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Question 1 of 5

A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

Correct Answer: D

Rationale: Contractions five minutes apart lasting 30-60 seconds indicate the onset of active labor. Two-minute contractions suggest advanced labor and back pain or urination are less specific signs.

Question 2 of 5

An appropriate nursing intervention for the client with borderline personality disorder is:

Correct Answer: A

Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.

Question 3 of 5

Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?

Correct Answer: C

Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and encouraging gentle hand movement. The other activities do not specifically alleviate joint stiffness.

Question 4 of 5

A client with a history of chronic lymphocytic leukemia is admitted with complaints of fever. The nurse should give priority to:

Correct Answer: A

Rationale: Fever in chronic lymphocytic leukemia suggests possible infection, a serious complication due to immunosuppression, so monitoring for infection is the priority.

Question 5 of 5

A client with a history of breast cancer is receiving tamoxifen (Nolvadex). Which adverse effect should the nurse monitor for?

Correct Answer: B

Rationale: Tamoxifen increases the risk of endometrial hyperplasia, a serious adverse effect due to its estrogenic effects on the uterus. Weight loss (
A), hypotension (
C), and hair loss (
D) are not typical.

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