The nurse is concerned that the spouse of a recently deceased client is experiencing spiritual distress. What did the nurse observe to come to this clinical decision? 1. Expressing anger toward God 2. Crying softly in the client’s room 3. Hugging family members 4. Talking with caregivers about the client’s personal items 5. Refusing comfort […]
Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with pe-riods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse re-ports this respiratory assessment as: 1. Biot’s respirations 2. Kussmaul’s respirations 3. Hyperpneic respirations 4. Cheyne-Stokes respirations ANSWER ANS: 4 Cheyne-Stokes respirations […]
The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub. The nurse should […]
The nurse is planning to assess a client’s family relationships. What questions should the nurse ask to obtain this information? 1. “How do you spend your free time?” 2. “What is your home like?” 3. “Who is most important to you?” 4. “How well do you feel you accomplish what is expected of you?” 5. […]
When assessing the external variables that influence a client’s health beliefs and practices, the nurse must consider his: 1. Income status 2. Religious practices 3. Educational background 4. Reaction to the heart disease ANSWER ANS: 1 External variables influencing a person’s health beliefs and practices include family practices, cultural background, and socioeconomic factors, such […]
Research has shown that certain postpartum factors negatively affect a woman’s general health status after pregnancy. Which of the following women has the greatest risk factor for poor post-partum health? 1. A mother with complaints of fatigue, loss of appetite, and insomnia 2. A practicing attorney who has reluctantly taken a 3-month maternity leave 3. […]
The nurse is helping in discharge planning of a client who needs extensive rehabilitation and is on a complicated medication schedule. The nurse would want to include which of the following persons in this client’s plan? 1. Client’s spouse 2. Physician 3. Pharmacist 4. Social worker ANSWER Correct Answer: 1 Rationale: Effective discharge planning […]
A nurse is discussing the need to use a specific cleansing agent when redressing an infected hand. The client prefers using, “plain old soap and water.” The nurse knows that the primary factor that will affect client compliance is: 1. The ease with which the client can use the special agent 2. The client’s acceptance […]
A nursing intervention to assist the client with a nursing diagnosis of sleep pattern disturbance related to the loss of spouse and fear of nightmares should be to: 1. Administer sleeping medication per order 2. Refer the client to a psychologist or psychotherapist 3. Have the client complete a detailed sleep pattern assessment 4. Sit […]
Use of the intellectual standard of critical thinking implies that the nurse: 1. Questions the physician’s order 2. Recognizes conflicts of interest 3. Listens to both sides of the story 4. Approaches assessment logically ANSWER ANS: 4 Use of the intellectual standard of critical thinking implies that the nurse approaches assessment logically and consistently. […]
