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发布时间:2023-12-25 18:44:14

[单项选择]While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid( )
A. Paralytic ileus.
B. Gastric distention.
C. Hiatal hernia.
D. Gastrointestinal ulceration.

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[单项选择]The nurse is caring a client in an acute care mental health program. The client refuses his morning dose of an oral antipsychotic medication and believes he’s being poisoned. What should the nurse do( )
A. Crushing the medication and putting it in his food.
B. Consulting with the physician about a plan of care.
C. Administering the medication by injection.
D. Omitting the dose and trying again the next day.
[单项选择]The nurse is caring for a client with otosclerosis scheduled to undergo a stapedectomy. The client asks the nurse when her hearing will improve. Which response by the nurse is most appropriate()
A. Your hearing may not improve but you’ll no longer be bothered by tinnitus.
B. Your hearing may be dramatically improved right after surgery.
C. You may notice improved hearing within 1 to 2 weeks.
D. Your hearing may improve 3 to 6 weeks after surgery.
[单项选择]When caring for a client with ulcerative colitis, the nurse should include which of the following nursing interventions in the plan of care()
A. Encouraging the use of stool softeners.
B. Suggesting sitz baths as needed.
C. Arrange for the client to have a private bathroom.
D. Wearing a gown to provide direct care.
[单项选择]The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice()
A. Straw-colored urine.
B. Reduced hematocrit.
C. Clay-colored stools.
D. Elevated urobilinogen in the urine.
[单项选择]When caring for a client with preeclampsia, which action is a priority()
A. Monitoring the client’s labor carefully and preparing for a fast delivery.
B. Continually assessing the fetal tracing for signs of fetal distress.
C. Checking vital signs every 15 minutes to watch for increasing blood pressure.
D. Reducing visual and auditory stimulation.
[单项选择]When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should
A. position the client in a supine position.
B. elevate the head of the bed 90 degrees during meals.
C. encourage the client to remove dentures.
D. encourage thin liquids for dietary intake.
[单项选择]When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provides the most accurate picture of retention with overflow()
A. Frequent trips to the bathroom with an average output of 200 to 300 mL per void.
B. Intense urge to urinate with an average output of 250 mL.
C. A varying urge to urinate with an average output of 100 mL.
D. Uterus displaced to the right with increased vaginal bleeding.
[单项选择]When caring for an adolescent client diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include which of the following( )
A. Helplessness, hopelessness, hypersomnolence, and anorexia.
B. Truancy, a change of friends, social withdrawal, and oppositional behavior.
C. Curfew breaking, stealing from family members, truancy, and oppositional behavior.
D. Hypersomnolence, obsession with body image, and valuing of peers’ opinions.
[单项选择]The nurse is caring for a client with diabetes mellitus. When teaching the client about foot care, which instruction should the nurse provide()
A. Examine feet once per week for redness, blisters, and abrasions.
B. Apply lotion to dry feet, especially between the toes.
C. Avoid hot-water bottles and heating pads.
D. Dry feet vigorously after each bath.
[单项选择]The nurse is caring for a client infected with methicillin-resistant Staphylococcus aureus (MRSA). What’s the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting()
A. Using antibacterial soap when bathing clients with MRSA.
B. Conducting culture surveys periodically.
C. Ensuring that personnel wash their hands before and after contact with every client.
D. Using specific housekeeping practices for environmental cleaning.
[单项选择]The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate()
A. Catheterization to protect the bladder from trauma.
B. Perineal assessments for swelling and bleeding.
C. Vital signs and fundal checks every 15 minutes.
D. Time with the neonate to initiate breast-feeding.
[单项选择]The nurse is caring for a client who exhibits signs of somatization. Which of the following statements is most relevant()
A. Clients with somatization are cognitively impaired.
B. Anxiety rarely coexists with somatization.
C. Somatization exists when medical evidence supports the symptoms.
D. Clients with somatization often have lengthy medical records.
[单项选择]The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems()
A. Depression is commonly characterized by pain disorders and somatic complaints.
B. Combining evaluations will save time and allow for quicker delivery of health care.
C. Most insurance plans won’t cover evaluation of both as separate entities.
D. The physician doesn’t have the training to evaluate for psychosocial considerations.
[单项选择]The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is()
A. helping him communicate.
B. keeping his airway patent.
C. encouraging him to perform activities of daily living.
D. preventing him from developing an infection.
[单项选择]The nurse is caring for a client who exhibits magical thinking. Which of the following best describes magical thinking()
A. Strong positive and negative feelings that cause conflict.
B. Returning to an earlier developmental stage.
C. Meaningless repetition of words.
D. The belief that thoughts or wishes can control other people or events.
[单项选择]The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia()
A. Atropine.
B. Dobutamine (Dobutrex).
C. Bretylium (Bretylol).
D. Lidocaine (Xylocaine).
[单项选择]When caring for a client during the second stage of labor, which action would be least appropriate()
A. Assisting the client with pushing.
B. Ensuring the client’s legs are positioned appropriately.
C. Allowing the client clear liquids.
D. Monitoring the fetal heart rate.

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