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Questions 149

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Question 1 of 5

The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:

Correct Answer: A

Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.

Question 2 of 5

A 51-year-old client received a kidney transplant. Which of the following signs and symptoms indicates possible rejection of the kidney? Select all that apply.

Correct Answer: B,C,D

Rationale: Kidney rejection causes hypertension (
B), fluid retention (weight gain,
C), and graft pain (
D). Decreased urine output (not increased) and elevated creatinine (not decreased) are typical.

Question 3 of 5

An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:

Correct Answer: B

Rationale: Narcan reverses opioid overdose, a potential complication of narcotic use post-surgery.

Question 4 of 5

A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?

Correct Answer: C

Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.

Question 5 of 5

The nurse is performing discharge teaching to the parents of a 7-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?

Correct Answer: B

Rationale: Swimming is ideal for asthma clients as it promotes controlled breathing in a warm, humid environment, reducing the risk of exercise-induced bronchospasm.

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