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Questions 158

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Question 1 of 5

The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?

Correct Answer: B

Rationale: A child must be able to use verbal or nonverbal skills to communicate needs, indicating readiness for toilet training.

Question 2 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.

Question 3 of 5

The client is admitted with a diagnosis of postpartum depression. Which vital sign change is most likely to be observed?

Correct Answer: A

Rationale: Postpartum depression is a psychological condition and typically does not cause vital sign changes. Fever tachycardia or hypotension suggest physical conditions like infection or hemorrhage.

Question 4 of 5

The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?

Correct Answer: A

Rationale: Rales and distended neck veins suggest cardiotoxicity (e.g., heart failure), a serious doxorubicin side effect requiring immediate reporting. Red urine (
B) is expected, nausea/vomiting (
C) are common, and BUN/skin changes (
D) are less urgent.

Question 5 of 5

The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:

Correct Answer: D

Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.

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