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1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to:
A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in one week.
C. Check for any change in responsiveness every two hours until the follow-up visit.
2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:
A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered
3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to:
A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s emotional illness. The nurse’s most therapeutic initial response would be:
A. “You may be able to lessen your feelings of guilt by seeking counseling”
B. “It would be helpful if you become involved in volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
D. “Joining a support group of parents who are coping with this problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should:
A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of blood
C. Outline the blood as it appears on the dressing to observe any progression
D. Press gently around the incision to express accumulated blood from the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
