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A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
- A. Heart rate
- B. Breath sounds
- C. Blood pressure
- D. Activity tolerance
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.
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The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
- A. Give higher doses of pain medication.
- B. Keep patches on the client's eyes to prevent corneal abrasion.
- C. Monitor the temperature of the bathwater.
- D. Avoid turning the client.
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, which of the following feelings are expected?
- A. Vulnerability.
- B. Confirmation.
- C. Ambivalence.
- D. Body image disturbance.
Correct Answer: C
Rationale: Ambivalence is common in pregnancy, reflecting mixed emotions about impending motherhood and life changes.
The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother:
- A. Newborns cannot hear well until they are at least 6 weeks old.
- B. Her concern is unfounded because hearing problems are rare in newborns.
- C. The majority of states now mandate that newborns undergo a screening test for hearing.
- D. The mother can test the baby's hearing by clapping her hands 24 inches from the infant's head.
Correct Answer: C
Rationale: Most states mandate newborn hearing screening to detect issues early, addressing the mother's concern appropriately without dismissing it or suggesting unreliable home testing.
The nurse is caring for a 25-year-old client who will undergo bilateral orchiectomy for testicular cancer. Considering the nature of the illness, the nurse should make it a priority to explore which potential psychological concern with this client?
- A. Postoperative pain
- B. Postoperative swelling
- C. Loss of reproductive ability
- D. Length of recuperative period
Correct Answer: C
Rationale: Although the client will need factual information about the postoperative period and recuperation, the nurse should place priority on addressing loss of reproductive ability as a psychological concern. The radical effects of this surgery in the reproductive area make it likely that the client may have some difficulty in adjustment to this consequence of surgery.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.