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Questions 158

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Extract:


Question 1 of 5

The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:

Correct Answer: C

Rationale: The child with asthma may not have fever unless there is an underlying infection. Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. Coughing and wheezing are not early signs of difficulty.

Question 2 of 5

The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should:

Correct Answer: D

Rationale: Nephrotic syndrome causes edema due to protein loss, requiring fluid management. Offering additional fluids is inappropriate unless prescribed, as it may worsen edema. Visitors, diet, and dialysis depend on specific orders.

Question 3 of 5

A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:

Correct Answer: B

Rationale: Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. Male and female clients with sickle cell disease can pass the trait on to their offspring.
Therefore, this client should receive genetic counseling prior to having children.

Question 4 of 5

A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

Correct Answer: A

Rationale: The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. This statement reflects lack of insight into the importance of compliance. This statement reflects no insight into his illness or his responsibility in health maintenance.

Question 5 of 5

A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?

Correct Answer: A

Rationale: The 9-month-old infant can sit alone for long periods. Sitting briefly alone with assistance at this age suggests a developmental delay, warranting further evaluation.

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