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Questions 148

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Question 1 of 5

The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:

Correct Answer: B

Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication processing.

Question 2 of 5

Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?

Correct Answer: C

Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.

Question 3 of 5

The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority

Question 4 of 5

The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.

Correct Answer: B, D, E

Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.

Question 5 of 5

The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

Correct Answer: B

Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.

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