A client has reported to the nurse that his sprained ankle resulted from “a careless accident. I seem so clumsy and unfocused lately.” Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms? 1. “How many accidents have you had lately?” 2. “Have the accidents resulted in […]
A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. When formulating a nursing diagnosis, an appropriate selection would be which of the following? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis ANSWER Correct […]
A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output ANSWER Correct Answer: […]
Taking into consideration the hospice client’s chronic pain from bone cancer, the most appropri-ate person to collaborate with regarding management of pain is: 1. Occupational therapist to devise a splint for the client’s leg 2. Physical therapist to determine exercises to strengthen the leg muscles 3. Art therapist to provide creative therapy as a diversion […]
A client who is confined to a wheelchair is encouraged to engage in resistive isometric exercises to increase muscle strength and decrease the development of pressure ulcers. Which of the following is the most appropriate example of such an exercise for this client? 1. Hip lifting 2. Gluteal contraction 3. Foot pressure off-loading 4. Bicep-tricep […]
The nurse can best minimize the risk for infection when initiating an intravenous site by: 1. Proper vein site selection 2. Effective topical skin preparation 3. Appropriate site dressing 4. Gloving for the procedure ANSWER ANS: 2 When a needle pierces a client’s skin regardless of the location, organisms enter the body if prop-er […]
A 46-year-old male client with chronic renal problems is in the hospital for a nephrostomy. The nurse understands that this is the surgical insertion of a tube that will drain urine from the cli-ent’s: 1. Bladder 2. Urethra 3. Ureters 4. Renal pelvis ANSWER ANS: 4 Some clients have a need for urinary drainage […]
The nurse is obtaining preoperative assessment data. What should be included in this assessment? 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother’s maiden name ANSWER Correct Answer: 1, 2, 3, 4 Rationale 1: The client’s current health status should be obtained when completing a preoperative assessment. Rationale 2: […]
Experiencing normal grief over losses allows the adolescent to successfully: 1. Move past the loss 2. Regain a sense of security 3. Develop effectual coping skills 4. Deal with an actual loss later in life ANSWER ANS: 3 Normal grief experiences often help persons to mature and develop coping methods for dealing with other […]
The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region ANSWER Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse will auscultate heart sounds over […]
