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Questions 149

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Question 1 of 5

The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?

Correct Answer: D

Rationale: Sexual function is not directly related to bowel and bladder retraining, unlike diet, mobility, and fluid intake.

Question 2 of 5

A 6-month-old is hospitalized with symptoms of botulism. What aspect of the infant's history is associated with Clostridium botulinum infection?

Correct Answer: B

Rationale: Honey can contain Clostridium botulinum spores, which are a common cause of infant botulism in children under 12 months, as their digestive systems cannot eliminate the spores.

Question 3 of 5

The nurse is assisting a client to adjust crutches to the proper measurement. With the client in standing position, where should the tips of the crutches be placed?

Correct Answer: B

Rationale: Crutch tips should be 4-6 inches to the side and 4-6 inches in front of the feet (
B) for stability and balance.

Question 4 of 5

A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

Correct Answer: A

Rationale: Footling breech presentation often requires a Caesarean section due to risks of cord prolapse and delivery complications.

Question 5 of 5

A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:

Correct Answer: B

Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.

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