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Questions 149

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Extract:


Question 1 of 5

The client who is 2 weeks post-burn with a 40% deep partial-thickness injury still has open wounds. The nurse's assessment reveals the following findings: temperature 96.5°F, BP 87/40, and severe diarrhea stools. What problem does the nurse most likely suspect?

Correct Answer: C

Rationale: Hypothermia, hypotension, and diarrhea suggest systemic gram-negative infection, likely sepsis, due to bacterial translocation from open wounds or the gut in a burn patient.

Question 2 of 5

The nurse is teaching a new breastfeeding mother about breast care, but the mother has engorgement and asks if she should quit breastfeeding. Which information should the nurse include? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Continue nursing (
A), massaging breasts (
B), using pain relievers (
D), and noting engorgement resolution in 24-48 hours (E) manage engorgement. Hot compresses (
C) may worsen swelling.

Question 3 of 5

Which of the following is the primary focus of cognitive behavioral therapy (CBT)?

Correct Answer: D

Rationale: CBT focuses on identifying and correcting automatic thoughts (
D) to change behavior. Rewards (
A), underlying causes (
B), and social effects (
C) are secondary.

Question 4 of 5

A nurse is working with an immobile client and doing passive range-of-motion (ROM) exercises on his legs. The client states the exercise is too painful and does not want to continue. The nurse should

Correct Answer: D

Rationale: Pain during ROM exercises may indicate injury. Stopping the exercise prevents harm, with further assessment or pain management to follow.

Question 5 of 5

At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:

Correct Answer: C

Rationale: Most infants begin to sleep through the night by 3-4 months as their sleep patterns mature.

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