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Question 1 of 5

The nurse is talking with a client. The client abruptly says to the nurse, 'The moon is full. Astronauts walk on the moon. Walking is a good health habit.' The client's remarks most likely indicate

Correct Answer: C

Rationale: Loose associations. The client's statements are loosely connected by related words, indicating disorganized thought.

Question 2 of 5

The nurse is talking with a client. The client abruptly says to the nurse, 'The moon is full. Astronauts walk on the moon. Walking is a good health habit.' The client's remarks most likely indicate

Correct Answer: C

Rationale: Loose associations. The client's statements are loosely connected by related words, indicating disorganized thought.

Question 3 of 5

The licensed practical nurse is caring for a client with congestive heart failure. The nurse should immediately report the presence of:

Correct Answer: A

Rationale: Pink, frothy sputum indicates pulmonary edema, a life-threatening complication of CHF requiring immediate reporting. Edema, shortness of breath, and weak pulses are expected but less urgent.

Question 4 of 5

Assessment of the client with an arteriovenous fistula for hemodialysis should include:

Correct Answer: B

Rationale: Palpating a thrill confirms the patency of an AV fistula. Visible pulsation is not typical, percussion is irrelevant, and blood pressure is not auscultated in the fistula limb. Physiological Adaptation

Question 5 of 5

An adult is being evaluated for a possible pituitary tumor. What test(s) does the nurse expect may be ordered for this client to confirm the diagnosis? Select all that apply.

Correct Answer: C,F

Rationale: MRI visualizes pituitary tumors, and visual field tests assess optic nerve compression from tumor growth. Urine, coagulation, x-rays, or nerve studies are less specific for diagnosis.

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