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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

The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:

Correct Answer: A

Rationale: Expressive aphasia (Broca’s aphasia) impairs the ability to speak and write due to damage in the frontal lobe’s speech center. Comprehension and motor activity are less affected.

Question 4 of 5

Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?

Correct Answer: C

Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and
A), and zinc. Baked chicken breast (protein), broccoli (vitamin
C), wheat roll (carbohydrates), and an orange (vitamin
C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).

Question 5 of 5

A young boy tells the nurse, 'I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.' The nurse recognizes this stage of growth and development as:

Correct Answer: B

Rationale: The Oedipus complex involves a young boy's erotic attachment to his mother and jealousy toward his father.

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