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Questions 176

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Question 1 of 5

The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A, D, E, F

Rationale: Natural sunlight exposure (
A) helps regulate circadian rhythms and improve mood. Warm milk (
D) contains tryptophan, which promotes sleep. A quiet environment (E) and soft music (F) reduce stimulation and promote relaxation. Naps (
B) may disrupt nighttime sleep, and exercise before bedtime (
C) can be stimulating.

Question 2 of 5

Which finding by the nurse suggests that the mother is not giving the toddler iron supplements as ordered?

Correct Answer: B

Rationale: Iron supplements typically cause dark or black stools; light brown stools suggest non-compliance with iron supplementation.

Question 3 of 5

The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the supervising registered nurse?

Correct Answer: D

Rationale: Pleural friction rub (
D) indicates pleuritis or pleural effusion, a serious complication requiring immediate reporting. Other findings (A, B,
C) are less specific or urgent.

Question 4 of 5

A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?

Correct Answer: C

Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.

Question 5 of 5

The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?

Correct Answer: B

Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.

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