单选题While auscultating heart sounds of a client with heart failure, the
nurse hears an extra heart sound immediately after the second heart sound
(S2). The nurse should document this as
A. a first heart sound (S1).
B. a third heart sound (S3).
C. a fourth heart sound (S4).
D. a murmur.
单选题The nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to A. install safety devices in his home. B. wear comfortable shoes. C. get help when lifting objects. D. wear protective devices when exercising.
单选题Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? A. Monitoring intake and output. B. Allowing the infant to rest undisturbed. C. Providing age-appropriate diversionary activities. D. Initiating oral feedings.
单选题A 40-year-old client is admitted to the psychiatric emergency department because of sleeping difficulty, poor judgment, and incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. Which diagnosis would the nurse suspect? A. Schizophrenia. B. Paranoid personality. C. Bipolar illness. D. Obsessive-compulsive disorder (OCD).
单选题Vasodilation or vasoconstriction produced by an external cause will
interfere with an accurate assessment of a client with peripheral vascular
disease (PVD). Therefore, the nurse should
A. keep the client warm.
B. maintain room temperature at 78°F (25.6℃).
C. keep the client uncovered.
D. match the room temperature with the client's body temperature.
单选题The nurse noticed that an 8-month-old child's posterior fontanel is slightly open. Which of the following should the nurse do next? A. Check the child's head circumference. B. Question the mother about the child's delivery. C. Schedule an X-ray of the child's head. D. Document this as a normal finding.
单选题Which of the following would the nurse expect to assess as presumptive signs of pregnancy? A. Amenorrhea and quickening. B. A positive pregnancy test and a fetal outline. C. Braxton Hicks contractions and Hegar's sign. D. Uterine enlargement and Chadwick's sign.
单选题The primary nursing diagnosis for a client with a medical diagnosis of major depression would be: A．Spiritual distress related to depression B．Self-esteem disturbance related to altered role C．Powerlessness related to the loss of idealized self D．Impaired verbal communication related to depression
单选题A patient with BPD cries bitterly, pounds the bed in frustration, and said: "this therapist also dislike me, I am going to die rather than stay here. " If you were his attending nurse, what would be the most helpful for you to assist the patient? A．Leave him alone until he calm down B．Tell him that the therapist is very kind and experienced C．Sit down and listen attentively if he wishes to talk about something D．Pat the patient reassuringly on the back and say, "I can understand it's difficult to bear. /
单选题The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called A. contusion. B. concussion. C. coup. D. contrecoup.
单选题A young adult had a significant reaction to the Mantoux test. What conclusion would the nurse make from the findings? A. The client has active tuberculosis. B. The client had active tuberculosis. C. The client has been exposed to tuberculosis. D. The client is immunocompromised.
单选题A 9-year-old child is in diabetes. The nurse offers to meet with the mother and the child's teacher before school to discuss the teacher's responsibilities in relation to the child's diabetes. Which of the following would the nurse expect to discuss in this meeting? A. How to perform a glucometer test. B. How to give an insulin injection. C. Signs and symptoms of hypoglycemia. D. The American Diabetic Association (ADA) diet.
单选题Which of the following would not be an indication of placental detachment? A. An abrupt lengthening of the cord. B. An increase in the number of contractions. C. Relaxation of the uterus. D. Increased vaginal bleeding.
单选题A client is recovering from coronary artery bypass grafting (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common, spontaneously resolving symptom? A. Depression. B. Ankle edema. C. Memory lapses. D. Dizziness.
单选题Which one is not right about personality disorder? A．Multiple personality disorder is distinct and separate personalities within the same person B．People with personality disorder often experience child abuse or traumatic C．Only the symptoms of personality disorder represent the person's stable characteristics and social functioning, he can be diagnosed personality disorder D．Paranoid and antisocial personality disorders are more commonly diagnosed in women than men
单选题Which of the following is an early symptom of glaucoma? A. Hazy vision. B. Loss of central vision. C. Blurred or "sooty" vision. D. Impaired peripheral vision.
单选题A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action? A. Assess and stabilize the client's medical needs. B. Assess and stabilize the client's psychological needs. C. Attempt to locate the nearest family member to get an accurate history. D. Arrange a transfer to the nearest medical facility.
单选题Which signs and symptoms are associated with an acoustic neuroma? A. Amenorrhea and obesity. B. Acromegaly. C. Ataxia and intention tremor. D. Unilateral hearing loss and tinnitus.
单选题Nitroglycerin is also available in ointment or paste form. Before applying nitroglycerin ointment, what should the nurse do first? A. Cleanse the skin with alcohol where the ointment will be placed. B. Obtain the client's pulse rate and rhythm. C. Remove the ointment previously applied." D. Instruct the client to expect pain relief in the next 15 minutes.
单选题James T. is admitted to the unit in an acute manic episode. He has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which of the following disorders would reflect James'symptom profile? A．Bipolar Ⅰ B．Bipolar Ⅱ C．Cyclothymic disorder D．Dysthymic disorder