9) The nurse is assessing the motor function of an unconscious client. The nurse would
plan to use which of the following to test the client's peripheral response to pain?
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
Give this one a try later!
4. Nail bed pressure
A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis
(RA). Which client should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
,c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
Give this one a try later!
b. Client with a red, hot, swollen right wrist
The nurse is caring for the male client who begins to experience seizure activity while
in bed. Which of the following actions by the nurse would be contraindicated?
a. Loosening restrictive clothing
b. Restraining the client's limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward
Give this one a try later!
b. Restraining the client's limbs
10) The client is having a lumbar puncture performed. The nurse would plan to place
the client in which position for the procedure?
1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburg's position
4. Prone, with a pillow under the abdomen.
Give this one a try later!
1. Side-lying, with legs pulled up and head bent down onto the chest
,23) Meningitis occurs as an extension of a variety of bacterial infections due to which
of the following conditions?
1. Congenital anatomic abnormality of the meninges
2. Lack of acquired resistance to the various etiologic organisms
3. Occlusion or narrowing of the CSF pathway
4. Natural affinity of the CNS to certain pathogens
Give this one a try later!
2. Lack of acquired resistance to the various etiologic organisms
After a total knee replacement, a client is on the postoperative nursing unit with a
continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses
are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to
dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
a. Document the findings and monitor as prescribed.
b. Increase the frequency of monitoring the client.
c. Notify the surgeon or anesthesia provider immediately.
d. Palpate the clients bladder or perform a bladder scan.
Give this one a try later!
c. Notify the surgeon or anesthesia provider immediately.
The nurse on the postoperative inpatient unit assesses a client after a total hip
replacement. The clients surgical leg is visibly shorter than the other one and the
client reports extreme pain. While a co-worker calls the surgeon, what action by the
nurse is best?
a. Assess neurovascular status in both legs.
, b. Elevate the affected leg and apply ice.
c. Prepare to administer pain medication.
d. Try to place the affected leg in abduction.
Give this one a try later!
a. Assess neurovascular status in both legs.
A female client is admitted in a disoriented and restless state after sustaining a
concussion during a car accident. Which nursing diagnosis takes highest priority in this
client's plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury
Give this one a try later!
d. Risk for injury
A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home
assessment. What options can the nurse suggest for the client to maintain
independence in activities of daily living (ADLs)? (Select all that apply.)
a. Grab bars to reach high items
b. Long-handled bath scrub brush c. Soft rocker-recliner chair
d. Toothbrush with built-up handle e. Wheelchair cushion for comfort
Give this one a try later!
plan to use which of the following to test the client's peripheral response to pain?
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
Give this one a try later!
4. Nail bed pressure
A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis
(RA). Which client should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
,c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
Give this one a try later!
b. Client with a red, hot, swollen right wrist
The nurse is caring for the male client who begins to experience seizure activity while
in bed. Which of the following actions by the nurse would be contraindicated?
a. Loosening restrictive clothing
b. Restraining the client's limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward
Give this one a try later!
b. Restraining the client's limbs
10) The client is having a lumbar puncture performed. The nurse would plan to place
the client in which position for the procedure?
1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburg's position
4. Prone, with a pillow under the abdomen.
Give this one a try later!
1. Side-lying, with legs pulled up and head bent down onto the chest
,23) Meningitis occurs as an extension of a variety of bacterial infections due to which
of the following conditions?
1. Congenital anatomic abnormality of the meninges
2. Lack of acquired resistance to the various etiologic organisms
3. Occlusion or narrowing of the CSF pathway
4. Natural affinity of the CNS to certain pathogens
Give this one a try later!
2. Lack of acquired resistance to the various etiologic organisms
After a total knee replacement, a client is on the postoperative nursing unit with a
continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses
are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to
dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
a. Document the findings and monitor as prescribed.
b. Increase the frequency of monitoring the client.
c. Notify the surgeon or anesthesia provider immediately.
d. Palpate the clients bladder or perform a bladder scan.
Give this one a try later!
c. Notify the surgeon or anesthesia provider immediately.
The nurse on the postoperative inpatient unit assesses a client after a total hip
replacement. The clients surgical leg is visibly shorter than the other one and the
client reports extreme pain. While a co-worker calls the surgeon, what action by the
nurse is best?
a. Assess neurovascular status in both legs.
, b. Elevate the affected leg and apply ice.
c. Prepare to administer pain medication.
d. Try to place the affected leg in abduction.
Give this one a try later!
a. Assess neurovascular status in both legs.
A female client is admitted in a disoriented and restless state after sustaining a
concussion during a car accident. Which nursing diagnosis takes highest priority in this
client's plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury
Give this one a try later!
d. Risk for injury
A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home
assessment. What options can the nurse suggest for the client to maintain
independence in activities of daily living (ADLs)? (Select all that apply.)
a. Grab bars to reach high items
b. Long-handled bath scrub brush c. Soft rocker-recliner chair
d. Toothbrush with built-up handle e. Wheelchair cushion for comfort
Give this one a try later!
