All Clients Need (0801-1000) Flashcards Preview

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Flashcards in All Clients Need (0801-1000) Deck (200)
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Which of the following outcomes should the nurse include in the initial plan of care for a client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions?

The client will interact with the nurse.


When the open method is used for treating burns, which of the following actions should the nurse take to help prevent discomfort caused by air currents over the client’s burned skin surfaces?

Support the bed linens on a cradle.


A client with cirrhosis should be encouraged to follow which diet?

Well-balanced normal nutrients, low-sodium diet.


A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?

Playing with the child every day.


The nurse is reviewing the chart of a 55-year-old male client who is scheduled for a lumbar laminectomy. The nurse should report which of the following to the surgeon?

Pimple on the lower back.


A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:

Bowel regimen.


An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?

Deficient knowledge (disease process and treatment regimen)


When developing appropriate short-term goals with clients who are inpatients, which of the following is most realistic?

The client will write a list of strengths and needs.


Four months ago, the son and daughter of a client who was in a vegetative state gave consent for a feeding tube and agreed to long-term care placement. Nurses in the long-term care facility note that the son and daughter have recently become more distraught over their mother's condition. One day while visiting together, the son and daughter approach the nurse about having the feeding tube removed. Which statement by the nurse best explains the legal rights of individuals in this situation?

Legally, there are no time constraints on previous decisions made.


A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:

hold and rock him and give him a security object.


Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested?

Ketoconazole suppresses adrenal steroid secretion.


The charge nurse on an antepartal unit is making staffing assignments for the day. There is an RN, licensed practical nurse (LPN), and an unlicensed personnel (UAP) to care for 25 patients. The nurse should assign which of the following clients to the LPN?

A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4-6 hours prn while awaiting urine cultures to be returned.


A 19-year-old unmarried college student is approximately 8 weeks pregnant asks the nurse, "If I have an abortion in the next 2 or 3 weeks, how will it be done?" The nurse instructs the client that at this gestational age an abortion is usually performed by which of the following techniques?

Dilatation and curettage.


While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do?

Irrigate the tube with cola.


A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:

Wait until the father arrives.


A female client who has a urinary diversion tells the nurse, "This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore." The most appropriate nursing goal for this client is to:

Express fears about the urinary diversion.


Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?

Ask the client to identify other situations in which he demonstrated responsibility for himself.


The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the accompanying chart and compares these findings to the Apgar score obtained at birth, also found in the chart. What should the nurse do next?

Continue to assess the neonate.


When developing the discharge teaching plan for a child with chronic renal failure and the family, the nurse should emphasize restriction of which of the following nutrients?



The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be most appropriate for this client?

Ask the client's spouse to supervise the daily administration of the medications.


A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and doesn't respond to verbal or tactile stimuli. In formulating nursing care interventions, the nurse should give priority to:

observing and evaluating the client's nutritional needs.


Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term?

Sole creases covering the entire foot.


The mother of a 3-year-old child tells the nurse her child is "fussy" and not as "easy going" as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:

Provide structured feeding times and routines.


Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?

Absence of tear formation.


The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?

Rebound hypoglycemia.


After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:

Take thyroxine replacement for the remainder of the client's life.


An 18-year-old tells the nurse, "Everyone does it, so it's all right," to justify rule-breaking behavior. The nurse realizes this is an example of which level or stage of moral reasoning development as described by Kohlberg?



A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply.

  • T-wave inversion
  • ST-segment elevation
  • Pathologic Q-wave


An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which of the following actions should the school nurse do ?

Move the adolescent to a cool environment.


A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors is most likely of greatest significance in causing an exacerbation of ulcerative colitis?

A demanding and stressful job.