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Question 1 of 5

The client tells the nurse, 'I have pain in my left shoulder.' This is considered:

Correct Answer: C

Rationale: Subjective information is provided by a person.

Question 2 of 5

An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:

Correct Answer: A

Rationale: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.

Question 3 of 5

The nurse is preparing to check a client for Trousseau's sign. Which equipment should the nurse obtain?

Correct Answer: B

Rationale: Trousseau’s sign is elicited by inflating a blood pressure cuff on the arm to induce carpopedal spasm indicating hypocalcemia. The other equipment is not used for this assessment.

Question 4 of 5

Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

Correct Answer: B

Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C,
D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.

Question 5 of 5

A client with a history of glaucoma is prescribed timolol (Timoptic) eye drops. Which instruction should the nurse include in the teaching?

Correct Answer: B

Rationale: Pressing the inner corner (nasolacrimal occlusion) after instilling timolol prevents systemic absorption. Direct corneal application (
A) is incorrect, pain-based use (
C) is wrong, and refrigeration (
D) is unnecessary.

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The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
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The client with a history of gout is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
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