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Questions 149

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Question 1 of 5

The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

Correct Answer: D

Rationale: should eat at regular time; remain in the seclusion room for client’s safety

Question 2 of 5

The nurse is caring for a client in intensive care with a diagnosis of traumatic brain injury. The client is found to be restless, complains of extreme nausea, and is weak on the left arm and leg. Which is the best response by the nurse?

Correct Answer: B

Rationale: Elevating the head to 30 degrees reduces intracranial pressure in traumatic brain injury, addressing symptoms like nausea and restlessness.

Question 3 of 5

The nurse is caring for a client with a history of ulcerative colitis who is admitted with a flare-up. Which of the following dietary recommendations should the nurse provide?

Correct Answer: C

Rationale: avoiding dairy products if lactose intolerant reduces gastrointestinal irritation in ulcerative colitis

Question 4 of 5

A client with end stage renal disease is being managed with peritoneal dialysis. If the dialysate return is slowed the nurse should tell the client to:

Correct Answer: D

Rationale: Changing position or turning side to side can help dislodge obstructions or reposition the catheter, improving dialysate flow.

Question 5 of 5

The nurse cares for two children brought into an emergency shelter. Law enforcement suspects the children have been neglected. The nurse should assess

Correct Answer: C

Rationale: Height and weight assess for failure to thrive, a key indicator of neglect. Bruises on knees/elbows are common in children and less specific.

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