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Questions 164

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Extract:


Question 1 of 5

The home health nurse is caring for a 75-year-old client with dementia and suspects that the client may be experiencing elder mistreatment. Which of the following findings would be consistent with elder mistreatment? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Pressure injuries, significant weight loss, broken eyeglasses, and expired medications suggest neglect or mistreatment. Disorientation is expected in dementia.

Question 2 of 5

The nurse is caring for a client admitted 3 days ago with bacterial pneumonia who has become short of breath, restless, and difficult to rouse. Which additional finding indicates to the nurse that the client may be developing sepsis?

Correct Answer: A

Rationale: Prolonged capillary refill time suggests poor perfusion, a sign of sepsis, requiring immediate intervention.

Question 3 of 5

Which of the following indicates failure of a ventriculoperitoneal shunt?

Correct Answer: A

Rationale: Projectile vomiting is a sign of increased intracranial pressure due to ventriculoperitoneal shunt failure, indicating obstruction or malfunction.

Question 4 of 5

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?

Correct Answer: D

Rationale: Ativan (lorazepam), a benzodiazepine, is used to manage alcohol withdrawal symptoms like seizures and agitation. Antabuse deters drinking, flumazenil reverses benzodiazepines, and methadone treats opioid withdrawal.

Question 5 of 5

The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.

Correct Answer: A,D,E

Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.

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