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Questions 158

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Extract:


Question 1 of 5

Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:

Correct Answer: D

Rationale: The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations, addressing the core issue of social withdrawal.

Question 2 of 5

An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:

Correct Answer: B

Rationale: (A, C,
D) These agents would not cause ulcerations on mouth and lips. Strong alkali or acids will cause burns and ulcerations on the mucous membranes.

Question 3 of 5

The nurse is planning for discharge teaching to a client after a total hip replacement. Which teaching points will be included?

Question Image

Correct Answer: A, B, C, D

Rationale: Hip replacement teaching includes avoiding leg separation (
A), maintaining hydration/fiber (
B), monitoring for dislocation signs (
C), and limiting hip flexion (
D). Sleeping on affected side (E) is not advised to prevent dislocation.

Question 4 of 5

A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?

Correct Answer: D

Rationale: Alcohol and tobacco use are the most significant risk factors for laryngeal cancer due to their carcinogenic effects on the laryngeal mucosa. Family history, fumes, and vocal strain are less impactful.

Question 5 of 5

Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:

Correct Answer: B

Rationale: The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. It is important that the infant take in 2-3 full days of milk or formula feedings to preclude a false-negative reading. At 2-3 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. The biochemical buildup of serum phenylalanine is detectable after 2-3 days of milk or formula ingestion.

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