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Questions 164

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Question 1 of 5

An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?

Correct Answer: D

Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.

Question 2 of 5

The nurse is giving home care to an elderly client with angina pectoris and Type 2 diabetes mellitus. Which observation is of most concern and should be reported immediately?

Correct Answer: A

Rationale: Chest discomfort in a client with angina suggests possible cardiac ischemia, requiring immediate reporting to prevent myocardial infarction. Brown spots, toenail pain, or exertional dyspnea are less urgent.

Question 3 of 5

A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:

Correct Answer: B

Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.

Question 4 of 5

Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?

Correct Answer: B

Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.

Question 5 of 5

While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?

Correct Answer: A

Rationale: Respiratory rate of 42. An elevated respiratory rate indicates potential airway obstruction, requiring urgent intervention.

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