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Questions 149

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Question 1 of 5

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

Correct Answer: B

Rationale: Fetal heart tones are a definitive, objective sign of pregnancy, detectable around 20 weeks.

Question 2 of 5

A client is admitted to the intensive care unit after falling on an icy sidewalk and striking the right side of the head. An MRI revealed a right-sided epidural hematoma. Which physical force explains the location of the client's injury?

Correct Answer: A

Rationale: A coup injury occurs at the site of impact, explaining the right-sided epidural hematoma from striking the right side of the head.

Question 3 of 5

The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

Correct Answer: C

Rationale: A heart rate of 60 bpm in a 6-month-old is too low (normal is 80-160 bpm), indicating possible digitalis toxicity, which should be reported.

Question 4 of 5

A client with pelvic skin traction for low back pain is at risk of which of the following problems associated with decreased mobility? Select all that apply.

Correct Answer: A,B,C

Rationale: Decreased mobility from traction increases risks of orthostatic hypotension (
A), muscle weakness (
B), and venous stasis (
C). Dysuria (
D) and confusion (E) are less directly related.

Question 5 of 5

When providing care for a client with pancreatitis, the nurse would anticipate which of the following orders?

Correct Answer: B

Rationale: Pancreatitis often requires an NG tube with suction to reduce gastric secretions and pancreatic stimulation, aiding in symptom management.

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