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Questions 158

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Question 1 of 5

The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

Correct Answer: B

Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (
A) and anxiety (
C) are common in both, and normal temperature (
D) is nonspecific.

Question 2 of 5

The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:

Correct Answer: B

Rationale: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.

Question 3 of 5

A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:

Correct Answer: A

Rationale: Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. Distraction does not focus on the client's need for control. Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.

Question 4 of 5

Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?

Correct Answer: B

Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.

Question 5 of 5

Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

Correct Answer: A

Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.

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