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Questions 164

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Question 1 of 5

At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to

Correct Answer: A

Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

Question 2 of 5

The nurse is caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s

Correct Answer: A

Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.

Question 3 of 5

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?

Correct Answer: C

Rationale: Prednisone increases blood glucose, necessitating a higher insulin dose in diabetes. Hypotension is not a primary concern, prednisone is not typically titrated upward, and intake/output monitoring is less critical.

Question 4 of 5

The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?

Correct Answer: B

Rationale: Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.

Question 5 of 5

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

Correct Answer: C

Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.

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