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Questions 164

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Question 1 of 5

The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?

Correct Answer: B

Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.

Question 2 of 5

Which of the following symptoms is associated with exacerbation of multiple sclerosis?

Correct Answer: C

Rationale: Diplopia (double vision) is a common symptom during multiple sclerosis exacerbations, resulting from demyelination affecting the optic nerves or brainstem.

Question 3 of 5

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction?

Correct Answer: B

Rationale: The harness straps should only be adjusted by a healthcare provider to ensure proper fit and treatment efficacy. Other statements reflect correct understanding of harness care.

Question 4 of 5

The nurse is talking with the parent of a 1-day-old female client who has a small amount of blood-tinged, mucoid vaginal drainage. Which of the following statements would be most appropriate for the nurse to make?

Correct Answer: C

Rationale: Blood-tinged vaginal drainage in a newborn is often due to maternal hormone exposure and typically resolves. Monitoring is appropriate.

Question 5 of 5

The licensed vocational nurse cannot assume the primary care for a client:

Correct Answer: A

Rationale: The fourth stage of labor requires advanced nursing skills due to potential complications, unsuitable for an LVN's primary role. Post-appendectomy , venous access , and bipolar disorder are within LVN scope.

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