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Question 1 of 30
1. Question
1 point(s)Category: Physiological AdaptationThe client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
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Question 2 of 30
2. Question
1 point(s)Category: Psychosocial IntegrityThe client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
CorrectIncorrect -
Question 3 of 30
3. Question
1 point(s)Category: Psychosocial IntegrityThe client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
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Question 4 of 30
4. Question
1 point(s)Category: Psychosocial IntegrityThe client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
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Question 5 of 30
5. Question
1 point(s)Category: Pharmacological and Parenteral TherapiesThe doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?
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Question 6 of 30
6. Question
1 point(s)Category: Reduction of Risk PotentialA client is admitted to the labor and delivery unit in active labor. During the examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
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Question 7 of 30
7. Question
1 point(s)Category: Physiological AdaptationA client with a diagnosis of HPV is at risk for which of the following?
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Question 8 of 30
8. Question
1 point(s)Category: Physiological AdaptationDuring the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
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Question 9 of 30
9. Question
1 point(s)Category: Physiological AdaptationA client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
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Question 10 of 30
10. Question
1 point(s)Category: Reduction of Risk PotentialA 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
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Question 11 of 30
11. Question
1 point(s)Category: Reduction of Risk PotentialThe nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
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Question 12 of 30
12. Question
1 point(s)Category: Safety and Infection ControlA primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
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Question 13 of 30
13. Question
1 point(s)Category: Reduction of Risk PotentialA diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidylglycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
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Question 14 of 30
14. Question
1 point(s)Category: Health Promotion and MaintenanceWhich observation in the newborn of a diabetic mother would require immediate nursing intervention?
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Question 15 of 30
15. Question
1 point(s)Category: Pharmacological and Parenteral TherapiesThe nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
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Question 16 of 30
16. Question
1 point(s)Category: Reduction of Risk PotentialThe client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
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Question 17 of 30
17. Question
1 point(s)Category: Physiological AdaptationA client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
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Question 18 of 30
18. Question
1 point(s)Category: Reduction of Risk PotentialThe nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
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Question 19 of 30
19. Question
1 point(s)Category: Physiological AdaptationThe client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
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Question 20 of 30
20. Question
1 point(s)Category: Safety and Infection ControlThe home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
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Question 21 of 30
21. Question
1 point(s)Category: Reduction of Risk PotentialThe nurse working the organ transplant unit is caring for a client with a decreased white blood cell count. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
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Question 22 of 30
22. Question
1 point(s)Category: Physiological AdaptationThe nurse is caring for the client following a laryngectomy when suddenly the client becomes unresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
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Question 23 of 30
23. Question
1 point(s)Category: Reduction of Risk PotentialThe client admitted 2 days earlier that a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
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Question 24 of 30
24. Question
1 point(s)Category: Reduction of Risk PotentialA client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
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Question 25 of 30
25. Question
1 point(s)Category: Health Promotion and MaintenanceWhich selection would provide the most calcium for the client who is 4 months pregnant?
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Question 26 of 30
26. Question
1 point(s)Category: Pharmacological and Parenteral TherapiesThe client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
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Question 27 of 30
27. Question
1 point(s)Category: Management of CareA 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
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Question 28 of 30
28. Question
1 point(s)Category: Physiological AdaptationA client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
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Question 29 of 30
29. Question
1 point(s)Category: Physiological AdaptationThe nurse is evaluating nutritional outcomes for a with anorexia nervosa. Which data best indicates that the plan of care is effective?
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Question 30 of 30
30. Question
1 point(s)Category: Physiological AdaptationThe client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
CorrectIncorrect