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Questions 158

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Question 1 of 5

A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:

Correct Answer: A

Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.

Question 2 of 5

The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?

Correct Answer: B

Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.

Question 3 of 5

The client with cancer refuses to care for herself. Which action by the nurse would be best?

Correct Answer: C

Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.

Question 4 of 5

Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:

Correct Answer: D

Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.

Question 5 of 5

The nurse is caring for a client with a history of schizophrenia. Which medication is most likely to be prescribed?

Correct Answer: B

Rationale: Risperidone, an antipsychotic, is used to treat schizophrenia by managing hallucinations and delusions. Fluoxetine and bupropion are antidepressants, and clonazepam is for anxiety.

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