更多"During the assessment of a geriatri"的相关试题:
[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 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]In performing a routine fundal assessment, the nurse finds a client’s fundus to be "boggy. " What action should the nurse take first()
A. Call the physician.
B. Massage the fundus.
C. Assess lochia flow.
D. Start methylergonovine as ordered.
[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]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.
[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. "
[单项选择]During the admission interview, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, "Do you think I will ever get better I don’t know what is wrong with me. " The nurse’s most supportive response would be()
A. "It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal. "
B. "I’m not sure what is wrong, but the medication will help you soon enough. "
C. "It’s important to talk to your physician about an issue such as this. "
D. "Don’t feel bad; the treatment will help you. "
[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]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]During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurse’s best action()
A. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.
B. Be alert for a possible eating problem and do a further in-depth assessment.
C. Report the client’s concerns to her caregiver.
D. Ask her to come back to the clinic every 2 weeks for a weight check.
[单项选择]During the first 24 hours after a client is diagnosed with addisonian crisis, which of the following should the nurse perform frequently()
A. Weigh the client.
B. Test urine for ketones.
C. Assess vital signs.
D. Administer oral hydrocortisone.
[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 the evening shift on the day of the client’s surgery, the nurse notices that the nasogastric tube drains 500 mL of green-brown fluid. What should the nurse do( )
A. Record the amount of drainage on the client’s chart.
B. Irrigate the tube with normal saline solution.
C. Call the physician immediately.
D. Increase the intravenous infusion rate.
[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]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.