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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:

Correct Answer: D

Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.

Question 2 of 5

Which one of the following statements is correct when measuring the client for crutches?

Correct Answer: B

Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.

Question 3 of 5

Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?

Correct Answer: A

Rationale: Broiled fish and rice are excellent protein sources, aiding in restoring albumin levels for tissue repair. The other options are lower in protein.

Question 4 of 5

Which of the following is a late sign associated with oral cancer?

Correct Answer: C

Rationale: Pain is a late sign of oral cancer, often occurring as the tumor invades deeper tissues or nerves. Early signs include ulcers or white/red patches, while warmth and odor are less specific, and flat-edged ulcers are not typical.

Question 5 of 5

The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?

Correct Answer: C

Rationale: Tension pneumothorax, a medical emergency, requires needle decompression to relieve pressure on the lung and mediastinum, followed by chest tube insertion. Oxygen and bronchodilators are secondary.

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