A gravida two para one has just delivered a full-term infant. Which finding indicates separation of the placenta?
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Solution
Answer B is correct. Increased length of the cord is a sign that the placenta has separated. Answers A, C, and D are not associated with separation of the placenta; therefore, they are incorrect.
Which lab finding would the nurse expect to find in the client with diverticulitis?
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Solution
Answer C is correct. An elevated white cell count is expected in inflammatory conditions such as diverticulitis. Answers A, B, and D are not associated with inflammation; therefore, they are incorrect.
The nurse is caring for a 9-month-old with suspected celiac disease. Which diet is appropriate?
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Solution
Answer D is correct. The appropriate diet for the 9-month-old with suspected celiac disease is breast milk and rice cereal. Answer A is incorrect because the 9-month-old is too young to have whole milk, and oats contain gluten, which is associated with celiac disease. Both mixed cereal and barley cereal contain gluten, which is associated with celiac disease; therefore, answers B and C are incorrect.
The nurse is applying karaya powder to the skin surrounding the client’s ilestomy. The purpose of the karaya powder is to:
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Solution
Answer B is correct. Karaya powder is applied to help form a seal that will protect the skin from the liquid stool. Answer A is incorrect because karaya powder will not prevent the formation of odor. Answer C is incorrect because karaya powder will not prevent the loss of electrolytes from the ileostomy. Answer D is incorrect because karaya powder will not increase the time between bag evaluations.
A client is admitted for treatment of essential hypertension. Essential hypertension exists when the client maintains a blood pressure reading at or above:
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Solution
Answer A is correct. Essential hypertension is defined as maintenance of a blood pressure reading at or above 140/90. Answers B, C, and D are incorrect because the blood pressures are lower than 140/90.
The nurse is assessing a client following a subtotal thyroidectomy. Part of the assessment is asking the client to state her name. The primary reason for asking the client to state her name is to check for:
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Solution
Answer D is correct. Hoarseness and weak voice are signs of laryngeal nerve damage. These would be evident when the client states her name. Answer A is incorrect because it is not assessed by having the client state her name. The nurse would check the client’s dressing and check behind the neck for signs of post-operative bleeding. Answer B is incorrect because it is not assessed by having the client state her name. Signs of decreased calcium include tingling around the mouth and muscle twitching. Answer C is incorrect because it is not assessed by having the client state her name. Signs of laryngeal stridor include harsh, high-pitched respirations.
The physician has ordered an injection of morphine for a client with post-operative pain. Before administering the medication, it is essential that the nurse assess the client’s:
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Solution
Answer B is correct. Morphine can severely depress the client’s respirations. Answer A is incorrect because the assessment of heart rate, a part of pain assessment, is not an essential assessment for administering morphine. Answer C is incorrect because temperature is not affected by the administration of morphine. Answer D is incorrect because assessment of blood pressure, a part of pain assessment, is not an essential assessment for administering morphine.
Which finding is associated with secondary syphilis?
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Solution
Answer D is correct. Secondary syphilis is characterized by well-defined generalized lesions on the palms, soles, and perineum. Lesions can enlarge and erode, leaving highly contagious pink or grayish white lesions. Answer A describes the chancre associated with primary syphilis; therefore, it is incorrect. Answer B describes the latent stage of syphilis; therefore, it is incorrect. Answer C describes late syphilis; therefore, it is incorrect.
A client is admitted with suspected pernicious anemia. Which finding is common in the client with pernicious anemia?
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Solution
Answer C is correct. Pernicious anemia is characterized by changes in neurological function such as loss of coordination and loss of position sense. Answers A, B, and D are applicable to all types of anemia; therefore, they are incorrect.
A client treated for depression is admitted with a diagnosis of serotonin syndrome. The nurse recognizes that serotonin syndrome can be caused by:
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Solution
Answer A is correct. Concurrent use of two SSRIs can result in serotonin syndrome, a potentially lethal condition. Answer B is incorrect because it refers to the “Parnatecheese” reaction or hypertension that results when the client taking an MAO inhibitor ingests sources of tyramine. Answer C in incorrect because it refers to neuroleptic malignant syndrome or elevations in temperature caused by antipsychotic medication. Answer D is incorrect because it refers to the hypertension that results when MAO inhibitors are used with cold and hayfever medications containing pseudoephedrine