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A client with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent:
- A. Quality and quantity of food intake.
- B. Type and amount of fluid intake.
- C. Weakness, fatigue, and ability to get around.
- D. Length and amount of menstrual flow.
Correct Answer: D
Rationale: Systemic lupus erythematosus (SLE) can cause thrombocytopenia, and diffuse petechiae suggest a low platelet count. Heavy menstrual bleeding is a common manifestation of thrombocytopenia in women and should be evaluated to assess the extent of bleeding and guide treatment. Food, fluid intake, and fatigue are less directly related to the petechiae.
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A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
- A. Placing the client on the back with a small pillow under the head.
- B. Keeping portable suctioning equipment at the bedside.
- C. Opening the client's mouth with a padded tongue blade.
- D. Cleaning the client's mouth and teeth with a toothbrush.
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.
The nurse is preparing an educational program on breast cancer for women at an African American community center. What information is important for the nurse to consider for the discussion?
- A. African American women have the lowest rate of breast cancer.
- B. Most African American women are diagnosed early in the disease process.
- C. Breast cancer concerns vary between socioeconomic levels of African American women.
Correct Answer: C
Rationale: Breast cancer incidence and outcomes can vary significantly across socioeconomic levels due to differences in access to healthcare, screening, and education. This is critical for tailoring an effective educational program. African American women do not have the lowest rate of breast cancer, and they are often diagnosed at later stages, not early.
The nurse is assessing a client with acute diverticulitis. Which symptom requires immediate reporting to the physician?
- A. Mild left lower quadrant pain.
- B. Temperature of 101°F (38.3°C).
- C. Soft, formed stools.
- D. Nausea without vomiting.
Correct Answer: B
Rationale: A temperature of 101°F (38.3°C) in acute diverticulitis may indicate worsening infection or abscess, requiring immediate reporting. Mild pain, formed stools, and nausea are less urgent unless escalating. CN: Physiological adaptation; CL: Analyze
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
- A. Quality of breath sounds.
- B. Presence of bowel sounds.
- C. Occurence of chest pain.
- D. Amount of peripheral edema.
- E. Color of nail beds.
Correct Answer: A,C,E
Rationale: Breath sounds (A) indicate lung involvement. Chest pain (C) may signal pleurisy or complications. Nail bed color (E) reflects oxygenation. Bowel sounds and peripheral edema are less relevant to pneumonia assessment.