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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of systemic lupus erythematosus. The nurse should expect the client to have:

Correct Answer: A

Rationale: Systemic lupus erythematosus causes autoimmune inflammation, commonly leading to joint pain and arthritis-like symptoms.

Question 2 of 5

The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most likely to be present?

Correct Answer: A

Rationale: Postpartum endometritis a uterine infection typically causes foul-smelling lochia due to bacterial infection. Painful uterine tenderness is common painless bleeding suggests other causes and fetal distress is irrelevant postpartum.

Question 3 of 5

A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?

Correct Answer: C

Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.

Question 4 of 5

A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:

Correct Answer: C

Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.

Question 5 of 5

A 32-year-old female client is being treated for Guillain-Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Correct Answer: C

Rationale: Headaches are not associated with Guillain-Barré syndrome. Loss of superficial and deep tendon reflexes is expected with this diagnosis. Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. Facial paralysis is expected and is not considered abnormal.

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