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A nurse is caring for a c lient who has hyperthyroidism. Which of
the following findings should the nurse expect?
Tremors
Tremors are a manifestation of hyperthyroidism, along with
tachycardia, diaphoresis, weight loss, insomnia, and
exophthalmia.
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A nurse is assessing a school-aged child who has bacterial
meningitis. Which of the following findings should the n urse
expect?
Nuchal rigidity
This is a manifestation of bacterial meningitis.
A nurse is assessing a newborn’s heart rate. Which of the
following actions should the nurse take?
Auscultate the apical pulse at least 1 min.
The nurse should auscultate the apical pulse to obtain an
accurate assessment of heart rate and rhythm. Auscultation
of a newborn’s heart sounds can be difficult because of the
rapid rate and the transmission of respiratory sounds.
A nurse is preparing t o assist with a thoracentesis for a client
who has pleurisy. The nurse should plan to perform which of the
following actions?
Instruct the client to avoid coughing during the procedure.
It is important for the nurse to remind the client to avoid
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coughing and to lie still during a thoracentesis to avoid
puncturing the pleura.
A nurse in the ED is a ssessing a preschooler who has a facial
laceration. The nurse should identify which of the f ollowing
findings as a potential indication of child sexual abuse?
The child exhibits discomfort while walking.
The nurse should identify this finding as a potential indication
of child sexual abuse.
A nurse is preparing t o teach about dietary management to a
client who has Crohn’s disease and an enteroenteric f istula.
Which of the following nutrients should the nurse instruct the
client to decrease in their d iet?
Fiber
The nurse should instruct the client to consume a low-fiber
diet to reduce diarrhea and inflammation.
A nurse is caring for a c lient who has a prescription for a
continuous passive motion (CPM) machine following a total knee
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arthroplasty. Which of the following actions should the nurse
take?
Turn off the CPM machine during
mealtime. This promotes client
comfort and dietary intake.
A nurse is preparing t o initiate IV access for an older adult client.
Which of the following sites should the nurse select when initiating
the IV for the client?
Radial vein of the inner arm.
This site will have adequate subcutaneous t issue.
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