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Questions 149

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Extract:


Question 1 of 5

The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?

Correct Answer: B

Rationale: Denial involves refusing to acknowledge a serious condition.

Question 2 of 5

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct Answer: C

Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.

Question 3 of 5

After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

Correct Answer: B

Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4

Question 4 of 5

A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

Correct Answer: A

Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.

Question 5 of 5

An elderly client's wife tells a nurse she is concerned because her husband insists on talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client's wife?

Correct Answer: D

Rationale: Reflecting on past events is a normal part of aging, especially in older adults, and this response reassures the wife while providing accurate information.

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