Nokea
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include:
- A. Decreased pulse rate
- B. Increased blood pressure
- C. Decreased respiratory rate
- D. Increased temperature
Correct Answer: B
Rationale: Severe pain from renal calculi can cause increased blood pressure due to sympathetic nervous system activation and stress response.
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The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.
A client is receiving hospice and palliative care, including analgesia and other comfort measures. Which of the following indicates the client is undergoing life review? Select all that apply.
- A. The client looks through old photo albums.
- B. The client states that her analgesia is not adequate.
- C. The client reminisces about her children when they were young and her parenting skills.
- D. The client states that she is ready to die.
- E. The client states she does not want her children to have a funeral for her.
Correct Answer: A,C
Rationale: Looking at photos (A) and reminiscing about parenting (C) indicate life review, reflecting on past experiences. Other statements (B, D, E) relate to pain or end-of-life wishes.
Which of the following examples represents parallel play?
- A. Jenny and Tommy share their toys.
- B. Jimmy plays with his car beside Mary, who is playing with her doll.
- C. Kevin plays a game of Scrabble with Kathy and Sue.
- D. Mary plays with a handheld game while sitting in her mother's lap.
Correct Answer: B
Rationale: Parallel play involves children playing side by side with similar toys but without direct interaction, as described in the scenario with Jimmy and Mary.
A newborn is diagnosed with congenital syphilis. Classic signs of congenital syphilis are:
- A. Red papular rash, desquamation, white strawberry tongue
- B. Rhinitis, maculopapular rash, hepatosplenomegaly
- C. Red edematous cheeks, maculopapular rash on the trunk and extremities
- D. Epicanthal folds, low-set ears, protruding tongue
Correct Answer: B
Rationale: Congenital syphilis presents with rhinitis (‘snuffles'), maculopapular rash, and hepatosplenomegaly due to systemic infection.
Nurses must be familiar with the American Nurses Association (ANA) Code of Ethics for Nurses. The nurse understands that which ethical principle is defined as the nurse's duty to do no harm? Fill in the blank.
- A. Nonmaleficence
- B. Bneficence
- C. autonomy
Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm, a core duty in nursing practice.