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Question 1 of 5

A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

Correct Answer: D

Rationale: Testing the fluid from the nares would determine the presence of CSF. Basilar skull fractures may cause dural lacerations, leading to CSF leakage. Insertion of a tube, tamponading, or suctioning could worsen the problem or increase brain damage.

Question 2 of 5

Which stage of labor lasts from delivery of the baby to delivery of the placenta?

Correct Answer: B

Rationale: This stage is from complete dilatation of the cervix to delivery of the fetus. This is the correct stage for the definition. This stage lasts for about 2 hours after the delivery of the placenta. There is no fifth stage of labor.

Question 3 of 5

The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?

Correct Answer: A

Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.

Question 4 of 5

A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

Correct Answer: D

Rationale: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.

Question 5 of 5

The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?

Correct Answer: B

Rationale: Hypercalcemia (calcium 13 mg/dL) is a common complication of bone metastases, causing confusion and hypertension. Hyperkalemia (
A), low phosphorus (
C), and normal sodium (
D) are less likely causes.

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A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
Which of the following interventions will be useful for the patient with Alzheimer's dementia who exhibits prosopagnosia?
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, 'I can't stay still at night. I toss and turn and can't fall asleep.' The nurse suspects that she may be experiencing:

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