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Questions 227

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Extract:

A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash.


Question 1 of 5

Which of the following tests is most likely to be performed first?

Correct Answer: C

Rationale: Fever and rash with unconsciousness suggest infection, making blood cultures the priority to identify the cause.

Extract:


Question 2 of 5

The nurse is implementing a plan of care for a client with myxedema. Based on the client's diagnosis, the nurse should:

Correct Answer: C

Rationale: Myxedema (hypothyroidism) causes cold intolerance, so an additional blanket is appropriate. High-calorie snacks are for hyperthyroidism. Foot elevation and ketone checks are unrelated.

Extract:

Which of the following clinical conditions exacerbates electrolyte excretion?


Question 3 of 5

Nasogastric feedings

Correct Answer: B

Rationale: Surgical drains remove fluid and electrolytes, exacerbating excretion.

Extract:

Which statement is best to document a patient's behavior in an unbiased way?


Question 4 of 5

The patient's hostility created difficulties for the nursing staff.'

Correct Answer: C

Rationale: Nursing documentation must be objective, describing specific actions without subjective judgments.

Extract:


Question 5 of 5

The nurse is caring for clients in the GYN clinic. A client at 28-weeks gestation states that she occasionally leaks urine when she coughs or sneezes. Which of the following actions by the nurse is BEST?

Correct Answer: A

Rationale: Urine leakage during coughing or sneezing at 28 weeks gestation suggests stress incontinence, common due to pelvic pressure. Kegel exercises strengthen pelvic floor muscles, improving control. A urine specimen (
B) is unnecessary without infection signs, leakage is not ‘expected’ (
C), and specialist referral (
D) is premature.

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