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Questions 148

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Question 1 of 5

The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.

Correct Answer: B, C

Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.

Question 2 of 5

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

Correct Answer: C

Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.

Question 3 of 5

The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?

Correct Answer: C

Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.

Question 4 of 5

The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority

Question 5 of 5

The '5 A's' of smoking cessation intervention begin with which of the following?

Correct Answer: B

Rationale: The 5 A's begin with Ask (
B), identifying tobacco use at every visit, followed by Advise, Assess, Assist, and Arrange.

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