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Questions 163

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Question 1 of 5

Which statement, if made by the client, indicates a possible problem?

Correct Answer: B

Rationale: Black stools may indicate gastrointestinal bleeding, a serious concern requiring evaluation. Other statements reflect normal variations or minor issues.

Question 2 of 5

Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

Correct Answer: C

Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.

Question 3 of 5

The client tells the nurse she is having trouble falling asleep. What initial nursing action is least appropriate?

Correct Answer: A

Rationale: Requesting sleeping medication is premature and least appropriate without exploring non-pharmacologic interventions like back rubs, addressing concerns, or repositioning, which promote sleep naturally.

Question 4 of 5

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?

Correct Answer: A

Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.

Question 5 of 5

The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to

Correct Answer: A

Rationale: Avoid caffeine. Caffeine can trigger vasoconstriction, exacerbating Raynaud's phenomenon symptoms, making it a priority after smoking cessation.

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