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Questions 164

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Question 1 of 5

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

Correct Answer: C

Rationale: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

Question 2 of 5

The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?

Correct Answer: A

Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.

Question 3 of 5

The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?

Correct Answer: A

Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.

Question 4 of 5

Which client would be at greatest risk for a fat emboli following a fracture?

Correct Answer: C

Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.

Question 5 of 5

The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.

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