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Questions 149

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Question 1 of 5

The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.

Correct Answer: C,D,A,B

Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.

Question 2 of 5

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?

Correct Answer: A

Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program

Question 3 of 5

Which would be included in the nursing care plan of a client experiencing severe delirium tremens?

Correct Answer: B

Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.

Question 4 of 5

The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:

Correct Answer: C

Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.

Question 5 of 5

The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet?

Correct Answer: C

Rationale: Cooked broccoli is high in fiber and should be avoided on a low-roughage diet for diverticulitis to prevent irritation.

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