24.The registered nurse (RN) is caring for a client who has a closed head injury from a
motor vehicle collision. Which finding should the RN assess the client for the risk of
diabetes insipidus (DI)?
A. High fever.
B. Low blood pressure.
C. Muscle rigidity.
D. Polydipsia.
Give this one a try later!
, ANS: D
A characteristic finding of DI is excretion of large quantities of urine (5 to
20L/day), and most clients compensate for fluid loss by drinking large
amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI.
(B) can be characteristic of hypovolemia, but not an initial finding of DI.
Muscle rigidity (C) can be a serious manifestation of a closed head injury
that requires immediate action, but is not related to DI.
19.The registered nurse (RN) is interviewing a female client who states she has a
persistent productive cough during the winter caused by bronchitis. Which additional
finding should the RN assess for bronchitis?
A. Phlegm production and wheezing.
B. Smoking history.
C. Hemoptysis.
D. Night sweats.
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ANS: A
A chronic seasonal cough related to bronchitis is likely accompanied
withphlegm production and wheezing (A). Although smoking can
contribute to a chronic cough, the typical seasonal cough is an
inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new"
cough or changes in a persistent chronic cough is likely related to lung
cancer (C). Night sweats (D) is a trend in fever that is often seen with
tuberculosis.
22.The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine
oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which
information is most important for the RN to assess?
A. Consumptiion of any alcohol or tyramine-rich foods.
B. Complaints of nausea or vomiting.
C. Therapeutic serum drug levels.
D. Blood pressure and pulse prior to taking each dose.
, Give this one a try later!
ANS: A
All alcohol (A) and any foods that contain tyramine should be avoided
while taking an MAO inhibitor, which interact to cause a hypertensive crisis.
(B and C) should be discussed, but are not as important as (A). Although
assessing blood pressure and pulse may be indicated, it is not necessary
prior to taking each dose (D).
2.The registered nurse (RN) palpates a weak pedal pulse in the client's right foot.
Which assessment findings should the RN document that are consistent with
diminished peripheral circulation? (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities.
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ANS: A, C
Diminished hair on the legs (A) and skin that is cool to touch (C) are
symptoms of decreased arterial blood flow. (B, D, and E) are not indicators
for impaired peripheral circulation.
46.Twenty four hours after a client returns from surgical gastric bypass, the registered
nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister.
Which assessment finding should the RN report as early signs of hypovolemic shock?
A. Faint pedal pulses.
B. Decrease in blood pressure.
C. Lethargy.
D. Slow breathing.
Give this one a try later!
motor vehicle collision. Which finding should the RN assess the client for the risk of
diabetes insipidus (DI)?
A. High fever.
B. Low blood pressure.
C. Muscle rigidity.
D. Polydipsia.
Give this one a try later!
, ANS: D
A characteristic finding of DI is excretion of large quantities of urine (5 to
20L/day), and most clients compensate for fluid loss by drinking large
amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI.
(B) can be characteristic of hypovolemia, but not an initial finding of DI.
Muscle rigidity (C) can be a serious manifestation of a closed head injury
that requires immediate action, but is not related to DI.
19.The registered nurse (RN) is interviewing a female client who states she has a
persistent productive cough during the winter caused by bronchitis. Which additional
finding should the RN assess for bronchitis?
A. Phlegm production and wheezing.
B. Smoking history.
C. Hemoptysis.
D. Night sweats.
Give this one a try later!
ANS: A
A chronic seasonal cough related to bronchitis is likely accompanied
withphlegm production and wheezing (A). Although smoking can
contribute to a chronic cough, the typical seasonal cough is an
inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new"
cough or changes in a persistent chronic cough is likely related to lung
cancer (C). Night sweats (D) is a trend in fever that is often seen with
tuberculosis.
22.The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine
oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which
information is most important for the RN to assess?
A. Consumptiion of any alcohol or tyramine-rich foods.
B. Complaints of nausea or vomiting.
C. Therapeutic serum drug levels.
D. Blood pressure and pulse prior to taking each dose.
, Give this one a try later!
ANS: A
All alcohol (A) and any foods that contain tyramine should be avoided
while taking an MAO inhibitor, which interact to cause a hypertensive crisis.
(B and C) should be discussed, but are not as important as (A). Although
assessing blood pressure and pulse may be indicated, it is not necessary
prior to taking each dose (D).
2.The registered nurse (RN) palpates a weak pedal pulse in the client's right foot.
Which assessment findings should the RN document that are consistent with
diminished peripheral circulation? (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities.
Give this one a try later!
ANS: A, C
Diminished hair on the legs (A) and skin that is cool to touch (C) are
symptoms of decreased arterial blood flow. (B, D, and E) are not indicators
for impaired peripheral circulation.
46.Twenty four hours after a client returns from surgical gastric bypass, the registered
nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister.
Which assessment finding should the RN report as early signs of hypovolemic shock?
A. Faint pedal pulses.
B. Decrease in blood pressure.
C. Lethargy.
D. Slow breathing.
Give this one a try later!
