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Questions 148

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Question 1 of 5

A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.

Question 2 of 5

The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?

Correct Answer: A

Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.

Question 3 of 5

A client scheduled for a cardiac catheterization tells the nurse, 'My mother died during this same procedure 10 years ago. I'm afraid the same thing will happen to me.' Which of the following responses by the nurse is the most appropriate?

Correct Answer: A

Rationale: Acknowledging the client’s fear and discussing the procedure provides reassurance and addresses concerns therapeutically.

Question 4 of 5

A client has recently been diagnosed with open-angle glaucoma. The nurse should tell the client to avoid taking:

Correct Answer: B

Rationale: Benadryl, an antihistamine, can increase intraocular pressure, worsening open-angle glaucoma, and should be avoided.

Question 5 of 5

A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:

Correct Answer: D

Rationale: Absence seizures cause brief lapses in consciousness, often appearing as staring spells, without motor symptoms.

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