Exam 1: Changes in Health

As the nurse assesses a six-month-old female infant, the nurse notices that when the infant's feet are placed on a firm surface, she pushes down with her legs. Which of the following is the nurse's initial action?

A nurse is assigned to the in-hospital triage area, which utilizes a three-tier system: emergent, urgent, and non-urgent. Which of the following clients has an emergent condition and needs to receive treatment immediately or within 15 to 30 minutes of admission?

John Isles, a 10-year-old client with sickle cell disease, is admitted for sickle cell crisis. Initials assessment shows a temperature of 38.2°Cand swelling in the left leg. The client complains of severe pain in the affected extremity. The nurse recognizes this as what type of sickle cell crisis?

A client with schizophrenia refuses to leave his room to have dinner. The client tells the nurse that the Queen of England will be seeing him in his room. The nurse's best response is:

A client with total parenteral nutrition complains of chest pain and difficulty breathing. The nurse suspects air embolism. Which of the following is the initial action of the nurse?

Joe Engel, a 15-year-old high school student, had a skating accident. A cast is applied to his left arm due to an ulnar fracture. The nurse teaches the client exercises that maintain the muscle strength of the affected arm. The most recommended group of exercises to regain or maintain muscle strength is:

A client complaining of joint pain is diagnosed with osteoarthritis, a progressive degeneration of a joint as a result of wear-and-tear. The nurse expects to note which of the following findings in the client's record?

A nurse is assessing a client who gave birth twelve hours ago. On assessment, the nurse notes that the client's fundus is above the umbilicus to the right. Which of the following is the nurse's initial action?

A client undergoes a radical mastectomy of the right breast. The nurse interprets that the client is beginning to adjust to the physical change if which of the following behaviors is noted?

A nurse is caring for an eighty-year-old female client who is bedridden. The nurse would include the following nursing actions in the care plan, to prevent respiratory complications, except:

A nurse is monitoring an 82-year-old male who had a transurethral resection of the prostate 12 hours ago. A three-way urinary catheter is inserted through the client's urethra and into the bladder for continuous irrigation. A total of 3,000 mL of bladder irrigant has been infused for the past 8 hours. After assessing the client, the nurse immediately contacts the physician for a possible complication of the procedure. Which of the following is most likely noted by the nurse during the assessment?

A female client complains of vaginal burning and itching. Vaginal discharge with a cottage-cheese-like appearance is reported. History reveals that the client is on antibiotic therapy. The nurse suspects that the client is experiencing which of the following vaginal infections?

A twelve-year-old girl just had surgery, and an incision was made in the abdominal area. The nurse would expect which of the following questions from the client?

A client tells the nurse that her officemates are trying to sabotage her work because they do not want her to get a promotion. As the nurse assesses the situation, the client becomes aggressive. This behavior of the client shows personality traits associated with which of the following personality disorders?

A nurse notes that the site of the client's intravenous catheter is slightly edematous and cool. Blood return is not observed upon lowering the IV fluid below the IV site. Which of the following nursing actions is not appropriate for this client?

A nurse just received the report from the previous shift. Which of the following clients would the nurse see first?

A physician ordered Anthony, a male client who was admitted due to aspiration of gastric contents, to undergo decompression of the stomach. A nurse is tasked withinserting a nasogastric tube. As the nurse inserts the tube, resistance is met. Which of the following is the next action of the nurse?

Melissa is a 46-year-old office clerk with multiple sclerosis. Her symptoms have been progressing over the years. Melissa is complaining of difficulty of swallowing with occasional episodes of choking every time food particles get caught up in her throat. Which of the following would not be an appropriate strategy to prevent discomfort in swallowing for Melissa?

Cooper is a 7-year-old male diagnosed with bronchial asthma. The boy and his mother consult a physician after he experiences increasingly frequent episodes of Cooper's acute asthma over a period of several months. The child has a case of hypersensitivity. The physician describes a medication taken routinely to prevent acute asthma episodes. Which of the following medications is taken prophylactically?

The nurse attending Inna, a female client who had a recent surgery with spinal anesthesia, notes restlessness, cool clammy skin, and hypotension. Hypovolemic shock is suspected. Which of the following is NOT a safe nursing intervention for the client?