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Question 1 of 5

A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:

Correct Answer: C

Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.

Question 2 of 5

The nurse is caring for a newborn who has a large myelomeningocele. It would be a priority for the nurse to

Correct Answer: B

Rationale: A myelomeningocele requires a sterile, moist dressing (
B) to prevent infection and drying. Checking anus tone (
A), measuring head circumference (
C), and supine positioning (
D) are secondary or contraindicated.

Question 3 of 5

Which of the following activities would be best tolerated by a client with muscular dystrophy?

Correct Answer: A

Rationale: Swimming is low-impact and supports muscles, making it the best activity for a client with muscular dystrophy, which causes muscle weakness.

Question 4 of 5

The nurse is caring for a woman who has internal radiation for cancer of the cervix. Which of the following situations poses the greatest risk for others?

Correct Answer: A

Rationale: Prolonged close contact (daughter's hours-long visit) increases radiation exposure risk. Brief visits, tray setup, or mopping pose minimal risk.

Question 5 of 5

The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client?

Correct Answer: B,C,D,E

Rationale: Reflecting on triggers (
B), documenting intake (
C), staying during meals (
D), and daily weighing (E) support recovery. Exercise (
A) should be limited to prevent calorie expenditure.

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The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?

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