Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance?
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse should tell the client that:
a bowel-cleansing procedure will precede radioactive implantation.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
Call for immediate assistance in the client's room.
A client is entering the chemical dependency unit for treatment of alcohol dependency. Which of the client's possessions should the nurse place in a locked area?
A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor, the nurse should expect to administer:
A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.
Instill isotonic eye drops, as necessary.
Provide several small, well-balanced meals.
Provide rest periods.
Weigh the client daily.
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan?
Increased risk for urinary tract infections.
The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. Which of the following should the nurse do next?
Administer oxygen at 8 to 10 liters by mask.
Ibuprofen (Motrin) is prescribed for a client with osteoarthritis. Which of the following instructions about ibuprofen should the nurse include in the client's teaching plan?
Take with food or antacids.
A nurse is frustrated by her inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. Her most professional response would be to:
discuss the situation with a more experienced peer.
The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next?
Anticipate that the physician will order laboratory tests and cultures.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose.
At what age should a boy be taught how to do a monthly testicular self-examination?
A client with muscle weakness and an abnormal gait is being evaluated for muscular dystrophy. Which test or finding confirms muscular dystrophy?
A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. The client's blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure?
A nurse is caring for a client with cystic fibrosis. With which members of the health care team is it most appropriate for her to collaborate? Select all that apply.
In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client voices which of the following?
I get so angry at times that I have to have a couple of drinks before I sleep.
A client in the second stage of labor is fully dilated. Which nursing action is appropriate for this stage of labor?
Assessing vital signs every 15 minutes
The nurse is taking care of a client with Clostridium difficile. The nurse should do which of the following to prevent the spread of infection? Select all that apply.
Wear a protective gown when in the client's room.
Wash hands with soap and water.
The parents of a neonate with a cleft lip are shocked when they see their child for the first time. Which of the following nursing actions should the nurse include in the neonate's plan of care to help the parents accept their newborn's anomaly?
Showing them pictures of babies before and after corrective surgery.
A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?
A client 4 days postoperative after mitral valve replacement
A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action best identifies potential complications of this disease?
Instituting cardiac monitoring
A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? Select all that apply.
Staying with the client until she receives further instructions
Continuing to speak to the client in a reassuring tone
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
Which measurement should a nurse use to monitor the respiratory status of a client with pulmonary edema?
Arterial blood gas (ABG) analysis
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status?
Can you ride a tricycle?
A client commonly jumps when spoken to and reports feeling uneasy. The client says, “It’s as though something bad is going to happen.” In which order from first to last should the following nursing actions be done?
Reduce environmental stimuli.
Ask the client to deep breathe for 2 minutes.
Discuss the client’s feelings in more depth.
Teach problem solving strategies.
A client in the manic phase of bipolar disorder is admitted to the facility. Which agents are appropriate for this client?
Lithium (Lithobid) and valproic acid (Depakote)