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Questions 149

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Question 1 of 5

A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?

Correct Answer: B

Rationale: is an antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing

Question 2 of 5

The physician has inserted an esophageal balloon tamponade in a client with bleeding esophageal varices. The nurse should maintain the esophageal balloon at a pressure of:

Correct Answer: D

Rationale: A pressure of 20-25 mmHg effectively compresses varices to control bleeding without causing tissue damage.

Question 3 of 5

A 16-year-old girl presents with peptic ulcers, constipation, low self-esteem, irregular menstrual cycle, and dental erosion. Her weight has fluctuated between 96 and 128 pounds over the past year. The nurse suspects the girl is suffering from

Correct Answer: B

Rationale: Bulimia nervosa is characterized by binge-purge cycles, leading to dental erosion, peptic ulcers, irregular menses, and weight fluctuations.

Question 4 of 5

The nurse is assessing a client hospitalized with duodenal ulcer. Which finding should be reported to the doctor immediately?

Correct Answer: A

Rationale: A blood pressure of 82/60 and pulse of 120 indicate possible hypovolemic shock, likely due to gastrointestinal bleeding, which is a medical emergency requiring immediate reporting.

Question 5 of 5

The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?

Correct Answer: D

Rationale: Late ICP signs include Cushing’s triad: increased systolic BP, widened pulse pressure, and bradycardia, reflecting brainstem compression.

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