-A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, howshould
... [Show More] the nurse characterize the client’s condition?
a. The client has increased intracranial pressure
b . He has a good prognosis for recovery
c.This client is conscious, but is not oriented to time and place
d.He is in a coma, and has a very poor prognosis Correct D
• A client who had a cerebral vascular accident (CVA)
Is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client’s current health status?
-A Risk for impaired tissue integrity related to impaired physical mobility
-B Impaired skin integrity related to altered circulation and pressure
-C Ineffective tissue perfusion related to inability to move self in bed.
-D Impaired physical mobility related to the left side paralysis Correct B
• The nurse offers diet teaching to a female college student who was diagnosedwith iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
-A Drink whole milk instead of skim milk to enhance the body’s production ofamino acids
-B Take vitamin K 10mg PO daily to enhance production of red blood cells
-C Increase amounts of dark yellow vegetables such as carrots to fortify ironstores
-D Combine several legumes and grains such as beans and rice to form complete proteins
Correct D
• The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triagetag color should the nurse place on this client?
-A Black
-B Yellow
-C Green
-D Red Correct D
• Which action should the nurse include in the plan of care a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
-A Initiate cardiac telemetry monitoring
-B Maintain continuously pulse oximetry
-C Perform capillary glucose measurements
-D Monitor serum creatinine levels Correct D
• A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?
-A Bladder distention
-B Serum albumin level
-C Abdominal girth
-D Breath sounds Correct D
• A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to developa therapeutic relationship with this client, which information is most important for thenurse to determine?
-A The family’s reaction to this situation
-B The nurse’s feeling about this client
-C What losses the client recently experienced
-D Why the client attempted to kill himself Correct B
• Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?
-A A young adult client with intractable vomiting from food poisoning
-B A client who developed hyperparathyroidism in late adolescence
-C A middle-age male client in renal failure following an unsuccessful kidney transplant
-D A female client who is overzealous with her intake of simple carbohydrates Correct C
• While assessing a client who is experiencing Cheyne-Stokes respirations, thenurse observes periods of apnea. What action should the nurse implement?
-A Elevate the head of the client’s head
-B Auscultate the client’s breath sound
-C Measure the length of the apneic periods
-D Suction the client’s oropharynx Correct C
• At a community health fair, a 50-year-old woman tells the nurse that she has anannual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
a. Encourage the woman to explore her fears about breast cancer. b. Ask the woman if she also performs monthly breast self- exams.
c. Commend the woman for adhering to the recommended cancer detection guidelines.
d. Advise the woman that mammograms are only needed every two years ather age.
Correct B [Show Less]