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单项选择题

A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by

A．encouraging a discussion of her problems and fears.
B．asking her if she would like to talk to the chaplain.
C．giving her reassurance.
D．recommending a support group.
题目列表

你可能感兴趣的试题

单项选择题

The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should

A．encourage verbalizations about fears and stressful life situations.
B．agree with the client because she feels a specific physical feature is awful.
C．ignore the comment and talk about less threatening issues.
D．compliment the client on her appearance.
单项选择题

During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis

A．Bathing or hygiene self-care deficit.
B．Ineffective cerebral tissue perfusion.
C．Dysfunctional grieving.
D．Risk for injury.
单项选择题

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's

A．foot.
B．ankle.
C．lower thigh.
D．knee.
单项选择题

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

A．Administer 2 to 3 L of IV fluid rapidly.
B．Administer 6 L of IV fluid over the first 24 hours.
C．Administer a dextrose solution containing normal saline solution.
D．Administer IV fluid slowly to prevent circulatory overload and collapse.
单项选择题

A client asks the nurse what PSA is. The nurse should reply that it stands for

A．prostate-specific antigen, used to screen for prostate cancer.
B．protein serum antigen, used to determine protein levels.
C．pneumococcal strep antigen, a bacteria that causes pneumonia.
D．papanicolaou-specific antigen, used to screen for cervical cancer.
单项选择题

A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the client

A．she'll be in a private room with unrestricted activities.
B．a bowel-cleansing procedure will precede radioactive implantation.
C．she'll be expected to use a bedpan for urination.
D．the preferred positioning in bed will be semi-Fowler's.
单项选择题

The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for

A．hives.
B．a toxin.
C．a tubercle.
D．a virus.
单项选择题

A client who has a potassium level of 6 mEq/L should be treated with

A．antacids.
B．IV fluids.
C．fluid restriction.
D．sodium polystyrene sulfonate (Kayexalate).
单项选择题

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.
单项选择题

After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. Which of the following would the nurse expect the physician to do

A．Initiate insulin therapy.
B．Switch the client to a different oral antidiabetic agent.
C．Prescribe an additional oral antidiabetic agent.
D．Restrict carbohydrate intake to less than 30% of the total caloric intake.
单项选择题

Which of the following statements summarizes the underlying principle for the development of a parenbchild relationship

A．The parents to-be had good role models in their childhood.
B．The relationship is part of the adult maturational process.
C．The development is directly related to the physical needs of the neonate.
D．The relationship is based on the need for early and frequent parent-infant contact.
单项选择题

An 18-month-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the child is to

A．expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible.
B．ask the mother to wait briefly outside until the assessment is over.
C．tell the child the nurse is going to listen to his chest with the stethoscope.
D．allow the child to handle the stethoscope before listening to his lungs.
单项选择题

The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using

A．antiembolism stockings.
B．oxygen.
C．diuretics.
D．anticoagulants.
单项选择题

The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to

A．avoid shopping for large amounts of food.
B．control eating impulses.
C．identify anxiety-causing situations.
D．eat only three meals per day.
单项选择题

The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement

A．Give the medication on an empty stomach.
B．Warn the client that he'll experience mouth dryness.
C．Schedule the medication before meals.
D．Administer the medication for complaints of muscle weakness or difficulty swallowing.
单项选择题

A client with three children who is still in her childbearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon's preoperative teaching when the client states,

A．"If I should become pregnant again, the child would be delivered by cesarean delivery. "
B．"If I have another child, the procedure may need to be repeated. "
C．"This surgery may render me incapable of conceiving another child. "
D．"This procedure is accomplished in two separate surgeries. "
单项选择题

The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember

A．Use cosmetic camouflage techniques.
B．Protect the graft from direct sunlight.
C．Continue physical therapy.
D．Apply lubricating lotion to the graft site.
单项选择题

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that he'll require

A．monitoring of arterial oxygen saturation (SaO2).
B．arterial blood gas (ABG) studies.
C．chest auscultation.
D．a chest X-ray.
单项选择题

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.
单项选择题

When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately

A．Complaints of intense thirst.
B．Moderate to severe pain.
C．Urine output of 70 mL the 1st hour.
D．Hoarseness of the voice.
单项选择题

A 70-year-old client with a diagnosis of left-sided cerebrovaseular accident is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is most appropriate

A．Maintaining protein levels.
B．Maintaining vitamin levels.
C．Promoting weight-bearing exercises.
D．Promoting range-of-motion (ROM) exercises.
单项选择题

The nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncurled tube because the

A．vocal cords provide a natural seal.
B．trachea is shorter.
C．larynx is anterior and cephalad.
D．cricoid cartilage is the narrowest part of the larynx.
单项选择题

After a client receives an IM injection, he complains of burning pain in the injection site. Which nursing action would be the best to take at this time

A．Apply a cold compress to decrease swelling.
B．Apply a warm compress to dilate the blood vessels.
C．Massage the area to promote absorption of the drug.
D．Instruct the client to tighten his gluteal muscles to promote better absorption.
单项选择题

What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior

A．Ineffective coping.
B．Imbalanced nutrition: Less than body requirements.
C．Imbalaneed nutrition: More than body requirements.
D．Interrupted family processes.
单项选择题

A client with thyroid cancer undergoes a thyroidectomy. After surgery, the client develops peripheral numbness and tingling and muscle twitching and spasms. The nurse should expect to administer

A．thyroid supplements.
B．antispasmodics.
C．barbiturates.
D．IV calcium.
单项选择题

Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed for a client with type 2 diabetes mellitus. During discharge planning, the nurse would be aware that the client has understood teaching when the client states,

A．"If I have hypoglycemia, I should eat some sugar, not dextrose. "
B．"The drug makes my pancreas release more insulin. "
C．"I should never take insulin while I'm taking this drug. "
D．"It's best if I take the drug with the first bite of a meal. "
单项选择题

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action

A．Make an appointment because the client needs to be evaluated.
B．Explain that these are expected problems for the latter stages of pregnancy.
C．Arrange for the client to be admitted to the birth center for delivery.
D．Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.
单项选择题

The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. The client states, "I run apple, train, grass, window. " This response by the client is known as

A．echopraxia.
B．a word salad.
C．flight of ideas.
D．neologisms.
单项选择题

During a client's chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care

A．Instruct the client to consume plenty of raw fruits and vegetables.
B．Take rectal temperatures for greater accuracy.
C．Tell the client to avoid crowds and infected individuals.
D．Ask friends and relatives not to visit during the course of chemotherapy.
单项选择题

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver

A．Breast tenderness.
B．Breakthrough bleeding within first 3 months of use.
C．Decreased menstrual flow.
D．Blurred vision and headache.
单项选择题

Which of the following functions would the nurse expect to be unrelated to the placenta

A．Production of estrogen and progesterone.
B．Detoxification of some drugs and chemicals.
C．Exchange site for food, gases, and waste.
D．Production of maternal antibodies.
单项选择题

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take

A．Clear the client's airway.
B．Make the client comfortable.
C．Start eardiopulmonary resuscitation.
D．Stop the feeding and remove the NG tube.
单项选择题

A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother

A．how long the child has been like this.
B．if the child can walk without holding onto furniture.
C．how the child's condition today differs from his normal condition.
D．if the child always drools.
单项选择题

The nurse is caring for a client who recently underwent a total hip replacement. The nurse should

A．ease the client onto a low toilet seat.
B．allow the client's legs to be crossed at the knees when out of bed.
C．use soft chairs when the client is sitting out of bed.
D．limit client hip flexion when sitting.
单项选择题

Which of the following observations signals the onset of puberty in male adolescents

A．Appearance of pubic hair.
B．Appearance of axillary hair.
C．Testicular enlargement.
D．Nocturnal emissions.
单项选择题

Which of the following should be the nurse's initial action immediately following the birth of the neonate

A．Aspirating mucus from the neonate's nose and mouth.
B．Drying the infant to stabilize the neonate's temperature.
C．Promoting parental bonding.
D．Identifying the neonate.
单项选择题

A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be,

A．"You seem angry. Would you like to talk about it"
B．"Calm down. You know that stress will make your symptoms worse. "
C．"Would you like to talk about the problem with the nursing supervisor"
D．"I can see you're angry. I'll come back when you've calmed down. "
单项选择题

The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question

A．Heparin sodium (Hep-Lock).
B．Dexamethasone (Deeadron).
C．Methyldopa (Aldomet).
D．Phenytoin (Dilantin).
单项选择题

The nurse is teaching the parents of a school-age child. Which teaching topic should take priority

A．Preventing accidents.
B．Keeping a night light on to allay fears.
C．Explaining normalcy of fears about body integrity.
D．Encouraging the child to dress without help.
单项选择题

The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury

A．Bend over the object you're lifting.
B．Narrow the stance when lifting.
C．Push or puI1 an object using your arms.
D．Stand close to the object you're lifting.
单项选择题

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.
单项选择题

When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, the nurse should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate

A．Neonates. 10.6 to 16.5.
B．3 months. 10.6 to 16.5.
C．3 years. 9.4 to 15.5.
D．10 years. 10.7 to 15.5.
单项选择题

One day after an appendectomy, a 9-year-old rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart

A．The child is in no apparent distress, and no pain medication is needed at this time.
B．The child rates pain at 4 out of 5. Pain medication administered as prescribed.
C．The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling.
D．The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain.
单项选择题

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.
单项选择题

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care

A．Cover the cast with a blanket until the cast dries.
B．Keep your right leg elevated above heart level.
C．Use a knitting needle to scratch itches inside the cast.
D．A foul smell from the cast is normal.
单项选择题

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.
单项选择题

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care

A．Carefully titrating the oxytocin based on her pattern of labor.
B．Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.
C．Allowing the client to ambulate as tolerated.
D．Helping the client use breathing exercises to manage her contractions.
单项选择题

While performing rounds, a nurse finds that a client is receiving the wrong IV solution. The nurse's initial response should be to

A．remove the IV catheter and call the physician.
B．write up an incident report describing the mistake.
C．slow the IV flow rate and hang the appropriate solution.
D．wait until the next bottle is due and then change to the proper solution.
单项选择题

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of

A．somatic delusions.
B．waxy flexibility.
C．neologisms.
D．nihilistic delusions.
单项选择题

The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths per minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means

A．frequent bowel sounds.
B．heart rate greater than 100 beats/minute
C．hyperventilation.
D．respiratory rate greater than 20 breaths/minute
单项选择题

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.
单项选择题

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of

A．right-sided heart failure.
B．acute pulmonary edema.
C．pneumonia.
D．cardiogenic shock.
单项选择题

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which of the following denotes the child's level of consciousness

A．No motor or verbal response to noxious (painful) stimuli.
B．Remains in a deep sleep; responsive only to vigorous and repeated stimulation.
C．Can be aroused with stimulation.
D．Limited spontaneous movement; sluggish speech.
单项选择题

When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening

A．Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed.
B．Listen for a clicking sound as the child abducts the hips.
C．Have the child run the heel of one foot down the shin of the other leg while standing.
D．Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders.
单项选择题

The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to

A．restrict fluid intake to 1 qt (1,000 mL)/day.
B．drink liquids only with meals.
C．don't drink liquids 2 hours before meals.
D．drink liquids only between meals.
单项选择题

Which laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto's thyroiditis

A．Thyroxine (T4), 22μg/dL; triiodothyronine (T3), 320ng/dL; thyroid-stimulating hormone (TSH) undetectable.
B．T4, 22μg/dL; T3, 200ng/dL; TSH,0.1μIU/mL.
C．T4, 2μg/dL; T3, 200ng/dL; TSH,5.9μIU/mL.
D．T4, 2μg/dL; T3, 35ng/dL; TSH,45μIU/mL.
单项选择题

When a client experiences a loss of vibratory sense on examination, this indicates

A．injury to the cranial nerves.
B．injury to the peripheral nerves.
C．intact cranial nerves.
D．intact peripheral nerves.
单项选择题

A 45-year-old auto mechanic comes to the physician's office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by

A．inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris.
B．suggesting he take aspirin for relief because it's probably early rheumatoid arthritis.
C．validating his complaint but assuming it's an adverse effect of his vocation.
D．asking him if he has been diagnosed or treated for carpal tunnel syndrome.
单项选择题

The physician prescribes amoxicillin suspension 100 mg every 8 hours for a child who weighs 33 lb (15 kg). The drug is supplied in a bottle labeled 250 rag/teaspoon (1mL=50 mg). How many milliliters should the nurse administer

A．2 mL.
B．2.5 mL.
C．5 mL.
D．7.5 mL.
单项选择题

A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is

A．impending coma.
B．manipulating behavior.
C．suppression.
D．perceptual disorders.
单项选择题

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should

A．insert an oral airway.
B．withhold food and fluids.
C．position the client on his side.
D．introduce a nasogastric (NG) tube.
单项选择题

In an industrial accident, a client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client

A．A urine output consistently above 100 mL/hr.
B．A weight gain of 4 lb (1.8 kg) in 24 hours.
C．Body temperature readings all within normal limits.
D．An electrocardiogram (ECG) showing no arrhythmias.
单项选择题

When planning care for a 7-year-old boy with Down syndrome, the nurse should

A．plan interventions at the developmental level of a 7-year-old child because that is the child's age.
B．plan interventions at the developmental level of a 5-year-old because the child will have developmental delays.
C．assess the child's current developmental level and plan care accordingly.
D．direct all teaching to the parents because the child can't understand.
单项选择题

A child, age 5, with an IQ of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is

A．within the lower range of normal intelligence.
B．mildly retarded but educable.
C．moderately retarded but trainable.
D．completely dependent on others for care.
单项选择题

The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following

A．Poor clotting mechanism.
B．High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood.
C．Persistent fetal circulation.
D．Large, immature liver.
单项选择题

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. "
单项选择题

What is the nurse's most important role in caring for a client with a mental health disorder

A．To offer advice.
B．To know how to solve the client's problems.
C．To establish trust and rapport.
D．To set limits with the client.
单项选择题

A client is admitted with atrial fibrillation. The physician noted a pulse deficit. The pulse deficit measures which of the following

A．The difference between apical and radial pulse rates.
B．The difference between systolic and diastolic blood pressures.
C．The amount of blood ejected from the left ventricle per minute.
D．The percentage of blood emptied from the ventricle during contraction.
单项选择题

The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat

A．hypernatremia.
B．hypokalemia.
C．hyperkalemia.
D．hypercalcemia.
单项选择题

A client tells the nurse that she has been working hard for the last 3 months to control her type 2 (non-insulin-dependent) diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check

A．urine glucose level.
B．fasting blood glucose level.
C．serum fructosamine level.
D．glycosylated hemoglobin (Hb) level.
单项选择题

A client delivered a healthy full-term female neonate 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action

A．Tachycardia and hypotension.
B．Gush of vaginal blood when the client stands up.
C．Blood stain 2" (5 cm) in diameter on the abdominal dressing.
D．Complaints of abdominal pain.
单项选择题

A 21-year-old client with a history of ulcerative colitis is hospitalized for an exacerbation. When planning dietary teaching, the nurse should recommend that the client consume

A．high-protein foods, such as eggs, meat, and cheese.
B．whole milk and other dairy products.
C．raw fruits and vegetables.
D．products containing caffeine.
单项选择题

A client with type 1 (insulin-dependent) diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide

A．"Insulin requirements don't change during pregnancy. Continue your current regimen. "
B．"Insulin requirements usually decrease during the last two trimesters. "
C．"Insulin requirements usually decrease during the first trimester. "
D．"Insulin requirements increase greatly during labor. "
单项选择题

A client in acute renal failure is admitted to the nephrology unit. The period of oliguria in these clients usually lasts about t0 days. Which of the following assessments of kidney function would the nurse make during the oliguric phase

A．No urine output; kidneys in a state of suppression.
B．Urine output of 30 to 60 mL/hr.
C．Urine output of less than 400 to 600 mL in 24 hours.
D．Urine output directly related to the amount of IV fluids infused.
单项选择题

A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is

A．psychotherapy.
B．total abstinence.
C．Alcoholics Anonymous (AA).
D．aversion therapy.
单项选择题

A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid

A．The tubing from the client to the chamber is blocked.
B．There is a leak somewhere in the tubing system.
C．The client's affected lung has reexpanded.
D．The tubing needs to be cleared of fluid.
单项选择题

Which of the following statements should be included when teaching clients about monoamine oxidase (MAO) inhibitor antidepressants

A．Don't take prescribed or over-the-counter medications without consulting the physician.
B．Avoid strenuous activity because of the cardiac effects of the drug.
C．Have blood levels screened weekly for leukopenia.
D．Don't take with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
单项选择题

A 32-year-old black man is admitted to the hospital in vaso-occlusive sickle cell crisis. He complains of chest pain, shortness of breath, severe myalgia, and arthralgia. Which of the following may be effective in relieving the client's joint pain

A．Applying ice packs to the joints.
B．Performing active resistive range-of-motion exercises.
C．Applying warm compresses to the joints.
D．Applying transcutaneous electrical nerve stimulation (TENS).
单项选择题

When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx, which of the following actions can the nurse institute independently

A．Using a povidone-iodine wash on the ulceration three times per day.
B．Using a normal saline solution and applying a protective dressing as necessary.
C．Applying an antibiotic cream to the area three times per day.
D．Massaging the area with an astringent every 2 hours.
单项选择题

A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by

A．encouraging a discussion of her problems and fears.
B．asking her if she would like to talk to the chaplain.
C．giving her reassurance.
D．recommending a support group.
单项选择题

Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of

A．antisocial behavior.
B．manipulation.
C．poor boundaries.
D．passive-aggressive behavior.
单项选择题

In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says,

A．"The baby can get the virus from my placenta. "
B．"I'm planning on starting on birth control pills. "
C．"Not everyone who has the virus gives birth to a baby who has the virus. "
D．"I'll need to have a C-section if I become pregnant and have a baby. "
单项选择题

When caring for a client with preeclampsia, which action is a priority

A．Monitoring the client's labor carefully and preparing for a fast delivery.
B．Continually assessing the fetal tracing for signs of fetal distress.
C．Checking vital signs every 15 minutes to watch for increasing blood pressure.
D．Reducing visual and auditory stimulation.
单项选择题

A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by which of the following

A．An ectopic corticotropin-secreting tumor.
B．Adrenal carcinoma.
C．A corticotropin-secreting pituitary adenoma.
D．An inborn error of metabolisrn.
单项选择题

A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress

A．Intercostal retractions.
B．Bradycardia.
C．Decreased level of consciousness.
D．Flushed skin.
单项选择题

The nurse is teaching the mother of a neonate. The nurse should instruct the mother to introduce her infant to solid foods at what age

A．2 months.
B．4 months.
C．6 months.
D．8 months.
单项选择题

Which action should the nurse include in a plan of care for a client with a fiberglass cast on the right arm

A．Keep the casted arm warm with a light blanket.
B．Avoid handling the cast for 24 hours or until dry.
C．Assess pedal and posterior tibial pulses every 2 hours.
D．Assess movement and sensation in the fingers of the right hand.
单项选择题

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The specific type of MI the client had is most probably

A．anterior.
B．posterior.
C．lateral.
D．inferior.
单项选择题

Two middle-aged sisters have been diagnosed with Huntington's disease. The children of these clients want to know what their chances are of developing this genetic disorder. The nurse's best response would be.

A．"Only women become symptomatic. "
B．"This disorder is an autosomal dominant disorder, so each child has a 50% chance of inheriting it. "
C．"This disorder is an autosomal recessive disorder, so each child has a 25% chance of inheriting it. "
D．"Women are symptomatic and men are carriers of this disorder. "
单项选择题

A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has

A．patent ductus arteriosus.
B．coarctation of the aorta.
C．a ventricular septal defect.
D．truncus arteriosus.
单项选择题

An 82-year-old female is transferred to the hospital from a long-term care facility because of severe diarrhea. She is weak and dehydrated. Which acid-base imbalance could the client develop as a result of diarrhea

A．Respiratory acidosis.
B．Metabolic acidosis.
C．Carbonic acid deficit.
D．Metabolic alkalosis.
单项选择题

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.
单项选择题

Which of the following activities should a 2-year-old child to be able to do()

A．Build a tower of eight cubes.
B．Point out a picture.
C．Wash and dry his hands.
D．Remove a garment.
单项选择题

Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric (NG) tube

A．Abdominal X-rays.
B．Injection of a small amount of air while listening with a stethoscope over the abdominal area.
C．A check of the pH of fluid aspirated from the tube.
D．Visualization of the measurement mark on the tube made at the time of insertion.
单项选择题

The physician orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to use which oxygen delivery device

A．Nasal cannula.
B．Venturi mask.
C．Partial rebreathing mask.
D．Nonrebreathing mask.
单项选择题

A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms

A．The opportunity to verbalize memories of trauma to a sympathetic listener.
B．Family support.
C．Prescribed medications taken as ordered.
D．Alcoholics Anonymous (AA) meetings.
单项选择题

The nurse is caring for a 40-year-old woman who is a black Muslim. Which of the following choices is a concept on which black Muslims focus

A．Celibacy.
B．Prophecy.
C．Reincarnation.
D．Self-esteem.
单项选择题

Which of the following would not be an indication of placental detachment

A．An abrupt lengthening of the cord.
B．An increase in the number of contractions.
C．Relaxation of the uterus.
D．Increased vaginal bleeding.
单项选择题

After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client

A．Give him a barbiturate.
B．Place him on mechanical ventilation.
C．Perform a lumbar puncture.
D．Elevate the head of his bed.
单项选择题

A client seeks care for low back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk

A．Pain that radiates down the posterior thigh.
B．Back pain when the knees are flexed.
C．Atrophy of the lower leg muscles.
D．Positive Homans' sign.
单项选择题

A client is admitted to the hospital with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in

A．vitamin Ａ.
B．vitamin Ｂ6.
C．vitamin Ｂ12.
D．vitamin Ｃ.
单项选择题

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress

A．Avoiding the use of illicit drugs and alcohol.
B．Refraining from telling anyone about the diagnosis.
C．Following safer-sex practices.
D．Telling potential sex partners about the diagnosis, as required by law.
单项选择题

A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because

A．reducing sodium promotes urea nitrogen excretion.
B．reducing sodium decreases edema.
C．reducing sodium improves her glomerular filtration rate.
D．reducing sodium increases potassium absorption.
单项选择题

Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs, the nurse should incorporate which of the following instructions in her teaching plan

A．Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants.
B．Avoid taking antianxiety agents at bedtime.
C．Avoid taking antianxiety agents on an empty stomach.
D．Avoid consuming aged cheese when taking antianxiety agents.
单项选择题

A client reveals to the nurse that he's sexually impotent. Which statement best expresses what the nurse should understand her client to mean

A．He's disinterested in sexual intimacy.
B．He's unable to attain or retain an erection.
C．His ejaculate is void of sperm.
D．His semen isn't potent enough to impregnate.
单项选择题

The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1,500 mL for the 1st hour and the same for the 2nd hour. The nurse should suspect

A．Cushing's syndrome.
B．diabetes mellitus.
C．adrenal crisis.
D．diabetes insipidus.
单项选择题

Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems

A．Decreased heart rate.
B．Decreased cardiac output.
C．Increased plasma volume.
D．Increased blood pressure.
单项选择题

The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women

A．perform breast self-examination annually.
B．have a mammogram annually.
C．have a hormonal receptor assay annually.
D．have a physician conduct a clinical examination every 2 years.
单项选择题

The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first

A．establish unresponsiveness.
B．call for help.
C．open the airway.
D．assess the client for a carotid pulse.
单项选择题

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instructions

A．"Weigh yourself daily and report a loss of 1 lb in 1 day. "
B．"Eat a high-sodium diet. "
C．"Weigh yourself daily and report a gain of 2 lb in 1 day. "
D．"Maintain bedrest. "
单项选择题

What is the most appropriate nursing diagnosis for the client with acute pancreatitis

A．Deficient fluid volume.
B．Excess fluid volume.
C．Decreased cardiac output.
D．Ineffective gastrointestinal tissue perfusion.
单项选择题

Physical assessment findings in the eyes of elderly people may include

A．decreased lens thickness.
B．decreased visual acuity.
C．lightening of the skin around the orbits.
D．unequal pupillary light reflex.
单项选择题

Which vaginal infection doesn't require treatment for sexual partners

A．Neisseria gonorrhoeae.
B．Candida albicans.
C．Trichomonas vaginalis.
D．Chlamydia trachomatis.
单项选择题

A client admitted for a hysterectomy has a secondary diagnosis of Ménière s disease. Which of the following nursing interventions should the nurse include in the client's plan of care to decrease the effects of tinnitus

A．Reduce the amount of glucose and cholesterol in the diet.
B．Encourage the client to listen to the radio with earphones.
C．Encourage a weight-reduction diet.
D．Administer antihypertensive medications as ordered.
单项选择题

A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child

A．Providing fluids.
B．Maintaining protective isolation.
C．Applying cool compresses to affected joints.
D．Administering antipyretics, as prescribed.
单项选择题

When teaching the parents of a toddler with a congenital heart defect, the nurse should explain all medical treatments and should emphasize which instruction about their child

A．Reduce the caloric intake to decrease cardiac demand.
B．Relax discipline and limit setting to prevent crying.
C．Avoid contact with small children to reduce overstimulation.
D．Try to maintain the usual lifestyle to promote normal development.
单项选择题

The nurse is teaching the mother of an infant with tetralogy of Fallot. The mother asks what to do when her infant becomes very blue and has trouble breathing after crying. The nurse should tell the mother,

A．"Leave the infant alone until the crying stops. "
B．"Put the infant in the knee-chest position. "
C．"Offer the infant a bottle of formula. "
D．"Take the infant for a ride in the car. "
单项选择题

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.
单项选择题

When caring for a client who is having her second baby, the nurse can anticipate the client's labor will be which of the following

A．Shorter than her first labor.
B．About half as long as her first labor.
C．About the same length of time as her first labor.
D．A length of time that can't be determined based on her first labor.
单项选择题

A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today. " The nurse is using which therapeutic technique

A．Restating.
B．Making observations.
C．Exploring.
D．Focusing.
单项选择题

The nurse is caring for a primigravida who is scheduled for a fetal acoustic stimulation test (FAST). The nurse should explain to the client that the primary purpose of this test is to

A．induce contractions.
B．induce fetal heart rate accelerations.
C．shorten the contraction stress test.
D．determine fluid volume.
单项选择题

The nurse is teaching a parent how to administer antibiotics at home to a child with acute otitis media. Which statement by the parent indicates that teaching has been successful

A．"I'll give the antibiotics for the full 10-day course of treatment. "
B．"I'll give the antibiotics until my child's ear pain is gone. "
C．"Whenever my child is cranky or pulls on an ear, I'll give a dose of antibiotics. "
D．"If the ear pain is gone, there's no need to see the physician for another ear examination. "
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