The nurse is has just admitted a client with severe depression.
From which focus should the nurse identify a priority nursing
diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety
The correct answer is D: Safety
The nurse is assigned to a newly delivered woman with HIV/AIDS. The
student asks the nurse about how it is determined that a person has AIDS
other than a positive HIV test. The nurse responds
A) "The complaints of at least 3 common findings."
The correct answer is C: "CD4 lymphocyte count is less than 200."
The nurse is caring for a child who has just returned from
surgery following a tonsillectomy and adenoidectomy. Which action
by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns
The correct answer is D: Observe swallowing patterns
A 23 year-old single client is in the 33rd week of her first pregnancy.
She tells the nurse that she has everything ready for the baby and has
made plans for the first weeks together at home. Which normal
emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
The correct answer is C: Anticipation of the birth
The nurse is planning care for a client with pneumococcal pneumonia.
Which of the following would be most effective in removing respiratory
secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
The correct answer is B: Increasing oral fluid intake to 3000 cc per day
The nurse in a well-child clinic examines many children on a daily
basis. Which of the following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sip cup
The correct answer is D: A 30 month-old only drinking from a sip cup
Which of the following would be the best strategy for the nurse to use
when teaching insulin injection techniques to a newly diagnosed client with
diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
The correct answer is D: Observe a return demonstration
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