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Questions 149

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Question 1 of 5

The nurse is caring for a client with a stage II sacral ulcer. Which nursing intervention would be most effective in promoting healing?

Correct Answer: C

Rationale: Increased protein and calorie intake supports tissue repair and healing for a stage II ulcer, more than heat lamps, antibiotics (unless infection is present), or wet-to-dry dressings.

Question 2 of 5

The physician has prescribed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:

Correct Answer: A

Rationale: Tyramine with MAOIs like tranylcypromine can cause a hypertensive crisis.

Question 3 of 5

The nurse on a physical rehabilitation unit is assigned a 63-year-old male client post-amputation of his left lower limb above the knee two weeks prior. The client has a history of peripheral vascular disease due to diabetes mellitus. Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: Pain after wrapping the stump may indicate improper wrapping or complications, requiring further assessment and education.

Question 4 of 5

A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?

Correct Answer: A

Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.

Question 5 of 5

A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in intracranial pressure (ICP). The nurse should intervene by

Correct Answer: C

Rationale: Turning and repositioning the patient helps reduce ICP by promoting venous drainage. Elevating the head to 30-45 degrees (not 90) is appropriate; excessive suctioning or oxygen changes may not address ICP directly.

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