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Question 1 of 5

The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:

Correct Answer: A

Rationale: Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.

Question 2 of 5

A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

Correct Answer: D

Rationale: Testing the fluid from the nares would determine the presence of CSF. Basilar skull fractures may cause dural lacerations, leading to CSF leakage. Insertion of a tube, tamponading, or suctioning could worsen the problem or increase brain damage.

Question 3 of 5

Which of the following statements relevant to a suicidal client is correct?

Correct Answer: A

Rationale: This is a high-risk factor for potential suicide. A previous suicide attempt is a definite risk factor for subsequent attempts. Every threat of suicide should be taken seriously. The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.

Question 4 of 5

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Correct Answer: B

Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 5 of 5

A client is admitted with a blood glucose level of 740 mg/dl. Which actions should the nurse take at this time?

Question Image

Correct Answer: C, E, F

Rationale: Hyperglycemia (740 mg/dl) requires physician notification (
C), sliding scale regular insulin (E), and consciousness assessment (F) for potential diabetic ketoacidosis. Peripheral neuropathy (
A) is chronic, not acute. Dextrose (
B) worsens hyperglycemia. NPH insulin (
D) is long-acting, unsuitable for acute management.

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