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Questions 148

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Question 1 of 5

The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

Correct Answer: A

Rationale: Hematuria in a client with pelvic and femur fractures suggests possible urinary tract or bladder injury, requiring immediate reporting.

Question 2 of 5

A client has been diagnosed with renal insufficiency, which has led to pronounced fluid volume excess. The nurse would expect which of the following signs and symptoms? Select all that apply.

Correct Answer: A,C,E

Rationale: Renal insufficiency causes fluid retention, leading to decreased urine output, jugular vein distention, and tachycardia (compensatory response). Hypotension and weak pulse are more typical of fluid volume deficit.

Question 3 of 5

The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT

Correct Answer: A

Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.

Question 4 of 5

The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.

Correct Answer: B, C

Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.

Question 5 of 5

The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?

Correct Answer: D

Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.

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