ANSWERS
. The nurse has completed the admission assessment on a client who reports that
their mother is incapacitated by a stroke and father died from a ruptured aortic
aneurysm. Which statement by the client best indicates understanding of
personal risk?
1. "I check food labels for the amount of fat per serving."
2. "I eat lean meats and lots of vegetables."
3. "I monitor my blood glucose daily."
4. "I have labs drawn every month to assess kidney function." correct answer 2. "I
eat lean meats and lots of vegetables.
. The nurse is caring for the postpartum client who is experiencing disseminated
intravascular coagulation (DIC). The client's condition is deteriorating, and family
members are at the bedside. What is the priority action for the nurse when caring
for the family unit?
1. Show the family to waiting room until crisis resolved.
2. Provide reassurance to family that they will see improvement with treatment.
3. Ask family if they have a desire for religious or spiritual counsel.
4. Obtain additional client history from family members correct answer 3. Ask
family if they have a desire for religious or spiritual counsel.
. When providing nutrition to the client who is recovering from an embolic stroke,
what is the nurse's priority intervention?
1. Provide client with liquid diet only for first 24 hours.
2. Administer nutrition through peripheral intravenous line.
3. Consult speech therapist to perform swallowing evaluation.
, 4. Provide pureed food choices. correct answer 3. Consult speech therapist to
perform swallowing evaluation.
.The nurse is planning care for the client with systemic lupus erythematosus and
chronic disseminated intravascular coagulation. Which assessment findings
require immediate follow-up? Select all that apply.
1. Petechiae on lower arms.
2. Oozing from intravenous site.
3. Decreased heart rate.
4. Increased urinary output.
5. Altered mental status.
6. Abdominal distention correct answer 1. Petechiae on lower arms.
2. Oozing from intravenous site.
5. Altered mental status.
6. Abdominal distention
3.The nurse is caring for a client who has sustained significant blood loss following
a motor vehicle crash resulting in abdominal trauma. When implementing the
plan of care, which interventions are most important to decrease risk of
hypovolemic shock? Select all that apply.
1. Initiate crystalloid intravenous infusion.
2. Monitor urinary output.
3. Measure girth of abdomen at regular intervals.
4. Administer pain medication intravenously.
5. Assess for blood in urine and stool.