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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of a fractured tibia who is in a cast. The client complains of pain unrelieved by medication. The nurse should:

Correct Answer: C

Rationale: Unrelieved pain in a casted tibia may indicate compartment syndrome or infection, requiring immediate physician notification. Ice and elevation are insufficient, and massage is contraindicated.

Question 2 of 5

A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?

Correct Answer: C

Rationale: The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. Lithium must be taken with meals because it is irritating to the gastric mucosa. Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. Lithium is not to be taken with over-the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.

Question 3 of 5

The well child assessment of a one-year-old reveals orange discoloration of the nasolabial folds. Based on this finding the nurse should:

Correct Answer: A

Rationale: Orange discoloration of the nasolabial folds may result from excessive dietary beta-carotene (e.g. from carrots or sweet potatoes). Obtaining a diet history is the most appropriate action to identify the cause. The other options are more relevant for jaundice or liver issues.

Question 4 of 5

Assessment of a newborn for Apgar scoring includes observation for:

Correct Answer: C

Rationale: Heart rate is a critical component of Apgar scoring, assessed at 1 and 5 minutes to evaluate newborn vitality.

Question 5 of 5

The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?

Correct Answer: A

Rationale: Jaundice is specific to hemolytic anemia due to increased bilirubin from red blood cell destruction. Anorexia (
B), tachycardia (
C), and fatigue (
D) are nonspecific and occur in other anemias.

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