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Questions 164

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Question 1 of 5

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?

Correct Answer: B

Rationale: Alteration in mobility is priority for a detached retina, as positioning and activity restrictions prevent further detachment. Comfort, skin integrity, and O2 perfusion are secondary concerns.

Question 2 of 5

The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with

Correct Answer: C

Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.

Question 3 of 5

The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?

Correct Answer: A

Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.

Question 4 of 5

The nurse is caring for a client who does not speak English. Which of the following actions should the nurse take to facilitate communication with the client? Select all that apply.

Correct Answer: B,C,E

Rationale: Short sentences aid clarity. Gender preference respects cultural needs. Ensuring understanding confirms effective communication. Using a spouse risks bias, and speaking to the interpreter excludes the client.

Question 5 of 5

A client with chronic pancreatitis is receiving Pancreatin. Which of the following observations is most indicative that the drug treatment is having the desired effect?

Correct Answer: C

Rationale: Pancreatin replaces pancreatic enzymes, aiding fat digestion. Reduced fat in stools and less frequent bowel movements indicate effective treatment. Appetite improvement is secondary, weight loss is undesirable, and bruising is unrelated.

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