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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a client with a diagnosis of preeclampsia. Which intervention is most appropriate?

Correct Answer: D

Rationale: Magnesium sulfate prevents seizures blood pressure monitoring tracks hypertension and antihypertensives (e.g. hydralazine) manage severe hypertension in preeclampsia. All interventions are appropriate.

Question 2 of 5

The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:

Correct Answer: A

Rationale: The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. MAO inhibitors affect neurotransmitters and may produce hypotensive reactions, but hypertensive crisis is the primary concern with tyramine. Gastrointestinal side effects may occur, but they are not the most serious adverse reactions.

Question 3 of 5

The physician has ordered an injection of RhoGAM (Rho[D] immune globulin) for the postpartum client whose blood type is A negative and whose baby is O positive. To provide postpartum prophylaxis,RhoGAM should be administered:

Correct Answer: A

Rationale: RhoGAM prevents Rh sensitization in Rh-negative mothers by neutralizing fetal Rh-positive blood cells. It must be administered within 72 hours of delivery for effective prophylaxis.

Question 4 of 5

A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:

Correct Answer: C

Rationale: The temperature elevation related to febrile seizures generally exceeds 101°F, and seizures occur during the temperature rise rather than after a prolonged elevation. Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. Febrile seizures are associated with disease of the central nervous system.

Question 5 of 5

The client is diagnosed with Bell’s palsy. Which intervention should the nurse implement to protect the client’s affected eye?

Correct Answer: A

Rationale: Bell’s palsy causes facial paralysis, impairing eye closure and risking corneal damage. An eye patch at night protects the eye from drying and injury. Corticosteroids reduce inflammation, blinking is encouraged, and antibiotics are not indicated.

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