QUESTION 433
A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?

QUESTION 434
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

QUESTION 435
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse’s first intervention should be to:

QUESTION 436
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months.
Which of the following best describes the client at the present?

QUESTION 437
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

QUESTION 438
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:

QUESTION 439
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, “The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?” The best explanation for the nurse to give the client would be that balanced anesthesia:

QUESTION 440
A client has been uncomfortable in crowds all her life. After the birth of her child, she has
been housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?

QUESTION 441
A primigravida with a blood type A negative is at 28 weeks’ gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

QUESTION 442
The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:

QUESTION 443
A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client’s:

QUESTION 444
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

QUESTION 445
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?

QUESTION 446
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

QUESTION 447
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?

QUESTION 448
In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:

QUESTION 449
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

QUESTION 450
An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:

QUESTION 451
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

QUESTION 452
A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?