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Questions 158

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Question 1 of 5

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

Correct Answer: C

Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.

Question 2 of 5

The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

Correct Answer: A

Rationale: Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories.

Question 3 of 5

A client with a history of a brain tumor is receiving Decadron (dexamethasone). The nurse should monitor the client for:

Correct Answer: A

Rationale: Dexamethasone, a corticosteroid, causes weight gain due to fluid retention and increased appetite. Hypotension, hypoglycemia, and hair loss are not typical side effects.

Question 4 of 5

Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

Correct Answer: A

Rationale: Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. Range of motion exercises are not appropriate to presenting symptoms. These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. Phenytoin is indicated for seizure activity mainly of neurological origin.

Question 5 of 5

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:

Correct Answer: B

Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.

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