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Questions 158

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Extract:


Question 1 of 5

The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:

Correct Answer: D

Rationale: A large goiter can compress the trachea, posing a risk for ineffective airway clearance, which is a priority due to its potential to impair breathing.

Question 2 of 5

A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:

Correct Answer: C

Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.

Question 3 of 5

What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?

Correct Answer: A

Rationale: Human chorionic gonadotropin is the biochemical basis for pregnancy tests, produced by the placenta to maintain the corpus luteum.

Question 4 of 5

The client is diagnosed with glaucoma. Which medication is most likely to be prescribed?

Correct Answer: A

Rationale: Timolol, a beta-blocker, is commonly prescribed for glaucoma to reduce intraocular pressure by decreasing aqueous humor production. Atropine increases pressure, pilocarpine is less common, and acetazolamide is used acutely.

Question 5 of 5

A client with a history of a heart transplant is receiving Cyclosporine (Sandimmune). The nurse should monitor the client for:

Correct Answer: A

Rationale: Cyclosporine suppresses immunity, increasing infection risk, requiring vigilant monitoring. Hypotension, hyperkalemia, and weight loss are less common.

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