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Questions 149

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Question 1 of 5

The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

Correct Answer: C

Rationale: Sundowning is a common phenomenon in dementia where confusion worsens in the late afternoon and evening.

Question 2 of 5

A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:

Correct Answer: B

Rationale: Washing the skin with water and patting dry ensures cleanliness and prevents irritation during hyperbaric oxygen therapy.

Question 3 of 5

The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?

Correct Answer: B

Rationale: A high-calorie, low-fat diet is suitable post-acute pancreatitis to support recovery while minimizing pancreatic stimulation.

Question 4 of 5

A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 cc in 2 hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?

Correct Answer: A

Rationale: Signs of fluid overload (JVD, edema, low urine output, crackles) suggest the need for furosemide (Lasix) to reduce excess fluid and prevent pulmonary edema.

Question 5 of 5

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about:

Correct Answer: A

Rationale: With a platelet count of 80,000, the client is at risk for bleeding, so teaching bleeding precautions is critical to prevent complications.

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