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Questions 158

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Question 1 of 5

A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:

Correct Answer: B

Rationale: A 2-lb weight gain in 24 hours suggests fluid retention due to decreasing cardiac output, activating the renin-angiotensin-aldosterone system.

Question 2 of 5

Which of the following is an expected finding in a child with osteogenesis imperfecta?

Correct Answer: A

Rationale: Blue sclera is a hallmark of osteogenesis imperfecta due to thin connective tissue in the eyes. Hutchinson’s teeth are associated with congenital syphilis anisocoria is unequal pupil size and pectus excavatum is a chest deformity not specific to this condition.

Question 3 of 5

A client with a history of prostate cancer is admitted with complaints of bone pain. The nurse should give priority to:

Correct Answer: A

Rationale: Bone pain in prostate cancer often indicates bone metastasis, so monitoring for metastasis is the priority.

Question 4 of 5

When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

Correct Answer: A

Rationale: Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia, and warm, dry skin. In hypovolemic shock, the client is hypotensive, tachycardiac, with cool skin and delayed capillary refill (>5 seconds).

Question 5 of 5

Nursing assessment of early evidence of septic shock in children at risk includes:

Correct Answer: A

Rationale: Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. Respiratory distress, cold skin, and pale extremities are later signs of septic shock. Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. Normal pulses, hypotension, and oliguria are not early signs of septic shock.

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