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Questions 149

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Question 1 of 5

A client has just finished her lunch, consisting of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, 'My throat feels thick and I'm having trouble breathing.' What action should the nurse implement first?

Correct Answer: C

Rationale: Symptoms suggest an allergic reaction, possibly anaphylaxis from shrimp. Placing the client in high Fowler's position facilitates breathing, and calling the physician ensures rapid intervention.

Question 2 of 5

How many hours of activity per day are necessary to prevent disuse syndrome with muscle atrophy and joint contracture?

Correct Answer: C

Rationale: Approximately 2 hours of activity daily (
C), including range-of-motion exercises or ambulation, helps prevent disuse syndrome, muscle atrophy, and joint contractures in immobilized clients.

Question 3 of 5

A client has been diagnosed with glossopharyngeal neuralgia. The nurse will expect the client to

Correct Answer: D

Rationale: Glossopharyngeal neuralgia causes severe pain in the throat, ears, tongue, and tonsils due to irritation of the ninth cranial nerve.

Question 4 of 5

Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?

Correct Answer: A

Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.

Question 5 of 5

The nurse is assessing a client with a history of diabetes mellitus who is admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect?

Correct Answer: B

Rationale: fruity breath odor is a classic sign of DKA due to the presence of acetone

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