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Questions 164

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Question 1 of 5

A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.

Correct Answer: C,D

Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.

Question 2 of 5

A client taking Zoloft (sertraline) tells the nurse that she has also been taking St. John's wort. The nurse should report this information to the doctor because:

Correct Answer: B

Rationale: St. John's wort can induce the metabolism of Zoloft, potentially reducing its effectiveness, so the doctor may need to adjust the dose. Answer A is incorrect as they do not have opposing effects. Answer C is incorrect as St. John's wort has pharmacological effects. Answer D is incorrect as increasing the dose may not be necessary.

Question 3 of 5

At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:

Correct Answer: A

Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.

Question 4 of 5

At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially

Correct Answer: D

Rationale: Facilitate creative thinking on staffing. The 'moving phase' of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff's solving the problem.

Question 5 of 5

The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

Correct Answer: A

Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.

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