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Questions 148

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Extract:


Question 1 of 5

Which one of the following infants needs a further assessment of growth?

Correct Answer: B

Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.

Question 2 of 5

A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.

Correct Answer: A,B,E

Rationale: Phenytoin's long-term effects include gingival hypertrophy (
A), hirsutism (
B), and anemia (E). Facial hypertrophy (
C) and dementia (
D) are not associated with phenytoin.

Question 3 of 5

The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:

Correct Answer: A

Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.

Question 4 of 5

The nurse has just received a report from the previous shift. Which of the following clients should the nurse visit first?

Correct Answer: B

Rationale: Shortness of breath post-MVA suggests potential trauma (e.g., pneumothorax), requiring immediate assessment. The other clients' conditions are less acute.

Question 5 of 5

As serum calcium levels rise, which hormone is excreted?

Correct Answer: E

Rationale: Calcitonin (not listed) is secreted by the thyroid to lower high serum calcium. Parathyroid hormone (
D) increases calcium. None of the options are correct.

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