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Questions 210

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Question 1 of 5

The nurse is caring for an adult who was admitted for observation following an automobile accident. The client has several lacerations that were sutured in the emergency room and a fractured leg that has been casted. The baseline vital signs are BP=120/72, P=76, and R=16. One hour after arriving on the unit, the client's vital signs are BP=108/68, P=90, and R=22. The nurse most correctly interprets these results to mean that the client may be developing which condition?

Correct Answer: A

Rationale: Decreased BP, increased pulse, and respirations suggest shock, possibly from occult bleeding or trauma response, requiring urgent evaluation.

Question 2 of 5

A 5-year old with a suspected ventricular septal defect is scheduled for a cardiac catheterization. The child's mother asks the nurse, 'Why does my little girl have to have that tube put into her heart?' The nurse should tell the mother that the cardiac catheterization will:

Correct Answer: B

Rationale: Cardiac catheterization visualizes the heart's structures, allowing precise identification of the size and location of a ventricular septal defect.

Question 3 of 5

A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?

Correct Answer: A

Rationale: Stimulation of the breast during nursing releases oxytocin, which contracts the uterus, reducing the risk of further bleeding.

Question 4 of 5

What is the primary theory that explains a family's concept of health and illness?

Correct Answer: A

Rationale: The Health Belief Model explains how families perceive health threats and motivations for wellness, guiding their health and illness concepts. The other options are not recognized theories. Health Promotion and Maintenance

Question 5 of 5

A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?

Correct Answer: A

Rationale: Denial, per Kübler-Ross's

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