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Questions 164

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Question 1 of 5

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?

Correct Answer: C

Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.

Question 2 of 5

During the discharge teaching of a client with Buerger's disease, the nurse should teach the client:

Correct Answer: A

Rationale: Exercises to improve vascular return, such as ankle pumps, help manage Buerger's disease by promoting circulation in the extremities.

Question 3 of 5

Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

Correct Answer: C

Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.

Question 4 of 5

A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent?

Correct Answer: A

Rationale: Age of the child. Stuttering is often a normal part of language development in preschoolers, making age a critical factor.

Question 5 of 5

A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:

Correct Answer: A

Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.

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