Question: Exit A_Alt Calculator Time Remaining 01:07:43 39 Of 100 The Nurse Provides Care For An Adolescent Client Diagnosed With Conduct Disorder. The Treatment Plan Includes Limit-setting. The Client Is Told What Behavior Is Acceptable, Not Acceptable, And The Consequences Of Behaving Unacceptably. The Nurse Prepares To Enforce The Consequences Of Unacceptable …

Exit A_Alt Calculator Time Remaining 01:07:43 39 of 100 The nurse provides care for an adolescent client diagnosed with conduct disorder. The treatment plan includes limit-setting. The client is told what behavior is acceptable, not acceptable, and the consequences of behaving unacceptably. The nurse prepares to enforce the consequences of unacceptable behavior. The client states in a sincere tone of voice, “I’ll be good. Please give me one more chance.” Which action by the nurse is best? 01. Ask what other consequence the adolescent desires. O 2. Discuss the reasons for the limit-setting. O 3. Allow for one more chance for correct behavior. 04. Implement the limit-setting consequence. Exit A_Alt Time Remaining: 00:56:32 47 of 100 Calculator The nurse observes an infant client who is diagnosed with developmental dysplasia of the night hip. Which statement by the parent most concerns the nurse? 01. T’m glad I can still hold and feed my child as I did before.” O2. This harness looks so uncomfortable to my child.” O 3. “I’m glad there is no pain with this condition.” 4. “The diaper will go on first, then the straps will be adjusted.” Exit A_Alt Calculator 53 of 100 A client on bed rest is instructed to perform active range of motion (ROM) exercises 4 times a day. The nurse evaluates the client’s ability to complete the exercises. Which information tells the nurse that the client needs assistance with these exercises? 01. Client moves neck and upper extremities independently. O2. Client partially moves left arm and leg independently O3. Client moves neck and right arm and leg independently O 4. Client is able to move all extremities independently. Calculator A client has a deep leg wound with a puncture site. The nurse irrigates the wound every 4 hours during the day. The nurse identifies which nursing diagnosis as most appropriate for this client situation? 1. Risk for impaired skin integrity. O2. Risk for impaired tissue integrity O 3. Risk for contamination O 4. Ineffective tissue perfusion 55 of 100 Calculator A client diagnosed with pneumonia has oxygen therapy and pulse oximetry in place. During the client assessment, the nurse notes that the SpO2 is 95%. Which action does the nurse take next? O 1. Compare to previous readings. O 2. Document the current reading O 3. Lower the oxygen by 2 L/min O 4. Adjust the nasal oxygen cannula. Exit A_Alt Time Remaining: 00:40:60 64 of 100 Calculator A client receives full-thickness burns to both legs. The client shows no indication of lung involvement. The nurse plans which immediate care for the client? 01. Place client in isolation to protect others from infection. O2. Establish two IV access sites for fluid replacement O 3. Restrict fluid intake to less than 2000 mL in 24 hours. O 4. Prepare to place client on respiratory assist for 48 hours. Exit A_Alt Remaining. 00.44.43 58 of 100 o Calculator The nurse provides care for an infant diagnosed with a stage Ill neuroblastoma located in the abdomen. The nurse implements which action in the plan of care first? 01. Teach parents to care for the colostomy. O2. Allow parents to express feelings of guilt. O 3. Give parents information about a parent group. O 4. Refer parents to the social worker for death preparations. Exit A_Alt Time Remaining 00:45:13 57 of 100 Calculator A client diagnosed with schizophrenia emphatically reports being Jesus and being ‘sent directly by God to save the world from its sins.” Which is the best response for the nurse to make? 01. “When people feel bad about themselves, sometimes they think they are a very important person like Jesus.” O2. Thank you for sharing your thoughts with me. Let me show you around the unit now. You will be safe here.” O 3. “You are not Jesus. You are a client here in the hospital because you have schizophrenia and need help.” 04. “I feel very honored, blessed, and humbled to have you as my client.” Exit A_Alt Time Remaining: 00:41:23 62 of 100 Calculator A client is to receive a unit of packed RBCs. Which is the most important action for the nurse to take when initiating the transfusion? 1. Be certain the correct tubing and filter are connected. O2. Assess the client prior to starting the transfusion O 3. Explain the procedure to the client and verify understanding. 04. Verify the correct unit and client with another nurse