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Questions 149

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Extract:


Question 1 of 5

A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?

Correct Answer: A

Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.

Question 2 of 5

The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?

Correct Answer: B

Rationale: Severe autism often involves sensory processing issues, increasing risk for sensory perception alterations, especially during stressful procedures like surgery.

Question 3 of 5

A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in intracranial pressure (ICP). The nurse should intervene by

Correct Answer: C

Rationale: Turning and repositioning the patient helps reduce ICP by promoting venous drainage. Elevating the head to 30-45 degrees (not 90) is appropriate; excessive suctioning or oxygen changes may not address ICP directly.

Question 4 of 5

The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:

Correct Answer: B

Rationale: Exploring the interaction addresses the behavior appropriately.

Question 5 of 5

A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

Correct Answer: D

Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.

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