The nurse is caring for a client with arteriosclerotic heart disease. The nurse recognizes that a nonmodifiable risk factor in the development of arteriosclerotic heart disease is:
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Solution
Answer A is correct. A family history of arteriosclerotic heart disease is a nonmodifiable risk factor in the development of arteriorsclerotic heart disease. Answers B, C, and D are incorrect because the risk of developing arteriosclerotic heart disease can be modified or altered by controlling hypertension, eliminating high cholesterol and high saturated fats from the diet, and enrolling in a program of regular exercise.
Which one of the following measures decreases abdominal discomfort when the post-operative client is asked to cough?
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Solution
Answer B is correct. The client can decrease abdominal discomfort by splinting the incision with a pillow. Answers A and C are incorrect because they increase abdominal discomfort. Answer D is incorrect because it does not decrease abdominal discomfort.
The nurse is checking the fetal heart rates of a client in labor. The normal range for fetal heart rates is:
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Solution
Answer B is correct. The normal range for fetal heart tones is 110–160bpm. Answer A is incorrect because the heart rate is too slow. Answers C and D are incorrect choices because the heart rate is too rapid.
A nurse complains that a client is noncompliant because she prefers to take herbs prescribed by her herbalist rather than taking “real medicine.” The nurse’s statement is an example of:
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Solution
Answer C is correct. The nurse believes that her way of treating illness (real medication) is superior to the client’s way of treating illness (herbals). Answer A refers to belonging to a particular ethnic group; therefore, it is incorrect. Answers B and D are incorrect choices because the nurse’s statement did not reflect cultural sensitivity or cultural tolerance.
A client refuses to take the medication prescribed for her. Which action should the nurse take first?
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Solution
Answer B is correct. The nurse should first try to determine the client’s reason for refusing the medication so that she can decide what action needs to be taken. The nurse should not encourage the client to do anything she does not want to do; therefore, answer A is incorrect. Answers C and D are incorrect because they are not the first action the nurse should take.
A pediatric client is admitted with Munchausen’s syndrome by proxy. The nurse would expect the child to have:
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Solution
Answer B is correct. Munchausen’s syndrome by proxy is characterized by unexplained illness brought on by another person, usually the mother, for the purpose of gaining attention. Answer A refers to nursing bottle syndrome; therefore, it is incorrect. Answer C refers to oral allergy syndrome; therefore, it is incorrect. Answer D refers to Christ-Siemen’s Touraine syndrome; therefore, it is incorrect.
Which of the following tasks is within the developmental norm for the 22-month-old child?
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Solution
Answer A is correct. The 22-month-old child can be expected to feed herself with a spoon. Answers B, C, and D are developmental tasks of the older child; therefore, they are incorrect.
A client who was admitted with a closed head injury is asked to tell the nurse today’s date. The nurse is assessing the client’s orientation to:
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Solution
Answer C is correct. The nurse can assess the client’s orientation to time by asking the date, the month, the year, or the season. Asking the client to state his name or to identify family members or friends is a way of assessing the client’s orientation to person; therefore, answer A is incorrect. Answer B is incorrect because it elicits information regarding where the client is at the present time. Answer D is incorrect because it elicits information regarding the client’s recognition of familiar objects.
The nurse is admitting a newborn to the nursery. Which finding is expected in the full-term newborn?
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Solution
Answer B is correct. Vernix caseosa covers the body of the full-term infant. Absence of sucking pads, presence of the scarf sign, and the absence of solar creases are expected findings in the preterm infant; therefore, answers A, C, and D are incorrect.
Otitis media occurs more frequently in infants and young children because of the unique anatomic features of the:
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Solution
Answer D is correct. The urine should be removed using a sterile syringe and needle. Removing the urine from the port nearest the client ensures that the urine is more sterile. Answer A is incorrect because urine in the bag is not sterile. Answer B is incorrect because urine in the drainage tube is not sterile. Answer C is incorrect because urine in the bag is not sterile.