An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
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Solution
Answer B is correct. Bright red bleeding with many clots indicates arterial bleeding that requires surgical intervention. Answer A is within normal limits; therefore, it is incorrect. Answer C indicates venous bleeding, which can be managed by nursing intervention; therefore, it is incorrect. Answer D does not indicate excessive need for pain management that requires the doctor’s attention; therefore, it is incorrect.
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
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Solution
Answer A is correct. The client with acute adrenal crisis has symptoms of hypovolemia and shock; therefore, the blood pressure would be low. Answer B is incorrect because the pulse would be rapid and irregular. Answer C is incorrect because the skin would be cool and pale. Answer D is incorrect because the urinary output would be decreased.
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
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Solution
Answer D is correct. The client with an abdominal aortic aneurysm frequently complains of pulsations or “feeling my heart beat” in the abdomen. Answers A and C are incorrect because they occur with rupture of the aneurysm. Answer B is incorrect because back pain is not affected by changes in position.
The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
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Solution
Answer A is correct. Antacids containing aluminum and calcium tend to cause constipation. Answer A refers to the side effects of anticholinergic medications used to treat ulcers; therefore, it is incorrect. Answer C refers to antacids containing magnesium; therefore, it is incorrect. Answer D refers to dopamine antagonists used to treat ulcers; therefore, it is incorrect.
Which play activity is best suited to the gross motor skills of the toddler?
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Solution
Answer B is correct. The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand. Answers A and C are incorrect because they require fine motor skills. Answer D is incorrect because the toddler lacks gross motor skills for play on the swing set.
A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?
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Solution
Answer A is correct. Lanoxin (digoxin) slows and strengthens the contraction of the heart. An increase in urinary output shows that the medication is having a desired effect by eliminating excess fluid from the body. Answer B is incorrect because the weight would decrease. Answer C might occur but is not directly related to the question; therefore, it is incorrect. Answer D is incorrect because pedal edema would decrease, not increase.
A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
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Solution
Answer C is correct. Symptoms associated with nontropical sprue and celiac disease are caused by the ingestion of gluten, which is found in wheat, oats, barley, and rye. Creamed soup and crackers contain gluten. Answers A, B, and D do not contain gluten; therefore, they are incorrect.
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
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Solution
Answer A is correct. The infant’s birth weight should double by 6 months of age. Answers B, C, and D are incorrect because they are greater than the expected weight gain by 6 months of age.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
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Solution
Answer C is correct. Holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness of the hands. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
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Solution
Answer B is correct. The client with echolalia repeats words or phrases used by others. Answer A is incorrect because it refers to clang association. Answer C is incorrect because it refers to circumstantiality. Answer D is incorrect because it refers to neologisms.