: […]
