Terms in this set (29)
A 20-year-old female client B) Most lumps are benign, but it is always best to come
calls the nurse to report a in for an examination.
lump she found in her
breast. Which response is (B) provides the best response because it addresses the
the best for the nurse to client's anxiety most effectively and encourages prompt
provide? and immediate action for a potential problem. (A)
A) Check it again in one postpones treatment if the lump is malignant, and does
month, and if it is still there not relieve the client's anxiety. (C and D) provide false
schedule an appointment. reassurance and do not help relieve anxiety.
B) Most lumps are benign,
but it is always best to come
in for an examination.
C) Try not to worry too
much about it, because
usually, most lumps are
benign.
D) If you are in your
menstrual period it is not a
good time to check for
lumps.
,A 46-year-old female client A) Serum creatinine.
is admitted for acute renal
failure secondary to (B) is also an indicator of renal activity, but it can be
diabetes and hypertension. affected by non-renal factors such as hypovolemia and
Which test is the best increased protein intake. (C) is a nonspecific test for
indicator of adequate acute or chronic inflammatory processes. (D) is useful in
glomerular filtration? assessing hydration status, but not as useful in assessing
A) Glomerular Filtration glomerular function.
Rate (GFR)
B) Blood Urea Nitrogen
(BUN).
C) Sedimentation rate.
D) Urine specific gravity.
A 77-year-old female client D) take digitalis?"
is admitted to the hospital.
She is confused, has no Elderly persons are particularly susceptible to digitalis
appetite, is nauseated and intoxication (D) which manifests itself in such symptoms
vomiting, and is as anorexia, nausea, vomiting, diarrhea, headache, and
complaining of a headache. fatigue. Although it is important to obtain a complete
Her pulse rate is 43 beats medication history (B and C), the symptoms described
per minute. Which question are classic for digitalis toxicity, and assessment of this
is a priority for the nurse to problem should be made promptly. (A) is irrelevant.
ask this client or her family
on admission? "Does the
client
A) have her own teeth or
dentures?"
B) take aspirin and if so,
how much?"
C) take nitroglycerin?"
D) take digitalis?"
, Based on the analysis of the C) Anticoagulation therapy.
client's atrial fibrillation, the
nurse should prepare the The client is experiencing atrial fibrillation, and the nurse
client for which treatment should prepare the client for anticoagulation therapy (C)
protocol? which should be prescribed before rhythm control
A) Diuretic therapy. therapies to prevent cardioembolic events which result
B) Pacemaker implantation. from blood pooling in the fibrillating atria. (A, B, and D)
C) Anticoagulation therapy. are not indicated.
D) Cardiac catheterization.
A client has been taking C) Purulent sputum.
oral corticosteroids for the
past five days because of Steroids cause immunosuppression, and a purulent
seasonal allergies. Which sputum (C) is an indication of infection, so this symptom
assessment finding is of is of greatest concern. Oral steroids may increase (A)
most concern to the nurse? and often cause (D). (B) may remain normal, borderline,
or increase while taking oral steroids.
A) White blood count of
10,000 mm3.
B) Serum glucose of 115
mg/dl.
C) Purulent sputum.
D) Excessive hunger.