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Questions 158

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Question 1 of 5

A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

Correct Answer: B

Rationale: Exercising the unaffected extremities will prevent contractures and emboli. Crossing and uncrossing the affected leg after surgery can dislocate the joint. Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.

Question 2 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.

Question 3 of 5

Which of the following nursing diagnoses is of highest priority for the patient with hypothyroidism?

Correct Answer: D

Rationale: Hypothyroidism reduces metabolic rate potentially decreasing cardiac output which can lead to life-threatening complications like heart failure. While hypothermia and other diagnoses are relevant decreased cardiac output is the most critical.

Question 4 of 5

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Correct Answer: C

Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.

Question 5 of 5

The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?

Correct Answer: A

Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.

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