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Questions 158

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Extract:


Question 1 of 5

The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?

Correct Answer: C

Rationale: Tension pneumothorax, a medical emergency, requires needle decompression to relieve pressure on the lung and mediastinum, followed by chest tube insertion. Oxygen and bronchodilators are secondary.

Question 2 of 5

Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

Correct Answer: C

Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.

Question 3 of 5

A client with a history of a brain tumor is receiving Decadron (dexamethasone). The nurse should monitor the client for:

Correct Answer: A

Rationale: Dexamethasone, a corticosteroid, causes weight gain due to fluid retention and increased appetite. Hypotension, hypoglycemia, and hair loss are not typical side effects.

Question 4 of 5

The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:

Correct Answer: A

Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.

Question 5 of 5

Which one of the following situations represents a maturational crisis for the family?

Correct Answer: A

Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.

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