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Questions 148

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Question 1 of 5

The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.

Correct Answer: B, D, E

Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.

Question 2 of 5

The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?

Correct Answer: B

Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification

Question 3 of 5

The nurse is admitting a client with a diagnosis of severe malignant catatonia to the in-patient psychiatric unit. Under which condition would the nurse support the use of electroconvulsive therapy (ECT) as a first-line treatment?

Correct Answer: C

Rationale: ECT may be considered first-line for severe malignant catatonia in a controlled setting like an assisted living facility, where monitoring is feasible. Pregnancy and age are contraindications or require caution, and employment is irrelevant.

Question 4 of 5

A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?

Correct Answer: C

Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.

Question 5 of 5

The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:

Correct Answer: B

Rationale: A pH of 7.47 and PCO2 of 28 indicate respiratory alkalosis, likely due to hyperventilation from the head injury.

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