单选题During a morning assessment, the nurse percusses tympany. The nurse understands that tympany is a loud, high-pitched, moderately long sound with a drumlike, musical quality that's most commonly heard over the A. heart. B. liver. C. pancreas. D. stomach.
单选题As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal of the report? A. Staff involved so they're reprimanded for their actions. B. Learning needs of staff to prevent recurrence of incidents. C. Patterns of client care problems. D. Facts surrounding each incident.
单选题When assessing a client with chest pain, the nurse obtains a thorough
history. Which statement by the client is most suggestive of angina pectoris?
A. "The pain lasted for about 45 minutes. "
B. "The pain resolved after I ate a sandwich. "
C. "The pain worsened when I took a deep breath. "
D. "The pain occurred while I was mowing the lawn. "
单选题What laboratory finding is the primary diagnostic indicator for pancreatitis? A. Elevated blood urea nitrogen (BUN). B. Elevated serum lipase. C. Elevated aspartate aminotransferase (AST). D. Increased lactate dehydrogenase (LD).
单选题A 15-year-old girl with anorexia refuses to eat in a mental health unit. Which of the following statements is the best response from the nurse? A. "Why do you think you're fat? You're underweight. Here--look in the mirror. " B. "You really look terrible at this weight. I hope you'll eat. " C. "You don't have to eat. It's your choice. " D. "I hope you'll eat your food by mouth. Tube feedings and IV lines can be uncomfortable. /
单选题The nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her neonate. Which of the following should the nurse do? A. Call the pediatrician and report the behavior. B. Anticipate and support the behavior as a normal part of bonding. C. Encourage the mother to rewrap the neonate because the room is cold. D. Take the neonate back to the nursery and recheck the neonate's temperature.
单选题A multigravida in her 34th week of gestation presents in the emergency department complaining of vaginal bleeding. Which of the following should be the nurse's first action? A. Establish IV access. B. Assess fetal heart rate (FHR) and maternal blood pressure. C. Prepare the client for a cesarean delivery. D. Assess maternal heart rate and respiratory rate.
单选题During the night, a 50-year-old Vietnam veteran with posttraumatic stress syndrome wakens shaking and tells you that someone is trying to smother him. What is the appropriate response for the nurse in this situation? A. "It was a bad dream. You are safe. I'll stay here with you until you go back to sleep. " B. "We can talk about it tomorrow. Try to see if you can get back to sleep. " C. "It was only a dream. There's nothing to be frightened about. " D. "I'll call the physician and see whether I can get you medication to help you go back to sleep. /
单选题The nurse is caring for a client who has hemoconcentration after fluid loss. Which IV fluids would be the most appropriate fluid replacement therapy for this client? A. Distilled water. B. Dextrose 5% in water (D5W) only. C. DSW with 40 mEq of potassium chloride. D. Dextrose 10% in saline.
单选题Which of the following ego defense mechanisms is most pronounced in paranoid conditions in which there is an actual break with reality? A．Displacement B．Isolation C．Regression D．Projection
单选题A client with multiple sclerosis has been prescribed baclofen. The nurse teaches the client about the action of the drug. Which of the following is an accurate instruction regarding this drug's action? A. "Baclofen will decrease your fatigue and help increase your energy levels. " B. "Baclofen will help relieve the muscle spasms that you have been experiencing. " C. "It is an antibiotic that will help treat your urinary tract infection. " D. "Taking this drug will help decrease the visual problems you have been having. /
单选题A client is receiving chemotherapy for cancer. The nurse reviews his laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? A. Activity intolerance. B. Impaired tissue integrity. C. Impaired oral mucous membranes. D. Ineffective tissue perfusion (cerebral, cardiopulmonary, GI).
单选题A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching? A. "I'll need to keep several pillows between my legs at night. " B. "I need to remember not to cross my legs. It's such a habit. " C. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed. " D. "I don't know if I'll be able to get off that low toilet seat at home by myself. /
单选题WhichpartonthewavedeflectioncorrespondstoventricularmusclerepolarizationinthefollowingECGgraph?A.AB.BC.CD.D
单选题On initial assessment of a 7-year-old with rheumatic fever, which of the following would require the nurse to contact the physician immediately? A. Heart rate of 150 bpm. B. Twitching in the extremities. C. Red rash on the trunk. D. Swollen and painful knee joints.
单选题A 14-year-old female client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone? A. Autonomy. B. Initiative. C. Industry. D. Identity.
单选题Which of the following describes a preterm neonate? A. A neonate weighing less than 2,500 g (5 lb, 8 oz). B. A low-birth-weight neonate. C. A neonate born at less than 37 weeks' gestation regardless of weight. D. A neonate diagnosed with intrauterine growth retardation.
单选题A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by A. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. B. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. C. draining urine from the drainage bag into a sterile container. D. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.
单选题A 6-year-old girl has been hospitalized with rheumatic fever for 4
weeks. Her symptoms have gradually subsided, and she's now ready for discharge.
Which of the following plans for her health care is most important for her
future well-being?
A. Arrange for her to return to school as soon as possible to promote
psychosocial development.
B. Encourage her to engage in unrestricted physical activity to regain
physical strength.
C. Arrange for the administration of prophylactic antibiotics to prevent a
recurrence of rheumatic fever.
D. Maintain seizure precautions, as central nervous system involvement may
persist for several months.
单选题The nurse is developing a care plan for a client who's at risk for ineffective coping due to the effects of chronic illness. Which factor provides the best evidence that the client is at risk for difficulty in coping with his illness? A. Poor sleeping habits. B. Lack of social support. C. Adverse drug effects. D. Presence of panic disorder.