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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

A client with moderate Alzheimer disease is started on memantine. What should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer: A

Rationale: Memantine may slow decline and improve daily functioning (
A). It does not stop progression (
B), provide rapid improvement (
C), or reverse Alzheimer's (
D).

Question 3 of 5

Prior to administering a feeding, the nurse checks for placement of a feeding tube. What is the best way to do this?

Correct Answer: B

Rationale: Measuring the pH of aspirated fluid (pH <5.5) confirms gastric placement, the most reliable method to prevent aspiration.

Question 4 of 5

A client with insulin-dependent diabetes takes 20 units NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:

Correct Answer: C

Rationale: NPH insulin peaks 6-12 hours after administration (1-3 p.m.), making 3 p.m. the time to watch for hypoglycemia. Other times are outside the peak window.

Question 5 of 5

The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?

Correct Answer: A

Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (
A). Warming dialysate (
B), pain medication (
C), and positioning (
D) do not address the infection.

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