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Questions 158

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Question 1 of 5

A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

Correct Answer: C

Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.

Question 2 of 5

A client with a history of chronic migraines is admitted with complaints of photophobia. The nurse should give priority to:

Correct Answer: A

Rationale: A dark environment reduces photophobia in migraines, improving comfort and reducing symptom severity.

Question 3 of 5

The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician?

Correct Answer: D

Rationale: Increasing abdominal girth post-hemicolectomy may indicate complications like bleeding, ileus, or perforation, requiring immediate physician notification. Sluggish bowel sounds, umbilical pain, and liquid stool are expected early post-op.

Question 4 of 5

The client with hyperemesis gravidarum is at risk for developing:

Correct Answer: B

Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to dehydration and loss of stomach acid resulting in metabolic acidosis. The dehydration exacerbates the acid-base imbalance.

Question 5 of 5

On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:

Correct Answer: C

Rationale: Leukoplakia cannot be rubbed off.

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