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Questions 148

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Question 1 of 5

The client presents to the emergency room with a 'bull's eye' rash. Which question would be most appropriate for the nurse to ask the client?

Correct Answer: A

Rationale: A bull's eye rash is characteristic of Lyme disease, often caused by tick bites, making this the most relevant question.

Question 2 of 5

The nurse is caring for a client admitted to ICU following a heart attack. The nurse notes on the chart that the client has named his spouse to make decisions regarding his care if he is unable to speak for himself. What is the name of the document the client has signed? Fill in the blank.

Correct Answer: C

Rationale: The document is a **Durable Power of Attorney for Healthcare** or **Healthcare Proxy**, designating the spouse as the decision-maker.

Question 3 of 5

The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:

Correct Answer: C

Rationale: The earlobe is a suitable site for pulse oximetry in peripheral vascular disease, as it is less affected by impaired peripheral circulation.

Question 4 of 5

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Correct Answer: C

Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.

Question 5 of 5

The initial assessment of a newborn reveals a chest circumference of 34 cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:

Correct Answer: A

Rationale: Diminished breath sounds and chest asymmetry suggest a respiratory issue, such as pneumothorax, requiring immediate supplemental oxygen.

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