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Questions 164

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Question 1 of 5

A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timoptic should be used with caution in the client with a history of:

Correct Answer: C

Rationale: Timolol, a beta-blocker, can exacerbate emphysema by causing bronchoconstriction. Diabetes , ulcers , and pancreatitis are not contraindications.

Question 2 of 5

Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 196/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?

Correct Answer: D

Rationale: Automated BP readings can be inaccurate. Rechecking with a manual cuff ensures accuracy before escalating or medicating, as severe hypertensionزه://www.youtube.com/watch?v=9Q7sE1Xh_1Qsevere hypertension (≥180/110 mm Hg) requires prompt action if confirmed.

Question 3 of 5

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the well in the wheelchair. What is the priority nursing action?

Correct Answer: C

Rationale: Multiple bruises in various stages raise suspicion for elder abuse, requiring reporting to the HCP for investigation. Further questioning may cause distress, and hygiene/nutrition assessments are secondary. Discussing with family risks alerting potential abusers.

Question 4 of 5

The nurse is caring for an older adult client who has experienced recent multiple falls and weight loss. The client lives with an adult child, but the nurse is questioning the safety of the home. Which of the following interdisciplinary team members would be most appropriate for the nurse to consult?

Correct Answer: C

Rationale: A social worker can assess the home environment, coordinate resources for safety modifications, and address caregiving concerns, making them the most appropriate consult for home safety evaluation.

Question 5 of 5

A mother has brought her 9-month-old baby to the physician's office for a well baby visit. Based on knowledge of normal growth and development, the nurse would expect that the ability the child has acquired most recently is which of the following?

Correct Answer: A

Rationale: By 9 months, sitting unsupported is a recently acquired milestone, typically achieved around 6-8 months, following earlier skills like rolling over and head control.

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