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Questions 158

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Question 1 of 5

A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

Correct Answer: C

Rationale: The client may be anxious and hyperresponsive to stimuli but not necessarily restless. This is not a physiological response to an elevated blood pressure in PIH. The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. External stimuli might induce a convulsion but are not annoying to the client with PIH.

Question 2 of 5

The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client’s heart rate is 58 beats per minute. What is the nurse’s best action?

Correct Answer: B

Rationale: A heart rate of 58 bpm is below the threshold (60 bpm) for digoxin administration, as it may worsen bradycardia. Holding the dose and notifying the physician (
B) is safest. Administering (
A), reducing (
C), or delaying (
D) is inappropriate.

Question 3 of 5

A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?

Correct Answer: C

Rationale: Behavior modification for oppositional defiant disorder often uses a token economy system, where positive behaviors are reinforced with rewards to encourage compliance.

Question 4 of 5

An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?

Correct Answer: B

Rationale: Interstitial cystitis is characterized by chronic pelvic pain and urinary symptoms without bacterial infection, so the urine is typically free of bacteria, unlike bacterial cystitis.

Question 5 of 5

An elderly client has been noted to have increasing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing:

Correct Answer: C

Rationale: Sundowning is increased confusion or agitation in the late afternoon or evening common in elderly patients with dementia. Proprioception agnosia and confabulation do not describe this time-specific behavior.

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