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Questions 158

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Question 1 of 5

The client is admitted with a diagnosis of molar pregnancy. Which symptom is most likely to be present?

Correct Answer: A

Rationale: Molar pregnancy (hydatidiform mole) often causes severe nausea and vomiting due to high levels of human chorionic gonadotropin (hCG). The uterus is typically larger than expected and fetal heart tones are absent as there is no viable fetus.

Question 2 of 5

After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:

Correct Answer: B

Rationale: Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site.

Question 3 of 5

Which newborn assessment is considered an abnormal finding that requires immediate attention?

Correct Answer: C

Rationale: Jitteriness and shaking in a newborn may indicate hypoglycemia seizures or neurological issues requiring immediate attention. Cyanosis of hands and feet (acrocyanosis) three umbilical vessels and harlequin sign are normal or benign findings.

Question 4 of 5

A client with a history of chronic kidney disease is admitted with complaints of fatigue. The nurse should give priority to:

Correct Answer: A

Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.

Question 5 of 5

A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:

Correct Answer: C

Rationale: Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.

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