Tüm alıştırma soruları

An occupational health nurse is evaluating a 68-year-old male client during a retirement health assessment. The client's medical record reveals a 35-pack-year smoking history, though he successfully quit smoking 10 years ago. He currently takes no daily medications. The client states, "I feel perfectly healthy, but my wife says I have been misplacing my glasses and forgetting appointments lately. I am sure it is just my old age, so I only came in today to get my updated pneumonia and shingles vaccines."

Based on evidence-based health screening guidelines, which comprehensive plan of care is the most appropriate for this client?

An adolescent client admitted to a general pediatric unit for the management of diabetic ketoacidosis becomes increasingly upset after being informed that friends cannot visit after visiting hours. The client yells profanities, throws a plastic water pitcher against the wall, and demands to leave the hospital immediately. What is the priority nursing action?

A clinic nurse is evaluating the developmental progress of a 24-month-old toddler during a routine health maintenance visit. Which of the following findings should the nurse recognize as an expected developmental milestone for this age? Select all that apply.

The nurse is planning care to promote independence in self-care for an older adult client. Which nursing action is most appropriate?

A client is admitted to the cardiac step-down unit with an acute exacerbation of heart failure. During visiting hours, the client's family brings in several containers of homemade herbal teas and traditional broths. The client tells the nurse, 'These remedies will heal my heart better than the hospital food.' Which of the following is the most appropriate response by the nurse?

During a routine home visit, a community health nurse evaluates a 29-year-old client with a profound intellectual disability. While assisting with hygiene, the nurse discovers several distinct, circular burn marks on the client's posterior thorax. The client's primary caregiver claims the burns occurred accidentally from a hot radiator and adamantly demands that the nurse keep the observation strictly confidential to prevent a potential state investigation. Which action represents the most appropriate legal and ethical response by the nurse regarding the disclosure of this information?

A client diagnosed with schizophrenia is experiencing active auditory hallucinations and severe paranoia. The client is pacing the unit's dayroom, staring suspiciously at the ceiling fixtures, and repeatedly stating, "The cameras are tracking my movements." Which initial action by the nurse best establishes a therapeutic and safe environment?

A nurse is planning care for a client who is receiving internal radiation therapy via a sealed vaginal implant (brachytherapy) for cervical cancer. Which of the following safety measures should the nurse implement? Select all that apply.

During a 2-year well-child visit, the registered nurse is reviewing the required clinical protocols for a healthy toddler. Which secondary prevention and developmental evaluations are indicated for this client? Select all that apply.

A nurse in an outpatient oncology clinic is preparing to conduct an initial intake assessment for a newly referred client who speaks limited English. The client is accompanied by their bilingual teenage child, who immediately offers to translate for the nurse. In what order should the nurse perform the following actions? (Arrange from first to last)

An ambulatory care nurse is mentoring a newly graduated nurse on health promotion frameworks. They are reviewing the care plan for a 58-year-old client with type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). The nurse asks the graduate to identify interventions that specifically represent primary prevention. Which of the following selections by the graduate indicate a correct understanding? Select all that apply.

A pediatric nurse is performing a comprehensive developmental assessment on an 18-month-old client during a health maintenance visit. Which of the following assessment findings should the nurse identify as indicating a potential developmental delay?

A client experiencing an acute manic episode is pacing rapidly in the dayroom, speaking loudly, and beginning to invade the personal space of other clients. The nurse must intervene to prevent further escalation. Arrange the following nursing interventions in order from least restrictive to most restrictive.

A $62\text{-year-old}$ client is admitted to the telemetry unit with an exacerbation of heart failure. The client has +3 pitting edema in the bilateral lower extremities. The client's vital signs are blood pressure $148/92\text{ mmHg}$, heart rate $88\text{ bpm}$, and respiratory rate $22\text{ breaths/min}$. The most recent basic metabolic panel reveals a serum potassium level of $4.2\text{ mEq/L}$. The healthcare provider prescribes $40\text{ mg}$ of intravenous (IV) furosemide. Which of the following is the most important nursing action when administering this medication?

The home health nurse is teaching a client how to independently change a one-piece colostomy pouch. In which order should the client perform the following steps to ensure proper skin protection and pouch adhesion? (Arrange the steps from first to last.)

A nurse is developing a care plan focusing on basic care and comfort for a client admitted with acute decompensated heart failure. The client is experiencing severe orthopnea, fatigue, and marked dependent pitting edema in the lower extremities. Which nursing interventions should be included in the plan of care? Select all that apply.

A nurse is formulating a plan of care focusing on basic care and comfort for an older adult client who sustained deep partial-thickness burns to the anterior neck, chest, and bilateral axillae 48 hours ago. Which of the following interventions should the nurse include? Select all that apply.

A client with acute delirium and severe agitation in the emergency department is shouting at staff, refusing care, and attempting to climb over the bed rails. Which interventions should the nurse implement as the initial approach to manage this behavioral escalation? Select all that apply.

A registered nurse in a family health practice is prioritizing interventions for a group of pediatric clients. The nurse's current objective is to identify and implement secondary prevention measures. Which of the following clinical activities accurately represents a secondary prevention strategy?

A client who observes Orthodox Judaism is in the active phase of the first stage of labor. The client is visibly uncomfortable and crying during contractions. The client's spouse is present in the labor room but remains seated in the corner reciting prayers from a book and does not make physical contact with the client. Which action by the nurse is most appropriate?