A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance
... [Show More] Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance Directives. This
documentspecifies the client's wishes
Question 2
You are the of a health care team that consists of one licensed
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practical/vocational nurse, one nursing assistant, a nursing student and
yourself. To whom is it appropriate to assigncomplete care for
A) Yourself
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
Review Information: The correct answer is:A) Yourself.
While the nurse may delegate a bed bath for a stable client, this care should
be performedby an RN for a new admission. Only tasks that do not require
independent judgment should be delegated.
Question 3
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A mother brings her the clinic, complaining that the child seems to be .The
nurse expectsto find which of the following on the initial history and
physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is: B) Rash and restlessness.
Question 4
As the nurse takes a history of a 3 year-old with neuroblastoma, what
comments by theparents require follow-up and are consistent with the
diagnosis?
A) "The child has been listless and has lost weight."
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B) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her
abdomen." D+) "We notice muscle weakness and
some unsteadiness."
Review Information: The correct answer is:C) "Clothes are becoming tighter
across herabdomen.".
One of the most common signs of neuroblastoma is increasing abdominal
girth. The parents'' report that clothing is tight is significant, and should be
followed by additionalassessments.
Question 5
A 16 year-old presents to the emergency department. The triage nurse finds
that this teenager is legally married and signed the consent form for treatment.
What would be theappropriate INITIAL action by the nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
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B) Withhold treatment until telephone consent can be obtained from the
spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: The correct answer is:D) Assess and treat in the same
manner asany adult client.
Minors may become known as an "emancipated minor" through marriage,
pregnancy,high school graduation, independent living or service in the
military. Therefore, this client, who is married, has the legal capacity of an
adult.
Question 6
A newly admitted elderly client is severely dehydrated. When planning
care for thisclient, which one of the following is an appropriate task for
an Unlicensed AssistivePersonnel (UAP)?
A) Obtain a history of fluid loss
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B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review Information: The correct answer is:B) Report output of less than 30
ml/hr.
When directing a UAP, the nurse must communicate clearly about each
delegated task with specific instructions on what must be reported. Because
the RN is responsible for allcare-related decisions,only implementation
tasks should be assigned because they do not require independent judgment.
Question 7
The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the
followingwould the nurse suspect is related to this diagnosis?
A) Diagnosis of chickenpox six months ago
B) Exposure to strep throat in daycare last month
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C) Treatment for ear infection two months ago
D) Episode of fungal skin infection last week
Review Information: The correct answer is:B) Exposure to strep throat in
daycare lastmonth.
Evidence supports a strong relationship between infection with Group A
streptococci andsubsequent rheumatic fever (usually within 2-6 weeks).
Therefore, the history of playmates recovering from strep throat would
indicate that the child diagnosed with rheumatic fever most likely also had
strep throat. Sometimes, such an infection has no clinical symptoms.
Question 8
When the nurse becomes aware of feeling reluctant to interact with a
manipulative client,the BEST action by the nurse is to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcing the manipulative
behavior
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C) Confront the client regarding the negative effects of his/her behavior on
others
D) Develop a behavior modification plan that will promote more functional
behavior
Review Information: The correct answer is:A) Discuss the feeling of
reluctance with anobjective peer or supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain
objectivity through supervision. The nurse must attempt to discover attitudes
and feelings in the selfthat influence the nurse-client relationship.
Question 9
A client is being treated for paranoid schizophrenia. When the client
became loud and boisterous, the nurse immediately placed him in
seclusion as a precautionary measure.The client willingly complied. The
nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
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C) Was appropriate in view of the client's history of violence
D) Was necessary to maintain the therapeutic milieu of the unit
Review Information: The correct answer is:A) May result in charges of
unlawfulseclusion and restraint.
Seclusion should only be used when there is an immediate threat of
violence orthreatening behavior.
Question 10
A client has been admitted to the Coronary Care Unit with a Myocardial
Infarction.Which of the following nursing diagnosis should have
PRIORITY?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety
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Review Information: The correct answer is:A) Pain related to ischemia.
Pain is related to ischemia, and relief of pain will decrease myocardial
oxygen demands,reduce blood pressure and heart rate and relieve anxiety.
Pain also stimulates the sympathetic nervous system and increased preload,
further increasing myocardial demands.
Question 11
The nurse manager who is responsible for hiring professional nursing staff is
required tocomply with the Americans with Disabilities Act. The provisions
of the law require the nurse manager to
A) Maintain an environment free from hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals [Show Less]