更多"While assessing a client who compla"的相关试题:
[单项选择]An elderly female client, who is quite confused and often does not recognize her children, is admitted to a nursing home. The client appears slovenly in attire, often soiling her clothing with feces and urine. The nurse can best manage this problem by（ ）
A. Putting the client into orientation therapy
B. Toileting the client at least once every 2 hours
C. Supervising the client’s bathroom activities closely
D. Explaining to the client how offensive her behavior is to others
[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]A client with three children who is still in her childbearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon’s preoperative teaching when the client states（）
A. "If I should become pregnant again, the child would be delivered by cesarean delivery. "
B. "If I have another child, the procedure may need to be repeated. "
C. "This surgery may render me incapable of conceiving another child. "
D. "This procedure is accomplished in two separate surgeries. "
[单项选择]A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client（）
A. Acute pain related to surgery.
B. Deficient fluid volume related to blood and fluid loss from surgery.
C. Impaired physical mobility related to surgery.
D. Risk for aspiration related to anesthesia.
[单项选择]A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to（）
A. prevent leaning.
B. distribute weight away from the involved side.
C. maintain stride length.
D. prevent edema.
[单项选择]A hospitalized client craves a drink while withdrawing from alcohol. Which of the following measures is the best way to help the client resist the urge to drink（）
A. A routine search of visitors.
B. A locked-door policy.
C. One-to-one supervision by the staff.
D. Support from other alcoholic clients.
[单项选择]Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. Which nursing observation most suggests the client is bleeding（）
A. Prolonged partial thromboplastin time (PTT).
B. Recent history of warfarin (Coumadin) usage.
C. Diminished breath sounds.
D. Orthostatic hypotension.
[单项选择]The nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize（）
A. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.
B. Store the drug in a cool, well-lit place.
C. Lie down or sit in a chair for 5 to 10 minutes after taking the drug.
D. Restrict alcohol intake to two drinks per day.
[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]The nurse is evaluating a client who is complaining of shortness of breath. The client’s respiratory rate is 26 breaths per minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means（）
A. frequent bowel sounds.
B. heart rate greater than 100 beats/minute
C. hyperventilation.
D. respiratory rate greater than 20 breaths/minute
[单项选择]The nurse is interviewing a client who is currently under the influence of a controlled substance and shows signs of becoming agitated. What should the nurse do（）
A. Use confrontation.
B. Express disgust with the client’s behavior.
C. Be aware of hospital security.
D. Communicate a scolding attitude to intimidate the client.
[单项选择]A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention isn’t appropriate for this client（）
A. Acknowledging the client’s spiritual distress.
B. Inviting the client’s clergyman to visit him.
C. Encouraging the client to discuss religious beliefs and practices.
D. Encouraging the client to discuss concerns with the clergy.
[单项选择]The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to（）
A. change his own dressing.
B. walk in the hallway.
C. walk from his room to the end of the hall and back before discharge.
D. eat a special diet.
[单项选择]A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver（）
A. Breast tenderness.
B. Breakthrough bleeding within first 3 months of use.
C. Decreased menstrual flow.
D. Blurred vision and headache.
[单项选择]A client who is planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse’s best response（）
A. "Pregnancy is a human process; you don’t have to worry. "
B. "You practice good health habits; just follow them and you’ll be fine. "
C. "There is nothing you can do to have a healthy pregnaney; it’s all up to nature. "
D. "Folic acid, 400 mcg(1mcg= 10μg), improves pregnancy outcomes by preventing certain complications. "
[单项选择]A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub--a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position（）
A. Semi-Fowler’s.
B. Leaning forward while sitting.
C. Supine.
D. Prone.
[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.
