b. BUN 16 mg/dL (Normal 10-20)

c. PT 12.2 seconds (Normal 11-14)

d. Fasting blood glucose 103 mg/dL

180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of

the following responses is the priority for the nurse to state?

a. “How long have you been hearing the voices?”

b. “What are the voices telling you?”

c. “Have you taken your medication today?”

d. “I realize the voices are real to you, but I don’t hear anything.”-

Last Priority - Taken last Tuesday.

1. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel

(AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should

intervene and explain to the AP that this statement constitutes which of the following torts?

a. Malpractice

b. Battery-physical

c. Assault- verbal

d. Negligence

2. A nurse is providing discharge instructions to the parent of a newborn. Which of the following statement by

the parent indicates an understanding of the teaching?

a. I will suction my baby’s mouth before I suction his nose.

b. I will lubricate the tipof the syringe with water prior to suction his nose.

c. I should insert the syringe into the center of his mouth.

d. I should compress the bulb after inserting it into the mouth.

3. A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the

following statements by the parent indicates an understanding of the teaching?

a. I willplace my baby in a forward- facing car seat in my back seat (facing the rear)

b. I can place my baby in the front seat with the airbag turned off. (dont put newborn in front)

c. I will position my baby at a 45 degree angle in the car seat.

d. I can turn my baby car seat around when she weighs 15pounds.

4. A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions

should the nurse include in the plan for delivery?

a. Instill erythromycin ointment into the newborn's eye

b. Apply miconazole vaginal cream to the mother prior to delivery