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The definition of "family" has evolved as society has changed. The most comprehensive definition of the term includes:

• A unit of people related by birth or adoption or by marriage
• Two or more emotionally involved people
• Related people who live in close proximity to each other
• A changing group of people
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The nurse is caring for a client who is nauseated and in danger of aspiration. Which action would the nurse take first?

• Administer an ordered antiemetic medication
• Obtain an ice bag and apply to the client's throat
• Turn the client to one side
• Notify the physician
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A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy?

• Positive
• Probable
• Presumptive
• Diagnostic
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A client had cardiothoracic surgery. After a long stay in the cardiovascular recovery unit (CVRU), the client has not yet been out of bed. The client's medical history reveals that the client lives in a one-story home alone and drives a car. The nurse notes that the client has been lethargic, unwilling to participate in basic ADL, and needs one-on-one encouragement to eat. What is the most logical rationale for the client's unwillingness to participate in self-care, and what is the best plan of care for the nurse to follow to promote independence?

• The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.
• The client has been immobile in the CVRU for an extended period of time and is most likely experiencing grief, withdrawal, and fear of not being able to return to an independent lifestyle upon discharge. The nurse should allow the client plenty of quiet time, isolated and alone, to reflect and to grieve. The nurse should promote proper hygiene by performing all ADL activities for the client.
• The client is experiencing "ICU syndrome." The nurse should notify the physician of the nurse's observations and request antianxiety medication. The nurse should then monitor the client closely.
• The client is experiencing "ICU syndrome." The nurse should notify the physician of the nurse's observations and request antianxiety medication. The nurse should then encourage discussion with the client regarding the client's feelings about the hospitalization and the client's fears. The nurse should compassionately dispel any irrational fears; encouraging and praising all attempts by the client to regain independence.
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A client who is rushed to the emergency department is diagnosed with a ruptured aortic aneurysm. Which intervention should the nurse expect for this client?

• Administration of beta-blockers.
• Administration of antihypertensives.
• Arteriogram.
• Surgical repair.
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A patient, age 76, is transferred to the medical-surgical unit from the emergency department (ED) with a diagnosis of left-sided stroke in evolution. On admission to the unit, he has a blood pressure of 150/90 mm Hg, an apical pulse of 78 beats/minute and regular, a respiratory rate of 20 breaths/minute, and a rectal temperature of 100º F (37.8º C). The practitioner orders oxygen by nasal cannula at 2 L/minute; vital sign assessment every hour for the first 4 hours, every 2 hours for the next 4 hours, and then every 4 hours; I.V. D5W in half-normal saline solution at a rate of 100 ml/hour, and no oral intake. When helping to transfer the patient to his bed, the nurse notices a snoring quality to his respirations. Which nursing action is the highest priority at this time?

• Place the patient in Fowler's position
• Assess the patient's ability to communicate his needs
• Position the patient on his side, with the head of the bed elevated slightly
• Place items the patient may need to the left side of the bed
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The nurse is assessing a client who has undergone a right lobectomy. Which assessment should alert the nurse to the possibility of internal bleeding?

• Urinary output of 200mL during the past 3 hours
• Sanguineous chest tube drainage at a rate of 50mL per hour for the past 3 hours
• Restless and shortness of breath
• Decreased pulse rate and decreased respirations
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After instructing participants in a childbirth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which of the following?

• Biofeedback
• Effleurage
• Guided imagery
• Pelvic tilt exercises
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A client has a nasogastric (NG) tube placed after abdominal surgery. Which finding indicates the NG tube may be removed?

• Drainage volume decreases
• The client experiences flatus
• The client no longer feels nauseous
• The client is burping
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A client is receiving Theodur. The nurse monitors the theophylline blood level and assesses that the level is within therapeutic range when it is at what level?

• 5ug/mL
• 8ug/mL
• 15ug/mL
• 25ug/mL
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