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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

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:

Correct Answer: A

Rationale: Vaginal bleeding in labor may indicate placental abruption or previa both of which threaten fetal well-being. Assessing fetal heart tones is the first action to ensure fetal stability before further evaluation.

Question 3 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 4 of 5

The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

Correct Answer: A

Rationale: This technique provides effective rinsing and gingival stimulation. This technique does not provide gingival stimulation. This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. This technique provides effective rinsing but not gingival stimulation.

Question 5 of 5

A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

Correct Answer: D

Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

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