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Questions 149

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Question 1 of 5

A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?

Correct Answer: C

Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.

Question 2 of 5

A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

Correct Answer: B

Rationale: Phantom limb pain results from peripheral nervous system interruptions, and offering pain medication addresses the client's discomfort appropriately.

Question 3 of 5

What clinical manifestation is most indicative of possible carbon monoxide poisoning?

Correct Answer: C

Rationale: Cherry red mucous membranes are a hallmark of carbon monoxide poisoning due to carboxyhemoglobin formation, which gives tissues a bright red appearance.

Question 4 of 5

The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:

Correct Answer: A

Rationale: Increased dilute urine suggests diabetes insipidus, a complication of pituitary surgery, requiring immediate physician notification for evaluation and treatment.

Question 5 of 5

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:

Correct Answer: A

Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.

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