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Questions 164

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Question 1 of 5

The nurse employed in a woman's health care clinic would be most concerned about which client statement?

Correct Answer: C

Rationale: Red, warm breast with indented skin suggests inflammatory breast cancer, requiring urgent evaluation. A mobile lump is often benign, nipple pain is common in breastfeeding, and cyclic nodules are typically hormonal.

Question 2 of 5

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?

Correct Answer: C

Rationale: A spiral fracture in a non-mobile infant is inconsistent with rolling off a bed, suggesting abuse. Reporting is the priority to ensure safety. Documentation , questioning , and separation follow.

Question 3 of 5

Because a client is scheduled for a liver biopsy, the nurse should check to be sure that which laboratory test results have been received?

Correct Answer: B

Rationale: Liver biopsy carries a risk of bleeding due to the liver's vascular nature. Prothrombin time assesses clotting ability, critical to ensure the client can safely undergo the procedure without excessive bleeding risk. Electrolytes, CBC, and creatinine are less directly related to bleeding risk.

Question 4 of 5

The nurse is discussing hypertension with a group of people. Which person is at greatest risk for hypertension?

Correct Answer: A

Rationale: Age, obesity, smoking, and family history of hypertension confer the highest risk, as seen in the 63-year-old Caucasian female.

Question 5 of 5

The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?

Correct Answer: D

Rationale: Slow, irregular respirations. A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.

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