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Question 1 of 5

A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?

Correct Answer: A

Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.

Question 2 of 5

A client visiting a family planning clinic is suspected of having an STD. The most diagnostic test for all stages of treponema pallidum (syphilis) is the:

Correct Answer: C

Rationale: The FTA-Abs test is the most specific and diagnostic for all stages of syphilis. VDRL and RPR are non-treponemal tests that can have false positives, so A and B are incorrect. Thayer-Martin culture is used for gonorrhea, so D is incorrect.

Question 3 of 5

A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?

Correct Answer: A

Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.

Question 4 of 5

A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:

Correct Answer: D

Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.

Question 5 of 5

When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?

Correct Answer: A

Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.

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The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
A 52-year-old woman who has thyroid cancer is treated with radioactive iodine (Iodotope). What should be included in the nursing care plan following administration of the drug? Select all that apply.
The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective?

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