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Questions 158

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Question 1 of 5

The client has surgery for removal of a prolactinoma. Which of the following interventions would be appropriate for this client?

Correct Answer: C

Rationale: After prolactinoma surgery (transsphenoidal hypophysectomy) elevating the head of the bed 30° reduces intracranial pressure and prevents cerebrospinal fluid leakage. Trendelenburg position coughing and nose blowing may increase pressure or disrupt the surgical site.

Question 2 of 5

A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to 'feel kind of shaky.' Based on the information given above, nursing care goals for this client will initially focus on:

Correct Answer: D

Rationale: Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.

Question 3 of 5

A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:

Correct Answer: D

Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.

Question 4 of 5

A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

Correct Answer: C

Rationale: The transition stage is characterized by irritability, nausea, and strong contractions as the cervix completes dilation.

Question 5 of 5

The client is admitted with a diagnosis of postpartum depression. Which medication is most likely to be ordered?

Correct Answer: B

Rationale: Postpartum depression is treated with antidepressants (e.g. SSRIs) to address mood symptoms. Antibiotics magnesium sulfate and tocolytics are used for other conditions not depression.

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