Extract:

Question 1 of 5

The nurse is assessing a client with suspected appendicitis. Which finding supports this diagnosis?

Correct Answer: B

Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis due to peritoneal irritation.

Question 2 of 5

Which of the following security concerns is also a sentinel event that must be reported?

A. A possible vulnerability of the facility's information technology to hacking B. The assisted suicide of a client in your facility by the spouse of the client C. Vulnerability to computer hacking D. Potential information theft

Correct Answer: B

Rationale: The assisted suicide of a client is a sentinel event, as it is an unexpected occurrence involving death, requiring immediate investigation and reporting per The Joint Commission standards.

Question 3 of 5

A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.

A. I have been so nauseous. B. I am having so much trouble with diarrhea. C. I have not had a menstrual period in 2 months. D. I have to go to the restroom to urinate all the time. E. I have been going to the health club regularly because I have so much energy.

Correct Answer: A,C,D

Rationale: Because the nurse is asking the woman, she would expect presumptive signs of pregnancy to be vocalized. Specifically the presumptive signs of pregnancy are nausea, vomiting, breast changes, amenorrhea, urinary frequency, fatigue, and quickening. Diarrhea is not a typical sign of early pregnancy, and increased energy is less common as fatigue is more typical.

Question 4 of 5

Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?

A. Ask the client if she desires an epidural anesthetic. B. Tell the physician that the client desires a natural childbirth with no analgesia or anesthesia. C. Tell the client that her labor will be more comfortable with an anesthetic. D. Ask the client to discuss this with her husband and then make a decision.

Correct Answer: B

Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.

Question 5 of 5

The nurse is teaching a client with a new diagnosis of epilepsy about driving restrictions. Which of the following instructions is most appropriate?

A. You can drive after being seizure-free for 6 months. B. You can drive if you take your medication regularly. C. You can drive with a passenger at all times. D. You can drive during the daytime only.

Correct Answer: A

Rationale: Most regions require a client to be seizure-free for 6 months before driving, ensuring safety.