Question 1

When maintaining accurate records in situations of suspected abuse, the nurse should document

Volume A

Options :

A : an interpretation of the client-s statements regarding the abuse.

B : a body map to indicate size, color, areas and types of injuries.

C : a description of the suspected abuser.

D : generalized statements about the events leading up to the abuse.

Answer: B

Question 2

A patient in the recovery room complains of incisional pain. Which of the following nursing interventions would be most appropriate?

Volume C

Options :

A : Give meperidine (Demerol) 50 mg, IM, as ordered

B : Encourage deep breathing exercises

C : Place the patient in a prone position

D : Give acetaminophen (Tylenol), two tablets as ordered

Answer: A

Question 3

To which of the following assessment data should the nurse give highest priority for a client admitted to the emergency room in a hepatic coma?

Volume A

Options :

A : Neurological status

B : Airway adequacy

C : Ammonia levels

D : Gastrointestinal bleeding

Answer: B

Question 4

A 6-year-old is admitted to the hospital with a tentative diagnosis of acute lymphocytic leukemia. When assessing the child for symptoms of leukemia, the nurse should consider which of these questions?

Volume D

Options :

A : What reaction does the child have when tested for the presence of Homan-s sign?

B : What is the color of the child-s sclera?

C : Does the child have a pulse deficit?

D : Does the child have bone pain?

Answer: D

Question 5

A client says to the nurse, "My doctor told me they are going to do some kind of test on me. I really didn't understand it." The nurse's best response would be

Volume B

Options :

A : "Tell me your concerns."

B : "In the future tell your doctor he needs to speak more loudly."

C : "I would not worry about it too much. There is no pain involved."

D : "I'm sure you will be fine once you see what they are doing."

Answer: A

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