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The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to
- A. obtain a pulse oximetry reading for the client
- B. offer the client medication prescribed PRN for pain
- C. check the client's lower extremities for warmth and redness
- D. encourage guided imagery and breathing techniques for relaxation
Correct Answer: A
Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.
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The nurse has attended a staff education program about various types of diets. The nurse recognizes that which diet would place a client at the highest risk for megaloblastic anemia?
- A. lactoovovegetarian
- B. lactovegetarian
- C. ovovegetarian
- D. vegan
Correct Answer: D
Rationale: A vegan diet excludes all animal products, including vitamin B12 sources, which can lead to megaloblastic anemia if not supplemented. Other diets include dairy or eggs, which provide some B12.
Which finding is commonly noted in the client with bladder cancer?
- A. Painless hematuria.
- B. Bladder spasms.
- C. Lower back pain.
- D. Urinary frequency.
Correct Answer: A
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.
A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?
- A. Lethargy
- B. Agitation
- C. Ataxia
- D. Hearing loss
Correct Answer: A
Rationale: Lethargy. The level of consciousness or responsiveness is the most important measure of the client's rising intracranial pressure, requiring immediate attention.
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
- A. Risk for self-injury
- B. Identity disturbance
- C. Self-esteem disturbance
- D. Sensory-perceptual alteration
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.
The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot
- A. catch a ball at least 50% of the time
- B. copy a square with a pencil or crayon
- C. eat with a spoon
- D. hop on one foot
Correct Answer: B
Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.