During a Preparation for Parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" The nurse should tell the participant which of the following about true labor contractions?
True labor contractions are felt first in the lower back, then the abdomen.
A 14-month-old child has a severe diaper rash. Which of the following recommendations should the nurse provide to the parents?
Wash the buttocks using mild soap.
A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate?
Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:
dysfunction in the brain stem.
The primary goal in the plan of care for the client after cataract removal surgery is to:
Promote safety at home.
Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed?
Nurses who are pregnant must wear gloves during administration of cytotoxic drugs.
A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
The client has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?
I don't think about killing myself as much as I used to.
A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis?
The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
Sitting all afternoon in her room.
A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using:
Saline nose drops.
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following problems should receive the highest priority during the acute phase?
Ineffective breathing pattern related to neuromuscular impairment.
A client with Alzheimer's disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which of the following statements?
Dad said that what he missed most while he was here was using his aftershave.
The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has:
Reduced intestinal peristalsis.
When observing the client in a ritualistic pattern of behavior, the nurse should:
Allow the client to continue so that he will not become more anxious.
When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client's anxiety?
As a precaution, we wear gowns, goggles, and gloves to administer the medication.
Which of the following is appropriate language development for an 8-month-old? The child should be:
Saying "dada" and "mama" nonspecifically.
The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to:
Prevent dislocation of the prosthesis.
After a bronchoscopy with biopsy, the nurse assesses the client. Which of the following signs should be reported immediately to the physician?
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
The operative incision is near the diaphragm.
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?
Discuss meals that include low-fat high-carbohydrate content.
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Providing a solution of viscous lidocaine for use as a mouth rinse
A community health nurse is asked to consult with the family of a 4-year-old boy who is often disruptive at preschool, difficult to engage, and rarely speaks. When upset, the client flaps his arms and screeches. Which of the following questions and comments would be appropriate for the nurse to make to the parents? Select all that apply.
"Has a pediatrician evaluated your child? He seems to have some abnormal behaviors for his age."
"How does your child behave at home? If you do not see acting-out behavior there, part of his problem may be dealing with new situations, such as school."
"How do you respond if he disobeys or acts out at home? If your techniques help prevent negative behavior, perhaps teachers can try similar measures at school."
A nurse is caring for a client 24 hours after an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
Auscultate for bowel sounds.
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output
A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
Place a tongue blade lightly on the posterior aspect of the pharynx.
Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
Auscultation of moist crackles.
Which step should a nurse take first when administering a liquid medication to an infant?
Verify the physician order.
A client chronically complains of being unappreciated and misunderstood by others. He is argumentative and sullen. He always blames others for his failure to complete work assignments. He expresses feelings of envy toward people he perceives as more fortunate. He voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
Place the client in a private room.