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Questions 158

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Question 1 of 5

A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?

Correct Answer: B

Rationale: Any change in any part of the system affects all other parts.

Question 2 of 5

The nurse is caring for a client after a burn. Which assessment finding best indicates that the client's respiratory efforts are currently adequate?

Correct Answer: C

Rationale: An O2 saturation of 97% directly indicates adequate oxygenation from respiratory efforts. Talking (
A), alertness (
B), and chest movement (
D) are indirect and less specific.

Question 3 of 5

The nurse is caring for a client with a history of psoriasis. The nurse should expect the client to have:

Correct Answer: A

Rationale: Psoriasis causes scaly, silvery plaques due to rapid skin cell turnover, a hallmark symptom.

Question 4 of 5

A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:

Correct Answer: C

Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.

Question 5 of 5

The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?

Correct Answer: A,C,D,E

Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.

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