Question

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for a dietary consult. The client tells the nurse, "I will have to eat whatever the dietitian tells me." Which of the following statements by the nurse encourages the client's involvement in their plan of care?

Answer 1

Correct Answers:

"I can assist you with making a list of foods you like for the dietitian."

Rationale :

✍️ This response promotes client autonomy and collaboration in their own care.

✍️ It invites the client to participate in planning, which increases adherence and satisfaction with the dietary regimen.

✍️ Encouraging shared decision-making supports the principles of client-centered care.

✍️ The nurse helps bridge understanding between client preferences and the dietitian's expertise.

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Answer 2

Correct Answers:

Pinch the trapezius muscle.

Rationale :

◈ The trapezius pinch is a recognized technique to apply a central pain stimulus for assessing neurologic response.

◈ This method helps determine the client’s level of consciousness or responsiveness when verbal cues fail.

◈ It is a safe and effective stimulus without risking injury.

◈ Other methods like orbital pressure or using a needle are either too invasive or not appropriate.

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Answer 3

Correct Answers:

'We will respect what is important to you.

Rationale :

▪️ This open-ended, inclusive statement demonstrates cultural sensitivity and supports the client and family’s autonomy and values.

▪️ It avoids assumptions and allows the team to tailor care to individual beliefs.

▪️ Respecting diverse cultural beliefs is a core principle of hospice and palliative care.

▪️ This promotes trust and dignity during end-of-life care.

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Answer 4

Correct Answers:

Irrigate the affected eye from the inner corner toward the outer corner.

Rationale :

🔷 Irrigating from inner to outer canthus prevents contaminants from entering the unaffected eye or tear duct.

🔷 This technique helps direct chemicals away from the nasolacrimal duct, reducing systemic absorption or spread.

🔷 It’s essential to follow proper directional flow to ensure safety and effectiveness.

🔷 Sterile normal saline or lactated Ringer’s is preferred over sterile water to avoid corneal irritation.

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Answer 5

Correct Answers:

Standard precautions

Rationale :

✔️ AIDS is a bloodborne illness, not airborne or droplet, so standard precautions are sufficient for routine care.

✔️ These precautions include using gloves, hand hygiene, and safe needle disposal.

✔️ Special transmission-based precautions are not necessary unless another infection is present.

✔️ This helps avoid stigma while maintaining safety.

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Answer 6

Correct Answers:

Rebound tenderness with palpation

Rationale :

✳️ Rebound tenderness is a sign of peritoneal irritation or inflammation, which could indicate conditions like appendicitis or peritonitis.

✳️ It reflects a surgical emergency, making it the priority finding.

✳️ Other findings are non-urgent and can be monitored, but rebound pain suggests potential intra-abdominal infection or rupture.

✳️ This requires immediate provider notification and diagnostic imaging.

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Answer 7

Correct Answers:

A client who reports having fever, night sweats, and cough for 2 days

Rationale :

➡️ These symptoms raise concern for tuberculosis, which is an airborne infectious disease.

➡️ Clients with suspected TB should be placed in a private, negative-pressure room immediately.

➡️ This helps prevent airborne transmission to other patients or staff.

➡️ The other clients do not meet criteria for isolation based on their presenting symptoms.

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Answer 8

Correct Answers:

A client who has a right upper extremity arteriovenous fistula

Rationale :

💎 Blood pressure should not be taken on the arm with an AV fistula due to the risk of damaging the access site.

💎 Using the opposite extremity helps maintain patency and avoid complications like clotting or rupture.

💎 The left arm is safe unless another contraindication exists.

💎 Protecting the fistula is essential for long-term dialysis access.

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Answer 9

Correct Answers:

Altered level of consciousness

Rationale :

🔹 The first sign of increased intracranial pressure (ICP) is often a change in mental status or decreased responsiveness.

🔹 LOC changes occur before more severe signs like Cheyne-Stokes respirations or posturing.

🔹 Early recognition allows for prompt intervention to prevent brain herniation.

🔹 This makes it the most sensitive early indicator of neurologic deterioration.

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Answer 10

Correct Answers:

"I have a hard time with brushing my hair."

Rationale :

🍃 This statement indicates difficulty with upper extremity function, which is within the scope of occupational therapy (OT).

🍃 OT helps patients regain or adapt to daily living activities like grooming, bathing, and dressing.

🍃 Referring to OT promotes independence and quality of life.

🍃 Swallowing concerns are addressed by speech therapy, while ambulation is typically managed by physical therapy.

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RN Adult Medsurg II~2023

No.

2 :
A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

3 :
A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the clients and family's cultural beliefs?

4 :
A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take?

5 :
A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?

6 :
A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

7 :
A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

8 :
A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?

9 :
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

10 :
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

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RN Adult Medsurg II~2023

No.

2 : A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

3 : A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the clients and family's cultural beliefs?

4 : A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take?

5 : A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?

6 : A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

7 : A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

8 : A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?

9 : A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

10 : A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

2 :
A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

3 :
A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the clients and family's cultural beliefs?

4 :
A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take?

5 :
A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?

6 :
A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

7 :
A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

8 :
A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?

9 :
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

10 :
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?