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Questions 149

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Question 1 of 5

A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition?

Correct Answer: D

Rationale: A decrease in level of consciousness is an early and sensitive indicator of increased intracranial pressure, reflecting cerebral compromise before other signs like pupil changes or vital sign alterations.

Question 2 of 5

A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition?

Correct Answer: D

Rationale: A decrease in level of consciousness is an early and sensitive indicator of increased intracranial pressure, reflecting cerebral compromise before other signs like pupil changes or vital sign alterations.

Question 3 of 5

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

Correct Answer: B

Rationale: Fetal heart tones are a definitive, objective sign of pregnancy, detectable around 20 weeks.

Question 4 of 5

In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

Correct Answer: D

Rationale: Pitocin is effective if it promotes progressive cervical dilation, correcting secondary dystocia.

Question 5 of 5

The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:

Correct Answer: D

Rationale: Mitral stenosis murmurs are best heard at the fourth intercostal space midclavicular line, the mitral valve area.

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