1. Interpret the client's statement, 'The moon is full. Astronauts walk on the
moon. Walking is a good health habit,' in the context of mental health
assessment.
The statement reflects a disorganized thought process, indicative of
flight of ideas.
The statement shows a coherent thought process about health and
exercise.
The statement indicates a clear understanding of lunar phases and
their relevance.
The statement suggests the client is experiencing a dissociative
episode.
2. The nurse receives an order to give a client iron by deep injection. What does
the nurse understand about the reason for using this method of
administration?
Enhances absorption of the medication
Prevents the medication from tissue irritation
Provides more even distribution of the drug
Ensures that the entire dose of medication is given
3. Why is it important for the nurse to ask the client about acceptable foods in
this scenario?
It is a way to enforce hospital policies on food.
It helps to speed up the discharge process.
It allows the nurse to ignore the client's preferences.
, It helps to respect the client's cultural preferences and ensures
appropriate nutrition.
4. In a scenario where a nurse is caring for a distressed 6-month-old infant,
which action should the nurse prioritize to foster trust?
Ensure the infant feels secure by holding them close and speaking
softly.
Change the infant's diaper to ensure comfort.
Feed the infant immediately to distract them from distress.
Turn on soft music to calm the infant down.
5. Which symptom indicates a potential complication that requires immediate
evaluation by a healthcare provider?
I was started on medicine yesterday for a urine infection. Now my
lower belly hurts when I go to the bathroom.
I started my period and now my urine has turned bright red.
I have a headache and feel tired.
I am a diabetic and today I have been going to the bathroom every
hour.
6. Why is it important for a nurse to continuously evaluate a client's progress
toward goal achievement?
It allows the nurse to prioritize medication administration over patient
assessment.
It ensures that all interventions are completed within a set timeframe
without reassessment.
, It helps the nurse to focus solely on physical health without
considering psychosocial factors.
Continuous evaluation allows the nurse to adjust care plans based
on the client's changing needs and ensure effective outcomes.
7. A nurse is monitoring a patient with heart failure who has just received a dose
of Lanoxin (digoxin). What assessment finding would indicate that the
medication is having the desired effect?
Increased urinary output and improved respiratory status
Decreased heart rate and increased chest pain
Increased blood pressure and decreased respiratory rate
Decreased urinary output and increased edema
8. If a patient with a chest tube for a spontaneous pneumothorax begins to
exhibit signs of respiratory distress, what should the nurse assess first?
The patient's vital signs.
The presence of any drainage in the collection chamber.
The patient's pain level.
The patency and functioning of the chest tube.
9. If a patient shows signs of loss of pulse in the extremity after a cardiac
catheterization, what immediate action should the nurse take?
Document the finding and monitor vital signs only.
Encourage the patient to move their extremity.
Administer pain medication to the patient.
Notify the healthcare provider and assess the extremity for further
complications.
, 10. The nurse has inserted a nasogastric tube in a client per orders. Which action
will the nurse accomplish next?
Test the pH of aspirated content.
Obtain an abdominal ultrasound.
Ask about stomach distention and fullness.
Observe for immediate drainage from the tube
11. What is a common response of a batterer immediately after an incident of
violence?
Minimizing the episode and underestimating the victim's injuries
Seeking medical help for the victim's injuries
Being very remorseful and assisting the victim with medical care
Contacting a close friend and asking for help
12. The nurse is performing a physical assessment on a client who just had an
endotracheal tube (ET) inserted with a connection to a ventilator. Which
finding should prompt the nurse to take immediate action to resolve the
issue?
Client is unable to speak
Breath sounds are heard bilaterally
Mist is visible in the T-Piece of the ventilator circuit
Pulse oximetry of 86% saturation
13. Describe the psychological mechanisms that may lead a batterer to minimize
the severity of their partner's injuries after an incident.