更多"During the assessment stage, a clie"的相关试题:
[单项选择]During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his action（）
A. Somatic delusions.
B. Waxy flexibility.
C. Neologisms.
D. Nihilistic delusions.
[单项选择]Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation（ ）
A. Breech position.
B. Late decelerations.
C. Entrance into the second stage of labor.
D. Multiple gestation.
[单项选择]During the assessment of a geriatric client, a nurse would expect which findings（）
A. Eye structure and visual acuity changes.
B. Facial hair decreasing in a female client.
C. Facial hair increasing in a male client.
D. Wounds healing more quickly.
[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.
[单项选择]A client has a boggy uterus during stage IV of her delivery. Four hours postpartum, the nurse is preparing to administer methylergonovine maleate (Methergine) 0.2mg PO as prescribed every 6 hours. The client’s vital signs are; temperature, 100.4°F (38℃); pulse, 60 beats/minute; respirations, 14 breaths/minute; blood pressure, 140/90mmHg. Which is the most appropriate intervention
A. Immediately administer the drug.
B. Administer the drug and call the physician.
C. Administer the drug and recheek vital signs.
D. Don’t administer the drug.
[单项选择]During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis（）
A. Bathing or hygiene self-care deficit.
B. Ineffective cerebral tissue perfusion.
C. Dysfunctional grieving.
D. Risk for injury.
[填空题]S3. During the second stage, if the family wanted to consume new goods ’and services, they had to enter the marketplace_______.
[单项选择]During a client’s chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care（）
A. Instruct the client to consume plenty of raw fruits and vegetables.
B. Take rectal temperatures for greater accuracy.
C. Tell the client to avoid crowds and infected individuals.
D. Ask friends and relatives not to visit during the course of chemotherapy.
[单项选择]During a morning assessment, the nurse percusses tympany. The nurse understands that tympany is a loud, high-pitched, moderately long sound with a drumlike, musical quality that’s most commonly heard over the（）
A. heart.
B. liver.
C. pancreas.
D. stomach.
[单项选择]For a client with bulimia, which assessment is least important in the care plan
A. Observe the client after eating for 1 hour.
B. Note the client’s intake.
C. Note changes in appetite.
D. Note changes in respiratory rate.
[填空题]REM occurs at the third and fourth stage during which we experience the deepest sleep.
[单项选择]While evaluating the needs of a client during the second trimester, the nurse can anticipate which of the following（）
A. Feelings of disbelief and ambivalence.
B. Feelings of clumsiness and "ugliness".
C. Increasing introspection but a general sense of well-being.
D. Anxiety about the labor and delivery experience.
[单项选择]During a private conversation, a client with borderline personality disorder asks the nurse to "keep my secret" and then displays multiple self-inflicted, superficial lacerations on the forearms. What is the nurse’s best response（）
A. "This type of behavior requires you to be on suicide precautions. "
B. "I’m going to tell your physician. Do you want to tell me why you did that"
C. "Tell me what type of instrument you used. I’m concerned about infection. "
D. "Whenever something important occurs in treatment, the team needs to know about it. I’ll have to tell the others, but let’s talk about it first. "
