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The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
- A. Cool, moist skin.
- B. Bradycardia.
- C. Wheezing.
- D. Decreased bowel sounds.
Correct Answer: B
Rationale: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.
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Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital?
- A. The hospital chaplain.
- B. The social worker.
- C. The respiratory therapist.
- D. The director of nurses.
Correct Answer: C
Rationale: The respiratory therapist manages airway and ventilation during a code, critical for resuscitation. Chaplain, social worker, and director are supportive, not acute.
Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma?
- A. Infection of the renal tract.
- B. Ineffective tissue perfusion.
- C. Alteration in skin integrity.
- D. Alteration in temperature.
Correct Answer: B
Rationale: Renal trauma risks bleeding and hypoperfusion, making ineffective tissue perfusion the primary problem. Infection, skin integrity, and temperature are less immediate.
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
- A. The client’s potassium level is 3.8 mEq/L.
- B. The urine culture indicates high sensitivity to the antibiotic.
- C. The client’s pulse oximeter reading is 94%.
- D. The culture and sensitivity is resistant to the client’s antibiotic.
Correct Answer: D
Rationale: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.
A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first?
- A. Have the client stand under a shower while removing all clothes.
- B. Check the material safety data sheets for the antidote.
- C. Administer oxygen by nasal cannula.
- D. Collect a sample of the chemicals in the vat for analysis.
Correct Answer: A
Rationale: Removing clothes and showering decontaminates the skin, preventing further chemical absorption. MSDS, oxygen, and sampling are secondary.
The nurse working in a homeless shelter identifies an adolescent female sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior?
- A. The client is acting in a learned behavior pattern to get attention.
- B. The client had to leave home because of promiscuous behavior.
- C. The client has a psychiatric disorder called nymphomania.
- D. The client is a prostitute and is trying to get customers.
Correct Answer: A
Rationale: Sexual aggression in adolescents often reflects learned behavior from past abuse or trauma, seeking attention or control. Promiscuity, nymphomania, or prostitution are less likely or outdated terms.