nclex test

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?

Ankle brachial index of 0.65.

Question: A 68-year-old client is admitted to the addiction unit after treatment in the emergency department for an overdose of oxycontin. Her son calls the unit and expresses intense anger that his mother is being treated as a "common street addict." He says she has severe back pain and was given the prescription by her doctor. "She just accidentally took a few too many pills last night." In what order of priority from first to last should the nurse implement these actions?

"I can hear how upset you are. You sound very concerned about your mother." "I understand that your mother may not have intentionally taken too many pills. This medication can cause one to forget how many have been taken." "Unfortunately, it is fairly common for clients with pain to increase their use of pain pills over time." "It may be appropriate for your mother to be referred to a pain management program."

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?

Being an infant.

A nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first?

Check the client's bladder for distention.

Which clinical signs would indicate to a nurse caring for a terminally ill client that death may be imminent?

Diminished urine output and Cheyne-Stokes respirations

There is a predominant pattern of variations that occur during the male sexual response. Which of the following occurs during the orgasm phase?

Expulsive contractions of the urethra.

An autograft is taken from the client's left leg. The nurse should care for the donor site by:

Keeping the site clean and dry.

Which of the following nursing assessment findings in a client with septic shock would require immediate intervention?

Urine output of 90 mL of dark, concentrated urine for the past 6 hours

Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:

Verbalize absence of epigastric pain.

A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for:

abdominal tenderness.