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Question 1 of 5

The nurse is assessing a client with suspected dehydration. Which of the following findings would support this diagnosis?

Correct Answer: B

Rationale: Dehydration causes tachycardia and hypotension due to reduced blood volume. Moist mucous membranes (
A) and clear urine (
C) indicate hydration, and weight gain (
C) suggests fluid retention, not dehydration.

Question 2 of 5

A nurse's aide who had a tuberculosis test planted two days ago has a reddened area 15-mm in diameter. The aide asks the nurse what this means. The nurse understands that the test result is:

Correct Answer: D

Rationale: Redness alone without induration is not significant; a positive TB test requires a raised area ≥10 mm, indicating this is negative.

Question 3 of 5

A 9-year old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham's chorea?

Correct Answer: A

Rationale: Sydenham's chorea, a manifestation—of rheumatic fever, causes irregular movements and facial grimacing. Other options describe rheumatoid arthritis or other conditions.

Question 4 of 5

The nurse has taken the vital signs of a 95-year-old client: oral temperature = 98.6°F; pulse = 84 with a regular irregularity; respirations = 18; blood pressure = 140/86. Which nursing assessment(s) should be done first to obtain more data?

Correct Answer: A

Rationale: A regular irregularity in pulse suggests an arrhythmia, requiring an apical pulse for one minute to confirm and assess severity.

Question 5 of 5

All of the following adults are admitted to the surgical unit. Which client should the nurse prepare for immediate surgery?

Correct Answer: C

Rationale: Severe right lower quadrant pain with elevated WBC suggests appendicitis, requiring immediate surgery to prevent rupture. Scapular pain (gallbladder), vaginal bleeding, or hernia are less urgent unless complicated.

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