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A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
A chronic alcoholic client’s condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:
While the nurse is taking a male client’s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?
A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, “Something is wrong. This is like my labor.” Which reply by the nurse identifies the physiological response of the client?
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the “tension-building phase,” the nurse might expect the client to describe which of the following?
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse’s most therapeutic response will be:
A client is pleased about being pregnant, yet states, “It is really not the best time, but I guess it will be OK.” The nurse’s assessment of this response is:
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, “You leave me alone. You don’t care anything about me. It’s people like you who let my baby die.” The nurse’s best course of action is to:
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer’s disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:
A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14- year-old with some of the missing items. The best response of the nurse is to:
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