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Questions 164

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Question 1 of 5

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

Correct Answer: A

Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.

Question 2 of 5

The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of

Correct Answer: B

Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.

Question 3 of 5

A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply.

Correct Answer: A,C,E

Rationale: Inspecting the home identifies lead sources (e.g., paint, dust). Frequent hand washing reduces ingestion of lead dust. Follow-up testing monitors levels. Vacuuming may spread lead dust; wet mopping is preferred. Hot water can leach lead from pipes; cold water is safer.

Question 4 of 5

Which of the following instructions should be given to a client regarding testicular self-exam?

Correct Answer: B

Rationale: Testicular self-examination (TSE) is recommended monthly, not bimonthly or yearly, and is best performed during or after a warm shower or bath when the scrotum is relaxed, making it easier to detect abnormalities. Transillumination is a medical procedure, not part of TSE.

Question 5 of 5

Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 196/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?

Correct Answer: D

Rationale: Automated BP readings can be inaccurate. Rechecking with a manual cuff ensures accuracy before escalating or medicating, as severe hypertensionزه://www.youtube.com/watch?v=9Q7sE1Xh_1Qsevere hypertension (≥180/110 mm Hg) requires prompt action if confirmed.

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