An elderly client fractured his hip as a result of a fall at home. Because of his
extensive cardiac history and chronic obstructive pulmonary disease,
... [Show More] surgery isn't
an option. The client tells the nurse he doesn't know how he's going to get better.
Which response is best?
a) "You're doing fine."
b) "What is your biggest concern right now?"
c) "Give it some time and you'll be OK."
d) "You don't believe you're doing well?" - b
Open-ended questions allow a client to control what he wants to discuss and help a
nurse determine care needs. Telling the client that he's fine or that he just needs
more time doesn't encourage him to verbalize his concerns. Reiterating the client's
concerns may not encourage him to verbalize his feelings
A student nurse requires additional teaching if which of the following factors is
identified as contributing to a client's Risk for infection?
a) Proper nutrient intake
b) Impairment of primary body system defenses
c) Chronic disease
d) Inadequate secondary defenses - Proper nutrient intake
Explanation:
Malnutrition, rather than proper nutrient intake, would put the client at risk for
infection. Inadequate secondary defenses, impaired primary defenses, and chronic
disease put the client at risk by lowering the body's ability to fight infection.
The nurse assesses an older adult for signs of dehydration. Which findings would
be consistent with a diagnosis of dehydration?
a) orthostatic hypotension
b) moist crackles
c) bounding pulse
d) shortness of breath - orthostatic hypotension
Correct
Explanation:Orthostatic hypotension or persistent hypotension is present in dehydration, as are
poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration
is severe, the client may also be restless, confused, and thirsty.
Most instances of crackles is indicative of excess fluid volume, not dehydration.
Shortness of breath or a bounding pulse may be indicative of excess fluid, not
dehydration.
The nurse is planning care with the parents of a child who requires continuous
peritoneal dialysis. Which finding should be discussed with the health care
provider (HCP)?
a) The child reports having a previous surgery for a ruptured appendix.
b) The family lives a long distance from the medical facility.
c) The family feels the child cannot self-regulate to wake at night and change
bags.
d) The child attends a large public school. - The child reports having a previous
surgery for a ruptured appendix.
Explanation:
A client who has had a ruptured appendix may have peritoneal scarring that may
alter the effectiveness of treatment. Living a long distance from a medical facility
is typically a reason to select peritoneal dialysis. Attending a large school is not a
problem, but the school nurse needs to be included as part of the health care team.
Typically the treatment schedule can be planned to allow for uninterrupted sleep at
night.
A nurse is performing an admission assessment on a client newly admitted to the
hospital and has documented the client as being a member of the Native American
subculture. A subculture is best described as which of the following?
a) A cultural group with fewer than 5 million members in the United States.
b) A unique cultural group that exists within the larger culture.
c) A cultural group with values that are incongruent with those of the dominant
culture.
d) A unique cultural group with unspecified geographic origins. - A unique
cultural group that exists within the larger culture.
Correct
Explanation:Subcultures are unique cultural groups that coexist within the dominant culture of
the United States. Subcultures are not defined according to the size of their
membership or the lack of specific geographic origins. Subcultures may have some
values that differ from those of the dominant culture, but this is not their defining
characteristic.
A nurse reports to the hospital occupational health nurse (OHN) that he/she was
splashed with blood during the resuscitation of an HIV-positive client. The nurse
asks the OHN when he/she will know whether he/she is positive or negative for
HIV infection. Which of the following is the most appropriate response by the
OHN?
a) "The test results will vary during the first year of testing for the disease."
b) "We will test you in 4 weeks, and then we will have a definitive answer."
c) "Accurate results will be obtained by testing at 3 months and again at 6
months."
d) "Most nurses who have been splashed do not test positive if they wash
immediately." - "Accurate results will be obtained by testing at 3 months and again
at 6 months."
Correct
Explanation:
Ninety-five percent of exposed individuals will seroconvert within 3 months; 99%
will convert by 6 months. The other options do not accurately reflect the timeline
for seroconversion following exposure.
Which would be most helpful when coaching a client to stop smoking?
a) Review the negative effects of smoking on the body.
b) Explain how smoking worsens high blood pressure.
c) Discuss the effects of passive smoking on environmental pollution.
d) Establish the client's daily smoking pattern. - Establish the client's daily
smoking pattern.
Correct
Explanation:
A plan to reduce or stop smoking begins with establishing the client's personal
daily smoking pattern and activities associated with smoking. It is important that
the client understands the associated health and environmental risks, but this
knowledge has not been shown to help clients change their smoking behavior.A client presents to the OB triage unit with no prenatal care and painless bright red
vaginal bleeding. Which interventions are most indicated?
a) applying an external fetal monitor and completing a physical assessment
b) obtaining a fundal height assessment on the client
c) applying an external fetal monitor and performing a sterile vaginal examination
d) obtaining fundal height and performing a sterile vaginal examination - applying
an external fetal monitor and completing a physical assessment
Explanation:
Bright red vaginal bleeding without contractions could indicate a placenta previa.
A sterile vaginal exam should never be done on a woman with a known or
suspected placenta previa. Applying the external fetal monitor will allow the nurse
to assess fetal status. A complete physical assessment of the client is indicated. A
fundal height is used to monitor fetal growth during pregnancy but does not
provide information related to vaginal bleeding.
Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall
risk precautions for which client?
a) an 84-year-old client with diabetes admitted with new-onset confusion who
reportedly fell at home last week, is currently on bed rest, and has normal saline
infusing per saline lock
b) a 48-year-old alert and oriented client with quadriplegia admitted for wound
care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally
inserted central catheter
c) a 62-year-old client with a history of Parkinson's disease, admitted for
pneumonia and receiving IV antibiotics, who has fallen at home but is able to
ambulate with a cane and who during his hospitalization has gotten out of bed
without calling for assistance
d) a 27-year-old client with acute pancreatitis receiving morphine sulfate IV every
2 hours as needed for pain; no significant medical history, smokes two packs of
cigarettes per day; may be up independently; and has steady gait - a 62-year-old
client with a history of Parkinson's disease, admitted for pneumonia and receiving
IV antibiotics, who has fallen at home but is able to ambulate with a cane and who
during his hospitalization has gotten out of bed without calling for assistance
Explanation:
Using the Morse fall scale, risk factors for this client include history of falling,
secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and
forgetting limitations (100 points). Client no. 1 is also high risk with a secondary
diagnosis, history of falling, IV access, and confusion but is on bed rest (75points). Client no. 2 risks include IV access and secondary diagnosis (35 points).
Client no. 4 is at risk due to his IV access only (20 points) [Show Less]