What question would be most important to ask a male client who is in for a digital rectal examination?         A. “Have you noticed a change in the force of the urinary system?”      B. “Have you noticed a change in tolerance of certain foods in your diet?”      C. “Do you notice polyuria in the AM?”… Read More »

Nurse Renner is about to perform Romberg’s test on Pierro. To ensure the latter’s safety, which intervention should nurse Renner implement?         A. Allowing the client to keep his eyes open.      B. Having the client hold on to furniture.      C. Letting the client spread his feet apart.      D. Standing close to provide… Read More »

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%. Based on the result, the nurse plans to teach the client about the importance of:         A. Maintaining the result.      B. Preventing hypoglycemia.      C. Preventing hyperglycemia.      D. Avoiding infection.           Correct Answer: C. Preventing hyperglycemia. Glycosylated… Read More »

To respect a client’s personal space and territoriality, the nurse:         A. Avoids the use of touch.      B. Explains nursing care and procedures.      C. Keeps the curtains pulled around the client’s bed.      D. Stands 8 feet away from the bed, if possible.           Correct Answer: B. Explains nursing care… Read More »

Vivid dreaming occurs in which stage of sleep?         A. Stage I non-REM      B. Rapid eye movement (REM) stage      C. Stage II non-REM      D. Delta stage           Correct Answer: B. Rapid eye movement (REM) stage Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot… Read More »

Which statement regarding heart sounds is correct?         A. S1 and S2 sound equally loud over the entire cardiac area.      B. S1 and S2 sound fainter at the apex.      C. S1 and S2 sound fainter at the base.      D. S1 is loudest at the apex, and S2 is loudest at the base.… Read More »

A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?         A. Fever      B. Intact skin      C. Inflammation      D. Lethargy           Correct Answer: B. Intact skin Intact skin is considered a primary defense against infection. Usually, the skin… Read More »

The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?         A. Apical      B. Radial      C. Pedal      D. Femoral           Correct Answer: C. Pedal Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence… Read More »

Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s:         A. Physician      B. Non-Emergent, non-life-threatening needs      C. Future well-being.      D. Urgency of problems           Correct Answer: D. Urgency of problems Triage of… Read More »

The pathological process causing esophageal varices is/are:         A. Ascites and edema      B. Systemic hypertension      C. Portal hypertension      D. Dilated veins and varicosities           Correct Answer: C. Portal hypertension Esophageal varices result from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the… Read More »