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Questions 158

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Question 1 of 5

A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

Correct Answer: D

Rationale: Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.

Question 2 of 5

The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?

Correct Answer: A

Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (
B), oral care (
C), and breathing exercises (
D) are supportive but less critical for ICP control.

Question 3 of 5

A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods.

Correct Answer: A

Rationale: Raw foods like tossed salad (
A) can harbor pathogens, risky for AIDS patients with diarrhea. Baked chicken (
B), broiled fish (
C), and steamed rice (
D) are cooked and safer, indicating further teaching is needed for A.

Question 4 of 5

Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?

Correct Answer: C

Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.

Question 5 of 5

The client is admitted with a diagnosis of hypovolemic shock. Which fluid is most appropriate for initial resuscitation?

Correct Answer: A

Rationale: 0.9% Normal saline is the preferred isotonic fluid for initial resuscitation in hypovolemic shock to restore intravascular volume. Dextrose is hypotonic, 3% saline is hypertonic, and lactated Ringer’s is used in specific cases like burns.

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