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NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024., Exams of Nursing

NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024.NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE

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Download NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024. and more Exams Nursing in PDF only on Docsity! NCLEX COMPREHENSIVE TEST QUESTIONS WITH ANSWERS LATEST UPDATE 2024 **** 1. The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST? 1.A patient was raped 30 minutes ago and expresses feelings of selfblame, anxiety, and worthlessness. 2.A patient indicates an intent to kill himself and says he has access to a gun. 3. A patient had a miscarriage last evening and is experiencing anger and resentment. 4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety. 2. The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions? 1.Time the frequency of the contractions. 2. Assess the type of vaginal discharge. 3. Monitor the strength of the contractions. 4. Observe the perineum. 3. The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST? 1. Contact the nursing supervisor. 2. Tell the emergency management team they will have to reroute 25 victims. 3. Activate the hospital’s disaster plan. 4. Inform the emergency department nurses they must work overtime. 4. As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?" 1. "This medication helps me with my depression." 2. "I will notify my physician if I show signs of hyperactivity and mania." 3. "I will see improvement in my symptoms in 1 to 4 weeks." 4. "If I experience a fever I will take Tylenol." 5. The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with COPD with an PaO 2 of 70%. 2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured. 3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement. 4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back. 6. The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child? 1. Guacamole with pita bread, lettuce, tomato juice. 2. Poached halibut, brown rice, carrots, peach cobbler. 3. Scrambled eggs, whole wheat toast, grapes, skim milk. 4. Baked chicken leg, mashed potatoes, spinach, milkshake. 7. The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children? 1. A child just returned from a 2-week trip to Europe. 2. A child recently moved to an apartment because the family lost their home. 3. A child with a new nanny who just emigrated from Latin America. 4. A child who weighed 4 lb, 10 oz at birth. 8. The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions? 1. Obtain vital signs. 2. Identify the source of the bleeding. 3. Elevate the head of the bed 30°. 4. Administer 0.9% NaCl IV. 9. During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate? 1. "I want to see both of you in my office right away." 2. "Would you please lower your voices and finish the report." 3. "I want the two of you to stop yelling and work this problem out." 4. "Both of you are good nurses and are under a lot of stress right now." 10. A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following? 1. Slowed pulse and reduced blood pressure. 2. Constipation and decreased bowel sounds. 3. Palpitations and nervousness. 4. Difficulty voiding and oliguria. 11. The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the diabetes? 1. Glycosylated hemoglobin (HbA 1 c) 5% of total Hb. 2. Fasting blood sugar 128 mg/dL. 3. Blood pressure 130/82. 4. Serum amylase 100 Somogyi U/dL. 12. The nurse cares for a client in labor. The client's examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at -1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should the nurse take FIRST? 1. Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes. 2. Prepare for delivery and notify the care provider. 3. Apply an electronic fetal monitor and start an IV. 4. Encourage the client to void every 1-2 hours and take her temperature every hour. 13. The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions should the nurse take NEXT? 1. Administer medication as ordered. 2. Notify the physician. 3. Check the most recent serum partial prothrombin levels. 4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. 5. A client at 34 weeks' gestation diagnosed with generalized edema and complaints of epigastric pain. 6. A 2-day-old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBS). 27. The nurse cares for a client following a scleral buckling. Which of the following nursing actions is MOST important? 1. Remove all reading material. 2. Assess for nausea. 3. Assess drainage from affected eye. 4. Irrigate affected eye every 3 hours. 28. The nurse supervises care for a patient admitted to the psychiatric unit with a diagnosis of bipolar disorder: manic phase. A student nurse plans activities for the patient. The nurse should intervene if the student nurse chooses which of the following activities? 1. Volleyball. 2. Painting. 3. Walking. 4. Dancing. 29. The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate? 1. "I will assess the patient for oxygen toxicity." 2. "Are you concerned about the oxygen or the new graduate's competency?" 3. "Please tell me more about your concerns." 4. "Leave the oxygen in place." 30. The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant's pulse and respirations increase. The nurse should take which action? 1. Feed the infant soon after awakening. 2. Change the infant's diaper before feeding. 3. Increase the caloric content of the feeding to 30 kcal/oz. 4. Mix rice cereal in the formula. 31. The nurse instructs a client who is scheduled for a 24-hour creatinine clearance test. Which statement, if made by the client to the nurse, indicates further teaching is required? 1. "I will eat a high-protein meal before the test begins." 2. "I will use the specimen collection time to catch up on my reading." 3. "I will drink as much fluid as I want before and during the test." 4. "I will save all of my urine during the 24 hours and keep it in the refrigerator." 32. The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms? 1. In a semiprivate room with a 2-year-old in traction due to a fracture. 2. In a semiprivate room with a 9-month-old admitted for a shunt revision. 3. In a private room that is close to the nurse's station. 4. In any private room that is available. 33. A patient returns from surgery for a total replacement of the right hip with a large surgical dressing and a Jackson- Pratt drain. Which of the following, if observed by the nurse 2 hours after surgery, necessitates calling the physician? 1. There is a small amount of bloody drainage on the surgical dressing. 2. The patient complains of increased hip pain. 3. A harsh, hollow sound is auscultated over the trachea. 4. The patient's blood pressure is 136/86. 34. An older client is placed in balanced suspension traction for a compound fracture of the femur. The client reports, "My hands, feet, and nose feel cold. Which action should the nurse take FIRST? 1. Provide the client with more blankets. 2. Assess for dependent edema. 3. Assess that client is exhaling when moving in bed. 4. Increase the temperature of the room. 35. The nurse cares for a client at term in labor. The client's blood pressure is 182/88 and fetal heart rate (FHR) is 132-134 with minimal beat-to-beat variability. Her bloody show is dark red and there is more bleeding than anticipated. Her abdomen is firm between contractions and she complains of back pain. The nurse understands that the client is at risk for which of the following? 1. Placenta previa. 2. Abruptio placenta. 3. Miscarriage. 4. Imminent delivery. 36. The nurse cares for an older client diagnosed with terminal lung cancer. When told about the diagnosis, the client becomes very angry. He curses, throws objects, and hits the nurse tech and LPN/LVN when they attempted provide care for him. It is MOST important for the nurse to take which of the following actions? 1. Inform client that injury or risk of injury to staff is not acceptable. 2. Send the staff out of the room. 3. Administer prescribed antianxiety with full glass of water. 4. Report signs/symptoms to physician immediately. 37. The nurse, caring for clients in the outpatient clinic, performs a chart review for clients who are receiving medication. The nurse determines that which of the following clients is at risk to develop problems with hearing? 1. A client receiving spironolactone (Aldactone) and cefaclor (Ceclor). 2. A client receiving metformin (Glucophage) and alendronate (Fosamax). 3. A client receiving paroxetine (Paxil) and cholestyramine (Questran). 4. A client receiving furosemide (Lasix) and indomethacin (Indocin). 38. The nurse in the pediatric clinic receives a phone call from the mother of a 3-year-old child. The mother reports that her child has been complaining of a sore throat, has a temperature of 102°F (39°C), and he has suddenly begun drooling. Which of the following suggestions should the nurse make FIRST? 1. "Place a cold water vaporizer in your child's room." 2. "Take your child to the emergency department immediately." 3. "Look into your child's throat and tell me what you see." 4. "Frequently offer your child oral fluids." 39. The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two days after admission, the client begins complaining of severe nausea. Which of the following actions should the nurse take FIRST? 1. Determine the client's most recent fasting serum glucose level. 2. Perform a comprehensive client assessment. 3. Ask the client if she is pregnant. 4. Administer an antiemetic. 40. A new registered nurse asks the assigned nurse mentor to check on 4 clients who are receiving oxygen therapy. It is MOST important for the nurse mentor to ask the nurse which of the following questions? 1. "Which client should I see first?" 2. "Have you completed your assessment?" 3. "What are your specific concerns?" 4. "Don't you think you should be able to care for the clients?" 41. The nurse cares for a client receiving chlordiazepoxide (Librium). It is MOST important for the nurse to observe for which of the following? 1. Skeletal muscle spasms and insomnia. 2. Anorexia and dry mouth. 3. Diarrhea and euphoria. 4. Drowsiness and confusion 42. Following the administration of morphine sulfate for an adult client, the nurse expects to observe which finding? 1. The client states they feel better. 2. The client is talking with visitors. 3. The client appears to be physically relaxed. 4. The client is no longer crying or moaning. 43. After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST? 1. Administer an analgesic medication 2. Ask the client to rank the pain from 1 to 10. 3. Ask the client if he is worried about something. 4. Place the client in a sitting position. 44. The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. 2. A client diagnosed with right-sided heart failure and glaucoma. 3. A client diagnosed with chronic obstructive pulmonary disease and psoriasis. 4. A client diagnosed with rheumatoid arthritis and malnutrition. 45. The nurse cares for a 4-year-old on the pediatric unit. The child is unable to go to sleep while in the hospital. It is MOST important for the nurse to take which of the following actions? 1. Turn out the light and close the door. 2. Encourage the child to exercise during the evening. 3. Identify the child's home bedtime ritual. 4. Ask the child's siblings to visit during the evening. 46. The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and oriented and lives alone in her home. It is MOST important for the nurse to assess for which of the following? 1. Client's vision and manual dexterity. 2. Client's understanding of diabetes. 4. A client with diverticulitis complaining of abdominal pain. 10. The nurse performs a prenatal assessment on a client at 20 weeks' gestation. Identify the location where the nurse expects to palpate the client's fundus. 20 to 22 weeks — fundus at the level of the umbilicus 11. The home care nurse visits a client diagnosed with progressive systemic sclerosis. The client complains that she is having more trouble swallowing and moving her right hand. Which of the following responses by the nurse is MOST important? 1. "This must be a difficult time for you." 2. "You should schedule an appointment with your health care provider." 3. "Can you tolerate pressure on your hand?" 4. "Tell me more about the problems you are having swallowing." 12. A terminally ill client with excruciating pain episodes complains the pain medication given at night does not relieve the pain as well as it does during the day. A chart review reveals that clients report pain medication being less effective, and the clients receive more medication when a particular nurse is working. Which of the following actions should the nurse take FIRST? 1. Set up a hidden camera in the medication room. 2. Ask physician to consider increasing the dosage of medication at night. 3. Determine how long the client has been receiving the medication. 4. Temporarily assign another nurse to give all of the PRN medications. 13. The nurse cares for a patient hospitalized for a head injury. The client is receiving 0.9% sodium chloride at 100 cc/h and has an indwelling Foley catheter in place. The nurse notes the patient's urinary output is 1,000 cc in 3 hours. Which of the following actions by the nurse is MOST appropriate? 1. Contact the physician. 2. Decrease the amount of fluids the patient is receiving. 3. Assess the client's mucous membranes. 4. Measure the urine specific gravity. 14. The nurse cares for a patient with chest tubes. Two days after insertion, the chest tube is accidentally pulled out of the pleural space. Which of the following actions should the nurse take FIRST? 1. Don sterile gloves and replace the tube. 2. Apply pressure with a dressing that is tented on one side. 3. Instruct the client to cough and deep-breathe. 4. Auscultate the lung. 15. A tornado roared through a populated area, causing multiple casualties. Which of the following patients should the nurse see FIRST? 1. A patient with a small penetrating abdominal wound caused by flying debris. 2. A patient with blunt trauma to the abdomen that caused bruising. 3. A patient complaining of chest pain with asymmetrical chest movement noted. 4. A patient who is confused and restless with no visible injuries. 16. A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the patient becomes verbally abusive. Which of the following actions by the nurse is MOST appropriate? 1. Tell the patient to lower his voice. 2. Ask the patient what he wants from the cafeteria. 3. Calmly but firmly escort the patient to his room. 4. Assign a nursing attendant to accompany the patient to the cafeteria. 17. The nurse prepares a client for a skin biopsy. Which of the following statements, if made by the client, should the nurse report to the physician? 1. "I have been taking aspirin for my aching joints." 2. "I applied lotion to my skin after my shower last night." 3. "I laid out in the sun yesterday." 4. "I had coffee and a sweet roll for breakfast this morning.” 18. The nurse counsels a client diagnosed with degenerative joint disease. It is MOST important for the nurse to include which of the following instructions? 1. "Place your joints in the position of comfort." 2. "Place your joints in a flexed position." 3. "Place your joints in full extension." 4. "Place your joints in their functional position." 19. The nurse is making staff assignments on the medical/surgical unit. The nurse should assign a nursing assistant to care for which of the following clients? 1. A client diagnosed with a CVA 2 weeks ago requiring assistance ambulating. 2. A client diagnosed with COPD who is in acute distress requiring assistance bathing. 3. A client receiving total parenteral nutrition through a PICC line requiring a dressing change. 4. A client diagnosed with type 1 diabetes on mechanical ventilation requiring a bath. 20. The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client operates a horse ranch. It is MOST important for the nurse to include which of the following instructions? 1. Ride with a companion and wear an identification bracelet. 2. Carry a cell phone and dressings and tape. 3. Provide significant others with a written itinerary for the day.4. Temporarily change to activities that are safer for client 21. The nurse cares for clients in the outpatient clinic. A client with a pacemaker calls to report that he just had an episode of dizziness and shortness of breath. Which of the following responses by the nurse is MOST important? 1. "What is your pulse?" 2. "What were you doing before the episode?" 3. "Have you experienced this before?" 4. "Is the area over the pacemaker painful or red?" 22. A client is admitted to the labor and unit in a sickle-cell crisis. Which of the following nursing actions should the nurse take FIRST? 1. Administer oxygen. 2. Turn client to right side. 3. Begin an IV with normal saline. 4. Administer antibiotics. 23. The nurse cares for a laboring patient. The patient requests something for pain and says to the nurse, "I'm really scared of shots." Which of the following responses by the nurse is BEST? 1. "A shot is your only option, because labor slows the GI tract." 2. "I can give you a pill now, but it will not last as long as an injection." 3. "What was your previous experience with shots?" 4. "What are you afraid of?" 24. The nurse on the medical/surgical unit admits an elderly client after the patient has undergone a below-the-knee amputation. The nurse obtains vitals signs and assesses that the client is able to be aroused but is sleepy. When the client awakens and realizes that the amputation was performed, the client begins to scream. Which of the following statements by the nurse is MOST appropriate? 1. "The physician informed you that the amputation was required." 2. "I'll get you some medication so that you can rest." 3. "Your family is waiting in the lobby to come see you." 4. "Since you seem upset, I'll stay with you.” 25. The nurse determines that which of the following clients is MOST at risk to develop gastroesophageal reflux disease (GERD)? 1. A 16-year-old African American male who had an NG tube for 3 days after surgery for a ruptured appendix. 2. A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-tube in place. 3. A 52-year-old Caucasian female who is 5'5" tall and weighs 185 pounds. 4. A 65-year-old Caucasian male with a laryngectomy for laryngeal cancer. 26. The nurse cares for clients in the emergency department after an earthquake. Which of the following clients should the nurse see FIRST? 1. A client at 7 months' gestation complaining of cramping and blood-streaked discharge. 2. A client with a displaced fracture of the right radius with blood seeping from the wound. 3. A client complaining of lightheadedness; nurse notes client is clammy, pulse 112, respirations 28. 4. A client with type 1 diabetes who took insulin immediately before the earthquake and is complaining of lightheadedness. 27. The nurse on the medical unit is called to the room of an elderly client. The nurse finds the client sitting up in bed reporting pressure in the chest and jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a history of hypertension and is receiving IV antibiotics for a diagnosis of pneumonia. Which action should the nurse take first? 1. Administer oxygen at 4 L/min via nasal canula. 2. Place the client on a cardiac monitor and obtain a 12-lead ECG. 3. Obtain blood for CK-MB, troponin, and myoglobin levels. 4. Assess patency of the client's IV line. 28. The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient. Thirty minutes later, it is MOST important for the nurse to take which of the following actions? 1. Reposition the patient. 2. Elevate the patient's head and place a pillow under the shoulders. 3. Observe the patient for restlessness and distress. 4. Ambulate the patient. 29. The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It is MOST important for the nurse to clarify which of the following orders by the physician? 1. Furosemide (Lasix) 20 mg IV every 12 hours. 2. 2 g/day sodium diet 4. "I don't need to continue to do the leg exercises I learned in the hospital." 43. The mother of an 8-month-old boy is concerned because her son has started to scream and refuses to eat when left with the child-care provider. Which of the following statements by the nurse is BEST? 1. "Start looking for a different child-care provider." 2. "Check your son for bruises and other injuries." 3. "Remember that this is just a phase your son is going through." 4. "Hand your child his blanket as you say goodbye." 44. The mother of a 4-year-old tells the nurse she is worried because her daughter has begun to stutter. The mother asks the nurse what actions can be taken to stop the stuttering. Which of the following responses by the nurse is BEST? 1. "What has been happening in your child's life?" 2. "Reward your child when she speaks fluently." 3. "Instruct your child to start over and speak more slowly." 4. "Slow down your own speech and talk to your daughter calmly." 45. While sitting at the front desk completing an assessment sheet, a new graduate nurse asks the nursing assistant to perform a finger stick blood sugar for the assigned client. The nursing assistant responds, "Why can't you do it?" Which of the following responses by the nurse is BEST? 1. "Please page me when you have completed the task." 2. "It is important that the blood sugar be completed now." 3. "Why did you ask that?" 4. "If you don't have time, I will ask someone else to do it.” 46. The nurse cares for clients on the neurological unit. After receiving report, which of the following clients should the nurse see FIRST? 1. A client who is non-responsive with intermittent limb movement. 2. A client whose muscle tone of all four limbs is flaccid. 3. The client who is non-responsive but follows the staff with his eyes. 4. The client who immediately withdrawals from painful stimuli. 47. The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg OD. The client tells the nurse that he has been experiencing insomnia the last couple of weeks. Which of the following responses by the nurse is MOST appropriate? 1. "The physician may have to decrease the dose of medication." 2. "Tell me about your bedtime routine." 3. "When do you take the medication?" 4. "Take a warm bath before going to bed." 48. The nurse cares for a client diagnosed with hypertension and type 1 diabetes mellitus. The client complains to the nurse that the physician wants the client to discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril (Capoten) 50 mg PO tid. The client states, "It took a long time to find a medication that controls my blood pressure with minimal side effects, and I do not want to go through that again." Which of the following responses by the nurse is BEST? 1. "How many different antihypertensives did you try?" 2. "Captopril is the best drug for preventing or slowing down the destruction of your kidneys." 3. "Your physician is a specialist in this area and feels you need to change." 4. "Why not give it a try?" 49. The nurse cares for client diagnosed in stage I chronic renal failure. During the nursing assessment, the nurse expects the client to state which of the following? 1. "I don't seem to urinate as much as I used to." 2. "I seem to have more swelling in my feet and ankles." 3. "I urinate more at night." 4. "The doctor told me I need dialysis." 50. The nurse in the pediatric clinic performs a well-child assessment on a 15-month-old. The child's mother tells the nurse that she is very excited because her mother is visiting. The grandmother rarely visits, and the child's mother is pleased that grandmother and grandchild will spend time together. Which of the following responses by the nurse is MOST important? 1. "Your toddler may be fearful when left alone with her grandmother." 2. "How long is your mother staying?" 3. "Does your mother take any medication?" 4. "I'm sure your mother will enjoy her grandchild."