1. A client has cancer of the liver. The nurse should be most concerned about which nursing diagnosis?
A. Ineffective coping
B. Alteration in urinary elimination
C. Alteration in skin integrity
D. Alteration in nutrition
Answer D is correct. Cancer of the liver frequently leads to severe nausea and vomiting, thus the need for altering nutritional needs. The problems in answers B, C, and D are of lesser concern and, thus, are incorrect in this instance.
2. The client is having fetal heart rates of 100–110 beats per minute during the contractions. The first action the nurse should take is to:
A. Apply an internal monitor
B. Get the client up and walk her in the hall
C. Turn the client to her side
D. Move the client to the delivery room
Answer C is correct. The normal fetal heart rate is 120–160 bpm. A heart rate of 100–110 bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time, so answer D is incorrect as well.
A. Ineffective coping
B. Alteration in urinary elimination
C. Alteration in skin integrity
D. Alteration in nutrition
Answer D is correct. Cancer of the liver frequently leads to severe nausea and vomiting, thus the need for altering nutritional needs. The problems in answers B, C, and D are of lesser concern and, thus, are incorrect in this instance.
2. The client is having fetal heart rates of 100–110 beats per minute during the contractions. The first action the nurse should take is to:
A. Apply an internal monitor
B. Get the client up and walk her in the hall
C. Turn the client to her side
D. Move the client to the delivery room
Answer C is correct. The normal fetal heart rate is 120–160 bpm. A heart rate of 100–110 bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time, so answer D is incorrect as well.
3. A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
A. Bradycardia
B. Exophthalmos
C. Decreased appetite
D. Weight gain
Answer B is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss. Answers A, B, and D are not associated with hyperthyroidism.
B. Exophthalmos
C. Decreased appetite
D. Weight gain
Answer B is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss. Answers A, B, and D are not associated with hyperthyroidism.
options are misguiding
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