Health promotion and maintanance & Basic care and comfort
1.
During a neurological assessment, Nurse Maria needs to evaluate cranial nerves IX (glossopharyngeal) and X (vagus) in a client who reports difficulty swallowing and hoarseness. Which equipment is necessary to complete this part of the cranial nerve assessment?
2.
During a neurological assessment, a client who reports difficulty swallowing and hoarseness is being evaluated by the nurse for cranial nerve function. Which equipment is necessary to properly assess cranial nerves IX (glossopharyngeal) and X (vagus)?
3.
A 6-week-old infant weighing 8.5 lb, 6 oz is born to a mother with gestational diabetes. Shortly after birth, the neonate becomes jittery, lethargic, and irritable. Which nursing intervention should be implemented first?
4.
Mr. James, a 58-year-old male, comes to the clinic for a routine digital rectal examination (DRE). Which question should the nurse ask first to gather important information relevant to this procedure?
5.
A client in active labor is receiving IV oxytocin (Pitocin) for labor induction. During continuous fetal monitoring, the nurse observes prolonged late decelerations in the fetal heart rate. What is the priority nursing intervention?
6.
A 4-month-old infant is prescribed an oral medication during a routine hospital visit. Which nursing approach would be most appropriate to ensure safe and effective administration?
7.
A 2-month-old infant is recovering in the post-operative unit after surgery. Which nursing intervention should be prioritized during the immediate post-operative period?
8.
During a routine physical examination of a newborn, the nurse notes several findings. Which assessment should be reported immediately to the physician?
9.
During a routine physical examination of a newborn, the nurse notes several findings. Which assessment should be reported immediately to the physician?
10.
During a routine health history, a 21-year-old male client reports several personal and family health details. Which piece of information would indicate an increased risk for developing testicular cancer?
11.
While performing a routine assessment, the nurse observes a pulsating mass in the periumbilical area of a client. Which assessment should the nurse perform next to gather appropriate data?
12.
The nurse is observing 4-year-old children playing in the hospital playroom. Based on developmental stage, which type of activity would the nurse expect to see during playtime?
13.
During a well-baby visit, the nurse is teaching the parents of a 3-month-old infant about proper nutrition. Which fluid should the nurse emphasize as the primary source of hydration and nutrition for the infant until about 12 months of age?
14.
While administering medications, a client states, “I do not want to take that medicine today.” Which response by the nurse would be most appropriate to maintain client autonomy and safety?
15.
During a routine well-baby check, the nurse is assessing a 4-month-old infant for developmental milestones. Which motor skill would the nurse expect to observe at this age?
16.
During a routine assessment of an older adult client, the nurse observes several physical changes of the head and face. Which finding is not typically associated with normal aging?
17.
During a medication review, the nurse is assessing an older adult client for factors that may increase the risk of adverse drug effects. Which characteristic would not typically indicate increased risk?
18.
A newborn is delivered to a mother who consumed alcohol during pregnancy. During the initial assessment, which clinical manifestation should the nurse expect to observe?
19.
The nurse is preparing to perform a procedure on a 4-year-old child. Which statement would be most effective in communicating with the child to reduce anxiety and encourage cooperation?
20.
A 64-year-old client scheduled for surgery under general anesthesia refuses to remove their dentures before leaving the unit for the operating room. What is the most appropriate intervention by the nurse?
21.
A client reports her last menstrual period (LMP) was March 17 and she has missed one period. She is experiencing nausea and vomiting, and a urine pregnancy test is positive. Using Naegle’s rule, what is the estimated date of delivery (EDD)?
22.
The family of a 6-year-old child with a fractured femur asks the nurse whether the injury will affect the child’s future height. Which statement about long bone fractures in children is accurate?
23.
A 6-year-old child is admitted with a fractured femur. The family asks the nurse whether the injury could affect the child’s future height. Which statement about long bone fractures in children is correct?
24.
A client is admitted to the hospital with a history of confusion. The nurse notes that the client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would be the most effective to provide reality orientation for this client?
25.
A client expresses a desire to improve the appearance of the eyes by removing excess skin from the face and neck. Which cosmetic procedure should the nurse provide teaching about?
26.
A woman who is six months pregnant visits the antepartal clinic and reports trouble with constipation. Which instruction should the nurse provide to help minimize this condition?
27.
The nurse is caring for an elderly woman who underwent hip fracture repair. In the first few days post-surgery, which nursing intervention will best facilitate the client’s resumption of daily activities?
28.
A client with major head trauma is admitted to the ICU and is about to receive a bolus enteral feeding via a nasogastric tube. Which nursing order is most important to ensure the client’s safety?
29.
A 52-year-old client with liver cirrhosis is admitted for upper gastrointestinal bleeding. During assessment, the nurse notes esophageal varices. Which pathological process is primarily responsible for the development of esophageal varices?
30.
A client reports heartburn and regurgitation and is diagnosed with gastroesophageal reflux disease (GERD). Which intervention would best help lessen the effects of acid reflux?
31.
A client in the hospital reports muscle tension and stress. The nurse is considering therapeutic massage as a complementary intervention. What is the main benefit of therapeutic massage?
32.
A client diagnosed with gastroesophageal reflux disease (GERD) reports frequent heartburn. Which foods should the nurse advise the client to avoid to reduce the risk of acid reflux?
33.
A client in the hospital is receiving total parenteral nutrition (TPN) via a central venous catheter. Which intervention should the nurse include in the plan of care to ensure safe and effective therapy?
34.
A client diagnosed with lactose intolerance seeks guidance on dietary management. Which intervention should the nurse include in the client’s plan of care?
35.
An elderly client with cancer is being assessed for pain. How does pain tolerance typically present in older adults compared with younger adults?
36.
A client reports mild to moderate pain after surgery. The nurse considers using cutaneous stimulation techniques (such as massage, heat, or cold application) as part of pain management. What is the main advantage of cutaneous stimulation in managing pain?
37.
A 65-year-old female client diagnosed with osteoporosis visits the clinic for education. Which exercise instruction should the nurse emphasize as most important to promote bone health and prevent fractures?
38.
A client in a long-term care facility reports pain. The nurse begins a pain assessment. What is the first step the nurse should take to accurately evaluate the client’s pain?
39.
A 7-year-old child has been bedridden following orthopedic surgery. The nurse is educating the parents about the effects of immobility. Which statement best describes the consequences of immobility in children?
40.
A client recovering from a myocardial infarction (MI) is prescribed a sodium-restricted diet. When teaching the client about meal planning, which option would be most appropriate to suggest?
41.
A nurse is assessing several clients in a long-term care facility. Which client is at the highest risk for developing decubitus (pressure) ulcers?
42.
Mrs. Kennedy, who has right-sided weakness following a cerebrovascular accident (CVA), has been taught to walk using a cane. The nurse is evaluating her technique prior to discharge. Which demonstration reflects correct use of the cane?
43.
A nurse is teaching a woman about a low-fat, high-fiber diet. Which food choice, if selected by the client, indicates that she understands the dietary instructions?
44.
An 85-year-old male patient has been bedridden for two weeks. Which complaint reported by the patient indicates to the nurse that he may be developing a complication of immobility?
45.
An 11-month-old infant is brought to the pediatric clinic. The nurse suspects iron-deficiency anemia. Which information is most important for the nurse to obtain from the infant’s parents to support this suspicion?
46.
A 46-year-old female with chronic constipation is being assessed by the nurse for a bowel training regimen. Which factor in the client’s history indicates that the nurse needs to gather further information before planning interventions?
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