单选题The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal（）
单选题A voluntary client in a health care facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following? A. False imprisonment. B. Limit setting. C. Slander. D. Violation of confidentiality.
单选题The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication? A. Chills and tachycardia. B. Urinary frequency and burning on urination. C. Dizziness and fainting. D. Pink-tinged urine and bladder spasms.
单选题While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should A. attempt rescue breaths. B. attempt to reposition the airway a third time. C. administer five back blows. D. attempt to ventilate with a handheld resuscitation bag.
单选题The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this? A. Interpreting proverbs. B. Spelling words backward. C. Counting by serial sevens. D. Discussing hypothetical ethical situations.
单选题An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for （）.
单选题A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to indicate her ineffective coping? A. Inability to make choices and decisions without advice. B. Showing interest only in solitary activities. C. Avoiding developing relationships. D. Recurrent self-destructive behavior with history of depression.
单选题Which of the following would be most appropriate for the nurse to include in the plan of care for a dying child to meet the child's emotional needs during the last days of life? A. Restrict visitors to the parents to avoid overtaxing the child. B. Answer the child's questions about illness and death honestly. C. Focus on the child's physical needs to attempt to prevent sadness. D. Encourage the child to play quietly with a roommate to provide pleasure.
单选题After assessing a newly admitted 5-year-old child, the nurse makes the
nursing diagnosis of Parental role conflict related to child's hospitalization.
Which defining characteristic would most suggest this diagnosis?
A. Supportive child-parent interaction (speaking, listening, touching, and
eye-to-eye contact).
B. Parents' active participation in child's physical or emotional
care.
C. Parents' failure to use available support systems or agencies to assist
in coping.
D. Evidence of adaptation to parental role changes.
单选题A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response? A. "I can see you're upset. Why don't we discuss this with you at a later time when you're feeling better. " B. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again. " C. "Let me check with your physician and get you something that will help you relax. " D. "Pregnancy should be avoided until all of your testing is normal. /
单选题While admitting a young client with severe anorexia nervosa to the unit, the nurse finds a bottle of assorted pills in the client's luggage. The client tells the nurse they are antacids for stomach pains. The best initial response by the nurse would be A．"Let's talk about your drug use. " B．"These pills don't look like antacids. " C．"Tell me more about these stomach pains. " D．"Some adolescents take pills to lose weight. /
单选题The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should A. apply suction to the NG tube every hour. B. clamp the NG tube if the client complains of nausea. C. irrigate the NG tube gently with normal saline solution. D. reposition the NG tube if pulled out.
单选题A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub--a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position? A. Semi-Fowler's. B. Leaning forward while sitting. C. Supine. D. Prone.
单选题The nurse is instructing an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions? A. "I will empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag. " B. "I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container. " C. "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container. " D. "I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container. /
单选题While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to A. document findings thoroughly. B. question the client about the bruising. C. inform appropriate local authorities. D. tell the client's physician.
单选题A 35-year-old client is undergoing a brain computed tomography (CT) scan because of continued migraine headaches. He's placed in the CT scanner and suddenly begins to complain of palpitations, sweating, shortness of breath, and shaking. The client is most likely experiencing A. an allergic reaction. B. a myocardial infarction (MI). C. a panic attack. D. a hypoglycemic episode.
单选题The nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by A. genetic dysfunction. B. upper and lower motor neuron lesions. C. decreased conduction of impulses in an upper motor neuron lesion. D. a lower motor neuron lesion.
单选题Lily, a 23-month-old, pulled a pan of hot water off the stove and spilled it onto her chest and arms. Her mother was right there when it happened. Which of the following is the most appropriate that the mother should have done immediately
单选题A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia.
单选题The client with diverticulitis is treated as an outpatient with drug therapy. Which drug therapy will most probably be employed? A. Antidepressants. B. Laxatives. C. Steroids. D. Broad-spectrum antibiotics.