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Questions 158

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Question 1 of 5

A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

Correct Answer: A

Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.

Question 2 of 5

The client is admitted to the unit with a diagnosis of abruptio placenta. Which finding is most significant when assessing this client?

Correct Answer: C

Rationale: Abruptio placenta involves placental separation which can compromise fetal oxygenation leading to abnormal fetal heart tones (e.g. bradycardia or late decelerations). This is the most significant finding as it indicates fetal distress. Bleeding pain and rigidity are relevant but secondary to fetal well-being.

Question 3 of 5

A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:

Correct Answer: B

Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.

Question 4 of 5

The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)

Order the Items

Source Container

Client admitted from the emergency room previous shift with unrelieved migraine headache.
Client transferred from surgical intensive care after traumatic brain injury. Pulse oximetry reading 94%.
Client with a Glasgow coma scale (GCS) of 5 with evidence of cerebral aneurysm rupture on CT scan.
Client admitted from the emergency room after a motor vehicle accident and GCS of 13

Correct Answer: C, B, D, A

Rationale: Priority: GCS 5 with aneurysm (
C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).

Question 5 of 5

The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?

Correct Answer: B

Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.

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