A 64 year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What would
be the most appropriate intervention by the nurse? - ANSWER Ask the client if the
preference would be to remove the dentures in the operating room receiving area
The nurse has been teaching adult clients about cardiac risks when they visit the
hypertension clinic. Which form of evaluation would best measure learning? -
ANSWER Reported behavioral changes
The nurse is planning care for an 18 month-old child. Which action should be
included in the child's care? - ANSWER Encourage the child to feed himself finger
food
A partner is concerned because the client frequently daydreams about moving to
Arizona to get away from the pollution and crowding in southern California. The
nurse explains that - ANSWER Such fantasies can gratify unconscious wishes or
prepare for anticipated future events
An appropriate goal for a client with anxiety would be to - ANSWER Learn self-help
techniques
While the nurse is administering medications to a client, the client states "I do not
want to take that medicine today." Which of the following responses by the nurse
would be best? - ANSWER "Is there a reason why you don't want to take your
medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical
area. Which of the following assessments is appropriate for the nurse to perform? -
ANSWER Auscultate the mass
A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which
statement would provide the best reality orientation for this client? - ANSWER
"Good morning. You're in the hospital. I am your nurse Elaine Jones."
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the
main source of fluids for an infant until about 12 months of age? - ANSWER
Formula or breast milk
The family of a 6 year-old with a fractured femur asks the nurse if the child's height
will be affected by the injury. Which statement is true concerning long bone fractures
in children? - ANSWER Epiphyseal fractures often interrupt a child's normal growth
pattern
, The nurse is assessing a client who states her last menstrual period was March 16,
and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)? - ANSWER December 23
When screening children for scoliosis, at what time of development would the nurse
expect early signs to appear? - ANSWER During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The
nurse discovers that the client has not been following the prescribed diet. What
would be the most appropriate nursing action? - ANSWER Discuss diet with the
client to learn the reasons for not following the diet
A client states, "People think I'm no good, you know what I mean?" Which of these
responses would be most therapeutic? - ANSWER "I'm not sure what you mean.
Tell me a bit more about that."
A client being treated for hypertension returns to the community clinic for follow up.
The client says, "I know these pills are important, but I just can't take these water
pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to
go to the bathroom." Which of these is the best nursing diagnosis? - ANSWER
Noncompliance related to medication side effects
When teaching effective stress management techniques to a client 1 hour before
surgery, which of the following should the nurse recommend? - ANSWER Deep
breathing
When observing 4 year-old children playing in the hospital playroom, what activity
would the nurse expect to see the children participating in? - ANSWER Playing
cooperatively with other preschoolers
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding? - ANSWER Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form
of explanation meets the developmental needs of this age child? - ANSWER Explain
the surgery using a model of the heart
The parents of a child who has suddenly been hospitalized for an acute illness state
that they should have taken the child to the pediatrician earlier. Which approach by
the nurse is best when dealing with the parents' comments? - ANSWER Accept their
feelings without judgment
When caring for a client who is receiving a thrombolytic agent to open a clot
occluded coronary artery after a myocardial infarction, which finding would be of
greatest concern to the nurse? - ANSWER Hematemesis
When caring for a client with total parenteral nutrition (TPN), what is the most
important action on the part of the nurse? - ANSWER Sterile technique for dressing
change at IV site