All Clients Need (0001-0200) Flashcards Preview

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A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the nursing assistant to look for and report which of the following symptoms?

Tarry stools.


A nurse is assessing a 10-year-old girl. The girl's mother informs the nurse that she's concerned about her daughter's breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response?

The changes in your daughter's breasts are the first signs of puberty.


A 1-year-old child is admitted to the hospital with sickle cell crisis. Which of the following will be a part of the child's plan of care?

I.V. fluid therapy.


A mother tells the nurse that her 4-year-old boy has developed some strange eating habits including not finishing meals and eating the same food for several days in a row. She would like to develop a plan to correct this situation. When developing such a plan, which of the following should the nurse and mother consider?

Allowing him to make some decisions about the foods he eats.


When obtaining a client's history, the nurse should:

ask questions about the client's reason for seeking care.


A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. Which of the following is the nurse's best response?

What exactly are these terrible voices saying to you?


A graduate nurse is planning to perform a Romberg’s test on a client. The registered nurse would assess that the graduate nurse knows how to correctly perform this test when she sees the graduate nurse

Ask the client to try to balance himself with feet together and eyes open, and then eyes closed.


A school-age child diagnosed with attention deficit hyperactivity disorder is prescribed methylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?

Loss of appetite.


On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, “I look horrible! Will it ever look better?” Which of the following responses by the nurse would be most appropriate?

”You’re shocked by the sudden change in your appearance as a result of this surgery, aren’t you?”


A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should:

Report the finding to the health care provider.


Which situation violates the Health Insurance Portability and Accountability Act?

A nurse gives a client's family members a report on his progress.


When teaching a primigravid client at 24 weeks' gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include?

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.


While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother’s temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:

Continue to monitor the client’s vital signs.


A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area.


A nurse fails to give the evening dose of an I.V. antibiotic that is to be administered every 12 hours. The nurse should next:

Report the incident to the physician.


The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child's identity by checking the arm band and:

Asking the parent the child's name.


A physician orders gentamicin sulfate (Garamycin), 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least:

30 minutes.


While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement?

I tell her she is wrong and then I tell her what's right.


A female client with gonorrhea informs the nurse that she has had sexual intercourse with her boyfriend and asks the nurse, "Would he have any symptoms?" The nurse responds that in men the symptoms of gonorrhea include:



Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery?

Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.


A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?

Sew thick padding into the elbows and knees of the child's clothing.


Which of the following statements indicates that the client understands the home care of a colostomy?

”I should be able to establish a regular pattern of elimination with my colostomy.”


The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of which of the following?

A normal pattern in infants of this age.


An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods and liquids through a syringe. The nurse determine's his biggest nutritional risk factor is:

Impaired oral motor control.


After the nurse counsels a primiparous client who is breastfeeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?

“I should drink at least five glasses of fluid daily.”


A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client's room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?

If you're thinking about organ donation, my sister is waiting for a kidney transplant. She'd be an excellent recipient. I can give you her phone number.


During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?

A sachet of lavender.


When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight.


Which of the following indicates the client with ulcerative colitis has attained an expected outcome of nursing care?

The client maintains an ideal body weight.


The nurse is assisting a client with a stroke who has homonymous hemianopia? The client will:

Eat food on only half of the plate.