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Questions 164

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Question 1 of 5

The nurse prepares a 7-year-old client for an influenza injection. The nurse explains that the client will receive 'medicine under the skin,' and the client is visibly anxious. Which nursing intervention is appropriate?

Correct Answer: D

Rationale: Hiding the needle (
D) reduces anxiety. Counting (
A) may not distract enough, holding arms (
B) can increase fear, and denying pain (
C) is dishonest.

Question 2 of 5

A client admitted to the floor 3 days after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to:

Correct Answer: C

Rationale: The symptoms suggest a pulmonary embolus, a medical emergency. Placing the client in high Fowler's position facilitates breathing. Oxygen is secondary, chest compressions are inappropriate without cardiac arrest, and sedatives could worsen respiratory distress.

Question 3 of 5

When reviewing the chart of a client with long standing lung disease, the nurse should pay close attention to the results of which pulmonary function test?

Correct Answer: C

Rationale: The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answers A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.

Question 4 of 5

A client with a 10-year history of major depressive disorder has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.2 kg) but weighed 150 lb (68 kg) 3 months before admission. Which foods would be best for this client?

Correct Answer: C

Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods like cheese (
A) to prevent hypertensive crisis. Fish and potatoes (
C) are safe and nutritious. Eggs (
B) and avocado (
D) are safe but less balanced.

Question 5 of 5

The nurse is caring for a client with rheumatoid arthritis. Which of the following lifestyle modifications should the nurse recommend to the client?

Correct Answer: B,C,E

Rationale: Rest (
B), range-of-motion exercises (
C), and moist heat (E) manage rheumatoid arthritis symptoms. Ice (
A) can reduce inflammation, and a pillow under knees (
D) may worsen stiffness.

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