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Questions 158

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Question 1 of 5

The nurse is caring for a client with a T4 spinal cord injury. The client complains of a pounding headache. The nurse should:

Correct Answer: A

Rationale: A pounding headache in a T4 spinal cord injury suggests autonomic dysreflexia, often triggered by bladder or bowel issues, causing severe hypertension. Checking blood pressure is the priority to confirm.

Question 2 of 5

The most important reason to closely assess circumferential burns at least every hour is that they may result in:

Correct Answer: D

Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.

Question 3 of 5

The client with a history of gout is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:

Correct Answer: B

Rationale: Allopurinol reduces uric acid production, and taking it with a full glass of water promotes excretion of uric acid, preventing kidney stones. Fluid restriction is harmful, calcium is not restricted, and it can be taken with food.

Question 4 of 5

A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?

Correct Answer: D

Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (
A), pain medication (
B), and ABGs (
C) are supportive but less directly preventive.

Question 5 of 5

The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:

Correct Answer: C

Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.

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