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Questions 149

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Extract:


Question 1 of 5

The nurse is caring for a client in the intensive care unit. The nurse recognizes that to prevent sensory alteration in a client, the nurse needs to do which of the following interventions? Select all that apply.

Correct Answer: A, C

Rationale: Orienting the client and explaining care reduce sensory deprivation and confusion, while limiting visitors or consistent lighting may not be beneficial.

Question 2 of 5

A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

Correct Answer: A

Rationale: Unilateral neglect involves ignoring one side, such as shaving only one side of the face.

Question 3 of 5

A 40-year-old male client has been diagnosed with Huntington disease and his spouse asks the nurse if their 3-year-old son should be tested to determine if the son inherited the genetic disorder. Which of the following is the most appropriate response?

Correct Answer: B

Rationale: Referring to a genetic counselor (
B) ensures informed decision-making about testing a child for Huntington's. Other responses (A, C,
D) are directive or dismissive.

Question 4 of 5

The client has an order for Claforan 665 mg. The directions say to reconstitute with 10 mL of bacteriostatic water to yield a concentration of 95 mg/mL. How many milliliters of solution should the nurse administer to give the dose of 665 mg?

Correct Answer: 7 mL

Rationale: Dose: 665 mg. Concentration: 95 mg/mL. Volume: 665 mg ÷ 95 mg/mL = 7 mL.

Question 5 of 5

The nurse has just received the shift report and is preparing to make rounds. Which client should be seen first?

Correct Answer: C

Rationale: The client with shortness of breath is at highest risk for respiratory distress and requires immediate assessment.

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