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Questions 227

NCLEX-PN

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Extract:

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte balance?


Question 1 of 5

Skin turgor

Correct Answer: B

Rationale: Intake and output provide the most direct measure of fluid balance.

Extract:


Question 2 of 5

Which sign might the nurse see in a client with a high ammonia level?

Correct Answer: A

Rationale: High ammonia levels, often due to liver dysfunction, can lead to hepatic encephalopathy, with coma as a severe symptom. The other signs are not directly related to hyperammonemia. Reduction of Risk Potential

Question 3 of 5

A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?

Correct Answer: A

Rationale: MMR. Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine, and its administration should be delayed to ensure the body’s ability to form antibodies.

Question 4 of 5

An adult who has Bell's palsy says to the nurse, 'Will I always look this weird?' How should the nurse reply?

Correct Answer: B

Rationale: Bell's palsy often resolves completely within weeks to months, so reassuring the client of potential full recovery is accurate and supportive.

Extract:

Illusion:


Question 5 of 5

Illusion:

Correct Answer: A

Rationale: An illusion is a misperception of a real stimulus, unlike a hallucination.

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