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[单项选择]A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care()
A. Assessing the client’s temperature every 8 hours.
B. Placing the client in respiratory isolation.
C. Monitoring the client’s fluid intake and output.
D. Wearing gloves during all client contact.
[单项选择]A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn’t answered immediately. The most appropriate response to her would be()
A. "You seem angry. Would you like to talk about it"
B. "Calm down. You know that stress will make your symptoms worse. "
C. "Would you like to talk about the problem with the nursing supervisor"
D. "I can see you’re angry. I’ll come back when you’ve calmed down. "
[单项选择]An adolescent is admitted to the hospital for headaches. She approaches the nurse and confides that she is being sexually abused by a family friend. Which of the following would be the nurse’s best initial response
A. "Can you tell me what happened"
B. "I believe you; you were right to tell me. "
C. "Have you told your mother and father about this"
D. "Who else have you told about this"
[单项选择]An infant is admitted to the hospital because of having frequent diarrheal stools with acute rotaviral infection. The nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor, and the mucous membranes are dry. The nurse would make a nursing diagnosis of Deficient fluid volume related to
A. insufficient antidiuretic hormone.
B. inability to metabolize nutrients.
C. decreased gastric emptying.
D. increased gastrointestinal motility.
[单项选择]A school-aged child is admitted to the hospital with newly diagnosed, insulin-dependent diabetes mellitus. On admission his blood sugar is 180 mg/dL. His urine tests negative for ketones. He receives 10 units of regular humulin insulin subcutaneously half hour after admission. What should the nurse do next
A. Carefully regulate an intravenous solution of normal saline and insulin at 2. 5 hours after admission.
B. Encourage the child to drink at least 500 mL of a sugar-free clear liquid 1.5 hours after admission.
C. Begin intravenous administration of 5% dextrose in water 1 hour after admission.
D. Assess the child 2. 5 hours after admission for shakiness, feelings of anxiety, or decreased level of consciousness.
[单项选择]Mr. Smith is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts and two episodes of hitting a coworker at the grocery store where he works. He is very anxious and tells the nurse, "I didn’t mean to hit him. He made me so mad that I just couldn’t help it. I hope I don’t hit anyone here. " Which of the following is the nurse’s best response
A. "It sounds like you were angry. When you feel angry here, talk to the staff about it instead of hitting. "
B. "I’m sure you didn’t mean to hit him and that it won’t happen here. "
C. "You’d better not hit anyone here, even if you do get mad. "
D. "Tell me more about what happened. "
[单项选择]A pregnant client with premature rupture of the membranes has had contractions every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring. The nurse discusses with the client about preterm labor symptoms. Which of the following statements made by the client indicates that she needs further instruction
A. "I should report contractions that occur every 10 minutes in 1 hour. "
B. "I should lie in bed on my left side if contractions begin. "
C. "I should call the doctor if my contractions occur every hour for 6 hours. "
D. "If I start having contractions, I should empty my bladder. "
[单项选择]The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that
A. the delivery may need to be induced early.
B. the delivery must be by cesarean.
C. the mother will carry to term safely.
D. it’s too early to tell.
[单项选择]A 4-year-old girl is admitted to the hospital to rule out leukemi
A. a. Which of the following would be the best room assignment With a 4-year-old girl who has rheumatoid arthritis.B. With a 5-year-old boy who is having a tonsillectomy.C. With a 4-year-old girl who has leukemia.D. Alone in a private room.
[单项选择]After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs’test. What’s the purpose of performing this test on a pregnant client
A. To determine the fetal blood Rh factor.
B. To determine the maternal blood Rh factor.
C. To detect maternal antibodies against fetal Rh-positive factor.
D. To detect maternal antibodies against fetal Rh-negative factor.
[单项选择]A pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid
A. Egg yolks.
B. Fruit.
C. Bread.
D. Milk.
[单项选择]A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following
A. Excess sugar causing reduced placental functioning.
B. Insulin acting as a growth hormone on the fetus.
C. Maternal dietary intake of high calories.
D. Excess insulin reducing placental functionin
[单项选择]A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What’s the most important assessment the nurse should make of the client
A. Ability to care for himself.
B. Degree of danger to self and others.
C. Level of psychosis.
D. Intended compliance with aftercar
[单项选择]A 19-year-old pregnant client tells the nurse she’s concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn’t provide insurance. The nurse should recognize which of the following
A. The client may not take care of herself.
B. The client may not be fit to take care of a child.
C. The client needs to take up a second job.
D. The client should be referred to community resources available for pregnant women.
[单项选择]The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. The client states, "I run apple, train, grass, window. " This response by the client is known as()
A. echopraxia.
B. a word salad.
C. flight of ideas.
D. neologisms.
[单项选择]A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client’s arterial blood gas values indicate respiratory acidosis. What should the nurse do first()
A. Prepare to assist with ventilation.
B. Monitor the client’s heart rhythm.
C. Prepare to begin gastric lavage.
D. Obtain urine for drug screening.
[单项选择]The client was admitted with severe head injury resulting from a motor vehicle accident. The client is presently unconscious. To facilitate rehabilitation when the client’s condition allows, the nurse should
A. maintain limbs in the position of function.
B. apply restraints to arms and legs to control spasms.
C. exercise just the arms as the legs maintain their tone longer.
D. notify physical therapy as soon as the physician orders passive range of motion.
[单项选择]A client is admitted to the psychiatric unit with a diagnosis of anorexia nervos
A. a. Although she is 5’7" and weighs only 100 lb, she keeps on telling the nurse about how fat she is. What should the nurse do first Discuss cultural stereotypes regarding thinness and attractiveness.B. Explore the reasons why the client doesn’t eat.C. Teach the client about nutrition, calories, and a balanced diet.D. Establish a trusting relationship with the client.
[单项选择]A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to have which of the following findings
A. Tension and irritability.
B. Slow pulse.
C. Hypotension.
D. Constipation.