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Questions 158

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Question 1 of 5

The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?

Correct Answer: D

Rationale: (A, B,
C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.

Question 2 of 5

A male client tells his nurse that he has had an ulcer in the past and is afraid it is 'flaring up again.' The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:

Correct Answer: C

Rationale: Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time. Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.

Question 3 of 5

The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?

Correct Answer: B

Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (
A) suggests heart failure, cramping (
C) is nonspecific, and pale/cool foot (
D) indicates arterial occlusion.

Question 4 of 5

A mother calls the clinic to report that her otherwise healthy newborn has a rash on his forehead and face. The nurse should tell the mother:

Correct Answer: B

Rationale: Many newborns develop erythema toxicum or milia benign rashes that resolve within a month. This is the most likely explanation for a healthy newborn’s facial rash. Immediate evaluation or family illness checks are unnecessary unless other symptoms are present.

Question 5 of 5

A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?

Correct Answer: D

Rationale: Ribavirin is not supplied in an oral form. Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. Ribavirin is not approved for IV use to treat respiratory syncytial virus. Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask.

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