QUESTIONS AND ANSWERS 100%
CORRECT!!!!
,A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2
days ago. Which of the following findings is associated with this diagnosis?
A. Increased appetite
B. Elevated Temperature
C. Bradycardia
D. Drowsiness - ANSWER Elevated Temperature
Rationale: The content of this question emphasizes the concept of client-centered care
through identifying findings associated with a client's diagnosis. Client-centered care
focuses on the client and emphasizes the client's cultural, ethnic, and social values. The
identification of expected and unexpected findings associated with a client's diagnosis
assists the nurse to distinguish possible unrelated complications the client might be
experiencing, which indicates the need for further investigation. The specific focus on
the client enhances the provision of safe, quality nursing care. An elevated temperature
is a finding associated with acute alcohol delirium.
A nurse working in a hospice facility is talking to a client's son who is distressed
because his mother cries frequently and says she wants to die. Which of the following
responses by the nurse is appropriate?
A. "I know this must be difficult, but your mother will calm down soon."
B. "Lets discuss some strategies you can use when this happens again."
C. Individuals near death are ready to let go toward the end."
D. "Have you determined why she is crying and saying she is ready to die?" - ANSWER
" Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce
anxiety and enhance decision making. This response creates a safe environment,
fosters trust and respect, and is appropriate.
A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of
the following is the first sign of increased intracranial pressure (ICP)?
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia - ANSWER Lethargy
, rationale: Lethargy occurs when pressure is placed on the reticular activating system
within the brainstem. Along with other indicators of a change in level of consciousness,
such as restlessness, irritability, and disorientation. Lethargy is the first sign of
increased ICP.
A nurse is reinforcing teaching with a caregiver who has aphasia. The nurse should
include which of the following communication strategies in the teaching?
A. Cue the client by providing picture cards that portray common needs.
B. Increase the volume of the voice when speaking to a client.
C. Encourage the client to limit hand gestures when communicating.
D. Vary the use of phrases and terminology in discussions. - ANSWER Cue the client
by providing picture cards that portray common needs.
Rationale: Using picture cards enhances communication. The nurse should include this
communication strategy in the teaching.
A nurse is caring for a client who has a urinary tract infection and is prescribed
ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following
administration of the medication. Which of the following is the first action the nurse
should take?
A. Administer epinephrine (Adrenaline)
B. Elevate the lower extremities
C. Determine respiratory status
D. Apply oxygen via non-rebreather mask. - ANSWER Determine respiratory status
Rationale: The client is experiencing angioedema indicating a possible anaphylactic
reaction, which is life-threatening; therefore, the nurse should first determine the client's
respiratory status.
A nurse is caring for a client who has an acid-base imbalance. For which of the
following manifestations is metabolic alkalosis a possible complications?
A. Hyperkalemia
B. Severe diarrhea
C. Atelectasis
D. Excessive vomiting - ANSWER Excessive vomiting
rationale: Metabolic alkalosis is a potential complication of excessive vomiting because
of loss of acid from the body.