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发布时间:2023-10-18 21:21:11

[单项选择]A client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distention, it’s typically due to()
A. a neck tumor.
B. an electrolyte imbalance.
C. dehydration.
D. fluid overload.

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[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]A client who has been admitted to the emergency room is restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances()
A. Hypokalemia.
B. Hypercalcemia.
C. Hypomagnesemia.
D. Hypernatremia.
[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 aftercare.
[单项选择]The nurse in the emergency department is assessing a 64-year-old client experiencing substernal chest pain. The client’s electrocardiogram shows evidence of myocardial ischemia. Which statement should indicate to the nurse that the client may be a candidate for thrombolytic therapy()
A. "I have had chest pain for 2 days. "
B. "My chest pain started 3 hours ago. "
C. "My chest pain stops when I take a nitroglycerin pill. "
D. "I have had chest pain on and off all week. "
[单项选择]A client admitted for a hysterectomy has a secondary diagnosis of Ménière s disease. Which of the following nursing interventions should the nurse include in the client’s plan of care to decrease the effects of tinnitus()
A. Reduce the amount of glucose and cholesterol in the diet.
B. Encourage the client to listen to the radio with earphones.
C. Encourage a weight-reduction diet.
D. Administer antihypertensive medications as ordered.
[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 for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa()
A. "I’ve gained 3 pounds in the last month. "
B. "I eat loads of spinach and yellow vegetables each day. "
C. "I’m a perfectionist, and I work hard to get A’s. "
D. "I binge frequently in the morning and feel fat. "
[单项选择]An elderly client is admitted to the hospital with the diagnoses of dementia of the Alzheimer’s type and depression. The client has all of the following symptoms. The symptom that is unrelated to the depression would be( )
A. Shallow or labile affect
B. Neglect of personal hygiene
C. "I don’t know" answers to questions
D. Apathetic response to the environment
[单项选择]A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects the client has a belief that he is()
A. highly important or famous.
B. being persecuted.
C. connected to events unrelated to himself.
D. responsible for the evil in the world.
[单项选择]A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. 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()
A. 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 with atrial fibrillation. The physician noted a pulse deficit. The pulse deficit measures which of the following()
A. The difference between apical and radial pulse rates.
B. The difference between systolic and diastolic blood pressures.
C. The amount of blood ejected from the left ventricle per minute.
D. The percentage of blood emptied from the ventricle during contraction.
[单项选择]A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature()
A. Oral.
B. Rectal.
C. Axillary.
D. Tympanic.
[单项选择]A client is admitted to the hospital for treatment of Prinzmetal’s angina. When developing the client’s plan of care, the nurse should remember that this type of angina is triggered by()
A. coronary artery spasm.
B. an unpredictable amount of activity.
C. activities that increase oxygen demand.
D. an unknown source.
[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.
[单项选择]An elderly female client is admitted to a nursing home from the general hospital with a diagnosis of dementia of the Alzheimer’s type. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse notes that the client has laid out several dresses on her bed but has not changed from her nightclothes. It would be most helpful for the nurse to( )
A. Remind the client to dress more quickly to avoid delaying the other residents
B. Help the client select appropriate attire and offer her assistance in getting dressed
C. Help the client dress and tell her what time the residents are expected at the activity
D. Allow the client as much time as she needs but explain that she is too late to attend this activity
[单项选择]A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using()
A. Withdrawal.
B. Logical thinking.
C. Repression.
D. Denial.
[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]The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority()
A. Risk for self- or other-directed violence.
B. Imbalanced nutrition.
C. Ineffective coping.
D. Impaired verbal communication.
[单项选择]An unconscious client has been admitted with a head injury. Which of the following nursing diagnoses would receive the greatest priority in the plan of care( )
A. Disturbed sensory perception related to decreased level of consciousness.
B. Ineffective airway clearance related to inability to remove respiratory secretions.
C. Impaired gas exchange related to shallow irregular breathing.
D. Risk for injury related to disorientation and decreased level of consciousness.

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