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1. A nurse is closely monitoring a client who has recently been diagnosed with
an abdominal aortic aneurysm. What assessment finding would signal an
impending rupture of the client's aneurysm?
Sudden increase in blood pressure and a decrease in heart rate
New onset of hemoptysis
Sudden onset of severe back or abdominal pain
Cessation of pulsating in an aneurysm that has previously been
pulsating visibly
2. A client with a vitamin C deficiency is advised to increase their intake of fruits
and vegetables. If they dislike citrus fruits, which alternative food high in
vitamin C could the nurse recommend?
Eggs
Rice
Kiwifruit
Apples
3. What should a nurse do if a client expresses intentions to harm someone
after discharge from a mental health facility?
Allow the client to leave as planned.
Provide the client with a list of community resources.
Prevent the client from leaving the facility.
Encourage the client to talk about their feelings.
,4. If a nurse observes a parent incorrectly placing their newborn in a car seat
without head support, what should the nurse do to ensure the parent's
understanding of proper car seat use?
The nurse should advise the parent to switch to a booster seat
immediately.
The nurse should suggest using a different car seat brand.
The nurse should ignore the situation as it is not a critical issue.
The nurse should provide education on the importance of head
support and demonstrate the rolled towel method.
5. If a client with peptic ulcer disease reports persistent abdominal pain despite
following dietary recommendations, what should the nurse's next step be?
Schedule a follow-up appointment in a month.
Refer the client to a dietitian.
Assess the client for potential complications.
Reinforce dietary recommendations again.
6. Why is it important for a client recovering from a myocardial infarction to
receive education from a respiratory therapist?
A respiratory therapist focuses solely on medication management for
heart conditions.
A respiratory therapist can provide specialized guidance on
breathing exercises that enhance lung function and recovery.
A respiratory therapist is responsible for monitoring heart rhythms
during recovery.
A respiratory therapist only assists patients with chronic lung diseases.
,7. What type of specialist should a nurse refer a client to for assistance with
breathing exercises after a myocardial infarction?
Dietitian for nutritional counseling
Occupational therapist for daily living skills
Respiratory therapist for breathing exercises
Physical therapist for mobility training
8. Why is maintaining continuity of staff members important in the care of a
client with anorexia nervosa?
It allows for varied treatment approaches.
It fosters a trusting relationship and consistent care.
It minimizes the need for patient education.
It ensures that all staff members have the same qualifications.
9. Describe the significance of recognizing symptoms of a thoracic aortic
aneurysm rupture in nursing practice.
The symptoms of a thoracic aortic aneurysm rupture are not relevant
to nursing care.
Recognizing symptoms of a thoracic aortic aneurysm rupture is
crucial for timely intervention and preventing life-threatening
complications.
Symptoms of a thoracic aortic aneurysm rupture are often mild and do
not require immediate action.
Nurses should only focus on the patient's history and ignore current
symptoms.
, 10. A nurse is preparing a client for surgery. The client expresses concern that
someone might steal her purse during the procedure. Which of the following
actions should the nurse take?
Tell the client to leave her purse in a drawer of the bedside table
Offer to store the purse at the nurses' station
Offer to place the purse in the facility safe
Place the purse in the clothing bag with the client's other belongings
11. Why is it important for a nurse to assess the reason behind an AP's refusal to
perform a task?
The nurse must report the refusal without further discussion.
The nurse needs to ensure the task is completed immediately.
Understanding the reason can help address any concerns or
barriers the AP may have.
The nurse should avoid conflict and let the AP handle it.
12. If the repeated pulse oximeter reading remains at 89%, what should the
nurse's next step be after confirming the reading?
Perform a thorough respiratory assessment.
Increase the client's fluid intake.
Administer supplemental oxygen.
Document the reading and continue monitoring.
13. Why is it important for a nurse to place a client with evisceration in a side-
lying position?