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Questions 176

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Extract:


Question 1 of 5

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?

Correct Answer: B

Rationale: The client is now sleeping, suggesting reduced agitation. Determining if restraints can be removed (
B) is the priority to minimize harm and promote safety. Bipolar history (
A), ECG changes (
C), and blood alcohol level (
D) are important but less urgent.

Question 2 of 5

The nurse reviews the ECG of a client. Which prescribed medication should the nurse suspect as the cause of the ECG findings?

Question Image

Correct Answer: D

Rationale: Levothyroxine (
D) can cause arrhythmias, which may be reflected in ECG changes. Captopril (
A), Carvedilol (
B), and Glipizide (
C) are less likely to cause significant ECG alterations.

Question 3 of 5

The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply.

Correct Answer: B, D, E

Rationale: Checking toes (
B), weekly casts (
D), and keeping the cast dry (E) are correct. Cradling (
A) is safe, and alternating sleep positions (
C) is not cast-related.

Question 4 of 5

The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. Which of the following statements by the client would require follow-up?

Correct Answer: B

Rationale: Avoiding all green leafy vegetables (
B) is incorrect; consistent intake is needed to maintain stable INR. Avoiding aspirin (
A), caffeine (
C), and consulting about supplements (
D) are correct.

Question 5 of 5

A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize

Correct Answer: B

Rationale: Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.

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