Strategy: Answers are implementations.

Determine the outcome of each

answer choice. Is it desired?
(1) correctmost effective way of deep breathing and coughing, dilates airway and
expands lung surface area
(2) should splint incision before coughing to reduce discomfort and increase
efficiency
(3) partial answer, should take three deep breaths before coughing
(4) implies coughing routine is adequate, incision needs to be splinted
68. The nurse in a psychiatric emergency room is caring for a client who is a
victim of interpersonal violence. The INITIAL priority of the nurse is to
1.
2.
3.
4.

encourage the client to verbalize feelings.

assess for physical trauma.
provide privacy for the client during the interview.
help the client identify and mobilize resources and support systems.

Strategy: Think Maslow.

(1) psychosocial, priority is physical injury
(2) correctphysical, victim may have physical trauma and concealed injuries;
assessment is of utmost importance so that the clients physiologic integrity is
maintained
(3) psychosocial, done concurrently as the nurse is assessing for physical injury
(4) psychosocial, priority is physical injury
69. A client returns to his room following a myelogram. The nursing care
plan should include which of the following?
1.
2.
3.
4.

Encourage oral fluid intake.

Maintain the prone position for 12 hours.
Encourage the client to ambulate after the procedure.
Evaluate the clients distal pulses on the affected side.

Strategy: Answers are a mix of assessments and implementations. Is the

assessment appropriate? No. Determine the outcome of the
implementations.
(1) correctimplementation, fluids should be encouraged to facilitate dye excretion
and to maintain normal spinal fluid
(2) implementation, clients are not placed in the prone position
(3) implementation, bedrest is maintained for several hours after the test
(4) assessment, an extremity was not used for injection of the dye
70. The nurse in the well-baby clinic observes a group of children. The nurse
notes that one child is able to sit unsupported, play peek-a-boo with the
nurse and is starting to say mama and dada. The nurse would expect
these behaviors in a child that is
1.
2.
3.
4.

5
6
9
1

months of age.
months of age.
months of age.
year of age.