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Questions 149

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Question 1 of 5

A client is brought to the emergency room by the police. He is combative and yells, 'I have to get out of here. They are trying to kill me.' Which assessment is most likely correct in relation to this statement?

Correct Answer: C

Rationale: The client's statement reflects paranoid delusions, a belief that others intend harm, common in psychotic disorders.

Question 2 of 5

Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

Correct Answer: B

Rationale: Pregnant nurses should avoid caring for clients with radium implants due to the risk of radiation exposure to the fetus.

Question 3 of 5

A client taking furosemide (Lasix) comes into the clinic for routine bloodwork. Which of the following findings indicates an adverse effect of Lasix?

Correct Answer: C

Rationale: Furosemide can increase uric acid levels (normal 3.5-7.2 mg/dL), leading to hyperuricemia, a known adverse effect. Other values are within normal ranges.

Question 4 of 5

A nurse starts an IV medication for a client. It is ordered as IV push, and she pushes the medication slowly over two minutes. The client then becomes restless, complains of chest pain, has difficulty breathing, and becomes cyanotic. The nurse recognizes this is most likely caused by

Correct Answer: D

Rationale: Rapid onset of chest pain, dyspnea, cyanosis, and restlessness after IV push suggests pulmonary embolism, likely from air or thrombus introduced during administration.

Question 5 of 5

The nurse is caring for a client with an acoustic neuroma brain tumor. The location of this tumor warrants which of the following nursing diagnosis as the highest priority?

Correct Answer: D

Rationale: An acoustic neuroma affects the vestibulocochlear nerve, causing balance and hearing issues, increasing fall risk. High risk for injury is the priority due to potential for harm.

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