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Questions 158

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Question 1 of 5

A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

Correct Answer: A

Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.

Question 2 of 5

A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

Correct Answer: B

Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.

Question 3 of 5

The client is admitted with a diagnosis of abruptio placenta. Which vital sign change is most likely to be observed?

Correct Answer: D

Rationale: Abruptio placenta causes maternal tachycardia and hypotension (from bleeding) and fetal bradycardia (from hypoxia). All vital sign changes are likely in this condition.

Question 4 of 5

A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

Correct Answer: D

Rationale: Post-liver biopsy, vital signs are monitored frequently to detect hemorrhage or shock, the most likely complications.

Question 5 of 5

During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?

Correct Answer: A

Rationale: These are toxic symptoms of sodium salicylate. (B, C,
D) These are not symptoms associated with sodium salicylate.

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