Question

445. The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation? A. Glucose level of 120 B. History of myocardial infarction C. Long term steroid usage D. Diet high in carbohydrates

446. In assessing the healing of a client wound during a home visit, which of the following is the best indicator of good healing? A. White patches B. Green drainage C. Reddened tissue D. Eschar development

447. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of her heart conduction disturbance? A. Aterial septal defect B. Patent ductusarterious C. Aortic stenosis D. Ventricular septal defect

448. When an autistic client begins to eat with her hands, the nurse can best handle the problem by A. Placing the spoon in the client’s hand and stating, “Use the spoon to eat your food.” B. Commenting, “I believe you know better than to eat with your hand.” C. Jokingly stating, “Well I guess fingers sometimes work better than spoons.” D. Removing the food and stating, “You can’t have anymore food until you use the spoon.”

449. The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states “I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax.” The client is using which defense mechanism? A. Denial B. Projection C. Intellectualization D. Rationalization

450. When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first? A. Try to vigorously stimulate normal breathing B. Ask the RN to assess the vital signs C. Measure the pulse oximetry D. Continue to monitor respirations

451. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A. Craving B. Crashing C. Outward bound D. Nodding out

452. Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)? A. Permission to videotape B. Salivary pH C. Mini-mental status exam D. Pre-anesthesia work-up

453. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate is nursing action? A. Pack the nose and ears with sterile gauze B. Apply pressure to the injury site C. Apply bulky, loose dressing to nose and ears D. Apply an ice to the back of the neck

454. The nurse is caring for a client with increased intracranial pressure ( ICP) understands that which condition(s) can cause problem? Select all that apply. A. Edema B. Trauma C. Tumors D. Migraines E. Hemorrhages F. Hydrocephalus

456. The nurse understands that which are risk factor(s) for the development of breast cancer? Select all that apply. A. Age B. Obesity C. Multiparity D. Family history E. Early menarche F. Early menopause

Answer 1

Ans:- 445,

C,

Long term use of steroids most important risk factor for the delayed wound healing because steroids causes dehisecnce of wound, increases risk of wound infection and delayed wound healing.

446,

C,

Reddened tissue,

Reddened tissue is the best indicator of wound healing . As the wound granulates , redness indicates healing.

447,

A,

Atrial septal defect,

Because it has most common genetic association.

448,

A,

When an autistic client begins to eat with her hands,the nurse can best handle the problem by ,placing the spoon in the client's hand and stating, "use the spoon to eat your food,"

This response identifies adaptive behaviour with instructions and verbal expectations.