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Questions 158

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Question 1 of 5

The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection by the client indicates to the nurse that further instruction is needed?

Correct Answer: A

Rationale: Isoniazid has MAOI properties, requiring avoidance of tyramine-rich foods like tuna to prevent hypertensive crisis. Tuna casserole (
A) indicates a need for further teaching. Ham salad (
B) may have tyramine but is less definitive. Baked potato (
C) and beef roast (
D) are safe.

Question 2 of 5

A client with a diagnosis of HPV is at increased risk for which of the following?

Correct Answer: B

Rationale: Human papillomavirus (HPV) is a major risk factor for cervical cancer particularly high-risk strains like HPV-16 and HPV-18. It is not strongly associated with Hodgkin’s lymphoma multiple myeloma or ovarian cancer.

Question 3 of 5

A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:

Correct Answer: C

Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.

Question 4 of 5

A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:

Correct Answer: D

Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.

Question 5 of 5

The nurse is caring for a client with a diagnosis of rheumatoid arthritis who is receiving methotrexate. Which laboratory value would be most concerning?

Correct Answer: A

Rationale: Methotrexate can cause bone marrow suppression. A WBC of 4,000/mm3 (
A) indicates leukopenia, increasing infection risk, and is most concerning. Platelets (
B), hemoglobin (
C), and creatinine (
D) are within normal limits.

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