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Questions 158

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Question 1 of 5

The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?

Correct Answer: A

Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.

Question 2 of 5

In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?

Correct Answer: C

Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.

Question 3 of 5

Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

Correct Answer: C

Rationale: Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss.

Question 4 of 5

A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:

Correct Answer: D

Rationale: Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.

Question 5 of 5

Which of the following describes a positive Kernig's sign?

Correct Answer: A

Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.

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