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[单项选择]The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find()
A. hypotension.
B. thick, coarse skin.
C. deposits of adipose tissue in the trunk and dorsocervical area.
D. weight gain in arms and legs.
[单项选择]The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find
A. Rigid abdomen, Levine’s sign, pain relief leaning forward.
B. Rebound tenderness, McBurney’s sign, low-grade fever.
C. Right lower quadrant pain, Chvostek’s sign, muscle guarding.
D. Periumbilical pain, Trousseau’s sign, pain relief with pressure.
[单项选择]The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is()
A. sedation.
B. diarrhea.
C. vertigo.
D. urticaria.
[单项选择]The nurse is assessing a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is()
A. congenital deformity.
B. age.
C. trauma.
D. obesity.
[单项选择]When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris()
A. "The pain lasted for about 45 minutes. "
B. "The pain resolved after I ate a sandwich. "
C. "The pain worsened when I took a deep breath. "
D. "The pain occurred while I was mowing the lawn. "
[单项选择]The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client’s fundus()
A. One fingerbreadth above the umbilicus.
B. One fingerbreadth below the umbilicus.
C. At the level of the umbilicus.
D. Below the symphysis pubis.
[单项选择]The nurse is assessing a client with an ileal conduit. She notes that the client’s urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data( )
A. These findings are normal for the client.
B. There is irritation of the stoma.
C. The client is developing an infection of the urinary tract.
D. The mucus is caused by elevated levels of glucose in the urine.
[单项选择]The nurse is preparing the client with heart failure to go home. Which of the following should be most important to include in the discharge education()
A. Monitor urine output daily.
B. Monitor daily potassium intake.
C. Maintain bed rest for at least 1 week.
D. Weigh daily.
[单项选择]The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1,500 mL for the 1st hour and the same for the 2nd hour. The nurse should suspect()
A. Cushing’s syndrome.
B. diabetes mellitus.
C. adrenal crisis.
D. diabetes insipidus.
[单项选择]When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately()
A. Complaints of intense thirst.
B. Moderate to severe pain.
C. Urine output of 70 mL the 1st hour.
D. Hoarseness of the voice.
[单项选择]A client with heart failure develops pink frothy sputum, coarse crackles, and restlessness. Which of the following actions should the nurse take first()
A. Check the client’s blood pressure.
B. Place the client in high Fowler’s position.
C. Calculate the client’s fluid balance.
D. Notify the physician.
[单项选择]The nurse is assessing an elderly client for dementia. Which of the following is a primary symptom of dementia
A. Neurosis.
B. Loss of impulse control.
C. Psychosis.
D. Memory loss.
[单项选择]While assessing a client who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects()
A. a urinary tract infection.
B. renal calculi.
C. an enlarged kidney.
D. a distended bladder.
[单项选择]When assessing a client as a candidate for crutch walking, the nurse should take into account that for some elderly people, crutch walking is an impractical goal primarily because which of the following reason()
A. Decreased reaction time.
B. Decreased visual acuity.
C. Decreased motor coordination.
D. Decreased level of comprehension.
[单项选择]A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost( )
A. 1 pound.
B. 3 pounds.
C. 5 pounds.
D. 7 pounds.
[单项选择]The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client’s rehabilitation after discharge()
A. The family’s ability to take care of the client’s special diet needs.
B. The family’s expectation that the client will resume responsibilities and role-related activities.
C. Emotional support from the family.
D. The family’s ability to understand the ups and downs of the illness.
[单项选择]A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of()
A. right-sided heart failure.
B. acute pulmonary edema.
C. pneumonia.
D. cardiogenic shock.
[单项选择]A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema()
A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours.
B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours.
C. A 5-to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling.
D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling.
[单项选择]When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following()
A. Fetal hypoxia.
B. Maternal comfort.
C. The contraction pattern.
D. The status of a trapped cord.