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Questions 158

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Question 1 of 5

A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:

Correct Answer: D

Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.

Question 2 of 5

A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a 'miscarriage' with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:

Correct Answer: C

Rationale: The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The twin pregnancy counts as only one pregnancy, and because she delivered prior to 37 weeks' gestation, the third digit is recorded as 1. The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The second digit represents the total number of full-term deliveries; she has lost two pregnancies before 37 weeks' gestation. At present, she has no living children, so the fifth digit is noted as 0. The client is pregnant for the third time, and the first digit reflects the total number of pregnancies. She has had no full-term deliveries, because she delivered prior to 37 gestational weeks, so the second digit is recorded as 0. The third digit represents the number of preterm deliveries, and a twin pregnancy counts as only one delivery. She lost an earlier pregnancy prior to 20 gestational weeks, and the fourth digit reflects spontaneous or elective abortions. Lastly, the fifth digit indicates the number of children currently living, and she has no living children. She is pregnant for the third time, and the first digit reflects the total number of pregnancies. In the previous two pregnancies, she delivered prior to 37 gestational weeks, thus having no full-term deliveries, which is indicated by the second digit. The fourth digit represents the total number of abortions, spontaneous or elective, and she reported a spontaneous abortion with her first pregnancy.

Question 3 of 5

A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?

Correct Answer: B

Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.

Question 4 of 5

The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?

Correct Answer: D

Rationale: Wearing sunscreen protects against UV radiation, a key skin cancer risk factor. Regular checkups (
A) are less specific, sunbathing at peak hours (
B) increases risk, and routine mole removal (
C) is excessive.

Question 5 of 5

Which meal selection is most appropriate for a patient with iron deficiency anemia?

Correct Answer: C

Rationale: Spinach and kale are rich in iron ,which is essential for correcting iron deficiency anemia. The other meal options do not contain significant iron-rich foods making them less appropriate for this condition.

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