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Questions 164

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Question 1 of 5

A client visiting a family planning clinic is suspected of having an STD. The most diagnostic test for all stages of treponema pallidum (syphilis) is the:

Correct Answer: C

Rationale: The FTA-Abs test is the most specific and diagnostic for all stages of syphilis. VDRL and RPR are non-treponemal tests that can have false positives, so A and B are incorrect. Thayer-Martin culture is used for gonorrhea, so D is incorrect.

Question 2 of 5

A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?

Correct Answer: B

Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.

Question 3 of 5

The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?

Correct Answer: C

Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.

Question 4 of 5

The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.

Correct Answer: C,D,E

Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.

Question 5 of 5

A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: All topics are critical: adoption planning, emotional response, support systems, nutrition/substance use, and education planning address the client’s immediate and long-term needs in a sensitive, holistic manner.

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