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Questions 164

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Question 1 of 5

An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?

Correct Answer: B

Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.

Question 2 of 5

When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?

Correct Answer: C

Rationale: Diarrhea, dry mouth, weight loss, reduced libido. Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido.

Question 3 of 5

The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?

Correct Answer: D

Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.

Question 4 of 5

A client with acquired immunodeficiency syndrome is admitted with a diagnosis of pneumocystis jirovecki pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based on his mental status, the priority nursing diagnosis is:

Correct Answer: B

Rationale: The client's confusion and attempts to remove medical devices indicate a risk for self-injury, making this the priority nursing diagnosis.

Question 5 of 5

A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?

Correct Answer: B

Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.

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