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Questions 164

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Question 1 of 5

The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?

Correct Answer: B,D,E

Rationale: At 11 weeks, increased urinary frequency (
B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (
D). Fetal heart tones are detectable by Doppler (E). Fetal movement (
A) is felt later (16-20 weeks), and fundal height of 24 cm (
C) occurs around 24 weeks.

Question 2 of 5

In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?

Correct Answer: C

Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.

Question 3 of 5

The nurse has taught the parent of a pediatric client who will be receiving growth hormone replacement therapy. Which of the following statements by the parent would require follow-up?

Correct Answer: B

Rationale: Expecting equal height to peers (
B) is unrealistic, as outcomes vary. Bedtime dosing (
A), discontinuation at bone closure (
C), and x-rays (
D) are correct.

Question 4 of 5

The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?

Correct Answer: D

Rationale: Taking blood pressure (
D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (
A), dizziness (
B), and visual changes (
C) are signs of digoxin toxicity, requiring provider notification.

Question 5 of 5

A mother calls the pediatrician's office stating that her 15-month-old son received an MMR vaccination yesterday. Today, the site of the injection is red, warm, and puffy. What is the best action for the nurse to take?

Correct Answer: D

Rationale: Mild redness, warmth, and swelling at the MMR injection site are expected reactions, resolving without intervention.

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