Nokea
Which of the following characteristics should the nurse include in the teaching plan for a multiparous client after delivering a neonate diagnosed with trisomy 13?
- A. Webbed neck
- B. Small testes
- C. Congenital heart defects
- D. Polydactyly
Correct Answer: C
Rationale: Trisomy 13 is commonly associated with congenital heart defects. Webbed neck is more typical of Turner syndrome, and small testes or polydactyly are less specific to trisomy 13.
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The nurse is assessing a client with suspected pulmonary edema. Which of the following findings would support this diagnosis?
- A. Crackles in the lung bases.
- B. Bradypnea.
- C. Hypotension.
- D. Dry cough.
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in pulmonary edema.
The nurse is teaching a client with a new diagnosis of type 1 diabetes mellitus about insulin administration. Which of the following instructions is most important?
- A. Rotate injection sites.
- B. Store insulin in the freezer.
- C. Administer insulin at bedtime only.
- D. Use the same syringe for multiple doses.
Correct Answer: A
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following?
- A. Distend the veins.
- B. Stabilize the veins.
- C. Immobilize the arm.
- D. Occlude arterial circulation.
Correct Answer: A
Rationale: A tourniquet distends veins by restricting venous return, making them easier to access for I.V. insertion.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.