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Questions 164

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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

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

Correct Answer: B

Rationale: Asking about recent food intake helps identify unintentional gluten exposure, common in new celiac diagnoses. Assuming 6-8 weeks, immediate referral, or blaming non-compliance may overlook dietary errors or other causes.

Question 3 of 5

The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.

Correct Answer: A,B,D

Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.

Question 4 of 5

An adult who had a cerebrovascular accident (CVA) with expressive aphasia has started saying some words. The client's family is quite upset because the words are mostly profanity. They tell the nurse that the client usually does not use profanity. How should the nurse respond to the family?

Correct Answer: B

Rationale: Profanity in early expressive aphasia post-CVA is common due to disinhibition in damaged brain areas; reassuring the family that other words will follow is appropriate.

Question 5 of 5

The nurse is interviewing a 5-year-old client who is reporting abdominal pain. Which of the following are effective strategies for communicating with the child? Select all that apply.

Correct Answer: A,C,E

Rationale: Allowing the child to describe symptoms encourages open communication, and interviewing separately reduces parental influence, ensuring accurate reporting. Closed-ended questions may limit a young child’s ability to express complex symptoms.

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