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Question 1 of 5

Which priority problem should the clinic nurse identify for the client who is greater than ideal body weight and weighs 87 kg?

Correct Answer: A

Rationale: Obesity increases risks for complications (e.g., diabetes, CV
D), the priority problem per nursing assessment.

Question 2 of 5

The female client is complaining of dyspepsia, insomnia, and upper respiratory infection symptoms and has an elevated blood pressure. The client tells the nurse she recently moved to the area to care for an ill parent. Which statement best explains the client's clinical manifestations?

Correct Answer: B

Rationale: Stress from caregiving may suppress immunity, causing URI, dyspepsia, insomnia, and hypertension. Psychosomatic illness is vague, gastric reflux is specific, and essential hypertension is premature.

Question 3 of 5

The client is performing breast self-examination (BSE) by the American Cancer Society's recommended steps and has completed palpating the breast. Which step is next when completing the BSE?

Correct Answer: A

Rationale: After palpation, visual inspection in a mirror detects skin changes, the next ACS BSE step.

Question 4 of 5

The client is complaining of acute abdominal pain, and the next pain medication is not due for two (2) hours. Which interventions should the nurse implement? List in order of priority.

Order the Items

Source Container

Notify the health-care provider to increase pain medication.
Auscultate for bowel sounds and palpate the abdomen.
Instruct the client to visualize a pleasant memory.
Turn on the radio to soft, easy-listening music.
Offer the client a therapeutic back massage.

Correct Answer: B,C,E,D,A

Rationale: 1) Auscultate/palpate abdomen (assess for complications like obstruction); 2) Visualize pleasant memory (guided imagery for pain); 3) Offer back massage (nonpharmacological relief); 4) Play soft music (enhances relaxation); 5) Notify HCP (if pain persists or worsens).

Question 5 of 5

The unlicensed assistive personnel asked the wound care nurse why a client has cabbage leaves on the wound. Which statement would be the best response by the nurse?

Correct Answer: A

Rationale: Cabbage leaves have documented anti-inflammatory properties, used in folk medicine. Calling it ignorance, placebo, or only moisture is dismissive or inaccurate.

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The nurse is preparing a female client for surgery. The client tells the nurse that she is a Jehovah's Witness and is afraid that the staff will administer blood to her during the procedure while she is under anesthesia. Which is the nurse's best response to the client?
Which client should the charge nurse on the substance abuse unit assign to the licensed practical nurse (LPN)?
The client with a history of substance abuse presents to the emergency department complaining of right flank pain, and the urinalysis indicates microscopic blood. Which intervention should the nurse implement?

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