Mental Health
A nurse is discussing stress management with a client. Which of the following is the most effective way for the client to manage stress?
B) Engage in physical activity or exercise regularly
A nurse is administering a dose of lorazepam (Ativan) to a client with anxiety. Which of the following is the primary therapeutic effect of lorazepam?
B) Sedation and anxiety relief
A nurse is caring for a client with a new diagnosis of diabetes mellitus. The nurse should include which of the following as the primary goal of diabetes management?
A) Maintaining normal blood glucose levels
A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions is most effective in preventing the formation of pressure ulcers?
A) Repositioning the client at least every 2 hours
A nurse is teaching a pregnant client about the importance of folic acid supplementation. Which of the following statements should the nurse include in the teaching?
B) "Folic acid helps prevent neural tube defects in the baby."
A client with generalized anxiety disorder (GAD) tells the nurse, “I feel overwhelmed all the time and I’m constantly worrying about everything.” Which response by the nurse is most appropriate?
B) “Let’s talk about what triggers your anxiety.”
A nurse is providing education to a client prescribed digoxin (Lanoxin) for heart failure. Which of the following should the nurse include in the teaching?
B) “Notify your doctor if you experience a decrease in appetite or nausea.”
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing difficulty breathing. Which of the following interventions is most appropriate for this client?
B) Encouraging the client to breathe slowly and deeply through pursed lips
A nurse is preparing to administer oral medications to a client who has difficulty swallowing. Which of the following interventions should the nurse implement to ensure safe medication administration?
A) Crush the tablets and mix them with a small amount of applesauce
A nurse is caring for a 3-month-old infant who has just received the second dose of the diphtheria, tetanus, and pertussis (DTaP) vaccine. Which of the following findings should the nurse report to the healthcare provider?
C) Persistent crying for more than 3 hours and a high fever
A client with major depressive disorder is taking an antidepressant and reports feeling no improvement after 2 weeks. What is the nurse's best response?
A) “It may take several more weeks before you notice any improvement.”
A nurse is caring for a client who has been prescribed warfarin (Coumadin) for anticoagulation therapy. Which laboratory value should the nurse monitor regularly for this client?
C) Prothrombin time (PT) and International Normalized Ratio (INR)
A nurse is caring for a postoperative client following a laparotomy. The nurse should be most concerned about which of the following findings?
C) A heart rate of 112 beats per minute
A nurse is caring for a client who is receiving enteral feeding via a nasogastric tube (NGT). The client experiences abdominal distention and discomfort. Which of the following actions is most appropriate for the nurse to take first?
B) Check the tube placement to ensure it is correctly positioned
A nurse is caring for a client in labor who is experiencing late decelerations on the fetal heart monitor. Which of the following interventions should the nurse perform first?
B) Turn the client to her left side
A nurse is assessing a client diagnosed with post-traumatic stress disorder (PTSD). The client reports experiencing nightmares and flashbacks. Which intervention would be most helpful for this client?
C) Teaching the client relaxation techniques, such as deep breathing
A nurse is administering a dose of amlodipine (Norvasc) to a client with hypertension. The nurse knows that amlodipine works by which of the following mechanisms?
B) Blocking calcium channels to relax blood vessels and lower blood pressure
A nurse is caring for a client with a history of heart failure who is experiencing weight gain, edema, and shortness of breath. Which of the following actions should the nurse take first?
A) Administer a dose of diuretic as prescribed
A nurse is assessing a postoperative client who has a surgical wound. The client reports a sudden increase in pain and notices that the dressing is saturated with bright red blood. Which of the following actions should the nurse take first?
B) Assess the client's vital signs and notify the healthcare provider
A nurse is teaching the parents of a 2-year-old child who has been diagnosed with otitis media. Which of the following instructions should the nurse include to reduce the risk of recurrent ear infections?
C) "Limit the child’s exposure to second-hand smoke."
A nurse is caring for a client diagnosed with borderline personality disorder (BPD). The client exhibits impulsive behaviors and intense emotional reactions. Which of the following is the most appropriate nursing intervention to manage these behaviors?
A) Set firm and consistent boundaries to help the client understand appropriate behavior
A client who is prescribed a selective serotonin reuptake inhibitor (SSRI) reports symptoms of serotonin syndrome. Which of the following symptoms would the nurse expect to assess in this client?
B) Fever, altered mental status, and hyperreflexia
A nurse is caring for a client with acute kidney injury (AKI). The nurse should monitor for which of the following laboratory findings to assess for worsening kidney function?
A) Decreased creatinine clearance and elevated serum creatinine
A nurse is caring for a client who has been diagnosed with hypernatremia. Which of the following findings should the nurse expect to observe in this client?
A) Decreased urine output and confusion
A nurse is caring for a newborn who is 12 hours old and is being breastfed. The nurse notes that the newborn has yellowish skin (jaundice) and a bilirubin level of 15 mg/dL. Which of the following actions should the nurse take first?
B) Encourage the mother to breastfeed every 2 hours to promote hydration