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Question 1 of 5

The nurse is caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s

Correct Answer: A

Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.

Question 2 of 5

A client with cancer of the stomach has a gastric resection. The nurse should tell the client that following surgery:

Correct Answer: B

Rationale: Proteins and vitamins support tissue repair post-gastrectomy. Any food may cause dumping syndrome. High-calorie liquids are too restrictive. High fat delays gastric emptying.

Question 3 of 5

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

Correct Answer: C

Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.

Question 4 of 5

The health care provider prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?

Correct Answer: B

Rationale: Paroxetine may cause weight gain, so a healthy diet and exercise are appropriate. Stopping abruptly risks withdrawal, full effects take weeks, and sexual dysfunction is a common side effect.

Question 5 of 5

A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?

Correct Answer: C

Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.

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