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Questions 164

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Extract:


Question 1 of 5

The nurse is collecting data from assigned clients. It would require follow-up if a

Correct Answer: C

Rationale: A 6-month-old weighing only 12 lb (5400 g) from a birth weight of 7 lb 3 oz (3300 g) indicates failure to thrive, requiring follow-up. Other findings (fontanels, 12-month-old weight) are within normal ranges.

Question 2 of 5

A client on the psychiatric unit does not get to the dining room to eat because she is continually washing her hands and doesn't finish until after lunch. What should be included in the nursing care plan?

Correct Answer: B

Rationale: Advance notice allows the client with OCD to complete rituals before lunch, facilitating nutrition without confrontation.

Choices, discussions, or bans are less effective.

Question 3 of 5

The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?

Correct Answer: C

Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.

Question 4 of 5

Which finding is commonly noted in the client with bladder cancer?

Correct Answer: A

Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.

Question 5 of 5

The nurse is caring for an adult being admitted with a head injury. The nurse plans to place the client in which position?

Correct Answer: C

Rationale: Semi-reclining (30-45 degrees) reduces intracranial pressure in head injury by promoting venous drainage, unlike prone, supine, or upright positions.

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