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Questions 164

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Question 1 of 5

A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

Correct Answer: A

Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

Question 2 of 5

The nurse is caring for a client who had a total abdominal hysterectomy 2 days ago. The client reports hearing music coming from the television, which is turned off. Which of the following actions should the nurse take first?

Correct Answer: B

Rationale: Checking the medication record identifies potential causes of hallucinations, such as opioids or anesthetics. Timing, vital signs, and TV checks are secondary to ruling out medication effects.

Question 3 of 5

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?

Correct Answer: C

Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.

Question 4 of 5

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?

Correct Answer: D

Rationale: Verifying the activity prescription ensures the client is cleared for chair transfer, preventing injury. Assistance, delegation, or premedication are secondary until safety is confirmed.

Question 5 of 5

The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

Correct Answer: A

Rationale: Unequal leg length. Shortening of the affected leg is a sign of developmental dysplasia of the hip.

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