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Questions 164

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Extract:


Question 1 of 5

The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?

Correct Answer: B

Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.

Question 2 of 5

A primigravida arrives at the labor unit stating that she is having contractions. Which statement describes the presence of true contractions?

Correct Answer: B

Rationale: True contractions have a consistent frequency , becoming regular and stronger. They start in the back or upper abdomen (A is incorrect), intensify with activity (C is incorrect), and are regular (D is incorrect).

Question 3 of 5

The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

Correct Answer: D

Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.

Question 4 of 5

The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.

Correct Answer: C,D,E

Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.

Question 5 of 5

The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?

Correct Answer: B

Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.

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