The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open ...
,The nurse is monitoring neurological vital signs for a male client who lost consciousness after
falling and hitting his head. Which assessment finding is the earliest and most sensitive
indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness. - ANS D
A nurse is planning to teach self-care measures to a female client about prevention of yeast
infections. Which instructions should the nurse provide?
K
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
C
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. - ANS D
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most
LO
important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
YC
d. Assign the client to a negative air-flow room. - ANS D
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family
health clinic. Which individual has the greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
D
c. A 3-month-old infant.
d. A school-aged child. - ANS A
U
What nursing delivery of care provides the nurse to plan and direct care of a group of clients
over a 24-hour period?
a. Team nursing.
ST
b. Primary nursing.
c. Case management.
d. Functional nursing. - ANS B
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it. - ANS A
, The nurse is caring for a client who is the daughter of a local politician. When the nurse
approaches a man who is reading the names on the hall doors, he identifies himself as a
reporter for the local newspaper and requests information about the client's status. Which
standard of nursing practice should the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality. - ANS D
A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on
K
a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the
unit to give him part of their meals. What intervention should the nurse implement?
C
a. Remove the client from the table and have him sit alone.
b. Send the client back to his room and do not allow him to eat.
c. Report the behavior to the on-call psychologist immediately.
LO
d. Confront the client about the consequences of the behavior. - ANS D
Which information should the nurse give a client with chronic kidney disease (CKD)?
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
YC
c. Avoid salt substitutes.
d. Increase daily intake of fiber. - ANS C
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty
sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid
retraction, and a staring expression. These findings are consistent with which disorder?
D
a. Grave's disease.
b. Cushing syndrome.
c. Multiple sclerosis.
U
d. Addison's disease. - ANS A
A young adult female arrives at the emergency department with a black right eye and is
ST
bleeding from the left side of her head. She reports that her boyfriend has been abusing her
physically. The nurse performs a history and physical examination. How should the nurse
document these findings?
a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises and lacerations
present on face.
c. Client presents with a right black eye and a cut on the left side of her head that is bleeding.
Reports abusive boyfriend responsible for injuries. Needs referral to a safe place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left
parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive. -
ANS D
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