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Questions 158

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Question 1 of 5

The nurse is assessing elderly clients at a community center.

Correct Answer: D

Rationale: Rales bilaterally indicate possible pulmonary edema or infection, which are serious conditions requiring immediate attention. Dry mouth (
A), height loss (
B), and stiffened joints (
C) are common in aging but less urgent.

Question 2 of 5

A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?

Correct Answer: C

Rationale: The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. The Goodenough Draw-a-Person test is used to assess intellectual development. The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.

Question 3 of 5

A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?

Correct Answer: C

Rationale: With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).

Question 4 of 5

A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?

Correct Answer: D

Rationale: (A,
B) This statement can be answered with a simple yes or no. This statement is asked in a negative manner and therefore has a negative connotation. This statement is open ended and positively stated.

Question 5 of 5

A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?

Correct Answer: C

Rationale: One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.

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