A nurse is collecting data from a client who has

131: A nurse is collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect?

Ans: Well-groomed appearance

Ritualistic behavior

Flight of ideas

Command hallucinations

 

132: A nurse is reinforcing teaching with a client about advanced directive. Which of the following information should the nurse include?

Ans: “Your health care surrogate will make decision on your behalf if you are unable.’

”You will need an attorney to appoint a health care surrogate.”

”You should appoint a family member as your health care surrogate.”

”Once you have completed a living will, it cannot be changed.”

 

133: A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

Ans: Hypertension

Decreased body temperature

Bradycardia

Increased incisional drainage

 

134: A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP’s performance of the task?

Ans: Request the AP to provide a return demonstration of the task.

Ask the family if the AP performed the task correctly.

Tell the AP to list the steps of the task.

Instruct the AP to report back once the task is complete.

 

135: A nurse is administering a client’s morning oral medications. Which of the following actions should the nurse take?

Ans: Identify the client by using one identifier before giving the medication.

Document medication administration prior to administering medication.

Verify the medication three times with the medication administration record.

Administer time-critical medication 60 min before or after the scheduled time.

 

136: A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider?

Ans: Obtain an aPTT level.

Change the medication to heparin IV.

Reduce the dosage of the medication.

Administer protamine sulfate.

 

137: A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?

Ans: Neck pain

Voice Alteration

Tingling of the scalp

Temporary memory loss

 

138: A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching?

Ans: Repeat each exercise movement 10 times.

Position the bed at mid-thigh level.

Move each joint past the point of resistance.

Support the extremity above and below each joint during the exercises

 

139: A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client’s provider. The nurse should identify that the client is using which of the following defense mechanisms?

Ans: Spitting

Conversion

Sublimation

Displacement

 

140: A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse initiate?

Ans: Droplet

Protective environment

Airborne

Contact

 

141: A nurse is reinforcing teaching with a client who has a cystocele. Which of the following statements by the client indicates an understanding of the teaching?

Ans: ”I should use a perineal spray to reduce odor from urinary leakage.”

”I will decrease my fluid intake to reduce incontinence.”

”I will practice perineal exercises to decrease urinary leakage.”

”I will experience less urinary incontinence if I use artificial sweeteners.”

 

142: A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

Ans: ”You can skip a dose of this medication if you are nauseated.”

”You might experience swollen gums while taking this medication.”

”You should expect to have blood work every 6 months while taking this medication.”

”You can safely take this medication if you become pregnant.”

 

143: A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

Ans: Loss of taste

Increased appetite

Bladder infection

Loose stools

 

144: A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse include?

Ans: “You should avoid exercising for the next 6 weeks.”

”You should avoid lying on your right side.”

”You should avoid crossing your legs for 3 months.”

”You should avoid putting a pillow between your legs when in bed.”

 

145: A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Ans: Inspection

Auscultation

Light palpation

Deep palpation