Extract:

Question 1 of 5

A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?

Correct Answer: C

Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.

Question 2 of 5

The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?

A. Inappropriate laughter. B. An exaggerated sense of well-being. C. Slurring of words when excited. D. Visual hallucinations.

Correct Answer: B

Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.

Question 3 of 5

The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client's apical pulse is 58 bpm. What should the nurse do next?

A. Administer the dose as ordered B. Withhold the dose and notify the physician C. Reduce the dose by half D. Recheck the pulse in 30 minutes

Correct Answer: B

Rationale: Digoxin is typically withheld if the apical pulse is below 60 bpm in adults, as bradycardia may indicate toxicity. The physician should be notified for further evaluation.

Question 4 of 5

A comprehensive health assessment includes:

A. A complete medical history, a general survey and a complete physical assessment. B. A complete medical history, a general survey and a focused physical assessment. C. A client interview, a significant other interview, a general survey and a complete physical assessment. D. A client interview, a significant other interview, a general survey and a focused physical assessment.

Correct Answer: A

Rationale: A comprehensive health assessment includes a complete medical history, a general survey (vital signs, appearance), and a complete physical assessment covering all body systems.

Question 5 of 5

The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure?

A. Suction kit and tracheostomy dressing B. Bottle of sterile saline and a tracheostomy care kit C. Bottles of sterile saline and water and a tracheostomy dressing D. Tracheostomy care kit, sterile saline and water, and a suction kit

Correct Answer: D

Rationale: Equipment needed to perform tracheostomy care includes a tracheostomy care kit, sterile water and saline solutions for cleansing and rinsing, and a suction kit for client suctioning. As part of tracheostomy care, the client's airway should be suctioned before cleansing the tracheostomy. New sterile solutions are obtained once per 24 hours, which is often done at the beginning of the workday. A tracheostomy care kit contains the needed supplies for cleaning the tracheostomy and for changing the dressing and holder (trach ties).