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1. NGN: A nurse is assisting with the care of a client who was admitted to the
emergency department (ED).
For each potential assessment finding, click to specify if the finding is consis-
tent with schizophrenia or bipolar 1 disorder. Each finding may support more
than 1 disease process.: Schizophrenia:
-grandidose delusions
-social impairment
-pressured speech
Bipolar 1 Disorder:
-grandidose delusions
-social impairment
-pressured speech
2. NGN: A nurse is caring for a client in an inpatient mental health facility.
Select the 2 findings from the client's medical record that are manifestations
of borderline personality disorder.: -skin assessment
-behavior toward roommate
3. NGN: A nurse is assisting with the care of a client who is 1 day postoperative
following a total thyroidectomy.
The client is at highest risk for developing _____ as evidenced by the ______.-
: -hypocalcemia
-client's report of muscle spasms, numbness around lips, and decreased calcium
level
4. A nurse is assisting with the care of a client who has schizophrenia in
an inpatient facility. Click to highlight the findings that require immediate
follow-up. To deselect a finding, click on the finding again.: -Client reports an
increase in urination and had one episode of incontinence.
-Family noted increased agitation and delusions.
5. NGN: A nurse is assisting with the care of a client who has a new diagnosis
of anorexia nervosa. The nurse should first address the client's ______, fol-
lowed by the client's ______.: -electrolyte imbalance
-fear of weight gain
6. NGN: A nurse is reinforcing teaching with a client who is pregnant.
The client is at risk for experiencing _____ due to the client's ________.: -meta-
bolic acidosis
-excessive weight loss
7. NGN: A nurse is assisting with the care of a newborn. The nurse should plan
to first collect data about the newborn's ______, followed by the newborn's
_______.: -respiratory rate
-heart rate
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8. NGN: A nurse on the medical-surgical unit is assisting with the care of a
client who was admitted from the emergency department (ED). The client is at
risk for developing _______ due to ________.: -confusion
-sodium level
9. A nurse notices an assistive personnel (AP) taking a nap in the break room
during meal time. The nurse also notes that the AP is drowsy while performing
routine tasks. Which of the following actions should the nurse take?: Report
the observations about the AP to the unit's nurse manager.
10. A nurse in a long-term care facility is contributing to the plan of care for a
client who has a new ostomy. Which of the following interventions should the
nurse include?: Change the appliance two times each week
11. A nurse is caring for a client who is 12 hr postoperative following a total
hip arthroplasty. Which of the following actions should the nurse take?: Place
an abduction wedge between the client's legs when in bed.
12. A nurse is reinforcing teaching with a client who has a prescription for
nitroglycerin sublingual tablets. Which of the following instructions should
the nurse include in the teaching?: Take up to three tablets during a single angina
episode
13. A nurse is contributing to an in-service for newly licensed nurses about
child maltreatment. The nurse should include that which of the following
characteristics increases a child's risk of physical maltreatment?: The child
was born at 34 weeks of gestation
14. A nurse on a medical-surgical unit is delegating tasks to an assistive
personnel (AP). Which of the following tasks should the nurse delegate to the
AP?: Obtaining a client's vital signs prior to discharge
15. A nurse is collecting data from a client who reports recent methampheta-
mine use. Which of the following manifestations should the nurse expect?: -
Dilated pupils
16. A nurse is reinforcing teaching about confidentiality with a client who has
a new diagnosis of HIV. Which of the following information should the nurse
include in the teaching?: Your HIV status will be shared with members of your
health care team
17. A nurse in a pediatric clinic is collecting data from a toddler. Which of
the following findings should the nurse identify as a possible indication of
physical neglect?: The toddler is inadequately dressed for the weather
18. A nurse is collecting data from a client who has hypokalemia. Which of the
following findings should the nurse expect?: Muscle weakness
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19. A nurse is assisting with the care of a client who is receiving peritoneal
dialysis. Which of the following actions should the nurse plan to take?: Monitor
the client's intake and output
20. A nurse is assisting a client who is postoperative to sit on the side of the
bed. Which of the following actions should the nurse take?: Elevate the head
of the client's bed
21. A nurse is collecting data from a client who has a hip fracture. Which of the
following findings should the nurse expect?: External rotation
22. A nurse is reviewing the procedure for endotracheal suctioning with a
newly licensed nurse. Which of the following statements by the newly licensed
nurse indicates an understanding of the teaching?: I should apply sterile saline
to lubricate the suction catheter
23. A nurse is receiving change-of-shift report for four clients. The nurse
should plan to collect data from which of the following clients first?: A client
who has asthma and had frequent exacerbations on the previous shift
24. A nurse is receiving change-of-shift report for four clients. Which of the
following clients should the nurse see first?: A client whose urinary output was
100 mL for the past 12 hr
25. A nurse is observing an assistive personnel (AP) apply antiembolic stock-
ings for a client. Which of the following actions by the AP demonstrates an
understanding of how to perform this skill?: Applying the stockings before the
client gets out of bed
26. A nurse is receiving change-of-shift report for a group of clients. The
nurse should plan to implement which of the following time-management
strategies?: Prepare a priority list of client needs for the shift
27. A nurse is reinforcing teaching with a client who has a new prescription
for prednisone for the treatment of Addison's disease. Which of the following
instructions should the nurse include in the teaching?: You will need to sched-
ule a bone density test
28. A nurse is supervising an assistive personnel (AP) who is preparing to
remove personal protective equipment (PPE) after providing direct care to
a client who requires airborne and contact precautions. The nurse should
recognize that the AP understands the procedure when which of the following
PPE is removed first?: Gloves
29. A nurse is reinforcing teaching with a client who has acute diverticulitis.
Which of the following statements by the client indicates an understanding of
the instructions?: I will receive the nutrients I need through my IV fluid.