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Questions 158

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Question 1 of 5

The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?

Correct Answer: A

Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (
B) is for rectal exams, prone (
C) for back surgeries, and Trendelenburg (
D) for shock or upper abdominal access.

Question 2 of 5

A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

Correct Answer: B

Rationale: Auditory hallucinations involve sensory perceptions of hearing. Gustatory hallucinations involve sensory perceptions of taste. Olfactory hallucinations involve sensory perceptions of smell. Visceral hallucinations involve sensory perceptions of sensation.

Question 3 of 5

A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

Correct Answer: C

Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.

Question 4 of 5

A client with a history of epilepsy is admitted with status epilepticus. The nurse should give priority to:

Correct Answer: B

Rationale: In status epilepticus, prolonged seizures can obstruct the airway, so protecting the airway is the priority to ensure oxygenation and prevent asphyxia.

Question 5 of 5

A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being 'on the move,' sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?

Correct Answer: C

Rationale: During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. Grandiosity and an inflated sense of self-worth are characteristic of this disorder. Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.

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