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Questions 176

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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

The nurse is assisting with the admission of a client who attempted suicide after being diagnosed with end-stage kidney disease. It would be a priority for the nurse to

Correct Answer: C

Rationale: Continuous one-to-one observation (
C) is the priority to ensure safety after a suicide attempt. Room assignment (
A), exploring feelings (
B), and mental status exam (
D) are secondary.

Question 3 of 5

The nurse is talking with a client with major depressive disorder who has been taking paroxetine for the past 3 weeks. Which of the following statements by the client would require immediate follow-up?

Correct Answer: B

Rationale: Persistent depression with increased energy (
B) may indicate rising suicide risk, requiring immediate follow-up. Appetite (
A), sleep (
C), and libido (
D) changes are common side effects.

Question 4 of 5

A danger following a bone marrow transplantation is graft-host disease. The initial sign of graft-versus-host disease is:

Correct Answer: B

Rationale: A rash is often the earliest sign of graft-versus-host disease, reflecting immune attack on the skin. Other signs may follow but are less initial.

Question 5 of 5

The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is

Correct Answer: B

Rationale: Your child has fewer red blood cells that carry oxygen. This provides a simple explanation of iron deficiency anemia.

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