Nokea
A client with acromegaly will most likely experience which symptom?
- A. Bone pain
- B. Frequent infections
- C. Fatigue
- D. Weight loss
Correct Answer: A
Rationale: Acromegaly, caused by excess growth hormone, often leads to bone pain due to bone overgrowth. Infections , fatigue , and weight loss are less specific symptoms.
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The nurse is caring for an adult who had a cervical laminectomy this morning. In addition to routine vital signs, what should the nurse assess because of the location of the surgery?
- A. Pedal pulses
- B. Hand grasps
- C. Radial pulse
- D. Urine output
Correct Answer: B
Rationale: Cervical laminectomy affects the cervical spine, which innervates upper extremities; assessing hand grasps evaluates neurological function. Pedal pulses, radial pulse, and urine output are unrelated.
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings should the nurse report immediately?
- A. Absence of bowel sounds.
- B. Mild abdominal distension.
- C. Pain at the incision site.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on day 2 suggests ileus or obstruction, requiring immediate reporting. Options B, C, and D are expected or normal.
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?
- A. Have the client sit on the side of the bed before helping the client to walk.
- B. If the client is dizzy ask the client to take some slow, deep breaths.
- C. Help the client to walk in the room as often as the client wishes.
- D. When you help the client to walk, ask if any pain occurs.
Correct Answer: A
Rationale: This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client's first time out of bed after surgery.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glimepiride (Amaryl). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication before breakfast.
- B. I should report sweating to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glimepiride when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, sweating indicates hypoglycemia, and alcohol increases hypoglycemia risk.