Chapter 44-49 Quiz

A nurse is conducting a preliminary assessment on a middle-aged client diagnosed with hypertension. Which action indicates the nurse's attempt to engage in therapeutic communication?

• Keeping the time frame for the interview to a pre-established length

• Talking about experiences of other clients

• Asking only closed-ended questions to the client

• Encouraging the client to express personal thoughts

A nurse is ordered to maintain a fluid intake and output record (I&O record) for a client. During the last 24 hours, the client has had 300 mL of ice. How should the nurse document this?

• Fluid intake of 150 mL

• Fluid intake of 200 mL

• Fluid intake of 250 mL

• Fluid intake of 300 mL

The nurse spreads the feet sideways when lifting. Which principle of body mechanics is being followed to maintain balance?

• Center of gravity

• Line of gravity

• Base of support

• Gravital plane

When should a client's discharge planning begin?

• When the client demonstrates an interest in the information

• On admission to the healthcare facility

• At least 24 hours before discharge is planned

• When the client is able to assume self-care of their personal needs.

Which type of thermometer should the nurse use when monitoring the temperature of a client placed on contact precautions?

• Temporal artery

• Rectal

• Disposable single use

• Tympanic

Which forms of communication can the nurse use when communicating with a newly admitted client and client's family? Select all that apply.

• Written materials

• A picture board

• Simple phrasing

• Non-medical terminology

• Frequent summation of information

Which vital sign indicates an abnormal finding for a healthy adult?

• Blood pressure 118/74

• Oral temperature 37°C/98.6°F

• Pulse 66 beats per minute

• Respiration rate 21 breaths per minute

The nurse is updating the “communication board” in the client’s room. What information should the nurse be sure to include? Select all that apply.

• The date

• The nurse’s name

• The diagnosis

• The provider’s name

• Results of current laboratory studies

The nurse is testing the function of a client’s cranial nerves. What statement made by the nurse would indicate testing of cranial nerve IX (glossopharyngeal)?

• “Shrug your shoulders and turn your head.”

• “Move and clench your jaw.”

• “Swallow.”

• “Stand with your eyes closed.”

What type of crutch-walking gait should the nurse recommend to the client who is only able to partially bear weigh on either leg?

• Two-point gait

• Three-point gait

• Four-point gait

• Swing-through gait