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- A child, age 4, is taken to a clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal?
- Light pink
- Deep red
- Pearly gray
- Yellowish white
- A 37-year-old client with paranoid schizophrenia believes that his room is bugged by the CIA (Central Intelligence Agency) and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 15 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?
- Autonomy versus shame and doubt
- Generativity versus stagnation
- Integrity versus despair
- Trust versus mistrust
- The following clients present to a walk-in clinic at the same time. Which should the nurse schedule to be seen first?
- 25 year old with high fever, vomiting and diarrhea
- 38 year old with sore throat, fever, and swollen lymph glands
- 40 year old with severe headache, vomiting and stiff neck
- 44 year old limping on a very swollen bruised ankle
- A Client is at risk for fluid volume exess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status?
- Measuring and recording fluid intake and output
- Weighing the client daily at the same time each day
- Assessing vital signs every 4 hours
- Checking the lungs for crackles every shift
- A client comes to the emergency department complaining of a fast and irregular heartbeat. After examining the client, the physician gives a verbal order for digoxin (Lanoxin), 0.25mg IV q6h over the next 24 hours, starting with the first dose stat. How should the nurse respond to this order?
- Write and sign the order as dictated, then repeat it aloud for the physician's verification
- Verbally repeat the order to the physician for verification
- Insist that the physician write the order, then administer the drug
- Refuse to carry out the order.
- Of the four clients listed below, which responsibility should the nurse direct the technician to carry out first?
- 89 year old with COPD resting quietly on 2 liters of o2 needs morning vitals with 02 sat Correct
- 77 year old with gastrointestinal bleeding needs bedside commode emptied
- 55 year old diabetic with fasting blood sugar of 75, at 80% of breakfast and needs morning snack
- 49 year old with rheumatoid arthritis needs splints reapplied to both hands
- A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. What is the nurse's overall goal when planning care for this client?
- To help the client perform self-care activities
- To help the client function effectively in her environment
- To help control the client's symptoms
- Top help the client participate in group therapy
- After being in remission from Hodgkin's Disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin's Disease and infection. 24 hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these findings result from:
- Bleeding in the liver caused by the liver biopsy
- Perforation of the colon caused by the liver biopsy
- An allergic reaction to the contrast media used during the liver biopsy
- Normal postprocedural pain, with a change in level of consciousness resulting from the preexisting fever
- A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following instructions by the nurse is NOT correct?
- Continue to breastfeed frequently, at least every 2-4 hours.
- Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and exam.
- Watch for signs of dehydration, including decreased urinary output and changes in skin turgor.
- Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.
- A nurse is giving discharge instructions to the parents of a healthy newborn. Which of the following instructions should the nurse provide regarding car safety and the trip home from the hospital?
- The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position.
- The infant should be restrained in an infant car seat, properly secured in the front passenger seat.
- The infant should be restrained in an infant car seat facing forward or rearward in the back seat.
- For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.