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An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is:
- A. insertion of a Foley catheter.
- B. in and out catheter specimen for urinalysis.
- C. a voided urine specimen for urinalysis.
- D. a urologist consult.
Correct Answer: D
Rationale: Blood at the urethral meatus suggests trauma, contraindicating catheterization. A urologist consult is necessary for specialized evaluation and management. Physiological Adaptation
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Ron is 4-year-old child being discharge to home after an uneventful tonsillectomy.
The nurse would suggest that the appropriate car seat for the child is
- A. the rear-facing seat.
- B. the front facing seat.
- C. the booster seat with car seat belt.
- D. the back seat.
Correct Answer: C
Rationale: A booster car seat is appropriate for a bigger child like a 4-year-old, ensuring proper restraint and safety.
Because the client is thought to have Cushing's syndrome, the nurse should assess the client for the presence of which of the following? Select all that apply.
- A. High blood sugar
- B. Evidence of easy bruising
- C. Low blood pressure
- D. Immunosuppression
- E. Fluid retention
- F. Pitting acne
Correct Answer: A,B,D,E
Rationale: Cushing's syndrome causes hyperglycemia, easy bruising, immunosuppression, and fluid retention due to excess cortisol. Hypertension, not low blood pressure, and acne are common, but pitting is not specific.
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Correct Answer: C
Rationale: Antisocial personality disorder is associated with a history of cruelty to animals , reflecting disregard for others. Consistent employment and remorse are unlikely. Intelligence is typically average or above.
A nurse is administering metoprolol (Lopressor) to a patient with hypertension. Which of the following assessments is most important before administering this medication?
- A. Blood pressure
- B. Respiratory rate
- C. Temperature
- D. Oxygen saturation
Correct Answer: A
Rationale: Metoprolol, a beta-blocker, lowers blood pressure and heart rate, so assessing blood pressure prevents hypotension or bradycardia. Respiratory rate, temperature, and oxygen saturation are less critical.
The nurse is caring for a client with a history of bipolar disorder who is prescribed lithium. Which of the following laboratory values should the nurse monitor?
- A. Serum sodium.
- B. Serum glucose.
- C. Serum calcium.
- D. Serum hemoglobin.
Correct Answer: A
Rationale: Lithium can cause hyponatremia, and monitoring serum sodium ensures safe levels (therapeutic lithium range: 0.6–1.2 mEq/L). Glucose (B), calcium (C), and hemoglobin (D) are not directly affected by lithium therapy.