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Questions 148

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Extract:


Question 1 of 5

The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:

Correct Answer: A

Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.

Question 2 of 5

An end-of-life client receiving home hospice care states he no longer wants to eat. The nurse should

Correct Answer: C

Rationale: In hospice care, respecting the client’s autonomy is key. Accepting the decision to stop eating and focusing on comfort aligns with end-of-life care principles.

Question 3 of 5

The nurse observes a 2 1/2-year-old toddler in the waiting room. Based on expected child development, the nurse expects to see the child engaged in which type of play?

Correct Answer: C

Rationale:
Toddlers (2-3 years) engage in parallel play, playing alongside but not cooperatively with others, due to developing social skills.

Question 4 of 5

The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

Correct Answer: C

Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.

Question 5 of 5

A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

Correct Answer: A

Rationale: abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency

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