Cont.

Diagnostic Test 2
61. The nurse is collecting data on a 17 year-old female client with bulimia. Which laboratory report would the nurse anticipate? A) Increased serum glucose C) Decreased potassium B) Decreased albumin D) Increased sodium retention 62 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) B) Notify the RN Administer the prn dose of Albuterol C) D) Apply oxygen at 2 liters per nasal cannula Repeat the peak flow reading in 30 minutes

63 An elderly client was discussing his living will with a son and the nurse. The son did not understand the need for such a living will. Which of these explanations would be accurate? A) B) C) D) Health care decisions can be made based on the client's wishes A designated family member can make all decisions Specific instructions are listed for a specific disease Do-not-resuscitate orders (DNR) are automatic

64 In addition to standard precautions, a nurse should implement contact precautions for which client? A) A 60 year-old with herpes simplex C) A 45 year-old with viral pneumonia B) A 6 year-old with mononucleosis D) A 3 year-old with scarlet fever 65 The nurse is aware that which of the following psychosocial needs are best described in the adolescent when hospitalized? A) Independence, confidence, narcissism B) Group sports, competition, being right C) Privacy, autonomy, peer interactions D) School performance, reading, journal writing

66 The mother of a three month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse reinforces information about correct infant nutrition? A) B) C) D) Solid foods should be introduced at three-to-four months Whole milk is difficult for a young infant to digest Fluoridated tap water should be used to dilute the milk Supplemental apple juice can be used between feedings

67 A client had heart failure. Which intervention is most important for the nurse to implement prior to the initial admininstration of digoxin to this client? A) B) C) D) Assess the apical pulse, counting for a full 60 seconds Take a radial pulse, counting for a full 60 seconds Use the pulse reading from the electronic blood pressure device Check for a pulse deficit

68 The nurse is discussing with an elderly client the proper use of mult-idose inhalers (MDI's). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's best recommendation for the client is A) B) C) Nebulized treatments for home care Adding a spacer device to the MDI canister Asking a family member to assist the client with the MDI

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D) Request a visiting nurse to follow the client at home

69 A client arrives in the emergency department after a radiologic accident at a local factory. At the initial contact with this client the nurse should do which action? A) B) C) D) Begin the decontamination procedures for the client Establish the degree of physiologic stability of the client Wrap the client in blankets to minimize staff contamination Double bag the client's contaminated clothing

70 The nurse is reviewing the plan of care for a three month-old infant immediately pos-toperative after placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse expects to find which intervention in the plan of care? A) B) Measure the abdominal for distention Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Check the shunt to assess for proper function

71 As the nurse collects data about a three year-old with Wilm's tumor, what comment by a parent requires follow-up and is consistent with the diagnosis? A) B) C) D) "The child has been listless and has lost weight." "The urine is dark yellow and small in amounts." "Clothes are becoming tighter across the abdomen." "We notice muscle weakness and some unsteadiness."

72 While obtaining the history of a 2 week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24 hours-old. Which action should the nurse take next? A) B) C) D) Schedule the infant for a repeat test in two weeks Obtain a repeat blood test at this point Contact the hospital of birth for the results Document that the test results are pending

73

Therapeutic nurse-client interaction occurs when the nurse A) B) C) D) Clarifies the meaning of client communication Interprets the client's covert communication Praises the client for appropriate behavior Advises the client on resources to resolve problems

74 While the nurse is bathing a two month-old infant, the mother expresses concern because a flat pink birthmark on the baby's forehead and eyelid has not gone away. The nurse should tell the parents that A) B) C) D) Mongolian spots are a normal finding in dark-skinned children Port wine stains are often associated with other malformations Telangiectatic nevi are normal and will disappear as the baby grows The child is too young for surgical removal at this time

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75 When checking a client admitted to the hospital for diabetic ketoacidosis, which of the following findings would the nurse expect? A) B) C) D) 76 A blood pH level above 7.5 Arterial blood PaCO2 above 40 Blood pH level below 7.30 Arterial blood PaCO2 below 10

A client is admitted to a psychiatric unit with delusions. The nurse can expect which findings? A) B) C) D) Flight of ideas and hyperactivity Suspiciousness and resistance to therapy Anorexia and hopelessness Panic and multiple physical complaints

77 The nurse is collecting data about a four year-old with possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? A) B) C) D) Diagnosis of chickenpox six months ago Exposure to strep throat in daycare last month Treatment for ear infection two months ago Episode of fungal skin infection last week

78 Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) B) C) D) Record this information on the chart Give information about advance directives Assume that this client wishes a full code Refer this issue to the unit secretary

79 The nurse is caring for a client in a Coronary Care Unit one day after a myocardial infarction (MI). The client has many questions about the condition. The nurse should focus discussion on A) B) Immediate needs and concerns Post discharge rehabilitation C) D) Medication therapy at home Activity and rest schedule

80

A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first? A) B) C) D) Repeat glycohemoglobin in 24 hours Document accuchecks, intake and output every four hours Humulin N 20 units IV push IV fluids of 0.9% normal saline at 125 ml per hour

81 The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that A) B) C) D) the procedure be done prior to the bath family members should be taught the procedure cardiac dysrhythmias can result during the process increased dietary fiber can minimize such problems

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82 When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the appropriate action by the nurse would be to A) B) C) D) Discuss the feeling of reluctance with an objective peer or supervisor Limit contacts with the client to avoid the reinforcement of manipulative behavior Confront the client about the negative effects their behavior has on others Develop a behavior modification plan that will promote more functional behavior

83 During a morning bath for a client with a colostomy, the nurse should reinforce that the pouch be emptied A) B) When it is one third to one half full Prior to meals C) D) After each fecal elimination At the same time each day

84 The nurse is caring for a client with a distal tibia and femur fracture. The client has had a closed reduction and application of a toe to groin cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first action the nurse should do of these assigned tasks is A) B) Check orientation to time place and person Obtain the pulse oximetry reading C) Check the circulation to the casted extremity D) Take the blood pressure

85 item?

As the nurse interviews the parents of a child with asthma, it is appropriate to ask about which A) Household pets C) Lead based paint B) New furniture D) Plants such as cactus

86. The nurse should reinforce with the client who has Type 2 diabetes mellitus to A) B) C) D) Maintain previous calorie intake Keep a candy bar available Reduce carbohydrates intake to 25% of total calories Keep a regular schedule of meals and snacks

87 The nurse who works in an assisted living unit is assigned to care for an elderly client after a cerebrovascular accident (CVA). The nurse should recall that the most common cause of nosocomial infections in the client is which of these factors? A) B) Inadequate fluid intake Decreased mobility C) D) Intravenous access device Indwelling urinary catheter

88 The nurse is reinforcing information given to the parents of a child who will take Phenytoin (Dilantin) regularly. Which statement by the parents indicate a need for further information? A) B) C) D) "It is okay to change brands of drug to help control cost." "If we miss a dose, it needs to be given as soon as possible." "Regular trips to the dentist are important." "It is best to take the medication with food."

89 A client with a terminal condition is admitted to the nursing unit. The initial action by the nurse would be to A) ensure the client is free from pain, nausea, or dyspnea

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B) C) D) refer the client's family to the chaplain discuss the options for advance directions with the client and family collaborate with the multidisciplinary team members

90 While interviewing a client, the nurse notices that the client is shifting positions, wringing the hands, and avoiding eye contact. It is important for the nurse to A) B) C) D) Ask the client what the client is feeling or thinking Check the client for auditory hallucinations Recognize the behavior as a side effect of medication Re-focus the discussion on a less anxiety provoking topic

91 The nurse admits a seven year-old to the emergency room following a leg injury. The x-rays show that there is a femur fracture near the epiphysis. The nurse should be aware that at this age, the injury most likely will A) B) C) D) Heal quickly because of thin periosteum Result in retarded bone growth Stimulate bone growth in the affected leg Show more rapid union than that of a younger child

92 The nurse is caring for a client with sickle cell disease. The client is scheduled to receive a unit of packed red blood cells. Which action is appropriate for the nurse when monitoring the infusion? A) B) C) D) Store the packed red cells in the medicine refrigerator while the RN is starting the IV Slow the rate of infusion if the client develops fever or chills Limit the infusion time of each of the unit to a maximum of four hours Check vital signs every 15 minutes throughout the entire infusion

93 A 7 months-pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) B) C) D) Non stress test Abdominal ultrasound Pelvic exam C-section

94 The nurse has been assigned to four residents. Which client should have priority on the initial shift visit? A) A 65 year-old male client with hypertension who has a reported B/P of 180/90 after learning that the client is being discharged to home B) An 81 year-old female client with coronary artery disease (CAD) reported to have dyspnea, nausea, and unusual discomfort in the back C) A 70 year-old client with a past diagnosis of heart failure (HF) and a reported increased urinary output four hours after a dose of furosemide D) A 55 year-old client with peripheral artery disease (PAD) reported to experience cramp-like pain in calf muscles during walking in physical therapy

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95 The nurse is assisting in the discharge of a 90 year-old client with musculo-skeletal weakness. Which of these interventions would be most effective to prevent falls? A) B) C) D) Place a nightlight in the bedroom and bathroom Have client wear eyeglasses at all times Install grab bars in the bathroom Teach muscle strengthening exercises

96 A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions would be helpful? A) B) C) D) Assist the family to bathe the client Demonstrate an active-passive exercise routine Have the family feed the client Role play communication strategies

97 The nurse is discussing an autograft with a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from. A) B) C) D) a tissue bank." a pig." my thigh." synthetic skin."

98 A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) B) C) D) Promote the client's comfort Reduce the drying time Decrease irritation to the skin Improve venous return

99 A client with anorexia is hospitalized on a medical unit with "electrolyte imbalance and cardiac dysrhythmias." Additional findings that the nurse would expect to observe are A) B) C) D) Brittle hair, lanugo, amenorrhea Diarrhea, nausea, vomiting Hyperthermia, tachycardia, increased metabolic rate Excessive anxiety about findings, dental erosion, osteoporosis

100 A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best initial response to this statement? A) B) C) D) "Let's talk about your feelings." "Have you thought about hurting yourself?" "Did you tell that to your family?" "Have you started giving away items dear to you?"

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101 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The best response by the nurse would be which statement? A) B) C) D) "Folic acid should be taken before and after conception." "Multivitamin supplements are recommended during pregnancy." "A well balanced diet promotes normal fetal development." "Increased dietary iron improves the health of mother and fetus."

102 The nurse is to perform part of a physical assessment on a toddler. Which action would be the best to use with this age group? A) B) C) D) Perform traumatic procedures first Use minimal physical contact Proceed from head to toe in sequence Explain the exam in detail along the way

103 A nurse is preparing a new mother for discharge. She knows the mother lives in an older home. In discussing formula preparation, which action is important for the mother to do to prevent lead poisoning? A) B) C) D) Use ready-to-feed commercial infant formula Boil the tap water for ten minutes before adding to concentrated formula Let tap water run for two minutes before adding to concentrated formula Buy bottled water to mix with the concentrated formula

104 Parents of a four year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse evaluates their reaction as which phase of the crisis process? A) Pre-crisis phase C) Crisis phase B) Impact phase D) Resolution phase

105 A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." The nurse's best response is A) B) C) D) "This is a common occurrence after birth. Let's talk about how to accept the baby." "Many women have postpartum blues and need some time to love the baby." "What a beautiful baby! Her eyes are just like yours." "You seem upset; tell me what the pregnancy and birth were like for you."

106 The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk

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107

Which finding contraindicates the use of haloperidol (Haldol) and warrants withholding the dose? A) B) C) D) Drowsiness, lethargy, and inactivity Dry mouth, nasal congestion, and blurred vision Rash, anemia, severe depression Hyperglycemia, weight gain, and edema

108 An eight year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) B) C) D) Bologna sandwich, pudding, milk Frankfurter, baked potato, milk Chicken strips, corn on the cob, milk Grilled cheese sandwich, apple, milk

109 The unlicensed assistive personal (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A) B) C) D) Encourage oral fluids for the temperature elevation Tell the client not to drink anything and recheck the temperature in 15 minutes Ask the client to drink only cold water and juices Chart this temperature elevation on the flow sheet

110 The provider has asked the nurse to change the dressings and clean the incision on a surgical client. Which process is correct when cleaning a surgical incision? A) B) C) D) Scrub lightly around the incision without touching the incision itself Clean from top to bottom of the incision using slow downward strokes Start at the incision and clean in an outward direction from the incision Use a circular motion to clean from the bottom to the top of the incision

111 A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial documentation is expected? A) B) Recent weight gain Physical growth delay C) D) Protruding eyeballs Sudden onset of irritability

112 The nurse is caring for a newborn with a neural tube defect (myelomeningocele). The best covering for the lesion would be A) Telfa dressing with antibiotic ointment B) Moist sterile nonadherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing

113 The nurse is reinforcing information to parents about accidental poisoning in children. Which of these points should be discussed? A) B) C) D) Start treatment before calling the Poison Control Center Empty the child's mouth in any case of possible poisoning Do not move the child if a toxic substance was inhaled Induce vomiting if the poison is a petroleum product

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114

An appropriate goal for a client with anxiety would be to A) B) C) D) Express feelings to the nurse Establish contact with reality Learn self-help techniques for anxiety reduction Become desensitized to past trauma and issues

115 As a nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to inject the medication without first aspirating. What should the nurse do? A) B) C) D) Ask the student: "What did you forget to do?" Say: "Stop. Tell me why aspiration is needed." Loudly state: "You forgot to aspirate." Walk up and whisper in the student's ear: "Stop. Aspirate. Then inject."

116 While monitoring the client's initial post operative condition after a thyroidectomy, which findings should the nurse report immediately to the RN? A) B) Tetany and paresthesia Mild stridor and hoarseness C) D) Irritability and insomnia Headache and nausea

117 The nurse is reinforcing how to use the metered-dose inhaler (MDI) to a client newly diagnosed with asthma. The client asks when they will know the canister is empty. The best response is A) B) C) D) Drop the canister in water to observe floating. Estimate how many doses are usually in the canister. Count the number of doses as the inhaler is used. Shake the canister to detect any fluid movement.

118 The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) B) C) D) Leave the order for the oncoming staff to follow-up Contact the charge nurse for an interpretation. Ask the pharmacy for assistance in the interpretation. Call the provider for clarification

119 A client, admitted to the rehabilitation unit after a stroke, has mild dysphagia. The most appropriate intervention for this client is A) B) C) D) Position client in an upright position while eating Alternate a clear liquid diet with a soft diet Tilt head back to facilitate the swallowing reflex Offer finger foods such as crackers or pretzels

120 An 80 year-old client on digitalis (Lanoxin) and Bumex reports nausea, vomiting, and abdominal cramps. Which laboratory result should the nurse check first? A) Potassium levels B) Blood pH C) Magnesium levels D)Serum glucose

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121 A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? A) Abnormal breath sounds C) Increasing pulse rate B) Cyanosis of the lips D) Pulse oximeter reading of 92% 122 When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the best action the nurse would suggest to the parents is A) Administer syrup of ipecac C) Have the child drink milk B) Offer small amounts of water D) Give ginger ale or cola 123 When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to A) B) C) D) change whichever item is incorrect to the correct information use the bracelet and admission form until a replacement is supplied notify the Admissions Office and wait to apply the bracelet make a corrected identification bracelet for the client

124 A client was admitted to the eating disorder unit with bulimia nervosa. When the nurse gathers data on the history of complications of this disorder, which of these findings are expected? A) B) C) D) Respiratory distress, dyspnea Bacterial gastrointestinal infections, overhydration Metabolic acidosis, constricted colon Dental erosion, parotid gland enlargement

125 The nurse notes that a two year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The next action by the nurse should be to A) B) C) D) Reassure the mother that a low grade temperature is expected Offer the child cold oral fluids or popsicles Take the child's temperature Administer the prescribed PRN acetaminophen

126 The nurse participating in the plan of care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which approach as a priority? A) B) C) D) Forcing fluids Client controlled analgesia Compresses to the elbow area Periodic deep breathing x 3

127 The nurse is reinforcing teaching to parents about diet for a four month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) B) Formula or breast milk Broth and tea C) D) Rice cereal and apple juice Gelatin and ginger ale

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Cont. Diagnostic Test 2

128 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following items is critical for the nurse to include while discussing the plan of care with the charge nurse? A) Hourly urine output C) Blood glucose every four hours B) Hourly neuro checks D) Temperature every two hours 129 The nurse assigned to a nine year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? A) B) C) D) Risk for fluid volume deficit related to morphine overdose Decreased gastrointestinal mobility related to mucosal irritation Ineffective breathing patterns related to central nervous system depression Altered nutrition related to inability to control nausea and vomiting

130 An unconscious client is brought by ambulance to the emergency room, Which of these available documents should be given priority in guiding the care of this client? A) B) Client self determination act Health care provider's treatment orders C) D) Advance directives Clinical pathway protocols

131 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which nursing intervention on the plan of care should receive priority? A) B) C) D) Maintain proper body alignment Frequent neurovascular checks of the affected leg Inspection of pin sites for evidence of drainage or inflammation Apply an over-bed trapeze to assist the client with position changes

132 Which information would indicate that a 55 year-old female client who is scheduled for abdominal surgery is at risk for thrombus formation in the post-operative period? A) B) Hormonal replacement therapy 10% less than ideal body weight C) D) Hypersensitivity to heparin History of hepatitis

133 A newly admitted elderly client with severe dehydration has an IV started and urethral catheter inserted to a bedside drainage bag. When planning care for this client, which task would be a priority to assign to an unlicensed assistive personnel (UAP)? A) Reposition client every 1 to 2 hours B) Report a urine output of less than 30 ml/hr C) Identify any skin redness or breakdown D) Check skin turgor every 2 to 4 hours 134 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which finding would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite C) A decrease in lethargy B) A decrease in fluid retention D) A reduction in jaundice 135 The nurse is reinforcing the teaching of a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to measure A) B) Oxygen saturation Forced expiratory volume C) D) Presence of allergens Doses for inhaled bronchodilator

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136 A nurse who works in a high school is advising a class of unwed pregnant students that the most important action they can perform to deliver a healthy child is to A) Maintain good nutrition B) Stay in school to keep normal activities C) Keep in contact with the child's father D) Get adequate sleep and frequent rest 137 An 18 year-old client is admitted to intensive care from the emergency room after a diving accident. The injury is suspected to be at the level of the second cervical vertebrae. The nurse has the priority to collect data related to A) Response to stimuli C) Respiratory function B) Bladder control D) Muscle Weakness 138 A three year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and being irritable and restless." Based on these complaints, the nurse would suspect which problem? A) Allergies C) Tapeworms B) Hyperactivity D) Pinworms 139 Which disorder? A) B) C) D) statement made by a client indicates to the nurse that the client may have a thought "I'm so angry about this. Wait until my partner hears about this!" "I'm a little confused. What time is it?" "I can't find my 'mesmer' shoes. Have you seen them?" "I'm fine. It's my daughter who has the problem."

140 A client with Guillain Barre is in a nonresponsive state. Vital signs are stable and breathing is spontaneous. Which documentation most accurately describes the client's condition? A) B) C) D) Comatose, breathing unlabored Glascow Coma Scale 8, respirations regular Appears to be sleeping, vital signs stable Glascow Coma Scale 13, no ventilator required

141 The nurse is preparing a client with a deep vein thrombosis (DVT) for a venous doppler evaluation. Which would be necessary to prepare the client for this test? A) B) C) D) Keep NPO after midnight Have ready a sedative medication prior to the test Discontinue anti-coagulant therapy prior to the test No special preparation is necessary

142 A young adult seeks treatment in an outpatient mental health center. The client tells the nurse since he is a government official spies are following him. On further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? A) B) C) D) Listen quietly without comment Ask for further information on the spies Confront the client about the delusions Contact security for potential safety concerns

143 The nurse is assigned to a 14 year-old client returning from corrective surgery for scoliosis. Which action should receive priority in the plan of care?

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A) B) C) D) Assist with antibiotic therapy for 10 days Reinforce isometric exercises for the legs Monitor movement and sensation of extremities Assist to stand up at bedside within the first 24 hours

144 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's best explanation would be which of these comments? A) B) C) D) "It tells us how far along your pregnancy is." "The results help determine if the baby is growing normally." "Placental exchange of oxygen is measured." "Possible neurological defects may be identified."

145 An eight year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of these allergies should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap

146 A client has been admitted to the coronary care unit with a myocardial infarction. Which of the listed nursing diagnoses should the PN be sure to discuss as a priority during a client care conference? A) B) C) D) Pain related to ischemia Activity intolerance Risk for complication: dysrhythmias Anxiety

147 A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's best initial intervention is to A) B) C) D) Discuss with the mother sharing parenting responsibilities Help the mother to express her feelings and concerns Arrange for the parents to attend infant care classes Talk with the father and help him accept the partner's decision

148 A client diagnosed with hepatitis C discusses health history with the nurse. The nurse should recognize which information as the most important? A) Recent travel to Central America B) Ingestion of raw shellfish last week C) Multiple sex partners over the past two years D) Blood transfusions over 18 years ago 149 When talking with a client receiving warfarin sodium (Coumadin) about dietary habits, it is important that the nurse reinforce the need to avoid eating A) Hamburgers 150 A) B) C) D) B) Grapefruit C) Romaine lettuce D) Eggs

Which time is a depressed client at highest risk for suicide attempts? Within 72 hours after admission, during one-to-one observation Within one to two weeks after initiation of antidepressant medication with psychotherapy After an angry outburst with family members over insignificant issues When the client is removed from the security room during hospitalization

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