All Clients Need (0001-0200) Flashcards
A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the nursing assistant to look for and report which of the following symptoms?
Tarry stools.
A nurse is assessing a 10-year-old girl. The girl’s mother informs the nurse that she’s concerned about her daughter’s breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response?
The changes in your daughter’s breasts are the first signs of puberty.
A 1-year-old child is admitted to the hospital with sickle cell crisis. Which of the following will be a part of the child’s plan of care?
I.V. fluid therapy.
A mother tells the nurse that her 4-year-old boy has developed some strange eating habits including not finishing meals and eating the same food for several days in a row. She would like to develop a plan to correct this situation. When developing such a plan, which of the following should the nurse and mother consider?
Allowing him to make some decisions about the foods he eats.
When obtaining a client’s history, the nurse should:
ask questions about the client’s reason for seeking care.
A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. Which of the following is the nurse’s best response?
What exactly are these terrible voices saying to you?
A graduate nurse is planning to perform a Romberg’s test on a client. The registered nurse would assess that the graduate nurse knows how to correctly perform this test when she sees the graduate nurse
Ask the client to try to balance himself with feet together and eyes open, and then eyes closed.
A school-age child diagnosed with attention deficit hyperactivity disorder is prescribed methylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?
Loss of appetite.
On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, “I look horrible! Will it ever look better?” Which of the following responses by the nurse would be most appropriate?
”You’re shocked by the sudden change in your appearance as a result of this surgery, aren’t you?”
A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should:
Report the finding to the health care provider.
Which situation violates the Health Insurance Portability and Accountability Act?
A nurse gives a client’s family members a report on his progress.
When teaching a primigravid client at 24 weeks’ gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include?
A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.
While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother’s temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
Continue to monitor the client’s vital signs.
A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?
Use a warm moist compress over the painful area.
A nurse fails to give the evening dose of an I.V. antibiotic that is to be administered every 12 hours. The nurse should next:
Report the incident to the physician.
The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child’s identity by checking the arm band and:
Asking the parent the child’s name.
A physician orders gentamicin sulfate (Garamycin), 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least:
30 minutes.
While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement?
I tell her she is wrong and then I tell her what’s right.
A female client with gonorrhea informs the nurse that she has had sexual intercourse with her boyfriend and asks the nurse, “Would he have any symptoms?” The nurse responds that in men the symptoms of gonorrhea include:
Dysuria.
Which nursing action would be most successful in gaining a preschooler’s cooperation in preparing for surgery?
Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.
A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
Sew thick padding into the elbows and knees of the child’s clothing.
Which of the following statements indicates that the client understands the home care of a colostomy?
”I should be able to establish a regular pattern of elimination with my colostomy.”
The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby’s breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of which of the following?
A normal pattern in infants of this age.
An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods and liquids through a syringe. The nurse determine’s his biggest nutritional risk factor is:
Impaired oral motor control.
After the nurse counsels a primiparous client who is breastfeeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
“I should drink at least five glasses of fluid daily.”
A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client’s room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?
If you’re thinking about organ donation, my sister is waiting for a kidney transplant. She’d be an excellent recipient. I can give you her phone number.
During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?
A sachet of lavender.
When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?
When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client’s weight.
Which of the following indicates the client with ulcerative colitis has attained an expected outcome of nursing care?
The client maintains an ideal body weight.
The nurse is assisting a client with a stroke who has homonymous hemianopia? The client will:
Eat food on only half of the plate.
Initial client assessment information includes: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?
Headache, blurred vision, and facial and extremity swelling
A client with stage 1 Alzheimer’s disease is diagnosed with terminal lung cancer. He asks the nurse what he should do when he “reaches the end.” How should the nurse respond?
An advance directive will help to make sure that your wishes are carried out.
A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The child’s history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation?
Immediate isolation is required.
The mother of a 14-year-old girl who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which of the following responses by the nurse is appropriate?
Tell me what you have found in your reading that is leading you to that conclusion.
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client has chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
Call the rapid response team.
A client has been prescribed digoxin (Lanoxin). Which of the following symptoms should the nurse tell the client to report as a potential indication of digoxin toxicity?
Visual disturbances.
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?
Making a copy of the incident report for the client
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan? Check all that apply.
- Introducing foods on the unaffected side of the mouth.
- Maintaining an upright position while eating.
- Keeping distractions to a minimum.
To prevent catheter-associated urinary tract infection, the nurse should do which of the following? Select all that apply.
- Assess the client for signs of infection.
- Provide perineal care several times a day.
- Encourage the client to drink 3,000 ml of fluids a day.
During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks’ gestation and is now in her third trimester states, “I’ve been having strange dreams about the baby. Last week I dreamed he was covered with hair.” The nurse should tell the mother:
It’s not uncommon to have dreams about the baby, particularly in the third trimester.
A client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions? Select all that apply.
- Take daily weight.
- Assess urine specific gravity.
- Monitor intake and output.
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which of the following PaCO2 values as indicating the need for immediate intervention?
80 mm Hg.
A client has bursitis in the subacromial bursa. A nurse determines that the client understands teaching when the client says which of the following?
I will apply moist heat to my shoulder for 20 minutes three times each day.
A nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should emphasize the fact that:
most toddler deaths are accidental.
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
No, it can initiate premature uterine contractions.
The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which of the following would be the most effective method of follow-up?
Weekly visits by a community health nurse.
During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use?
1 mg I.V.
Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)?
Obtaining vital signs during blood administration
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- Stop the transfusion.
- Keep the I.V. open with normal saline infusion.
- Notify the attending physician and blood bank.
- Complete the appropriate Transfusion Reaction Form(s).
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:
Moderate pain that worsens on inspiration.
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?
Anticipatory grieving
A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after complaining of feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. The nurse should do which of the following from first to last?
- Monitor for suicide and self-mutilation.
- Monitor sleeping and eating behaviors.
- Discuss the issues of loneliness and emptiness.
- Discuss her housing options for after discharge.
A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
Foul-smelling discharge from the penis
A client receiving chemotherapy has pruritus. In order to develop a care plan, the nurse should ask if the client has been:
Taking daily baths with a deodorant soap.
Which of the following client statements identifies a knowledge deficit about cast care?
I can pull out cast padding to scratch inside the cast.
When a client cannot read or write but is of sound mind, the nurse should read the consent to the client in the presence of two witnesses and:
Have the client put an “X” on the signature line.
A nurse is interviewing the mother of a 7-year-old child. Which symptom reported by the mother leads the nurse to suspect that the child has type 1 diabetes?
Recent bed-wetting
A clinic client taking disulfiram (Antabuse) during alcohol rehabilitation therapy reports to the nurse that he has a mild cold and plans to use a cough medicine. What information about the use of cough medicine with disulfiram does the client need to know?
The client may experience violent vomiting if he takes cough medicine while taking disulfiram.
Which of the following positions is appropriate for palpating tissues during breast self-examination?
Flat on the back with a pillow under the shoulder of the side being examined.
The purpose of biofeedback is to enable a client to exert control over physiologic processes by:
Translating the signals of body processes into observable forms.
A nurse is making assignments for the infant unit. The shift’s team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN?
An infant requiring abdominal dressing changes for a wound infection
After receiving a change-of-shift report in the normal newborn nursery, which neonate should the nurse see first?
Neonate B: 4 hours old with a blood glucose level of 30.
The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
Hemorrhage.
Which of the following questions or statements should the nurse use to encourage client evaluation of his or her own behavior?
What did you do differently with your coworker this time?
When assessing a 34-year-old multigravid client at 34 weeks’ gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
Painless vaginal bleeding.
A client with gastric cancer is having a resection. What is the nursing management priority for this client?
Correcting nutritional deficits
A nurse is administering indomethacin to a neonate. To ensure that the nurse has identified the neonate correctly, the nurse should do which of the following? Select all that apply.
- Check the neonate’s identification band against the medical record number.
- Verify the date of birth from the medical record with the date of birth on the client’s identification band.
A client with bipolar disorder, manic phase, is scheduled for a chest radiograph. Before taking the client to the radiology department, the nurse should:
Explain the procedure in simple terms.
The nurse is teaching the mother of a newborn to develop her baby’s sensory system. To further improve the infant’s most developed sense, the nurse should instruct the mother to:
Stroke the newborn’s cheek with her nipple to direct the baby’s mouth to nipple.
What is the rationale that supports multidrug treatment for clients with tuberculosis?
Multiple drugs reduce development of resistant strains of the bacteria.
A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she’s admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress?
Blood pressure of 146/90 mm Hg
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?
I’ll call my neighbor who’s 2 months pregnant and tell her not to have contact with my son.
A client at 28 weeks’ gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:
promote fetal lung maturity.
During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:
at least three times per week.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:
Ineffective airway clearance.
A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The primary care provider is calling in a telephone order for ampicillin. The nurse should do which of the following? Select all that apply.
- Repeat the order to the primary health care provider.
- Ask the primary health care provider to confirm that the order is correct as understood by the nurse.
A 5-month-old infant is brought to the clinic by his parents because he “cries too much” and “vomits a lot.” The infant’s birth weight was 6 lb, 10 oz, and his current weight is 7 lb, 4 oz, falling below the 5th percentile on a standard growth chart. Which of the following data should the nurse identify as the priority?
Feeding pattern.
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
You must avoid coughing, sneezing, and blowing your nose.
A client admitted to the psychiatric unit for treatment of a panic attack comes to the nurses’ station in obvious distress. After finding the client short of breath, dizzy, trembling, and nauseated, a nurse should first:
escort the client to a quiet area and suggest that he use a relaxation exercise he’s been taught.