- Question 1 points
The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement, if made by the client, indicates that teaching about improving sleep is necessary?
1. “I swim three times a week.”
2. “I have stopped smoking cigars.”
3. “I drink hot chocolate before bedtime.”
4. “I read for 40 minutes before bedtime.”
- Question 1 points
The nurse is providing instructions to a nursing assistant regarding care of an older client with hearing loss. The nurse tells the assistant that clients with a hearing loss:
1. Are often distracted
2. Have middle ear changes
3. Respond to low-pitched tones
4. Develop moist cerumen production
- Question 1 points
The home care nurse is visiting an older female client whose husband died 6 months ago. Which behavior by the client indicates ineffective coping?
1. Neglecting her personal grooming
2. Looking at old snapshots of her family
3. Participating in a senior citizens 0f program
4. Visiting her husband’s grave once a month
- Question 1 points
The nurse employed in a long-term care facility is caring for an older male client. Which nursing action contributes to encouraging autonomy in the client?
1. Planning his meals
2. Decorating his room
3. Scheduling his barber appointments
4. Allowing him to choose social activities
- Question 1 points
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse explains that the best time to perform this exam is:
1. After a shower or bath
2. While standing to void
3. After having a bowel movement
4. While lying in bed before arising
- Question 1 points
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which of the following best describes the sound of a heart murmur?
1. Lub-dub sounds
2. Scratchy, leathery heart noise
3. Gentle, blowing or swooshing noise
4. Abrupt, high-pitched snapping noise
- Question 1 points
The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which of the following?
1. A defect in the cochlea.
2. A defect in the 8th cranial nerve.
3. A physical obstruction to the transmission of sound waves.
4. A defect in the sensory fibers that lead to the cerebral cortex.
- Question 1 points
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse expects to note which of the following?
1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration
- Question 1 points
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. What type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client?
1. Stridor
2. Crackles
3. Wheezes
4. Diminished
- Question 1 points
A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which of the following is the most appropriate activity for this child?
1. A radio
2. A sports video
3. Large picture books
4. Crayons and a coloring book