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Questions 164

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Question 1 of 5

In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?

Correct Answer: C

Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.

Question 2 of 5

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

Correct Answer: D

Rationale: Nurses cannot dispense medications without a prescription (A,
B). Checking blood pressure (
C) is irrelevant. Referring to a provider (
D) ensures proper evaluation and treatment.

Question 3 of 5

A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:

Correct Answer: C

Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.

Question 4 of 5

The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?

Correct Answer: D

Rationale: Taking blood pressure (
D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (
A), dizziness (
B), and visual changes (
C) are signs of digoxin toxicity, requiring provider notification.

Question 5 of 5

Which of the following clients is at highest risk for developing Sarcordosis?

Correct Answer: B

Rationale: Sarcoidosis is most common in African-Americans, particularly women of childbearing age, making the pregnant 30-year-old African-American the highest risk.

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