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Questions 158

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Question 1 of 5

A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being 'on the move,' sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?

Correct Answer: C

Rationale: During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. Grandiosity and an inflated sense of self-worth are characteristic of this disorder. Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.

Question 2 of 5

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Correct Answer: B

Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.

Question 3 of 5

The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?

Correct Answer: A

Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.

Question 4 of 5

A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:

Correct Answer: C

Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.

Question 5 of 5

The nurse is caring for a client with a history of peripheral artery disease. The nurse should expect the client to have:

Correct Answer: A

Rationale: Peripheral artery disease reduces blood flow, causing intermittent claudication (leg pain with activity) due to muscle ischemia.

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