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Questions 164

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Extract:


Question 1 of 5

A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest

Correct Answer: B

Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

Question 2 of 5

A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is

Correct Answer: C

Rationale: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise.

Question 3 of 5

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?

Correct Answer: C

Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.

Question 4 of 5

The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?

Correct Answer: B

Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.

Question 5 of 5

The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?

Correct Answer: A

Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.

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