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1. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct answer: A
Rationale: In a client experiencing vomiting and diarrhea, the nurse should expect findings such as dehydration, which can lead to hypovolemia and subsequent increased heart rate and decreased blood pressure. A blood pressure of 144/82 mm Hg is indicative of possible dehydration in this client. Urine specific gravity is typically increased in dehydrated individuals, so choices B and D are incorrect. Neck vein distention is not a typical finding associated with vomiting and diarrhea; therefore, choice C is also incorrect.
2. How should a healthcare professional monitor a patient for infection post-surgery?
- A. Monitor the surgical site
- B. Monitor for fever
- C. Check blood pressure
- D. Check for redness
Correct answer: A
Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.
3. From the cognitive-behavioral perspective, an important limitation with the behavioral perspective is that ________.
- A. Behaviorists went too far in attacking the psychoanalytic perspective.
- B. Behaviorists failed to attend to the importance of mental processes.
- C. Behaviorists were too focused on explaining how abnormal behavior is acquired.
- D. Behaviorists underestimated the role of reinforcement.
Correct answer: B
Rationale: The correct answer is B because behaviorists, from the cognitive-behavioral perspective, are criticized for not considering the significance of mental processes. This limitation is a key point in the cognitive-behavioral perspective, which emphasizes the interplay between thoughts, feelings, and behaviors. Choices A, C, and D are incorrect because they do not directly address the specific limitation of failing to account for mental processes in the behavioral perspective.
4. A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?
- A. An air leak
- B. A blocked chest tube
- C. Drainage from the site
- D. Blood clot in the chest tube
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.
5. A nurse is providing care to a patient who has just received a diagnosis of acute myeloid leukemia (AML). What is the priority nursing diagnosis for this patient?
- A. Risk for bleeding
- B. Risk for infection
- C. Impaired gas exchange
- D. Imbalanced nutrition
Correct answer: B
Rationale: Risk for infection is a high priority due to the patient's compromised immune system from AML.
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