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Questions 164

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Question 1 of 5

The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?

Correct Answer: C

Rationale: Ensuring safety by escorting others away (
C) is the priority. Rapid response (
A) may be premature, approaching the client (
B) risks escalation, and informing of consequences (
D) is secondary.

Question 2 of 5

The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum

Correct Answer: A

Rationale: Carpal spasm (Trousseau's sign) suggests hypocalcemia (
A), common in pancreatitis. Albumin (
B), troponin (
C), and potassium (
D) are unrelated to this finding.

Question 3 of 5

The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures?

Correct Answer: A

Rationale: Mechanical valve replacements (
A) require prophylactic antibiotics before dental procedures to prevent endocarditis. Mitral valvuloplasty (
B), heart failure (
C), and mitral valve prolapse with regurgitation (
D) have lower risks.

Question 4 of 5

An alert adult is being admitted for elective surgery. Which comment made by the client indicates a need for more instruction regarding advance directives?

Correct Answer: B

Rationale: Advance directives allow clients to specify care preferences, not relinquish decision-making entirely. This comment suggests a misunderstanding that requires further education.

Question 5 of 5

The nurse is providing home care to an elderly woman who had a cerebrovascular accident several weeks ago. All of the following need to be done. Which should the nurse plan to do first?

Correct Answer: A

Rationale: Auscultating lung fields assesses respiratory status, a priority post-CVA to detect complications like pneumonia or atelectasis. Hygienic care, ambulation, and ROM are secondary.

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