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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:

Correct Answer: C

Rationale: Thickening liquids reduces aspiration risk in dysphagia post-stroke. Thin liquids, flat positioning, and straws increase aspiration risk.

Question 2 of 5

A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:

Correct Answer: A

Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.

Question 3 of 5

A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

Correct Answer: A

Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.

Question 4 of 5

A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?

Correct Answer: C

Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.

Question 5 of 5

A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:

Correct Answer: A

Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.

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