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Questions 176

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Extract:


Question 1 of 5

The nurse is assisting with care of a client with blunt head injury admitted for observation, including hourly neurologic checks. At 1:00 AM, the client reports a headache; the neurologic check is normal, and the nurse administers acetaminophen prn. At 2:00 AM, the client appears to be sleeping. What action does the nurse anticipate taking?

Correct Answer: A

Rationale: Hourly neurologic checks require arousing the client to assess orientation (
A). Checking paresthesia (
B), assuming relief (
C), or only verifying respiratory rate (
D) do not meet monitoring requirements.

Question 2 of 5

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.

Correct Answer: A, B, D

Rationale: Applying to upper arm/chest (
A), folding patches (
B), and rotating sites (
D) ensure safe use. Removing for dizziness (
C) requires medical consultation, and shaving (E) can irritate skin.

Question 3 of 5

A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?

Correct Answer: D

Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.

Question 4 of 5

The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following client statements indicate proper understanding of teaching? Select all that apply.

Correct Answer: C, D

Rationale: Vitamin D-rich foods (
C) and physical activity (
D) improve bone health in osteomalacia. Avoiding calcium/phosphorus (
A), sunlight (
B), or using a cane (E) are incorrect or unnecessary.

Question 5 of 5

The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?

Correct Answer: A

Rationale: Elevated BUN (
A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (
B) or triglycerides (
C) are not directly related to vancomycin toxicity. Elevated glucose (
D) may need monitoring but is less urgent.

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