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Which of the following is a common complaint of the client with end-stage renal failure?
- A. Weight loss
- B. Itching
- C. Ringing in the ears
- D. Bruising
Correct Answer: B
Rationale: Itching is common in end-stage renal failure due to uremia and phosphate accumulation. Weight loss , tinnitus , and bruising are less specific.
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A client with a history of asthma is admitted with severe shortness of breath and cyanosis. Which finding would indicate that the client is experiencing status asthmaticus?
- A. Increased vocal fremitus
- B. Silent chest on auscultation
- C. Stridor during inspiration
- D. Rhonchi in bilateral lung fields
Correct Answer: B
Rationale: Silent chest on auscultation indicates severe airway obstruction with minimal air movement, a hallmark of status asthmaticus, requiring immediate intervention.
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.
The nurse is discussing activities for parallel play with the parents of a 2-year-old child. Which of the following activities are appropriate suggestions for this type of play? Select all that apply.
- A. Digging in a sandbox
- B. Finger painting
- C. Playing a board game
- D. Playing soccer
- E. Pushing toy cars
Correct Answer: A,B,E
Rationale: Parallel play involves independent activities side-by-side, like digging, painting, or pushing cars. Board games and soccer require cooperative play, unsuitable for 2-year-olds.
The nurse is talking with a postpartum client about resuming sexual activity after childbirth. The client had an uncomplicated vaginal delivery 2 weeks ago. Which statement by the client requires follow-up?
- A. I do not need to use condoms to prevent pregnancy until my menses returns
- B. "I should avoid resuming sexual intercourse until my vaginal bleeding has stopped."
- C. I should expect to experience vaginal dryness and can use water-soluble lubricants
- D. I will try to feed my baby before my partner and I engage in sexual activity
Correct Answer: A
Rationale: Ovulation can occur before menses returns, so condoms are needed to prevent pregnancy. Vaginal dryness is common, and feeding before sex reduces interruptions, both correct.
The nurse is caring for a client with a fiberglass cast applied to a distal fracture of the right tibia. The client should be able to bear weight on the cast within:
- A. 10 minutes
- B. 30 minutes
- C. 3 hours
- D. 24 hours
Correct Answer: D
Rationale: Fiberglass casts typically require 24 hours to fully dry and harden before weight-bearing. Choices A, B, and C are too short for the cast to achieve sufficient strength.